Background: Neonatal rickets, also known as metabolic bone disease (MBD), and osteopenia of prematurity (OOP) are serious but common concerns for parents of premature babies. Objective: to evaluate the wrist and arm X-ray changes and compared with evaluated the alkaline phosphatase (ALP) as a marker to predict MBD. Patients and Methods: 36 preterm infants with GA < 36 weeks and postnatal age > 6 weeks were included at Neonatal Intensive Care Unit of Zagazig University Hospitals. Serum parathyroid hormone (PTH), ALP, calcium (Ca), phosphorus (P), and vitamin D were all measured simultaneously during the first six postnatal weeks of pregnancy. It was determined that OOP was present by taking wrist radiographs at six weeks old. Results: A significant difference in X-ray was found in the case with biochemical and radiological change. Regarding ALP levels, a significant difference was detected among the three studied groups; the median of ALP was significantly higher in the group (I), and in the group compared to group (III). Only ALP was associated with occurrence of osteopenia in neonates. Conclusion: According to early biochemical criteria (serum ALP and phosphate), more than one in ten very preterm infants are affected by MBD.