Abstract
A 4‐month‐old previously healthy female presented with persistent nonbloody, nonbilious emesis, decreased urine output, weight loss, fussiness, and lethargy. Serum levels of calcium were increased at 14.1 mg/dL, serum phosphate decreased at 1.6 mg/dL, and serum parathyroid hormone decreased at <4 pg/mL. The patient had been consuming unsweetened almond milk due to inability to find infant formula during a national infant formula shortage. Milk alternatives including almond milk are calorie‐poor, low fat, low protein, and too high in free water and calcium to safely be the primary nutrition source for infants.
Keywords: alternative formula, hypophosphatemia, plant milk
Abbreviations
- PTH
parathyroid hormone
- PTHrP
parathyroid hormone‐related peptide
1. INTRODUCTION
Breast milk is the preferred source of nutrition in newborns and infants during the first 6 months of life, followed by infant formula. Infant formula is constructed with specific concentrations of nutrients to meet the needs of infants and is strictly regulated by the Food and Drug Administration (FDA). During the formula shortage of 2022 parents were seeking alternatives to infant formula, prompting the FDA to issue an official advisory against homemade infant formula. 1 Although more than 30 cases of nutrition‐related diseases have been reported for plant‐based milk alternatives, 2 , 3 , 4 the use of almond milk has been underreported. Almond milk can be associated with hyponatremia‐induced nonfebrile seizures, increased risk for kidney stone formation, and scurvy. 5 , 6 , 7 Almond milk is often fortified with calcium and can contain more than six times as much calcium as breast milk, but only half the phosphorus content. 8 , 9 A diet of exclusively almond milk would potentially cause severe, symptomatic hypercalcemia, although that has yet to be reported. Clinical manifestations of hypercalcemia are numerous and may include nausea, vomiting, nephrocalcinosis, acute renal insufficiency, constipation, cardiac arrhythmias, stupor, and coma. The severity of symptoms depends on the degree of calcium elevation and the rate serum calcium rises. 10
2. CASE REPORT
A 4‐month‐old previously healthy full‐term female presented with 1 month of worsening nonbloody, nonbilious postprandial emesis, and weight loss. Due to suboptimal weight gain from inadequate breast milk supply at her 3‐month well child check, her pediatrician recommended formula feeding. Despite efforts to find regular infant formula, parents were unable to consistently find it in commercial stores that were accessible to them given the national infant formula shortages in 2022; thus, they began feeding 3–4 oz of unsweetened commercial almond milk every 3 h. The infant subsequently began vomiting and continued to lose weight. Given concern for continued weight loss, her parents increased the volume of feeds to 8 oz leading to emesis with every bottle. This prompted the parents to present to the Emergency Department where it was noted that the patient had been constipated for 1 week and had 1 day of decreased urine output.
On exam, the patient was thin and fussy but consolable. Her vital signs were normal, and she was moderately malnourished (weight for height z score of −2.46). Her lab work showed elevated levels of calcium at 14.1 mg/dL with ionized calcium of 2.34 mmol/L and hypophosphatemia at 1.6 mg/dL. Parathyroid hormone (PTH) was appropriately decreased at <4 pg/mL and vitamin D was insufficient at 21 ng/mL. Vitamin A and PTH‐related peptide (PTHrP) were within normal limits at 21 mcg/dL and <2 pmol/L, respectively.
She was made nil per os and started on fluid resuscitation. Calcium levels were checked twice a day until they reached a level of 12 mg/dL after which infant formula was reintroduced at 3–4 oz every 4 h. Because of the suspected level of chronicity of her elevated calcium despite normal renal function and urine output, a renal ultrasound was obtained which showed bilateral nephrocalcinosis.
She was monitored for other electrolyte derangements and did require phosphorus supplementation once oral feeds were introduced. After 3 days, the patient was stable for discharge with calcium 9.5 mg/dL and phosphorus 6.1 mg/dL. Her parents were counseled extensively on infant nutrition and contingency plans for obtaining formula. They were discharged with a feeding plan of 3–4 oz of regular infant formula every 3–4 h.
At routine endocrinology follow‐up 1 month after discharge, the patient had robust weight gain with taking 4–6 oz of formula every 4 h without postprandial emesis. Her laboratory results showed normal calcium, magnesium, phosphorus, PTH (Table 1) which further confirmed that her electrolyte abnormalities at admission were due to inappropriate diet rather than an underlying medical condition. Upon primary care follow‐up at 6 months of age a repeat renal ultrasound showed resolution of nephrocalcinosis.
Table 1.
Patient's values for various nutrients and weight status at admission, hospital discharge, and 1‐month endocrinology follow‐up compared to reference ranges. 11
| Nutritional parameters | Admission | Discharge | Follow‐up | Reference |
|---|---|---|---|---|
| Calcium (mg/dL) | 14.1 | 9.5 | 9.9 | (8.4–10.6) |
| Magnesium (mg/dL) | 1.3 | 1.7 | 1.9 | (1.5–2.5) |
| Phosphorous (mg/dL) | 1.7 | 6.1 | 6 | (4.2–9.0) |
| Parathyroid hormone (pg/mL) | <4.0 | 64 | 65.2 | (15.1–87.7) |
| Vitamin D 25‐hydroxy (ng/dL) | 21 | ‐ | 43.1 | (30.0–70.0) |
| Weight (kg) | 4.96 | 5.5 | 7.2 | |
| Weight for Length Z score | −2.46 | ‐ | 0.8 |
3. DISCUSSION
Although moderate hypercalcemia (defined as 12–14 mg/dL) may be relatively asymptomatic, severe hypercalcemia can have serious complications. 12 Signs of severe hypercalcemia include vomiting, constipation, confusion, lethargy, and even coma. Management of severe hypercalcemia (>14 mg/dL) includes immediate, aggressive fluid resuscitation and potentially intravenous bisphosphonates or calcitonin, and dialysis for resistant hypercalcemia. 10 Of note, this patient also had hypophosphatemia in the setting of secondary hypoparathyroidism from hypercalcemia, requiring phosphorus repletion. Symptoms of hypophosphatemia are not limited to bone health but can also include extraskeletal symptoms of hypophosphatemia such as metabolic encephalopathy, respiratory failure from diaphragm weakness, hemolysis, ileus, and rhabdomyolysis. 13
Plant‐based milk alternatives are often advertised as being healthier and more natural than cow's milk‐based products. However, this can make them dangerous to infants, who require increased fat, proteins, and calories compared to adults. Without these specific formulations, infants will not adequately grow and develop. The calcium and phosphorus content of almond milk compared to breast milk, whole milk, and various infant formulas is included below (Table 2). This demonstrates that almond milk has 13 and 15 times the calcium to phosphorus ratio of breast milk and Similac Sensitive©. With such high levels of calcium content our patient's presentation is unsurprising. To our knowledge, however, no previous report of infant hypercalcemia related to almond milk consumption has been reported.
Table 2.
Calcium and phosphorous components and ratio in 8 oz of breast milk, common infant formulas, whole milk, and almond milk.
| Nutritional source (per 8 oz) | Calcium (mg) | Phosphorous (mg) | Ca:Phos ratio |
|---|---|---|---|
| Breast milk | 73 | 43 | 1.7 |
| Whole milk | 106 | 83 | 1.3 |
| Enfamil Gentlease© | 131 | 74 | 1.8 |
| Similac Sensitive© | 134 | 90 | 1.5 |
| Almond milk | 450 | 20 | 22.5 |
Pediatricians need to be aware of the health risks and nutritional limitations associated with these alternative beverages. Marketing and advertisements surrounding plant‐based milk are misleading to parents who are simply trying to choose the healthiest option for their infants. It is important to view this case in the setting of the infant formula shortage of 2022, where inaccessible formulas led parents to seek alternative options. Due to the parents' attempted efforts to find formula, appropriate interactions while hospitalized and reliable follow‐up with endocrinology as an outpatient, medical child abuse was not thought to be contributing to the patient's presentation. It is imperative for pediatricians to preemptively counsel parents against the use of milk alternatives in infancy, especially if another formula shortage were to occur.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ETHICS STATEMENT
Parents of the patient in this case study provided informed verbal consent for the writing and publishing of this article. Verbal consent for this case report was obtained by the patient's mother at the time of the patient's routine endocrinology follow‐up appointment on October 03, 2022. All attempts to obtain written consent have been exhausted and unsuccessful in trying to contact the parents for the purpose of attaining their consent to publish the submitted report.
ACKNOWLEDGMENTS
Thank you to Dr. Savannah Krause for providing care as the supervising resident during the patient's hospitalization. The authors have no funding to report.
Gulledge WC, Gerald BM, Sumpter KM, Rogers NG. Symptomatic hypercalcemia in an infant secondary to excessive consumption of almond milk as a formula alternative. JPGN Rep. 2024;5:90‐92. 10.1002/jpr3.12028
REFERENCES
- 1. Food and Drug Administration [homepage on the internet] . Alerts, Advisories, and Safety Information. https://www.fda.gov/food/alerts-advisories-safety-information/fda-advises-parents-and-caregivers-not-make-or-feed-homemade-infant-formula-infants
- 2. Carvalho NF, Kenney RD, Carrington PH, Hall DE. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics. 2001;107(4):e46. 10.1542/peds.107.4.e46 [DOI] [PubMed] [Google Scholar]
- 3. Vitoria I. The nutritional limitations of plant‐based beverages in infancy and childhood. Nutr Hosp. 2017;34(5):1205‐1214. 10.20960/nh.931 [DOI] [PubMed] [Google Scholar]
- 4. Le Louer B, Lemale J, Garcette K, et al. Conséquences nutritionnelles de l'utilisation de boissons végétales inadaptées chez les nourrissons de moins d'un an. Archives de Pédiatrie. 2014;21(5):483‐488. 10.1016/j.arcped.2014.02.027 [DOI] [PubMed] [Google Scholar]
- 5. Houck J, Ganti L, Vera AE. A case of hyponatremia‐induced seizures in an infant secondary to water intoxication from the use of almond milk. Cureus. 2019;11(10):5899. 10.7759/cureus.5899 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Borin JF, Knight J, Holmes RP, Joshi S, Goldfarb DS, Loeb S. Plant‐based milk alternatives and risk factors for kidney stones and chronic kidney disease. J Ren Nutr. 2022;32(3):363‐365. 10.1053/j.jrn.2021.03.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Vitoria I, López B, Gómez J, et al. Improper use of a plant‐based vitamin C–deficient beverage causes scurvy in an infant. Pediatrics. 2016;137(2):e20152781. [DOI] [PubMed] [Google Scholar]
- 8. Collard KM, McCormick DP. A nutritional comparison of cow's milk and alternative milk products. Acad Pediatr. 2021;21(Issue 6):1067‐1069. [DOI] [PubMed] [Google Scholar]
- 9. Verduci E, D'Elios S, Cerrato L, et al. Cow's milk substitutes for children: nutritional aspects of milk from different mammalian species, special formula and plant‐based beverages. Nutrients. 2019;11(8):1739. 10.3390/nu11081739 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Minisola S, Pepe J, Piemonte S, Cipriani C. The diagnosis and management of hypercalcaemia. BMJ. 2015;350:h2723. 10.1136/bmj.h2723 [DOI] [PubMed] [Google Scholar]
- 11. Soghier L, Fratantoni K, Reyes C, Mullins K. Reference Range Values for Pediatric Care. 2nd ed. American Academy of Pediatrics. 10.1542/9781610022811 [DOI] [Google Scholar]
- 12. Lietman SA, Germain‐Lee EL, Levine MA. Hypercalcemia in children and adolescents. Curr Opin Pediatr. 2010;22(4):508‐515. 10.1097/MOP.0b013e32833b7c23 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Tebben PJ. Hypophosphatemia: a practical guide to evaluation and management. Endocr Pract. 2022;28(10):1091‐1099. 10.1016/j.eprac.2022.07.005 [DOI] [PubMed] [Google Scholar]