Clinical Best Practice in Perioperative Calcium Management After Pediatric Total Thyroidectomy

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BACKGROUND

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.

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%. Although typically transient, published rates of permanent hypoparathyroidism have been as high as 9%. 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.

BEST PRACTICE

The evidence suggests that for pediatric patients undergoing total thyroidectomy, postoperative admission for serial calcium monitoring and supplementation, per 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. Still, additional prospective studies are needed to make definitive, generalizable recommendations.