Milk-alkali syndrome is a condition resulting from ingestion of excessive amounts of calcium and absorbable alkali (e.g., sodium bicarbonate and calcium carbonate):
- Usually occurs during self-treatment for indigestion, peptic ulcer, or gastroesophageal reflux disease, or as part of osteoporosis prevention
- Characterized by hypercalcemia, metabolic alkalosis, and renal insufficiency
- System(s) affected: Endocrine/Metabolic; GI; Renal/Urologic
- Synonym(s): Burnett syndrome; Milk poisoning; Milk drinker syndrome
- 3rd most common cause of hypercalcemia, with a prevalence of 9–12% among hospitalized patients with hypercalcemia
- Recent increase associated with osteoporosis prevention
- Chronic use of calcium-containing antacids or supplements
- Chronic kidney disease
- Vitamin D supplementation
- Thiazide diuretic therapy
Avoid excess milk and/or absorbable antacids.
Exact mechanism unclear:
- Increased calcium absorption may lead to suppression of parathyroid hormone, which leads to the kidneys retaining increased bicarbonate. This eventually leads to alkalosis, which also causes increased calcium resorption in the kidneys.
Excess intake of milk and alkali as therapy for gastrointestinal problems accompanied with gastric hyperacidity (e.g., peptic ulcer, esophageal reflux) or for prevention of osteoporosis
Commonly Associated Conditions
- Peptic ulcer disease
- Hiatal hernia
- Gastroesophageal reflux
- Hypercalcemia of malignancy
History of excessive calcium and absorbable alkali intake resulting in hypercalcemia, metabolic acidosis, and renal impairment
- Calcium-containing supplement use
- Food distaste, anorexia
- Dizziness, weakness
- Mental status changes, irritability, depression
- Nausea, vomiting
- Band keratopathy
- Periarticular calcinosis
Diagnostic Tests & Interpretation
Check calcium, renal function, lytes, BUN, creatinine, alkaline phosphatase, and PTH.
Initial lab tests
- Mild alkalosis
- Decreased urine phosphate
- Increased BUN and serum creatinine levels
- Normal alkaline phosphatase level
- Ectopic calcification
Other causes of hypercalcemia:
- Excessive osteolysis with malignant disease
- Vitamin intoxication
- Thyroid disease
- Thiazide diuretic treatment
- To treat hypercalcemia:
- Isotonic sodium chloride: 0.9% IV when serum calcium exceeds 15 mg/dL (3.75 mmol/L; see Hypercalcemia) plus
- Furosemide: 80–100 mg IV q2h for 24 hours after volume depletion has been corrected
- Precautions: Replace sodium and potassium losses associated with furosemide use.
- Bisphosphonates inhibit bone resorption.
- Dialysis is occasionally indicated.
- Withdraw milk and alkali (1)[B].
- Hydration (1)[B]
- Treat hypercalcemia.
- Goal is to maintain urine volume of 3 L/d
Issues for Referral
Withdraw milk and alkali.
- IV treatment to avoid calcinosis (usually with sodium chloride solution)
- Renal dialysis for significant renal insufficiency
Avoid excess alkali.
- Kidney function
- Fluid intake and output
- Urine electrolytes
- Increased fluid intake
- Avoid excess milk and alkali.
Favorable with appropriate therapy
- Renal failure
1. Medarov BI et al. Milk-alkali syndrome. Mayo Clin Proc. 2009;84:261–7.
Ulett K, Wells B, Centor R et al. Hypercalcemia and acute renal failure in milk-alkali syndrome: a case report. J Hosp Med. 2010;5:E18–20.
43258006 milk alkali syndrome (disorder)
- Inquire if patient uses over-the-counter antacids or calcium supplements.
- Daily calcium supplementation should not exceed 2 g.
- Hydration and withdrawal of calcium sources are the mainstays of treatment.