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Hypocalcemia update by sharmarke & mohamed
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
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
5.
6.
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.
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.
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
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
23.
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
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.
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