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Pediatric Calcium Disorders

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Summary

The parathyroid is made up of four glands about the size of a pea. It is located on the thyroid gland in the neck.

The parathyroid makes parathyroid hormone (PTH), which plays an important role in keeping the balance between calcium and phosphorous in your body. Any imbalance can result in problems with bones, muscles, skin and nerves.

Almost all of the calcium in your child’s body is stored in his bones and teeth, and helps strengthen them. The rest is used in different places throughout the body—in the blood, muscles, and in the fluids between the cells. Calcium also is needed to help muscles and blood vessels contract or expand, and to send messages through the nervous system.

Causes

There are several factors that can cause hypoparathyroidism. Perhaps the most common is acquired hypoparathyroidism, which occurs after accidental damage to, or removal of, the gland during surgery. Radiation treatment for cancers of the neck is another cause.

Symptoms

Hypoparathyroidism is a rare condition in which the body doesn’t make enough PTH. Signs and symptoms include

  • Tingling or burning in your child’s fingertips, toes and lips
  • Muscle aches and cramps in the legs, feet, abdomen or face
  • Twitching muscles around the mouth, hands, arms and throat
  • Fatigue or weakness
  • Painful menstruation in her teens
  • Patches of hair loss
  • Dry, coarse skin
  • Brittle, easily broken nails
  • Anxiety or nervousness
  • Headaches
  • Depression or mood swings
  • Memory problems 

Types

The hereditary type of hypoparathyroidism occurs when the parathyroid glands either are not present at birth or aren’t working properly. In some children there also may be problems evident in other hormone-producing glands.

Sometimes your child’s body may mistakenly see the gland as an invader. It forms autoantibodies that attack the gland, causing it to stop making PTH.

Low levels of magnesium are another reason that hypoparathyroidism can occur, since magnesium is required for making and secreting PTH.

Hyperparathyroidism occurs when the glands make too much PTH. When this happens, there is too much calcium in the blood.

Primary hyperparathyroidism occurs when there is a tumor, or the gland grows too large. Secondary hyperparathyroidism results from medical conditions that cause low blood calcium or high phosphate levels, either of which overwork the gland. These conditions can include kidney failure, not enough calcium in the diet, vitamin D disorders in children who are malnourished, or who have problems absorbing nutrients from food (malabsorption.)

Hyperparathyroidism can be a contributor to juvenile osteoporosis, in which the bones become less dense or there isn’t enough bone formation because of decreased calcium intake. This makes the bones weak and allows them to break more easily.

Most children with an overactive parathyroid gland have no symptoms. Those that do, however, may:

  • Feel weak or tired
  • Have general aches and pains all over the body
  • Have abdominal pain
  • Suffer frequent heartburn
  • Experience nausea and vomiting
  • Have a loss of appetite
  • Feel pain in the bone and joints
  • Suffer confusion and memory loss
  • Urinate frequently
  • Have high blood pressure

Parathyroid tumors can be either benign or cancerous. Both are very rare in adults and even more so in children.

Major symptoms follow those of hyperparathyroidism but also can include:

  • Pain in the abdomen, the side or the back that doesn’t go away
  • Pain in the bones
  • Bones that are easily broken
  • A lump in the neck
  • Trouble swallowing
  • Changes in the voice, especially increased hoarseness.

Tests

The first step in diagnosing hypoparathyroidism is taking a medical history. Your child’s doctor will ask about symptoms such as cramps or tingling in the hands and feet, or twitching of the muscles of the face. She will also ask about any recent surgeries that may have involved the head and neck.

Several blood tests will be taken looking for low levels of calcium, PTH or magnesium. Higher than normal phosphorous levels are another indicator of this condition. A urine test may also be used to see if too much calcium is being eliminated.

Some of the time, X-rays and bone density tests may be included. These help determine if abnormal calcium levels have had any effect on the strength of your child’s bones.

In diagnosing children, doctors check closely to see whether tooth development, which depends on proper calcium levels, is normal. They also should examine developmental milestones, especially those dealing with growth and height.

Many of the same tests performed to diagnose hypoparathyroidism will be used to diagnose hyperparathyroidism. Blood tests will look for increased levels of PTH and calcium and lower levels of phosphorous. Urine tests can help measure calcium levels. Bone X-rays and density testing detects bone loss, fractures or softening of the bones.

If cancer is suspected, your child’s doctor will perform the usual tests of parathyroid function, such as checking PTH and calcium levels. Other tests might be done to determine if a tumor is cancerous or not, including:

  • A sestamibi scan, which uses a small amount of a radioactive substance that collects in the gland, can determine which gland is abnormal
  • A CT scan takes a very detailed picture of the neck and parathyroid gland from different angles. It is used to see what the tumor looks like and where it is located
  • An ultrasound uses sound waves that bounce off tissues or organs, which helps locate tumors

Blood samples may be drawn from veins other than those in the hands or arms. This helps the physician determine the amounts of PTH or calcium in the blood, and narrow down the cause of the tumor.

Not every child needs all these tests. Your physician will tell you exactly what the next steps are. Each year, the endocrinology specialists at Children’s Medical Center see more than 12,000 pediatric patients for hypoparathyroidism and other endocrine-related conditions. We have the skill and resources necessary to provide comprehensive and compassionate care for your child too. 

Diagnosis

The first step in diagnosing hypoparathyroidism is taking a medical history. Your child’s doctor will ask about symptoms such as cramps or tingling in the hands and feet, or twitching of the muscles of the face. She also will ask about any recent surgeries that may have involved the head and neck.

Several blood tests will be taken looking for low levels of calcium, PTH, or magnesium. Higher than normal phosphorous levels are another indicator of this condition. A urine test may also be used to see if too much calcium is being eliminated.

Some of the time, X-rays and bone density tests may be included. These help determine if abnormal calcium levels have had any effect on the strength of your child’s bones.

In diagnosing children, doctors check closely to see whether tooth development, which depends on proper calcium levels, is normal. They also should examine developmental milestones, especially those dealing with growth and height.

Many of the same tests performed to diagnose hypoparathyroidism will be used to diagnose hyperparathyroidism. Blood tests will look for increased levels of PTH and  calcium and lower levels of phosphorous. Urine tests can help measure calcium levels. Bone X-rays and density testing detects bone loss, fractures or softening of the bones.

If cancer is suspected, your child’s doctor will perform the usual tests of parathyroid function, such as checking PTH and calcium levels. Other tests might be done to determine if a tumor is cancerous or not, including:

  • A sestamibi scan, which uses a small amount of a radioactive substance that collects in the gland, can determine which gland is abnormal.
  • A CT scan takes a very detailed picture of the neck and parathyroid gland from different angles. It is used to see what the tumor looks like and where it is located.
  • An ultrasound uses sound waves that bounce off tissues or organs, which helps locate tumors.
  • Blood samples may be drawn from veins other than those in the hands or arms. This helps the physician determine the amounts of PTH or calcium in the blood, and narrow down the cause of the tumor.  

Treatment

The treatment of hypoparathyroidism differs from the treatment of similar diseases of the endocrine glands. The goal is to restore calcium, magnesium and phosphorous levels to normal. At present, there is no approved replacement for the hormone itself.

The only therapies currently approved for use are synthetic forms of vitamin D and calcium, in addition to taking calcium and magnesium supplements. Some children may be encouraged to eat foods that are high in calcium such as dairy, breakfast cereals, fortified orange juice or leafy green vegetables. They also should avoid foods and beverages that are high in phosphorous, such as carbonated soft drinks, eggs and meat.

The physician treating your child will keep a close eye on the levels of calcium and phosphorous in the blood during the early stages. After the proper balance has been restored, the tests will be done less often.

For many children with hyperparathyroidism caused by a tumor, surgery may be all that is needed. For the first month afterward or so, the doctor will follow blood calcium levels until they return to normal. Calcium supplements are often prescribed immediately after surgery. For those who aren’t experiencing many symptoms, or if the symptoms are not severe, medication alone may be an effective treatment.

In other cases, “watchful waiting” may be the plan. No surgery or medication is prescribed, but monitoring of kidney function, bone density, and blood levels of calcium and PTH will be done.

For secondary hyperparathyroidism, treatment of the underlying medical condition may be all that is necessary. If a Vitamin D deficiency is the main issue, then supplementation with Vitamin D may be the only intervention required.

The treatment for osteoporosis mainly follows that of secondary hyperparathyroidism. Additional interventions may include maintaining an appropriate body weight to avoid extra stress on weakened bones, walking and doing other weight-bearing exercises, keeping caffeine out of your child’s diet and helping him get enough calcium by encouraging proper eating habits.

When hyperparathyroidism is related to kidney disease, the only treatment that offers a cure is a kidney transplant. If that is not possible or indicated, medications are often prescribed, including calcimimetic medications that cause the gland to produce less of the hormone, as well as Vitamin D supplements.

Dietary changes also may be suggested. Your child should limit his intake of phosphorus. 

There are four types of treatment for parathyroid cancers. Surgery is the most common, and because this type of cancer grows very slowly, this is often a cure.

High-energy X-rays, or radiation therapy, can be applied from outside the body (external) or implanted directly at the location of the cancer, depending on its type and stage. Chemotherapy uses drugs that kill cancer cells or stops them from dividing.

The last option is supportive care that includes drugs to lessen the problems caused by either the disease or its treatment.

Children’s Medical Center uses a multidisciplinary approach to caring for your child. This allows us to offer our patients care from multiple specialists and experts, in a single appointment, at one location. If your child has symptoms of an endocrine-related condition such as hyperparathyroidism, contact us. We provide the comprehensive and individualized care necessary to put your child back on the path to a healthy life.

FAQs

What is the parathyroid gland?

The parathyroid is made up of four small glands on the thyroid gland in the neck. The gland makes parathyroid hormone (PTH), which is important in keeping calcium and phosphorous in the body. An imbalance can result in problems with bones, muscles, skin, and nerves.

What is hypoparathyroidism?

Hypoparathyroidism is when too little PTH is being made. It can be either congenital (present at birth) or be seen later (acquired). PTH is the hormone that regulates calcium absorption and storage within the body. Most of the calcium in your child’s body is stored in the bones and teeth, giving them strength. Calcium is also important when blood vessels and muscles contract or expand and to send messages through the nervous system.

Common forms of the disease include:

  • Acquired, which is the most common and usually starts after accidental damage or removal of the parathyroid due to neck surgery. Radiation treatment of cancer is another frequent trigger.
  • Hereditary or congenial hypoparathyroidism is diagnosed when the gland is either missing or not working properly at birth.
  • Autoimmune is when your child’s immune system mistakes the gland for an invader and attacks it.

Symptoms include:

  • Tingling or burning feelings in the fingers, toes, and lips
  • Muscle aches and cramps
  • Twitching of muscles
  • Tiredness/weakness
  • Headaches
  • Coarse, dry skin
  • Hair loss

What is hyperparathyroidism?

Hyperparathyroidism occurs when the gland makes too much PTH, which results in too much calcium in the blood. Primary happens when there is a tumor or the parathyroid grows too large. Secondary type occurs when other medical conditions such as kidney failure, not enough calcium in the diet, or malabsorption of calcium causes the gland to become overworked.

Most children with this disease show no obvious symptoms. Those that do will be weak and tired, have aches and pains all over their body, frequent heartburn, loss of appetite, pain in the bones and joints, confusion and memory loss, and high blood pressure.

What is a parathyroid tumor?

Parathyroid tumors can be either benign or cancerous. They are rare in adults and even more so in children.

Major symptoms include:

  • Long-term pain in the abdomen or back
  • Pain in the bones
  • Lump in the neck
  • Trouble swallowing
  • Changes in the voice
  • Frequent broken bones


How is parathyroid disease diagnosed?


The first step in diagnosing parathyroid disease is the medical history. Your child’s doctor will ask about the presence of the symptoms outlined above. They will also ask about recent surgeries around the neck and head.

Several blood tests will be used to look for abnormal levels of calcium, PTH, or magnesium. A urine test may also be used to see if the kidneys are removing too much calcium.

If indicated, x-rays and bone density studies may be included. Tooth development will be checked. This is to assess any effect the disease might have had on your child’s bones and teeth since both use calcium for strength.

If cancer is a possibility, the doctors will do most of the usual tests for parathyroid function. In addition, they may also get a Sestamibi scan that uses a small amount of radioactive substance that collects in the gland to see which glands are the most active.

A CT scan may be obtained to get a very detailed look at different angles to help find the tumor’s location. Ultrasound bounces sound waves off of tumors and is another method used to locate and size tumors.

Additional blood samples may be drawn from specific veins instead of the ones usually used. This tells the physician what the levels of certain substances are near the glands and helps narrow down the diagnosis.

What are the treatments for parathyroid diseases?

How the disease is treated will depend largely on what the gland is doing and the cause. Hypoparathyroidism is most often treated using manmade supplements for the missing calcium along with vitamins. Your child may be encouraged to eat foods high in calcium and to avoid those with high phosphorous levels.

If hyperparathyroidism is caused by a tumor, surgery may be all that is needed to correct it. For others, “watchful waiting” involves no medicine or surgery, but your doctor will closely check kidney function, bone density, or blood levels to make sure there are no changes.

When related to kidney disease the only cure is a transplant. If that isn’t an option, medications that bind phosphate so it can’t be used by the body, vitamin D supplements, or calcimimetic medication that result in the gland producing fewer hormones may be prescribed. 

Resources

For more information about calcium and parathyroid disorders, please visit these sites:

This page tells you how much calcium younger children need and suggests ways to make sure they get it.
BabyCenter

For an overview, including symptoms and treatment, of hypercalcemia in children, see
Medscape

For a brief overview of parathyroid disorders:
U.S. National Library of Medicine

For information about hypoparathyroidism:
U.S. National Library of Medicine

For information about hyperparathyroidism:
The New York Times Health Guide

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