It includes, normal values, definition,epidemiology, etiology, clinical manifestations, management.

1. PRESENTATION ON
NEONATAL HYPOCALCEMIA,
HYPOGLYCEMIA,
HYPOMAGNESAEMIA
PRESENTED BY :
MISS GNANA JYOTHI
MSC(N) II YEAR

2. HYPOCALCEMIA
Children – is defined as a total serum calcium
concentration less than 2.1 mmol/L (8.5
mg/dL).
Term infants -less than 2 mmol/L (8 mg/dL) or
ionized fraction of less than 1.1 mmol/L (4.4
mg/dL)
Pre term -less than 1.75 mmol/L (7 mg/dL)

3. Normal calcium values
• Cord = 9-11.5 mg/dl
• Newborn, 3-24 hours = 9-10.6 mg/dl
• Newborn, 24-28 hours = 7-12 mg/dl
• Newborn, 4-7 days = 9-10.9 mg/dl

4. Anatomy & physiology

5. Epidemiology
Late onset hypoglycemia –common (developing
countries)
Age related demographics -:
-Mostly new borns
-older children : associated with
#critical illness
#acquired hypoparathyroidism
#mutations in calcium – sensing receptor
#defect in Vit.D supply or metabolism

6. INCIDENCE
• 30% VLBW (<1500 g)
• Infants of diabetic mother

7. Etiology
• In neonates :
Early onset neonatal hypocalcemia
Late onset neonatal hypocalcemia
• In infants and children :
Hypoparathyroidism,
Abnormal vitamin d production or action, and
Hyperphosphatemia

8. PATHOPHYSIOLOGY

9. DIAGNOSTIC FINDINGS
• History collection
• Physical examination
• Lab .findings

10. Lab . Findings
• Total and ionized serum calcium
levels
• Serum magnesium levels
• Serum electrolyte and glucose levels
• Phosphorus levels
• Parathormone levels
• Vitamin D metabolite (25-
hydroxyvitamin D and 1,25-
dihydroxyvitamin D) levels
• Urine calcium, magnesium,
phosphorus, and creatinine levels
• Serum alkaline phosphatase levels

11. Additional tests:
• Malabsorption workup
• Total lymphocyte and T-cell
subset analyses
• Chest radiography
• Ankle and wrist radiography
• Electrocardiography
• Karyotyping

12. Management
1 ml of Ca.gluconate (10%) -9 mg elemental ca.
EARLY NEOANTAL HYPOCALCEMIA:
Patients at increased risk of hypocalcemia
Patients diagnosed –asymptomatic
Patients diagnosed – symptomatic

13. Patients at increased risk of hypocalcemia
• -pre term + sick (DM) + perinatal asphyxia
= 40 mg/kg/day
• -infants (oral feeds)
calcium PO=q.6 hrly
• -therapy – continued ---3 days

14. Patients diagnosed –asymptomatic
• -80 mg/kg/day elemental calcium – 48 hrs
• Tapered 50% --------for another 24 hrs
• -oral feeds---------PO calcium

15. Patients diagnosed – symptomatic
Bolus ---2ml/kgldose -----5% D-----10 min
Contin. Infusion-----80mg/kg/day -----48hrs
50% dropped-----next 24 hrs-----discontinued

16. Late Neonatal Hypocalcemia
• Hypomagnesaemia
• High phosphate load
• Hypoparathyroidism
• Vit .D deficiency

17. Hypomagnesaemia
• Symptomatic hypocalcemia- unresponsive
= due tohypomagnesaemia
• 2 doses ---0.2 ml/kg----50% MgSO4 inj(12 hrs)
deep IM
• Maintenance dose----0.2 ml/kg/day---3 days

18. High phosphate loads
• EBM-----encouraged
• Phosphate binding gels---avoided

19. Hypoparathyroidism
• Hyperphosphatemic & hypocalcemic---normal
renal functions
• Ca. supple…----50mg/kg/day----3 divided
doses
• Vit . D3-----0.5-1 µg/day
• Syrup shelcal------250 mg/5ml

20. Vit .D deficiency states
Vit . D3 supple…30-60 ng/kg/day

21. NURSING MANAGEMENT
• Assessment
• Identify the infants at risk
• Administer supp. Ca, vit .D, phos.
• Monitor during infusion
• Nutritional supplementation

22. DIAGNOSIS
• Risk for injury r/t seizures secondary to
hypocalcemia
• Ineffective airway clearance r/t laryngospasm
sec. to hypocalcemia
• Impaired skin integrity r/t infiltration of
calcium infusion
• Ineffective perfusion r/t rapid infusion of
calcium

23. Hypomagnesaemia

24. Definition
Hypomagnesemia occurs when serum
concentrationsfall below 0.66mmol/L
(1.6mg/dL)

25. ETIOLOGY
-Decreased mg supply
-Mg loss

26. CLINICAL MANIFESTATIONS
NEONATALPERIOD –
• Malabsorption syndrome
• Intractable hypocalcemic
seizures

27. Management (medical)
• Should not be treated with Ca.or Vit.D
• Mg. salts ----can be given
• 50% solution of MgSO4, 0.005 to 0.1 mL/kg
(0.1 to 0.2 mmol/kg or 2.5 to 5.0 mg / kg )
slow IV 30-60 MIN
……..Repeated doses-q 8-12 hrs

28. • Concominant oral Mg suppl
• if Mal absorption- 1mg/kg/day PO (daily)
• Serum Mg. conc. Measured
• Oral MgSO4 --- are not well absorbed---
diarrhoea
• Well titrated

29. Nursing management
• Assessment
-fluid balances
-wt changes
-skeletal muscle strength(weakness)
-cardiac rhythm(arrythmia)
-cerebral func.(LOC)
-GI func(bowel sounds)
-neuro muscular excitability

30. • Monitor serum Mg. levels
• Monitor BP
• Monitor RR & depth
• Monitor deep tendon reflexes
• Admin. Drugs
• Monitor electrolyte balances
• Parent education

31. Complications
• Hypotonia
• Respiratory depression
• Hypotension
• Cardiac arrythmias

32. HYPOGLYCEMIA

33. DEFINITION:
Neonatal Hypoglycemia is defined as a plasma
glucose level of less than mg/dL ( mmol/L) in
the first 24 hrs of life and less than 45 mg/dL
(2.5 mmol/L) .

34. INCIDENCE
• Differs ----population, method & timing of
feeding
• Early feeding ------decreases incidence
• IBM :
CHO metabolism disorders(>1:10,000)
Fatty acid oxidation disorders(1:10,000)
Hereditary fructose intolerance (1:20,000/50…)
Glycogen storage diseases(1:25,000)
Galactosemia

35. RISK FACTORS
1.Decreased substrate availability
•Intra-uterine fetal growth restriction
•Glycogen storage disease
•Inborn errors (e.g., fructose intolerance)
• Prematurity
•Prolonged fasting without IV glucose

36. 2.Hyperinsulinemia
• Infant of diabetic mother
•Islet cell hyperplasia
•Erythroblastosis fetalis
•Exchange transfusion
•Beckwith-Wiedemann Syndrome
•Maternal ß-mimetic tocolytic agents
•”High” umbilical arterial catheter
•Abrupt cessation of IV glucose

37. 3.Other endocrine abnormalities
•Pan-hypopituitarism
•Hypothyroidism
•Adrenal insufficiency

38. 4.Increased glucose utilization
•Cold stress
•Increased work of breathing
•Sepsis
•Perinatal asphyxia

39. 5.Miscellaneous condition
•Polycythemia
•Congenital heart disease
•CNS abnormalities

40. GLUCOSE PHYSIOLOGY IN FETUS &
NEW BORN

41. CLINICAL MANIFESTATIONS
• Infants ---1st/ 2nd day of life ------asymptomatic
• Hypotonia
• Lethargy
• Poor feeding
• Jitteriness, seizures
• CHF
• Cyanosis
• Apnea
• Hypothermia

42. C/M ---ASSOCIATED WITH ANS
• Anxiety, tremulouness
• Diaphoresis
• Tachycardia
• Pallor
• Hunger, nausea, & vomiting

43. C/M ---OF HYPOGLYCORRHACHIA
Head ache
Mental confusion,
Staring, behavioral changes
Difficulty concentrating
Visual disturbances
Dysarthria
Seizures
Ataxia
Somnolence
Coma
Stroke

44. Diagnostic findings
• Serum or plasma glucose levels
• Serum insulin
• Urine for ketone bodies
• Screening for metabolic errors
• Angiography

45. Management
• Screening-------1,2,4,6,9,12 hrs
• At risk neonates-----2,6,12,24,48,72hrs
• Sick babies, sepsis,
asphyxia, shock 6-8 hrs
Asymptomatic babies
---with BS 20-40 mg/dL
–after 1 hr of oral feed
-later q 6 hrs till 48 hrs ( if BS > 50 mg/dL)

46. ----with BS levels < 20 mg/dL
-after 1 hr of starting IV fluids & then q hr
----BS <40 mg/dL-(even after 1 hr of oral feeds)
- q 6h for 48 hrs

47. To calculate rate of glucose
administration
• % glucose x mL/kg/d = glucose infusion rate
(mg/kg/min)
144
Or
• % glucose x mL/h = glucose infusion
rate (mg/kg/min)
• 6 x body weight (kg)

48. Asymptomatic hypoglycemia
• Are at risk for neurodevelopment
• Initially feed---BM/ formula---spoon or gavage
• Check BS-----30-60 min-before next feed
• If >45mg/dL---2-3 hrly feed ---q 4-6 hr monitor
for 48hrs

49. • IV Infusion if :
BS < 25 mg/dL
BS remains <45 mg/dL
Enteral feed –contra..
Baby becomes –sympt..

50. Symptomatic hypoglycemia
• Can result in high incidence ----neural inj.
• Bolus 2mL/kg –10%D—IV
• Following –IV dextrose (6mg/kg/min)
• BS –rechecked—after 15-30 min
• If BS 45 mg/dL ---hrly ---for 4-6 hrly
• If BS- remains < 45 mg/dL
GIR---increased 2mg/kg/min q 15-30
min… (+) checked

51. • Tappering glucose infusion –
Once BS values >45 mg/dL stabilized 24 hrs
infusion is tappered.
Infusion is tappered @ 2mg/kg/min-q 6hrs
Oral feeds ca be started if not
contraindicated

52. Nursing management
• Assessment
-maternal history
-immunization
-family history
-sepsis
-enteral feeding
-use of corticosteroids
-drug addiction
-cancer

53. Nursing Diagnosis
• Risk for complications related to lower plasma
glucose levels such as mental disorders,
behavioral disorders, autonomic nerve
function disorders, hypoglycemic coma

54. Nursing Diagnosis
• Risk for infection related to a decrease in
endurance