© 2021, The Author(s), under exclusive licence to Springer Nature America, Inc.Aim: The aim of this study is to determine the incidence of metabolic bone disease (MBD) and assess the risk factors for development radiologic evidence of MBD. Methods: Preterm infants with gestational age ≤32 weeks and birth weight ≤1500 g were included in this prospective study. Metabolic bone disease was defined as hypophosphatemia (phosphorus levels <4 mg/dl), ALP levels >450 U/L, or radiologic findings of MBD at four weeks of age. Results: The study included 254 infants (gestational age: 29 (27–30) weeks, birth weight: 1130 g (960–1300)). Metabolic bone disease was diagnosed in 96 patients (37%); 48 infants had only radiologic evidence of MBD, 24 infants had only biochemical diagnosis of MBD, and 24 infants had both radiologic evidence of MBD and biochemical diagnosis of MBD. Conclusions: Our results showed that radiologic evidence of MBD existed in some infants with normal biochemical results. That finding may guide further development of screening programs for MBD.