Calcium and bone disorders

​​​​​​​Emergency

If any of the following are suspected, seek emergency medical advice or refer the patient to the emergency department (via ambulance if necessary)

  • Corrected serum calcium < 1.8 mmol/L or ionised calcium < 0.9 mmol/L
  • Corrected serum calcium < 2.0 mmol/L with symptoms (e.g. seizures, cardiac arrhythmias, tetany, paraesthesia)
  • Corrected serum calcium ≥ 3.0 mmol/L, with or without symptoms of hypercalcaemia (e.g. cardiac arrhythmias, vomiting, altered mental state)

When public outpatient services are not routinely provided

  • Normocalcaemic hyperparathyroidism or hypoparathyroidism with normal calcium, phosphate and magnesium
  • Simple vitamin D deficiency or vitamin D deficiency without significant bowing of limbs or other nutritional deficiencies
    Note: referral to a general paediatric outpatient service is indicated​

​Criteria to access public outpatient services

CategoryCriteria
Category 1
Recommended to be seen within 30 calendar days.

  • Hypercalcaemia with corrected serum calcium > 3.0 mmol/L
  • Hypocalcaemia with corrected serum calcium between 1.8 mmol/L and lower end of the reference range
​Category 2
Recommended to be seen within 90 calendar days.
  • Concerns regarding bone fragility or osteoporosis
    (e.g. frequent long bone fractures, vertebral compression fractures, bone pain)
  • Hypophosphataemic rickets
  • Rickets not responsive to routine vitamin D supplementation​

Category 3
Recommended to be seen within 365 calendar days.

  • Low bone mineral density​

Information to include within a referral

Required

  • Reason for referral
  • Details of the presenting condition, including symptoms and their duration
  • Provisional diagnosis
  • Patient health summary (such as relevant medical history, relevant investigations, current medications and dosages, immunisations, allergies and/or adverse reactions), including specifically:
    • Height, weight, and centiles
    • 25-hydroxy vitamin D (25-OHD)
    • Calcium, Magnesium, Phosphate (CMP)
    • Albumin
    • Creatinine
    • Alkaline phosphatase (ALP)
    • Serum parathyroid hormone (PTH)
    • Fracture history (i.e. number of fractures and mechanism of injury)
    • Familial history of bone and mineral disorders and fractures
    • Ability to mobilise
    • Degree of bone pain
    • Dietary calcium intake
    • Onset of puberty
    • Examination results, including clinical evidence of rickets (e.g. bowed legs, frontal bossing, swollen wrists, rachitic rosary) and/or physical features of Osteogenesis Imperfecta (OI) and bone deformity

If available

  • Bone mineral density (for bone fragility disorders)
  • FGF23 level (in X-linked hypophosphataemic rickets)
  • Genetic testing result (if performed)
  • Maternal vitamin D status (if aged < 12 months)
  • X-ray: lateral spine (for vertebral compression fractures)
  • X-ray of fracture or bone deformities (if present) or skeletal survey (if indicated)

Important information for referring health professionals

If there is a change to a patient’s condition while waiting for their appointment, referring health professionals may further investigate and manage the situation, or send an updated referral to the outpatient service. Where there are significant concerns about a patient's condition, referring health professionals may check HealthPathways for urgent/same day advice or contact the relevant clinical team. 

Current as at: Monday 23 March 2026
Contact page owner: System Purchasing