Premature infants face unique challenges beyond respiratory support; one of the critical concerns in the NICU is metabolic bone disease, also known as osteopenia of prematurity. This condition arises because preemies miss out on the critical mineral accretion that typically happens in the third trimester, leading to deficiencies in calcium and phosphorus essential for strong bone development. Clinical signs of metabolic bone disease in preemies often include low serum phosphorus, elevated alkaline phosphatase levels, and, in severe cases, a higher risk of fractures due to fragile bones. The NICU medical team carefully monitors these laboratory findings to identify at-risk infants early. Optimizing nutrition plays a pivotal role in managing and preventing this condition. Ensuring adequate intake of calcium, phosphorus, and vitamin D through fortified feeds helps support bone mineralization. Vitamin D is especially important because it aids in calcium absorption and bone metabolism. Movement, even at very low levels, is another key factor as it stimulates bone growth and strength. This may include gentle passive range-of-motion exercises guided by occupational therapists and careful handling by healthcare staff and parents. Because metabolic bone disease can greatly impact a preemie's development and long-term health, education for parents and new NICU staff is emphasized to understand these nutritional needs and care protocols. Ultimately, the close attention NICUs give to calcium, phosphorus, vitamin D, and movement underscores how comprehensive care for preemies extends beyond breathing support to fostering healthy bone development—a vital foundation for their growth and well-being.