From the Guidelines
The initial approach to managing pediatric hypercalcemia involves aggressive hydration and identification of the underlying cause, with serum calcium determination and monitoring of renal function being crucial steps, as recommended by the most recent guidelines 1.
Initial Evaluation
The initial evaluation of pediatric hypercalcemia should include serum calcium determination, which should be obtained every 4 to 6 months until 2 years of age, every 2 years thereafter, and when hypercalcemia is suspected 1.
- Assessment of hydration status
- Measurement of serum calcium concentration
- Evaluation of dietary calcium intake
- Renal ultrasonography to evaluate for nephrocalcinosis if hypercalciuria is found
Management
Aggressive hydration with intravenous normal saline at 1.5-2 times maintenance rates is essential to promote calcium excretion through the kidneys.
- Discontinuation of medications that may contribute to hypercalcemia, such as thiazide diuretics, vitamin D supplements, and calcium supplements, is essential.
- Dietary calcium restriction should be implemented, but parents should be cautioned not to restrict calcium without medical supervision 1.
- For moderate to severe hypercalcemia (>14 mg/dL) or when symptoms are present, bisphosphonates like pamidronate (0.5-1 mg/kg IV over 2-4 hours) may be necessary.
- Calcitonin (4-8 IU/kg SC/IM every 6-12 hours) can provide rapid but temporary reduction in calcium levels.
- Glucocorticoids such as prednisolone (1-2 mg/kg/day) are useful particularly in vitamin D-mediated hypercalcemia.
Monitoring and Referral
Close monitoring of serum calcium, phosphorus, magnesium, and renal function is crucial during treatment.
- Referral to a pediatric nephrologist and/or pediatric endocrinologist should be considered for management of persistent hypercalcemia, hypercalciuria, or nephrocalcinosis 1.
- The underlying cause of hypercalcemia should be identified and addressed simultaneously, as the definitive management depends on treating the primary condition.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Initial Approach to Pediatric Hypercalcemia
The initial approach to managing pediatric hypercalcemia involves understanding the causes and clinical features of hypercalcemia, which can differ in various age groups 2.
Causes of Hypercalcemia
Hypercalcemia in children can be classified as parathyroid hormone (PTH)-dependent or PTH-independent, and may be congenital or acquired 3.
- PTH-independent hypercalcemia is more common in children and can be caused by:
- Hypervitaminosis
- Granulomatous disorders
- Endocrinopathies
- Congenital syndromes such as idiopathic infantile hypercalcemia (IIH), William's syndrome, and inborn errors of metabolism
- PTH-dependent hypercalcemia is usually caused by parathyroid tumors, which may give rise to primary hyperparathyroidism (PHPT) or tertiary hyperparathyroidism
Diagnostic Approach
Assessment of hypercalcemia requires an understanding of the normal physiological regulation of plasma calcium by the combined actions of parathyroid hormone, 1,25-dihydroxyvitamin D(3), and the calcium sensing receptor 4.
- The diagnostic approach includes:
- Measurement of serum calcium levels
- Parathyroid hormone assay to differentiate hyperparathyroidism from malignancy and other causes of hypercalcemia 5
- Evaluation of renal function and electrolyte levels
Treatment
The management of symptomatic hypercalcemia includes interventions such as:
- Fluids and loop diuretics to increase urinary excretion of calcium 5, 6
- Antiresorptive medications such as bisphosphonates, which are considered the drugs of choice for long-term management 6
- Calcitonin for short-term control of severe hypercalcemia 5, 6
- Parathyroid surgery for primary hyperparathyroidism 2, 3