HYPOCALCEMIA

AMRUTHA R

MScNSG

Ionic calcium

• is crucial for many biochemical processes including

• blood coagulation, • neuromuscular excitability, • cell membrane integrity, and• many of the cellular enzymatic activities.

high-risk neonates

• infants of diabetic mothers, • preterm infants and

infants with perinatal asphyxia.

TYPES

Early onset hypocalcemia • which presents within 72 hours

Late onset• hypocalcemia usually presents after 7 days

CALCIUM METABOLISM

• last trimester• Parathyroidhormone (PTH) and calcitonin • Do not cross placenta• PTH related peptide (PTHrP)• regulator of ca balance

Serum calcium (SCa) in the fetus is 10-11 mg/dL at term

(1-2 mg higher as compared to mother).

After birth

• PTH secretion, • Dietary calcium intake,• renal calcium reabsorbtion, • skeletal calcium stores• vitamin D status.• 7.5-8.5 mg/dL in healthy term babies by day

2 of life.

DROP IN CA LEVEL

• CAUSES• hypoparathyroidism, • end organ unresponsiveness to parathyroid

hormone • abnormalities of vitamin Dmetabolism,

hyperphosphatemia,• hypomagnesemia, and hypercalcitonemia

Calcium homeostasis in newborn

• two major compartments• skeleton (99%) • extracellular fluid (1%).

– bound to albumin (40%)– bound to anions 10%– free ionized form(50%)5

Ionized calcium

• biochemical processes including• blood coagulation,• neuromuscular excitability, • cell membrane integrity and function• cellular enzymatic • secretory activity.

Definition

• Hypocalcemia is defined as total serum calcium of less than 7 mg/dL (1.75mmol/L) or ionized calcium less than 4 mg/dL (1 mmol/L) in preterm infants and less than 8 mg/dL (2 mmol/L; total) or <1.2 mmol/L (ionic) in term neonates

Early onset neonatal hypocalcemia

• first 3-4 days of life• CAUSES• Prematurity• Infant of diabetic mother• Perinatal asphyxia• Maternal hyperparathyroidism• IUGR

Screening is recommended in at risk neonates

• 1.Preterm infants born before 32 wks• 2. Infants of diabetic mothers on iv fluids• 3.Infants born after severe perinatal

asphyxia

Time schedule for screening

• 24 and 48 hours of age in at risk babies

Clinical presentation:

• Asymptomatic

• Symptomatic

Symptomatic

• neuromuscular irritability -• myoclonic jerks• jitteriness• exaggerated startle• seizures.

• cardiac involvement like-• tachycardia• heart failure• prolonged QT interval• decreased contractibility

OTHERS

• Apnea • cyanosis,• tachypnoea,• vomiting • laryngospasm

Diagnosis

• Laboratory• Total or ionized serum calcium (total <7

mg/dL or ionized <4.0 mg/dL).• ECG

Treatment of early onset hypocalcemia

• Prophylactic• Preterm infants (£32 weeks), sick infants of

diabetic mothers. severe perinatal asphyxia should receive 40 mg/kg/day of

• elemental calcium (4 mL/kg/day of 10% calcium gluconate)

Asymptomatic hypocalcemia

• 80-mg/kg/day elemental calcium (8 mL/kg/day of 10% calcium gluconate) for 48 hours

Symptomatic hypocalcemia

• bolus dose of 2 mL/kg/dose diluted 1:1 with• 5% dextrose over 10 minutes under cardiac

monitoring• severe hypocalcaemia with poor cardiac

function,• calcium chloride 20 mg/kg may be given

through a central line over 10-30 minutes

• continuous IV infusion of 80 mg/kg/day elemental calcium for 48 hours

• Continuous infusion is preferred to IV bolus doses (1 mL/kg/dose q 6hourly).

Management of early neonatal hypocalcaemia

• Hypocalcemia• Total serum Cal <7 mg/dl

• Asymptomatic• 80 mg/kg/day for 48 hrs

• (8 mL/kg/day of 10% calcium gluconate )

• Taper to 40 mg/kg/day for one day• Then stop

Symptomatic

• Bolus of 2 mL/kg calcium gluconate 1:1 diluted with 5 % dextrose

• over 10 minutes under cardiac monitorin

• Followed by continuous infusion 80 mg/kg/day for 48 hrs

• (8 mL/kg/day of 10% calcium gluconate )• Document normal calcium at 48 hrs

• Then taper to 40 mg/kg/day for one day• Then stop

• Prophylactic• Preterm< 32 wks, sick IDM, severe

asphyxia• 40 mg/kg/day for 3 days

• (4ml/kg/day of 10% calcium gluconate )• IV or oral if can tolerate per oral

• Treatment is for 72 hours• Continuous infusion is better than bolus• Symptomatic babies treatment is 48 hrs

continuous

infusion

Precautions and side effects

• Bradycardia and• arrhythmia• extravasation • subcutaneous tissue necrosis.

Prolonged or resistant hypocalcemia

• Symptomatic hypocalcemia unresponsive to therapy

• · Infants needing calcium supplements beyond 72 hours of age

• · Hypocalcemia presenting at the end of the first week

Late onset neonatal hypocalcemia (LNH)

• symptomatic in the form of neonatal tetany or seizures

• 1. Hypomagnesemia• 0.2 mL/kgof 50% MgSO4 injection, 12 hours

apart, deep IM• Maintenance dose of 0.2 mL/kg/day of 50%

MgSO4, PO for 3 days.

• 2. High phosphate load• 3. Hypoparathyroidism• calcium (50 mg/kg/day in 3 divided doses)

and 1,25(OH)2 Vitamin D3 (0.5-1 mg/day).• 4. Vitamin D deficiency states

HYPOMAGNESEMIA

FunctionsBones teeth muscles nerves

Food to energy

Build proteins

Ca

CAUSES

• Diarrhoea• Suctioning• Chemotherapic drugs

– Cisplatin

• Diuretic therapy• Hyper ca• Malnutrition• Diabetic acidosis• Dehydration

Types

• Primary

• Secondary

CLINICAL FEATURES

• CARDIAC• Arrhythmia• Ecg • HTN• NEUROMUSCULAR MANIFESTATIONS

TREATMENT

• Mg so4• 50% solution• 500 mg• 4mEq/ml• 50—100 ml/kg of Mgso4

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