more details about hypocalcemia

1. Hypocalcemia
Ass.L.Pediatric EAU By -DR. YAHYE SAID FARAH
MBBS.CEOMONC.ERC.NEUROLOGY ASU
Batch Two Clinical officers sem “5” students
Presented by:-
1-Sharmarke Abdulkadir Osman
2-Mohamed Abdullahi Mohamed
Date: 21-Nov-2017

3. Outline / contents
 Introduction
 Epidemiology
 Pathophysiology
 Etiology
 Sign and symptom
 Diagnostic approach
 Management principles
 Prognosis
 Complications
 References

4. Introduction
 Calcium is the most abundant mineral in the body.
 In pediatric ICU, hypocalcemia has higher mortality
then normocalcemia.
 We are interested in ionized calcium levels

7. Age group
Daily recommended dietary allowance
(RDA)
Children, 9–18 years 1,300 mg
Children, 4–8 years 1,000 mg
Children, 1–3 years 700 mg
Children, 7–12 months 260 mg
Children, 0–6 months 200 mg

8. Epidemiology
 Occurrence in the United States
 The incidence of neonatal hypocalcemia varies in different
studies. Data on the incidence and prevalence rates in the
neonatal period are limited.
 Hypocalcemia occurs frequently in very low birth weight
infants (< 1500 g).
 In a small study of 19 infants, the reported incidence of
early onset hypocalcemia was 37% by 12 hours, 83% by
24 hours, and 89% by 36 hours in very preterm infants
less than 32 weeks’ gestation.

Among very preterm infants, the onset of hypocalcemia
is earlier than in more mature at-risk neonates.

9. Pathophysiology
 Ionized calcium is affected by:
 Albumin
 Blood pH
 Serum phosphate
 Serum magnesium
 Serum bicarbonate
 Exogenous factors
 Citrate / free fatty acids (TPN)

10. Why do we need it?
 Calcium messenger system – regulates cell function
 Activates cellular enzyme
 Smooth muscle and myocardial contraction
 Nerve impulse conduction
 Secretory activity of exocrine glands

11. Physiological function
 Intracellular Ca
 Muscle contraction
 Glycogen metabolism
 Cell division
 Extracellular Ca
 Bone mineralization
 Blood coagulation
 Plasma membrane potential
 Provides calcium ion for maintenance of intracellular
calcium

12. Etiology/ Cause
 Poor calcium intake over a long period of
time, especially in childhood
 Medications that may decrease calcium
absorption
 Dietary intolerance to foods rich in calcium
 Hormonal changes, especially in women
 Certain genetic factors

13. Etiology
 Neonatal hypocalcemia:
 Early neonatal hypocalcemia (48-72 hours)
is most commonly seen in
 preterm
 very low birth weight infants
 infants asphyxiated or depressed at birth
 infants of diabetic mothers
 The intrauterine growth restricted infants.

14. Etiology
 Late neonatal hypocalcemia
 Exogenous phosphate load
 Phosphate-rich formulas / cow’s milk
 Magnesium deficiency
 Vitamin D deficiency
 Hypoparathyroidism
 Gentamycin (24 hourly dosing schedule)
 Phototherapy of hyperbilirubemia

16.  NB:- Overall, one of the most common
causes of hypocalcemia in children is renal
failure, which results in hypocalcemia because
of inadequate 1-hydroxylation of 25-
hydroxyvitamin D and hyperphosphatemia due
to diminished glomerular filtration.

17. Symptoms and signs of hypocalcemia
 Neuromuscular irritability
 Paresthesias
 Laryngospasm / Bronchospasm
 Tetany (rare)
 Seizures
 Chvostek sign
 Trousseau sign
 Prolonged QTc time on ECG

18. Cont…
 Apnea
 Jitteriness
 Poor feeding
 Lethargy
 Increase extensor tone
 Clonus
 Hyper-reflexia
 Stridor

20. Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins,
www.wrongdiagnosis.com/bookimages/14/4721.1.png

22. Trousseau sign:
(very uncomfortable and painful)
 A blood pressure cuff is
inflated to a pressure above
the patients systolic level.
 Pressure is continued for
several minutes.
 Carpopedal spasm:
* flexion at the wrist
* flexion at the MP joints
* extension of the IP joints
* adduction thumbs/fingers

24.  Long QT interval with
normal T waves
 Prolongation of the ST
segment with little shift
from the baseline

25. Severe symptoms of hypocalcemia include:
 Confusion or memory loss
 Muscle spasms
 Depression
 Hallucinations
 Muscle cramps
 Weak and brittle nails
 Easy fracturing of the bones

26. History that suggests hypocalcemia
 Newborns (can be unspecific)
 Asymptomatic
 Lethargy
 Poor feeding
 Vomiting
 Abdominal distention
 Children
 Seizures
 Twitching
 Cramping
 Laryngospasm

27. Workup - blood
 Total and ionized calcium
 Magnesium
 Phosphate
 PTH
 Vitamin D metabolite

28. Workup - imaging
 CXR
 Ankle and wrist XR

29. Workup - other
 ECG
 Malabsorption workup
 Karyotyping and family screening

30. DDX
 Hypoalbuminemia
 Chronic renal failure
 Magnesium deficiency
 Hypoparathyroidism
 Vit D deficiency (osteomalacia and rickettsia)
 Etc..

31. Management
1. Dependent on the underlying cause and severity
2. Administration of calcium alone is only
transiently effective
3. Mild asymptomatic cases: Often adequate to
increase dietary calcium by 1000 mg/day
4. Symptomatic: Treat immediately

32. Treatment of hypocalcaemia
Symptomatic hypocalcaemia
Early neonatal hypocalcaemia
 Neonates: Ca gluconate:10 mg/kg (1 ml/kg of 10%
solution) Slowly IV + monitoring ECG
 Start oral Calcium as soon as possible
 Early neonatal hypocalcaemia normalizes in 2-3 days
 Oral Ca usually necessary for 1 week

33. Treatment of hypocalcaemia
Symptomatic hypocalcaemia
Late neonatal hypocalcaemia
 Decrease phosphate intake
 Give calcium containing phosphate binder
 Oral calcium (gluconate) supplementation
 100 mg/kg/dose 4 hourly per os

34. Hypocalcaemia in older children
 Same dose IV as for neonates
 More often require continuous infusion
 Oral supplementation 50 mg/kg/24 hr elemental Ca
Most need Vit D supplementation

35. Prognosis
 Hypocalcemia can be effectively controlled with close
monitoring of Ca, P , Vit D intake & Urinary Ca
losses in hypoglycemia and attenuated lipolysis during
the first hr after birth.
 Congenital anomalies correlate with poor metabolic
control and may be due to hypoglycemia-induced
teratogenesis.

36. Complications
 Osteoporosis
 Spinal or other bone fracture (fragile bone)
 Abnormal heartbeat
 Eye dysfunction
 Disability
 Difficult walking

37. Prevention

Routine administration of a supplement containing
oral calcium and vitamin D is effective in reducing the
incidence and severity of hypocalcemia after total
thyroidectomy.

38. References:
 1. Functional activities of mutant calcium-
sensing receptors determine clinical
presentations in patients with autosomal
dominant hypocalcemia
 Healthline →
 Reference Library →
 Hypocalcemia (Calcium Deficiency
Disease)
 US National Library of Medicine
National Institutes of Health

39. Any question?

40. Q1- mention the signs A & B?

41. ANSWER
A)Chvostek sign B)Trousseau sign