Clinical Best Practice in Perioperative Calcium Management After Pediatric Total Thyroidectomy

The understanding of pediatric thyroid disease has evolved tremendously in recent years. This is illustrated by recent changes to the recommendations of the American Thyroid Association that have trended toward more aggressive surgical management for differentiated thyroid cancer in the pediatric population because of the high propensity for multifocal and bilateral disease. Thyroidectomy in the pediatric population has also been shown to have a higher risk of complications than adult thyroid surgery, with that risk increasing with decreasing age 1. The most common postoperative complication is hypoparathyroidism manifested as hypocalcemia, which can be transient or permanent. Rates of postoperative hypocalcemia have been reported as high as 58%, with large population-based studies showing averages around 20%–30% 2. Although typically transient, published rates of permanent hypoparathyroidism have been as high as 9% 2. This is secondary to either inadvertent removal or trauma to the parathyroid glands intraoperatively, resulting in devascularization and injury. Less common complications include vocal fold paralysis, hematoma formation, respiratory distress, and infection. Previous studies have shown improved postoperative outcomes with high-volume surgeons specifically for pediatric thyroidectomy. In contrast to the adult population, there is a relative paucity of published data on optimal perioperative calcium management of the pediatric patient undergoing total thyroidectomy. There remains an opportunity to synthesize recent evidence to guide best practices for perioperative management in children. Although there is robust literature on perioperative management of adult patients following total thyroidectomy, the literature on pediatric patient management has been sparse until recent years. Although previous studies have demonstrated that high-volume surgeons tend to portend better outcomes in pediatric thyroidectomy, few studies have looked specifically at optimal perioperative management for prevention and treatment of hypocalcemia in this population. Radakrishnan et al. conducted a systematic review of 1552 pediatric thyroidectomy patients to assess strategies for hypocalcemia prevention and management. The authors found a 35.5% pooled rate of transient hypocalcemia with 4.2% of patients having permanent hypocalcemia 2. There is significant variability in how hypocalcemia is prevented and managed across institutions, and standardized pediatric protocols are lacking. Only three of the 15 included studies discussed preoperative calcium supplementation for high-risk patients, and just one study described a protocol discharging asymptomatic patients on calcitriol and calcium, highlighting the importance of further study in this area 2. In 2022, Cossen et al. demonstrated successful implementation of an institutional protocol for pediatric patients undergoing total thyroidectomy. This protocol incorporated scheduled calcium and PTH levels as well as postoperative oral calcium carbonate supplementation and use of PTH-directed calcitriol supplementation. The study included two large tertiary pediatric hospitals and included multidisciplinary teams of otolaryngologists, endocrinologists, and pediatric general surgeons 3. When compared to 122 pre-protocol patients, the 121 post-protocol patients demonstrated a decrease in postoperative permanent hypoparathyroidism rates from 20.5% to 10%. Although transient hypoparathyroidism rates remained similar, the severity of hypocalcemia decreased from 8% requiring intravenous calcium gluconate to 3% 3. Similarly, Kao et al. in 2024 established an institutional protocol incorporating preoperative calcium and vitamin D testing with supplementation as indicated 4. In addition, scheduled lab draws with supplementation of oral calcium and calcitriol as indicated were included. In a cohort of 22 patients, the protocol significantly reduced the incidence of postoperative hypocalcemia (from 54% to 13.6%) and decreased the number of inpatient blood tests, without increasing hypercalcemia or length of hospitalization 4. Rates of hypercalcemia were similar between the two groups 4. Banks et al. studied the use of preoperative calcitriol over the 72 h leading up to surgery. This was a retrospective cohort study with 50 cases serving as control and 44 study patients. Through the use of preoperative oral calcium carbonate and calcitriol, they were able to decrease the average length of stay by 17 h and decrease postoperative transient hypocalcemia from 64% to 30% 5. Although the results are significant, their end rate of 30% postoperative hypocalcemia is on par with previously described averages of about 30% in patients not treated preoperatively. The evidence suggests that for pediatric patients undergoing total thyroidectomy, postoperative admission for serial calcium monitoring and supplementation based on institutional protocol remains best practice. There is compelling evidence for preoperative calcium and 1,25-OH vitamin D supplementation; however, current data are insufficient for a formal recommendation. Current evidence suggests that multidisciplinary standardized protocols and perioperative supplementation strategies may reduce the incidence or severity of postoperative hypocalcemia, but additional prospective studies are needed to make definitive, generalizable recommendations. Savoca et al., Cossen et al., Banks et al., and Kao et al. are all Level 3 evidence as cohort studies and retrospective reviews. Radakrishnan et al. is Level 2 evidence as a systematic review. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.