Dynamic Function Tests

Paediatric & Adolescent Endocrinology

Leeds Children’s Hospital

Pamidronate Infusions: Paediatrics

Introduction
Pamidronate is a second-generation bisphosphonate drug. It binds strongly to bone mineral and interferes with bone
remodelling by slowing the process of osteoclastic bone resorption. The calcium doses are also included.
Indications
 Primary osteoporosis (eg Osteogenesis imperfecta (OI) / idiopathic juvenile osteoporosis)
 Secondary osteoporosis (eg prolonged steroids for systemic illness)
 Significant soft tissue calcification without bony abnormality - eg: dermatomyositis.
 Acute management of hypercalcaemia - eg: in malignancy.
 Chronic recurrent multifocal osteomyelitis (CRMO) – often only one course required
Contraindications
Vit D deficiency, hypocalcaemia, pregnancy, documented allergic reaction to bisphosphonates, renal impairment
(relative contraindication, dose adjustment can be considered)
Arrangements prior to treatment
 Prior to and within 3 months of the first cycle of treatment measure; serum Ca, PO4, LFTs, UE, Vit D, PTH
 Serum 25OHD should have been demonstrated to be ≥50nmol/L before the infusion is commenced.
 Request dental review prior to or at the time of the decision to start treatment. If a child has known significant
dental or gingival disease then this review should take place prior to treatment.
 Advise adequate calcium intake (around 1000mg a day (ie equivalent to about 3 glasses of milk a day))
On admission (if information not already available from clinic):
a) Clerk and examine the patient. Pay particular attention to 1) Fractures since last admission & whether these were
confirmed on X-ray 2) Pain (where, how long) & analgesia taken. 3) Mobility. 4) Dentition / caries. 5) Chance of
pregnancy, if any doubt, obtain pregnancy test and if positive withhold treatment and inform consultant, 6)
Intercurrent respiratory illness - acute deterioration has been observed, if in doubt with regards to fitness for
treatment discuss with responsible consultant.
b) For first admission, prescribe ibuprofen & paracetamol to be given regularly to minimise acute phase reaction.
Consider ondenstron with the first dose
c) Pre-infusion blood: FBC, U&E, Ca, PO4, ALP, PTH, vitamin D. (On request only: bone turnover markers). If there
are no recent electrolyte results within last 6 months or concerns regarding renal function, check results of U&E
before commencing infusion
d) In overweight or obese children, the dose should be adjusted to match the current height percentile.
e) Ensure good fluid intake and provide a prescription for calcium to be taken with first cycle only (see page 2).
f) Annual imaging: bone density scan, VFA / spine XR. In OI a lateral skull XR (centred on foramen magnum) may be
required on request.
g) Please do observations every 30 mins for first infusion and every hour for subsequent infusions.
h) The dose for the treatment of hypercalcaemia is usually 0.5mg/kg given over 4 hours and repeated if needed

Pamidronate Infusions: Check weight and calculate dose

 The normal dose for the first cycle of pamidronate is 1mg/kg for 2 days - see dilutions below.
 With the 2nd cycle, patients can go onto a 2 day regimen of 1.5mg/kg each day (up to a max 90mg/day)
 In obese children, use a weight that is corrected to the height centile
 For infant dosing for OI, please contact the paediatric endocrinology team
 Paediatric Rheumatology patients with CRMO can start on the 1.5mg/kg for two days
 For the acute management of hypercalcaemia, a single dose of 0.5 - 1mg/kg can be infused over 4 hours. This
may be repeated after discussion.
 It is given as a daily treatment with a minimum of 12 hours between infusions.
 (In the presence of poor renal function, pamidronate is preferred to zoledronate Acid)

Pamidronate Infusion (check weight) Flush

Dose Range Dilution Infusion Flush Volume Infusion
Rate (0/9% NaCl) Rate
Up to 5mg 28mls of 0.9% NaCl in syringe 7 mls/hr 5mls of 0.9%NaCl 5 mls/hr
5mg - 9mg 50 ml bag of 0.9% NaCl 13 mls/hr 30ml of 0.9%NaCl 13 ml/hr
10 - 18mg 100ml bag of 0.9% NaCl 25 mls/hr 30ml of 0.9%NaCl 25 ml/hr
19 - 45mg 250ml bag of 0.9% NaCl 65 mls/hr 30ml of 0.9%NaCl 65 ml/hr
46 - 90mg 500ml bag of 0.9% NaCl 130 mls/hr 30ml of 0.9%NaCl 130 ml/hr
90 - 120mg For use only in specific circumstances with authorisation. Dilutions as in row above.

LCH: Paediatric Endocrinology Dynamic Function Tests: Valid Jan 2022 to Jan 2026:
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 Dynamic Function Tests
Paediatric & Adolescent Endocrinology
Leeds Children’s Hospital

Warn the parents that during or after the first cycle of bisphosphonates (pamidronate or zoledronate
acid) the child may get may get flu-like side effects lasting around 2 days. These settle with simple
analgesia and do not recur on subsequent infusions.

(Adapted from Sheffield Children’s Hospital protocol 2014)

Calcium Doses

All children should receive a prescription for oral calcium supplements for 4 days after their first infusion. The doses of
oral calcium supplementation for calcium deficiency in the BNFc are a useful guide:

Dose: 100 mg/kg/day elemental calcium (1 mmol = 40 mg elemental calcium).

For preparations kept at LTHT see oral calcium monograph.

Age Oral Calcium Dose

2 to 4 years 0.25mmol/kg (10mg/kg) four times daily
5 to 12 years 0.2mmol/kg (8mg/kg) four times daily
12 to 18 years 10mmol (400mg) four times daily

Preparations: Calcium supplements available:

Oral calcium preparation Preparation composition Calcium per unit dose

Cacit (Effervescent) Calcium carbonate 1.25 g 500 mg or 12.5 mmol
Calcichew (Chewable tablets) Calcium carbonate 1.25 g 500 mg or 12.5 mmol
Calvive 1000 effervescent tablets Calcium carbonate 1.75g, Calcium lactate 1000mg or 25mmol
gluconate 2.263g

Children should be encouraged to keep well hydrated, drink milk and to consume calcium-rich foods (e.g. dairy
produce such as cheese and yoghurt) for at least a week following the infusion.

Vitamin D

Aim to keep vitamin D above 50nmol/L and ideally 75nmol/L

Colecalciferol Doses: Invita D3 (25,000U colecalciferol)

• Treatment of deficiency 0-18 years 25000 IU (1 ampoule) once every 2 weeks for 6 weeks
• Prevention of deficiency (maintenance treatment), 0-1 years 25000 IU (1 ampoule) every 8 weeks,
1-18 years 25000 IU (1 ampoule) every 6 weeks
• In practical terms maintenance therapy dose may need to be adjusted according to prevailing vitamin D
levels. Doses can include 400 - 1000 IU/day or InVita D 25000 given every 4 weeks.

Steroids
For children who are steroid dependent (eg, adrenal insufficiency or Duchenne Muscular Dystrophy) advise stress dose
steroids for 48 hours. Generally this is only needed for the first infusion.

Admission
Patients receiving their first dose of treatment may need to stay in a hospital ward overnight if there is any acute
phase reaction or other immediate effects of the infusion can be monitored.

If they are either due to have or have had an osteotomy or intramedullary rodding (or rod revision) since
the last administration of bisphosphonate then obtain confirmation from the metabolic bone consultant
as to whether or not treatment can proceed. Usually treatment is delayed for at least 6 weeks following an
osteotomy. We would not normally defer treatment when a child sustains a fracture.

Infusion Rescue
In the event of the pamidronate being infused over a shorter time (>50% reduction) than prescribed, the following
plan must be followed:-
1. Prescribe and infuse a ‘like for like’ infusion of 0.9% NaCl i.e. a child who has had a 250ml pamidronate infusion
should be prescribed a 250ml 0.9% sodium chloride ‘rescue’ infusion. Infuse at the normal rate as in above chart
2. Repeat U+E on completion of the rescue infusion and in 24 hours’ time
3. Report the incident to the metabolic bone team
4. Complete an incident form (datix)

LCH: Paediatric Endocrinology Dynamic Function Tests: Valid Jan 2022 to Jan 2026:
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