Referral to emergency
If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
- symptomatic hypocalcaemia: seizures, tetany, paraesthesia
- corrected serum calcium < 1.8 mmol/l or ionised calcium < 0.9 mmol/l
- symptomatic hypercalcaemia (vomiting, altered mental state) with a corrected serum calcium > 3.0 mmol/l
For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to 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
For information on referral forms and how to import them, please view general referral information.
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.
- identifies as Aboriginal and/or Torres Strait Islander
- identify within your referral 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
- interpreter requirements
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
- physical features of OI
- 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, anti-convulsants).
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