Clinical Briefs-With Comments from John La Puma, MD, FACP
Fatal Hypermagnesemia from Supplement
June 2000; Volume 3; 71
Source: McGuire JK, et al. Fatal hypermagnesemia in a child treated with megavitamin/megamineral therapy. Pediatrics 2000;105:E18.
"We report a case of fatal hypermagnesemia resulting from the unsupervised use of high doses of magnesium oxide administered as part of a regimen of megavitamin and megamineral therapy to a child with mental retardation, spastic quadriplegia, and seizures.
"The treatment regimen was given at the recommendation of a dietician working as a private nutritional consultant without the involvement or notification of the child’s pediatrician. Hypermagnesemia is an uncommon but serious side effect of the use of magnesium containing compounds. These compounds are widely used as laxatives and dietary supplements, and serious side effects are uncommon when used in appropriate dosages and with adequate supervision.
"The use of alternative medical therapies, including megavitamin/mega-mineral therapy, is widespread. Many patients use alternative medicine or seek care from alternative medicine practitioners without the recommendation or knowledge of their primary physicians.
"Despite unproved benefit, many alternative therapies may be safe. However, unsupervised use of generally safe treatments can result in serious side effects. This case report serves to illustrate the characteristic pathophysiologic changes of severe hypermagnesemia, an entity rarely seen in pediatric practice, and more importantly, it alerts primary care and subspecialty pediatricians to be aware of and monitor the use of alternative medical therapies in their patients."
COMMENT
These investigators report the tragic case of a 28-month-old severely mentally retarded, spastic quadriplegic boy who received nighttime mechanical ventilation and all feedings and medication through a gastrostomy tube. His mother had sought the counsel of a dietitian, who recommended a regimen including calcium carbonate, multivitamins, essential fatty acids, lactobacillus, bifidobacterium, and magnesium oxide, the latter of which the mother was told "would relax his muscles and relieve his constipation."
The mother brought the boy in full arrest to the emergency room. For several weeks, she had given him 1/2 teaspoon of magnesium oxide (800 mg) four times daily until several days before admission, when she increased the dose to 1/2 tablespoon because of continued constipation. The boy had been drowsy and less arousable for several days before he arrived.
He was found initially to be in third-degree heart block and to have a magnesium level of 20.3 mg/dL; he was paced and then dialyzed with correction of biochemical abnormalities. He died 20 hours after admission.
The authors note that hypermagnesemia is rarely seen in pediatric practice, but it is not uncommon in adults, even those with normal renal function. Not written here is the likely frustration on the mother’s part with her son’s chronic illness and the extent of her support system, if any.
In a cruel twist, this provider is licensed in the state of Illinois, where both the American Medical Association and the American Dietetic Association are, perhaps, their most powerful. A licensed nutritional counselor practicing under the Illinois Dietetic and Nutrition Services Practice Act, the consultant in the case does not appear to have broken the law or breached her agreement with the mother. As of early April, no lawsuits have been reported as filed.
Although many physicians resist the idea of being responsible for another licensed provider’s recommendations, tragic cases like this offer a good reason why doctors should supervise or be able to assign supervision of alternative medical therapies in practice.
Recommendation
For those patients who want to follow alternative nutritional routes, seek a physician who is licensed and preferably board-certified, who takes his or her medical responsibilities seriously, and who is committed to close follow-up, especially of complex patients. A licensed, registered dietitian, working with such a physician, is another good choice.
June 2000; Volume 3; 71
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