Calcium and Bone Disorders - Paediatric CPC

For clinical advice, please telephone the relevant specialty service.

Women's and Children's Health Network

• Women’s and Children’s Hospital (08) 8161 7000

Exclusions

• significant bowing of limbs or other nutritional deficiencies – refer to paediatric medicine
• simple vitamin D deficiency

Triage categories

Category 1 - appointment clinically indicated within 30 days

• symptomatic hypocalcaemia
• symptomatic hypercalcaemia
• please contact endocrine registrar/ doctor on call for advice about starting treatment

Category 2 — appointment clinically indicated within 90 days

• asymptomatic hypo or hypercalcaemia
• rickets not responsive to routine vitamin d supplementation
• hypophosphataemic rickets
• concerns around bone fragility/osteoporosis (frequent long bone fractures, vertebral compression fractures, bone pain)

Category 3 — appointment clinically indicated within 365 days

• low bone mineral density without a history of fractures or bone pain

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Calcium disorders

History

• past medical/surgical history
• onset, duration, and progression of symptoms
• current medications and dosages, and any supplements
• allergies and sensitivities
• management history including treatments trialled/implemented prior to referral

Examination

• examination results, including clinical evidence of rickets e.g. bowed legs, frontal bossing, swollen wrists
• height/weight

Investigations

• 25-hydroxy vitamin D (25-OHD)
• calcium (Ca)
• magnesium (Mg)
• phosphate (PO4)
• albumin
• creatinine
• alkaline phosphatase (ALP)
• serum parathyroid hormone (PTH)

Osteoporosis/frequent fractures

History

• past medical/surgical history, including
  • fracture history, e.g. number of fractures and mechanism of injury
  • family history of osteogenesis imperfecta (OI)
  • bone pain
  • ability to mobilise
• onset, duration, and progression of symptoms
• current medications and dosages, and any supplements
• allergies and sensitivities
• dietary calcium intake
• onset of puberty
• management history including treatments trialled/implemented prior to referral

Examinations

• examination results, including:
  • physical features of OI
  • bone deformity
• height/weight

Investigations

• 25-OHD
• Ca
• Mg
• PO4
• albumin
• creatinine
• ALP
• PTH

Rickets

History

• past medical/surgical history, including
  • onset of bowed legs/swollen wrists
  • fracture history, e.g. number of fractures and mechanism of injury
  • bone pain
  • ability to mobilise
• onset, duration, and progression of symptoms
• current medications and dosages, and any supplements.
• allergies and sensitivities
• dietary calcium intake
• onset of puberty
• management history including treatments trialled/implemented prior to referral

Examinations

• examination results, including:
  • bowed legs
  • swollen wrists
  • rachitic rosary
  • frontal bossing
• height/weight

Investigations

• 25-OHD
• Ca
• Mg
• PO4
• albumin
• creatinine
• ALP
• PTH
  • X-ray of wrists/knees

Additional information to assist triage categorisation

Osteoporosis

• consider bone density scan at a paediatric centre (total body and lumbar spine, adjusted for height)
• lateral X-ray spine to screen for vertebral compression fractures

Rickets

• maternal vitamin D status if child is less than 12 months

Clinical management advice

Calcium disorders

Ensure abnormal calcium level is real by using corrected serum calcium.

Common causes of hypocalcaemia include vitamin D deficiency and hypoparathyroidism.

Always check serum parathyroid hormone (PTH), 25, 25-hydroxy vitamin D (25- OHD) and alkaline phosphatase (ALP).

If symptomatic call (08) 8161 7000 and speak to endocrine registrar/doctor on call for advice around starting treatment.

Osteoporosis

Osteoporosis in childhood may present with frequent low trauma fractures, bone pain, or ‘osteopenia’ on plain X-ray.

The most common causes include osteogenesis imperfecta (OI), as well as secondary osteoporosis associated with malnutrition, immobilisation (e.g. cerebral palsy (CP) or Duchenne muscular dystrophy (DMD)), vitamin D deficiency, chronic inflammation (e.g. cystic fibrosis (CF), arthritis, inflammatory bowel disease (IBD)), or medications (eg, glucocorticoids, anticonvulsants).

Treatment includes optimising dietary calcium, ensuring adequate vitamin D levels, and improving mobilisation where possible.

Children/adolescents should be referred if there are concerns about low-trauma fractures, vertebral compression fractures or bone pain.

General Practitioner Management

Optimise dietary calcium and vitamin D levels. For replacement doses see SA Health Paediatric Clinical Practice Guidelines Vitamin D Deficiency (PDF 302KB)

Rickets

The most common cause of rickets is nutritional (e.g. vitamin D deficiency and/low calcium intake), and mild cases can be managed in a GP clinic following SA Health Paediatric Clinical Practice Guidelines –Health Paediatric Clinical Practice Guidelines – Vitamin D Deficiency (PDF 302KB).

In children with rickets and a normal 25-OHD level, consideration of other forms of rickets such as hypophosphataemic rickets is necessary.

Simple vitamin D deficiency can be managed in the community by supplementing with oral cholecalciferol, refer to clinical resources for further information.

Referral to Women’s and Children’s Hospital (WCH)

Referral is recommended if:

• Significant bowing of limbs/other nutritional deficiencies – refer to General Paediatric clinic
• Secondary fractures/hypocalcaemia/not responsive to vitamin D replacement/significant bowing of limbs - refer to Endocrine clinic
• Hypophosphataemic rickets - refer to Endocrine clinic
• Other nutritional deficiencies - refer to General Paediatric clinic.

General Practitioner Management

For replacement doses see SA Health Paediatric Clinical Practice Guidelines Vitamin D Deficiency (PDF 302KB)

General information

Contact WCH endocrinology on-call on (08) 8161 7000 for advice or to escalate and discuss any clinical concerns.

Recent pathology results will be required prior to outpatient appointment. Consider providing repeat pathology form to patient at time of referral.

Patients who have previously been seen by a specialist are encouraged to be referred back to their care for further review if required.

Referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but may not fit the criteria provided, you are encouraged to contact the specialist team to discuss your concerns.

Clinical resources

• SA Health - South Australian Paediatric Clinical Practice Guidelines: Vitamin D Deficiency in Children (PDF 302KB)
• Therapeutic Guidelines - Osteomalacia and Rickets
• Therapeutic Guidelines - Osteoporosis and Minimal-Trauma Fracture

Consumer resources

• Society for Endocrinology - Rickets
• Osteogenesis Imperfecta Society of Australia
• Osteogenesis Imperfecta Foundation

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

• full name, including aliases
• date of birth
• residential and postal address
• telephone contact number/s – home, mobile and alternative
• Medicare number, where eligible
• name of the parent or caregiver, if appropriate
• preferred language and interpreter requirements
• identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

• impact on employment
• impact on education
• impact on home
• impact on activities of daily living
• impact on ability to care for others
• impact on personal frailty or safety
• identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery, where surgery is a likely intervention.
• Choice to be treated as a public or private patient.
• Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The General Practitioners role in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the General Practitioner once the transfer of care has occurred.