This case report describes a 10-day-old boy admitted with new onset convulsions. Initial blood tests showed hypocalcemia. The cause was found to be maternal hypovitaminosis D due to a diet low in calcium and no prenatal vitamin supplements. The mother also always wore sunscreen outdoors. The baby was treated with IV calcium supplementation and oral calcium and vitamin D, and his seizures resolved within 48 hours. This case highlights the risk of neonatal hypocalcemia and seizures due to maternal vitamin D deficiency during pregnancy.

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Biochemistry for Medics
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2. CASE REPORT
Presented by:
Yashveer Anand Rughoobur
Roll number:107

3. CASE PRESENTATION
A 10 day old boy was admitted with new onset convulsions. In the
previous 6 days, his parents had noted left sided arm and leg twitching,
right sided head turning and lips smacking.

4. These episodes lasted for approximately 30secs and their
frequency had increased to seven times per hour before
admission.
There was no history of fever, trauma, sick contacts or neonatal
sepsis risk factors. The baby was breastfed and supplemented
with formula feed .

5. The pregnancy was unremarkable and the baby was born at
term by an uncomplicated caesarian section because of a
previous caesarian section. His birth weight was 4.1kg.
On admission seizures as described were witnessed. He was
afebrile with normal vital signs. He had no dismorphic
features and thus physical examination was otherwise
unremarkable

6. Blood Biochemistry
Initial blood biochemistry showed normal renal function and
electrolytes but with hypocalcemia.
 Total calcium - 1.80 mmol/L (Normal 1.96mmol/L- 2.66
mmol/L) and
 ionized calcium - 0.82 mmol/L (normal 1.62 mmol/L –
3.10mmol/L).
 His blood glucose level was within normal limits at 4.3 mmol/L.
There was low 25-OH vit D level 13mmol/L ( Normal 27-
110mmol/L), with a normal 1,25 hydroxy vit D urinary calcium,
Head ultrasound was normal and there was no clinical or
radiological evidence of Rickets.

7. Maternal investigations demonstrated normal calcium level of 2.27
mmol/L (Normal 2.19-2.60 mmol/L). 25-OH Vit D was low.
The diagnosis was further revealed after further maternal history. The
mother was noted to have a diet low in calcium and she reported not
taking any antenatal vitamin supplement. She also reported always
wearing sunscreen when outdoor. The baby had not been started on
vitamin D supplements.

8. CASE DISCUSSION

9. QUESTION?
What is the cause of Hypocalcemia in this baby?

10. HYPOCALCEMIA
Definition:
serum total concentration of <8mg/dL
(2mmol/L) in terms of infants or
<7mg/dL(<1.75mmol/L) in preterm infants.
It is also defined as an ionized calcium level of
<3.0 to 4.4 mg/dL (0.75- 1.10mmol/L)
depending upon the method used for
estimation.

11. CAUSES
• Infant with severe symptomatic hypocalcaemia due to maternal
hypovitaminosis D.
• Mother is reported to have been wearing sunscreen outdoor.

12. How did the mother get
hypovitaminosis D??
• Sunscreen with a sun protection factor of 8 reduces
cutaneous production of vitamin D by 98%.
• So she did not supplement with vitamin D during
pregnancy.

13. TESTS
• 25-OH and 1,25 –OH vit D levels,
• serum and urinary calcium level,
• PTH level ,
• Renal function tests.

14. RESULTS
• Low 25-OH vit D level in the baby indicates
that vit D stores are low.
• Note: Normal 1,25 hydroxy vitamin D
confirms that the child is able to convert vit D
to its active form.
• The child’s parathyroid hormone was
appropriately elevated.

15. SIGNS OF HYPOCALCEMIA
• Hypotonia
• Apnea
• Tetany.

16. RISK FACTORS OF NEONATAL
HYPOCALCEMIA
 Symptomatic hypocalcemia without evidence of
rickets may present in the early neonatal period.
 Risk factors of neonatal vit D deficiency
secondary to maternal hypovitaminosis D
include:
 having a mother with dark skin,
being born in winter months,
living at extreme latitude,
maternal diet low in vit D during pregnancy and
lactation
lack of maternal sun exposure.

17. CLINICAL MANIFESTATIONS OF
NEONATAL HYPOCALCEMIA
• Jitteriness
• Muscle jerking
• Generalized or focal seizures
• Stridor ( secondary to laryngospasm)
• Wheezing( secondary to bronchospasm)
• Vomiting (secondary to pylorospasm)

18. CLINICAL MANIFESTATIONS OF
NEONATAL HYPOCALCEMIA

19. TREATMENT
• Treatment is I/V or oral calcium supplementation.
The baby was managed with an I/V calcium
gluconate infusion , oral calcium ,vitamin D
(calcitriol) supplementation.
• The seizures resolved within 48 hours of admission

20. PREVENTION
• Vitamin D
deficiency in infants
and mothers is a
public health issue.
• There is no current
consensus for
maternal vitamin D
requirement,
however 400IU/day
is recommended for
a pregnant woman
to have a healthy
child.

21. References
• Class Notes
• Biochemistry for medics

22. THANK YOU FOR YOUR ATTENTION