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Severe hyperphosphatemia after administration of sodium-phosphate containing laxatives in children: case series and systematic review of literature

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Abstract

Introduction

Sodium phosphate-containing laxatives are commonly used as first-line treatment option for constipation in children and adolescents. Hyperphosphatemia is an infrequent, but potentially life-threatening complication of laxative application.

Methods

We report a case series of three children exhibiting severe hyperphosphatemia and hypocalcemia after utilization of sodium phosphate-containing laxatives, necessitating intensive care services in two of three cases. Additionally, we reviewed 32 case reports of similar occurrences.

Results

We identified 28 publications on the subject dating from 1968 to 2010. Mean age of all children in reports was 2.83 years; sex was approximately equally distributed. While 18 patients suffered from either pre-existing gastrointestinal comorbidity or other major systemic disease, no or only unrelated, minor conditions were present in ten children. One-third of patients received laxatives repeatedly before the incident. Findings associated with hyperphosphatemia include lethargy, dizziness, stiffness, tachypnea, tachycardia and severe dehydration in almost all cases, and tetany, carpopedal spasm, and prolonged QT interval in a subset. While about 80% of children recovered without residual findings, three deceased and one incurred persistent hypoxic brain damage.

Conclusion

Physicians should be alerted to the possibility of phosphate toxicity in children and adolescents treated with laxatives.

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References

  1. Biebl A, Grillenberger A, Schmitt K (2009) Enema-induced severe hyperphosphatemia in children. Eur J Pediatr 168:111–112

    Article  PubMed  Google Scholar 

  2. Butani L (2005) Life-threatening hyperphosphatemia and hypocalcemia from inappropriate use of Fleet enemas. Clin Pediatr (Phila) 44:93

    Article  Google Scholar 

  3. Craig JC, Hodson EM, Martin HC (1994) Phosphate enema poisoning in children. Med J Aust 160:347–351

    PubMed  CAS  Google Scholar 

  4. Davis RF, Eichner JM, Bleyer WA, Okamoto G (1977) Hypocalcemia, hyperphosphatemia, and dehydration following a single hypertonic phosphate enema. J Pediatr 90:484–485

    Article  PubMed  CAS  Google Scholar 

  5. Dissaneewate S, Vachvanichsanong P (2009) Severe hyperphosphatemia in a newborn with renal insufficiency because of an erroneous medical prescription. J Ren Nutr 19:500–502

    Article  PubMed  Google Scholar 

  6. Domico MB, Huynh V, Anand SK, Mink R (2006) Severe hyperphosphatemia and hypocalcemic tetany after oral laxative administration in a 3-month-old infant. Pediatrics 118:e1580–e1583

    Article  PubMed  Google Scholar 

  7. Forman J, Baluarte HJ, Gruskin AB (1979) Hypokalemia after hypertonic phosphate enemas. J Pediatr 94:149–151

    Article  PubMed  CAS  Google Scholar 

  8. Hebbar K, Fortenberry JD, Parks JS (2006) Severe hypocalcemic tetany and respiratory failure in an infant given oral phosphate soda. Pediatr Emerg Care 22:118–120

    Article  PubMed  Google Scholar 

  9. Helikson MA, Parham WA, Tobias JD (1997) Hypocalcemia and hyperphosphatemia after phosphate enema use in a child. J Pediatr Surg 32:1244–1246

    Article  PubMed  CAS  Google Scholar 

  10. Honig PJ, Holtzapple PG (1975) Hypocalcemic tetany following hypertonic phosphate enemas. Clin Pediatr (Phila) 14:678–679

    Article  CAS  Google Scholar 

  11. Hunter MF, Ashton MR, Griffiths DM, Ilangovan P, Roberts JP, Walker V (1993) Hyperphosphataemia after enemas in childhood: prevention and treatment. Arch Dis Child 68:233–234

    Article  PubMed  CAS  Google Scholar 

  12. Ismail EA, Al-Mutairi G, Al-Anzy H (2000) A fatal small dose of phosphate enema in a young child with no renal or gastrointestinal abnormality. J Pediatr Gastroenterol Nutr 30:220–221

    Article  PubMed  CAS  Google Scholar 

  13. Kostic D, Rodrigues AB, Leal A, Metran C, Nagaiassu M, Watanabe A, Ceccon ME, Tannuri U, Koch VH (2010) Flow-through peritoneal dialysis in neonatal enema-induced hyperphosphatemia. Pediatr Nephrol 25:2183–2186

    Article  PubMed  Google Scholar 

  14. Levitt M, Gessert C, Finberg L (1973) Inorganic phosphate (laxative) poisoning resulting in tetany in an infant. J Pediatr 82:479–481

    Article  PubMed  CAS  Google Scholar 

  15. Loughnan P, Mullins GC (1977) Brain damage following a hypertonic phosphate enema. Am J Dis Child 131:1032

    PubMed  CAS  Google Scholar 

  16. Marraffa JM, Hui A, Stork CM (2004) Severe hyperphosphatemia and hypocalcemia following the rectal administration of a phosphate-containing fleet pediatric enema. Pediatr Emerg Care 20:453–456

    Article  PubMed  Google Scholar 

  17. Martin RR, Lisehora GR, Braxton M Jr, Barcia PJ (1987) Fatal poisoning from sodium phosphate enema. Case report and experimental study. JAMA 257:2190–2192

    Article  PubMed  CAS  Google Scholar 

  18. McCabe M, Sibert JR, Routledge PA (1991) Phosphate enemas in childhood: cause for concern. BMJ 302:1074

    Article  PubMed  CAS  Google Scholar 

  19. Moseley PK, Segar WE (1968) Fluid and serum electrolyte disturbances as a complication of enemas in Hirschsprung’s disease. Am J Dis Child 115:714–718

    PubMed  CAS  Google Scholar 

  20. Oxnard SC, O’Bell J, Grupe WE (1974) Severe tetany in an azotemic child related to a sodium phosphate enema. Pediatrics 53:105–106

    PubMed  CAS  Google Scholar 

  21. Perlman JM (1997) Fatal hyperphosphatemia after oral phosphate overdose in a premature infant. Am J Health Syst Pharm 54:2488–2490

    PubMed  CAS  Google Scholar 

  22. Pfitzer L, Elitsur Y (1999) Hyperphosphatemia-hypocalcemia in gastroschisis. Am J Gastroenterol 94:1991–1992

    Article  PubMed  CAS  Google Scholar 

  23. Reedy JC, Zwiren GT (1983) Enema-induced hypocalcemia and hyperphosphatemia leading to cardiac arrest during induction of anesthesia in an outpatient surgery center. Anesthesiology 59:578–579

    Article  PubMed  CAS  Google Scholar 

  24. Shaoul R, Wolff R, Seligmann H, Tal Y, Jaffe M (2001) Symptoms of hyperphosphatemia, hypocalcemia, and hypomagnesemia in an adolescent after the oral administration of sodium phosphate in preparation for a colonoscopy. Gastrointest Endosc 53:650–652

    Article  PubMed  CAS  Google Scholar 

  25. Smith MS, Feldman KW, Furukawa CT (1973) Coma in an infant due to hypertonic sodium phosphate medication. J Pediatr 82:481–482

    Article  PubMed  CAS  Google Scholar 

  26. Sotos JF, Cutler EA, Finkel MA, Doody D (1977) Hypocalcemic coma following two pediatric phosphate enemas. Pediatrics 60:305–307

    PubMed  CAS  Google Scholar 

  27. Walton DM, Thomas DC, Aly HZ, Short BL (2000) Morbid hypocalcemia associated with phosphate enema in a six-week-old infant. Pediatrics 106:E37

    Article  PubMed  CAS  Google Scholar 

  28. Wason S, Tiller T, Cunha C (1989) Severe hyperphosphatemia, hypocalcemia, acidosis, and shock in a 5-month-old child following the administration of an adult fleet enema. Ann Emerg Med 18:696–700

    Article  PubMed  CAS  Google Scholar 

  29. Candy D, Paul S (2011) Go with the flow: in childhood constipation. J Fam Health Care 21(35):37–38 (40-1 passim)

    Google Scholar 

  30. Hunter A, Mamula P (2010) Bowel preparation for pediatric colonoscopy procedures. J Pediatr Gastroenterol Nutr 51:254–261

    PubMed  Google Scholar 

  31. Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2006) Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 43:e1–e13

    Article  Google Scholar 

  32. van Wering HM, Tabbers MM, Benninga MA (2012) Are constipation drugs effective and safe to be used in children?—a review of the literature. Expert Opin Drug Saf 11:71–82

    Article  PubMed  Google Scholar 

  33. Moe SM (2008) Disorders involving calcium, phosphorus, and magnesium. Prim Care 35:215–237 (v–vi)

    Article  PubMed  Google Scholar 

  34. Casais MN, Rosa-Diez G, Perez S, Mansilla EN, Bravo S, Bonofiglio FC (2009) Hyperphosphatemia after sodium phosphate laxatives in low risk patients: prospective study. World J Gastroenterol 15:5960–5965

    Article  PubMed  CAS  Google Scholar 

  35. Sabbagh Y, O’Brien SP, Song W, Boulanger JH, Stockmann A, Arbeeny C, Schiavi SC (2009) Intestinal npt2b plays a major role in phosphate absorption and homeostasis. J Am Soc Nephrol 20:2348–2358

    Article  PubMed  CAS  Google Scholar 

  36. Marks J, Debnam ES, Unwin RJ (2010) Phosphate homeostasis and the renal-gastrointestinal axis. Am J Physiol Renal Physiol 299:F285–F296

    Article  PubMed  CAS  Google Scholar 

  37. Gattineni J, Baum M (2012) Genetic disorders of phosphate regulation. Pediatr Nephrol [E pub ahead of print]

  38. Forsythe RM, Wessel CB, Billiar TR, Angus DC, Rosengart MR (2008) Parenteral calcium for intensive care unit patients. Cochrane Database Syst.Rev 4:CD006163

    PubMed  Google Scholar 

  39. Amerling R, Glezerman I, Savransky E, Dubrow A, Ronco C (2003) Continuous flow peritoneal dialysis: principles and applications. Semin Dial 16:335–340

    Article  PubMed  Google Scholar 

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Conflict of interest

No institutional, governmental or private funding was received for the production of this case series and systematic review by either of the authors. The authors declare that they and their family members have no conflict of interest.

Ethical standard

The ethics committee for the province of Salzburg exempted this case series from review and approved its publication.

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Authors and Affiliations

  1. Department of Pediatric and Adolescent Surgery, University Hospital Salzburg, Muellner Hauptstrasse 48, 5020, Salzburg, Austria

    Hannah N. Ladenhauf, Florian Spreitzhofer & Stefan Deluggi

  2. Department of Anesthesiology, University Hospital Salzburg, Muellner Haupstrasse 48, 5020, Salzburg, Austria

    Ottokar Stundner

Authors
  1. Hannah N. Ladenhauf
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  2. Ottokar Stundner
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  3. Florian Spreitzhofer
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Correspondence to Hannah N. Ladenhauf.

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Ladenhauf, H.N., Stundner, O., Spreitzhofer, F. et al. Severe hyperphosphatemia after administration of sodium-phosphate containing laxatives in children: case series and systematic review of literature. Pediatr Surg Int 28, 805–814 (2012). https://doi.org/10.1007/s00383-012-3124-4

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