Hypocalcemia

Last Updated: October 16, 2002

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Synonyms and related keywords: low calcium, low ionized calcium
AUTHOR INFORMATION
Section 1 o 1!

Author: A"#ay Sin$#al% M&, Attending Neonatologist, e!artment o" #ediatrics, i$ision o" Neonatolog%, Children&s 'emorial (os!ital, Chicago Coauthor)s*: &e"ora# 'amp"ell% M&, Chie", Associate #ro"essor, e!artment o" #ediatrics, i$ision o" Neonatolog%, Albert Einstein College o" 'edicine and 'onte"iore 'edical Center Abha% +inghal, ' , is a member o" the "ollowing medical societies: ,ndiana +tate 'edical Association Editor)s*: T#omas A (ilson% M&, irector o" #ediatric Endocrinolog%, Clinical Associate #ro"essor, e!artment o" #ediatrics, +tate -ni$ersit% o" New .or/ at +ton% 0roo/1 Mary L (indle% )#arm&, Ad2unct Assistant #ro"essor, -ni$ersit% o" Nebras/a 'edical Center College o" #harmac%1 Step#en *emp% M&% )#&, #ro"essor, e!artment o" #ediatrics, +ection o" #ediatric Endocrinolog%, -ni$ersit% o" Ar/ansas and Ar/ansas Children&s (os!ital1 Merrily )ot#% M&, #ro"essor, e!artment o" #ediatrics, -ni"ormed +er$ices -ni$ersit% o" the (ealth +ciences1 and +eor$e ) '#ro,sos% M&% FAA)% FA')% MA'-, Chie", #ediatric and Re!roducti$e Endocrinolog% 0ranch, #rogram irector, #ediatric Endocrinolog%, N,C( 3N,(1 Clinical #ro"essor, e!artment o" #ediatrics, 4eorgetown -ni$ersit% 'edical +chool INTRO&U'TION
Section . o 1!

/ack$ro,nd: (%!ocalcemia is a relati$el% "re5uentl% obser$ed laborator% and clinical abnormalit% seen es!eciall% in neonates6 7aborator% h%!ocalcemia is o"ten as%m!tomatic, and its treatment in neonates is contro$ersial6 (owe$er, children with h%!ocalcemia are re!orted to ha$e a higher mortalit% rate in !ediatric intensi$e care unit )#,C-* settings than children with normal calcium le$els6 (%!ocalcemia is de"ined as a total serum calcium concentration o" less than 869 mg3d7 in children, less than 8 mg3d7 in term neonates, and less than : mg3d7 in !reterm neonates6 )at#op#ysiolo$y: Calcium is the most abundant mineral in the bod%6 O" the bod%&s total calcium, ;;< is in bone, and serum le$els constitute less than 1<6 =arious "actors regulate the homeostasis o" calcium and maintain serum calcium within a narrow range6 >hese include !arathormone )#>(*, $itamin , he!atic and renal "unction )"or con$ersion o" $itamin to acti$e metabolites*, and serum !hos!hate and magnesium le$els6

Although total serum calcium le$els are measured and re!orted, ionized calcium is the acti$e and !h%siologicall% im!ortant com!onent6 >otal calcium le$el includes both the ionized "raction and the bound "raction6 >he ionized calcium le$el is a""ected b% the albumin le$el, blood !(, serum !hos!hate, serum magnesium, and serum bicarbonate, and it ma% be reduced b% e?ogenous "actors that ma% bind calcium, such as citrate "rom trans"used blood or "ree "att% acids "rom total !arenteral nutrition )>#N*6 At a !h%siologic !( o" :6@, @0< o" total calcium is bound to albumin1 10< is com!le?ed with bicarbonate, !hos!hate, or citrate1 and the remaining 90< is "ree ionized calcium6 >he normal range o" ionized calcium is @A9 mg3d76 >he concentration o" calcium in the serum is critical to man% im!ortant biological "unctions, including the "ollowing:

Calcium messenger s%stem b% which e?tracellular messengers regulate cell "unction Acti$ation o" se$eral cellular enz%me cascades +mooth muscle and m%ocardial contraction Ner$e im!ulse conduction +ecretor% acti$it% o" e?ocrine glands

(%!ocalcemia mani"ests as CN+ irritabilit% and !oor muscular contractilit%6 7ow calcium le$els decrease the threshold o" e?citation o" neurons, causing them to ha$e re!etiti$e res!onses to a single stimulus6 0ecause neuronal e?citabilit% occurs in both sensor% and motor ner$es, h%!ocalcemia !roduces a wide range o" !eri!heral and CN+ e""ects, including !aresthesias, tetan% )ie, contraction o" hands, arms, "eet, lar%n?, bronchioles*, seizures, and e$en !s%chiatric changes in children6 >etan% is not caused b% increased e?citabilit% o" the muscles6 'uscle e?citabilit% is actuall% de!ressed because h%!ocalcemia im!edes acet%lcholine release at neuromuscular 2unctions and, thus, inhibits muscle contraction6 (owe$er, the increase in neuronal e?citabilit% o$errides the inhibition o" muscle contraction6 Cardiac "unction ma% also su""er because o" !oor muscle contractilit%6 Fre0,ency: In t#e US: ,ncidence o" neonatal h%!ocalcemia $aries in di""erent studies6 (%!ocalcemia occurs in u! to B0< o" in"ants with $er% low birth weight )C1900 g* and u! to 8;< o" in"ants whose gestational age at birth is less than B2 wee/s6 (igh incidence is also re!orted in in"ants o" mothers with diabetes mellitus and in in"ants with birth as!h%?ia6

Internationally: No $ariation is re!orted across national boundaries1 howe$er, lateAonset h%!ocalcemia is more common in in"ants in de$elo!ing countries where babies are "ed cow&s mil/ or "ormulas containing high amounts o" !hos!hate than in countries where in"ants are "ed human mil/ or "ormulas containing less !hos!hate6

Mortality1Mor"idity: (igher mortalit% rates ha$e been re!orted in children with h%!ocalcemia than in normocalcemic children in #,C- settings6 Se2: No se?Abased $ariation in incidence is /nown6 A$e: 'ost !ediatric !atients with h%!ocalcemia are newborns6 ,n older children, h%!ocalcemia is usuall% associated with critical illness, ac5uired h%!o!arath%roidism, acti$ating mutations o" the calciumAsensing rece!tor, or de"ects in $itamin su!!l% or metabolism6 'LINI'AL Section 3 o 1! History: (istor% is $ariable de!ending on the age o" the !atient6 Newborns
o o o o o

#ossibl%, no s%m!toms 7etharg% #oor "eeding =omiting Abdominal distension

Children
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+eizures >witching Cram!ing 7ar%ngos!asm, a rare initial mani"estation

)#ysical: 7etharg%

C%anosis >remulousness +eizures A!nea >etan% and signs o" ner$e irritabilit%, such as Ch$oste/ sign, car!o!edal s!asm, >rousseau sign, and stridor Abdominal distension

#rematurit%, birth as!h%?ia, or congenital heart disease )"eatures associated with in"ants o" mothers with diabetes mellitus*

'a,ses: O$erall, one o" the most common causes o" h%!ocalcemia is renal "ailure, which results in h%!ocalcemia because o" inade5uate 1Ah%dro?%lation o" 29Ah%dro?%$itamin and h%!er!hos!hatemia "rom diminished glomerular "iltration6 Although h%!ocalcemia is most commonl% obser$ed among neonates, it is "re5uentl% re!orted in older children and adolescents, es!eciall% in #,C- settings6 >he causes o" h%!ocalcemia can be classi"ied b% the child&s age at !resentation6 Earl% neonatal h%!ocalcemia )within @8A:2 h o" birth*
o

#rematurit%: #ossible mechanisms include !oor inta/e, decreased res!onsi$eness to $itamin , increased calcitonin, and h%!oalbuminemia leading to decreased total but normal ionized calcium6 0irth as!h%?ia: ela%ed introduction o" "eeds, increased calcitonin !roduction, increased endogenous !hos!hate load, and al/ali thera!% all ma% contribute to h%!ocalcemia6 iabetes mellitus in the mother: Dunctional h%!o!arath%roidism induced b% magnesium de"icienc% !la%s a !redominant role increases the ris/ o" !rematurit% and as!h%?ia6 ,ntrauterine growth retardation ),-4R*: ,n"ants with ,-4R ma% ha$e h%!ocalcemia i" the% also are !reterm or ha$e had !erinatal as!h%?ia6

7ate neonatal h%!ocalcemia )BA: d a"ter birth*

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E?ogenous !hos!hate load: 'ost commonl% seen in de$elo!ing countries, h%!ocalcemia is caused b% "eeding with !hos!hateArich "ormula or cow&s mil/6 'agnesium de"icienc% >ransient h%!o!arath%roidism o" newborn (%!o!arath%roidism due to other causes

(%!ocalcemia in in"ants and children

(%!o!arath%roidism A!lasia or h%!o!lasia A i4eorge s%ndrome1 $elocardio"acial s%ndrome1 gestational diabetes mellitus, "etal e?!osure to retinoic acid1 com!le? o" $ertebral de"ects, anal atresia, tracheoeso!hageal "istula with eso!hageal atresia, and radial and renal abnormalities )=A>ER*, association o" coloboma, heart de"ects, choanal atresia, renal abnormalities, growth retardation, male genital anomalies, and ear abnormalities )C(AR4E*

#>( rece!tor de"ects A #seudoh%!o!arath%roidism Autoimmune !arath%roiditis ,n"iltrati$e lesions A (emosiderosis, Eilson disease, thalassemia Acti$ating mutations o" the calciumAsensing rece!tor leading to ina!!ro!riatel% su!!ressed #>( secretion ,dio!athic causes

Abnormal $itamin !roduction or action =itamin de"icienc% A ietar% insu""icienc%, maternal use o" anticon$ulsants Ac5uired or inherited disorders o" $itamin metabolism Resistance to actions o" $itamin (%!er!hos!hatemia E?cessi$e !hos!hate inta/e because o" im!ro!er "ormula E?cessi$e !hos!hate inta/e caused b% ina!!ro!riate use o" !hos!hateAcontaining enemas 7oading in >#N ,ncreased endogenous loading caused b% ano?ia, chemothera!%, or rhabdom%ol%sis Renal "ailure Others

'alabsor!tion s%ndromes Al/alosis A Res!irator% al/alosis caused b% h%!er$entilation1 metabolic al/alosis with the administration o" bicarbonate, diuretics, or chelating agents, such as the high doses o" citrates ta/en in during massi$e blood trans"usions #ancreatitis #seudoh%!ocalcemia )ie, h%!oalbuminemia* (ungr% bones s%ndrome A Ra!id s/eletal mineral de!osition seen in in"ants with ric/ets or h%!o!arath%roidism a"ter starting $itamin thera!% &IFF-R-NTIALS Section 4 o 1!

(%!ernatremia (%!ogl%cemia (%!omagnesemia (%!onatremia (%!o!arath%roidism 'alabsor!tion +%ndromes 'eningitis, Ase!tic 'eningitis, 0acterial Neonatal +e!sis

Ot#er )ro"lems to "e 'onsidered: Anoxia Intracranial bleeding Narcotic withdrawal Pseudohypoparathyroidism Rickets/osteomalacia/rachitis (ie, vitamin de!iciency" #yperphosphatemia #ypoalbuminemia Renal !ailure $etabolic disease a!!ecting vitamin , sei%ures
Section 5 o 1!

La" St,dies: +erum calcium, total and ionized

'easuring ionized calcium le$el is essential to di""erentiate true h%!ocalcemia "rom a mere decrease in total calcium concentration6 A decrease in total calcium can be associated with low serum albumin concentration and abnormal !(6

+erum magnesium
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+erum magnesium ma% be low in !atients with h%!ocalcemia6 (%!ocalcemia ma% not res!ond to calcium thera!% i" h%!omagnesemia is not corrected6

+erum electrol%tes and glucose: +eizures and irritabilit% in newborns and children can be associated with h%!ogl%cemia and sodium abnormalities6 #hos!horus
o

Estimating the !hos!hate le$el is essential to establish the etiolog% o" h%!ocalcemia6 #hos!hate le$els are higher in cases o" e?ogenous and endogenous !hos!hate loading and renal "ailure6 7e$els are usuall% high in h%!o!arath%roidism6 7e$els are low in cases o" $itamin abnormalities and ric/ets6

o o

#arathormone

(ormone studies are indicated i" h%!ocalcemia !ersists in the !resence o" normal magnesium and normal or ele$ated !hos!hate le$els6 7ow #>( le$els suggest h%!o!arath%roidism1 serum calcium rises in res!onse to #>( challenge6 Con$ersel%, #>( le$els are ele$ated in !atients with $itamin abnormalities and !seudoh%!o!arath%roidism, and calcium le$els do not rise in res!onse to #>( challenge6

=itamin metabolites )29Ah%dro?%$itamin and 1,29Adih%dro?%$itamin *: >his ma% be assessed along with hormone studies to eliminate uncommon causes o" h%!ocalcemia such as malabsor!tion or disorders o" $itamin metabolism6 -rine calcium, magnesium, !hos!horus, and creatinine: >hese should be assessed in !atients with sus!ected renal tubular de"ects and renal "ailure6 +erum al/aline !hos!hatase: >his is generall% ele$ated in !atients with ric/ets6

Ima$in$ St,dies: Chest radiogra!h%: E$aluate "or th%mic shadow, which ma% be absent in !atients with i4eorge s%ndrome6

An/le and wrist radiogra!h%

E$aluate "or e$idence o" ric/ets6 Changes a!!ear at an earl% stage in the radius and ulna1 distal ends are widened, conca$e, and "ra%ed6

Ot#er Tests: Electrocardiogra!h%

A !rolonged F>c )G06@ s*, a !rolonged +> segment, and > wa$e abnormalities ma% be obser$ed6 'easurements o" s!eci"ic inter$als are o" little $alue in !redicting h%!ocalcemia6

'alabsor!tion wor/u!

>otal l%m!hoc%te and >Acell subset anal%ses: Dindings are decreased in !atients with i4eorge s%ndrome6

'aternal and "amil% screening: >his is hel!"ul in "amilial "orms o" h%!ocalcemia, such as those caused b% acti$ating mutations o" the calciumAsensing rece!tor6 Medical 'are: 4eneral medical care in$ol$es stabilization with management o" the !atient&s airwa% and breathing i" he or she !resents with seizures6 Anticon$ulsants are commonl% administered be"ore con"irmation o" h%!ocalcemia in a new !atient6 +eizures usuall% do not res!ond to the usual antiseizure medications until calcium is administered intra$enousl%6

>reatment o" an as%m!tomatic !atient with h%!ocalcemia remains contro$ersial, es!eciall% in neonates6 +ome authorities suggest that treating such !atients is unnecessar%6 ,n contrast, most clinicians agree that h%!ocalcemia should be treated !rom!tl% in an% s%m!tomatic neonate or older child because o" its serious im!lications "or neuronal and cardiac "unction6 ,ntra$enous treatment is usuall% indicated in !atients ha$ing seizures, those who are criticall% ill, and those who are !lanning to ha$e surger%6 Oral calcium thera!% is used in as%m!tomatic !atients and as "ollowAu! to intra$enous calcium thera!%6

'ons,ltations: #ediatric endocrinologist

4eneticist

&iet: A diet high in calcium and low in !hos!hate is re5uired in most instances6 ,n"ants ta/ing regular cow&s mil/ or e$a!orated mil/ need to be gi$en humanized in"ant "ormula instead6 #atients with renal "ailure should be gi$en a lowAsolute lowA!hos!hate "ormula, such as +imilac #' 603@06 M-&I'ATION Section 6 o 1 Calcium thera!% is the mainsta% o" treatment "or h%!ocalcemia6 >hera!% with intra$enous calcium is the most e""ecti$e and ra!id means o" ele$ating serum calcium concentration6 Once h%!ocalcemia is controlled, "ollowAu! treatment with oral thera!% can be gi$en6 (owe$er, in !atients with as%m!tomatic h%!ocalcemia, thera!% with oral calcium alone ma% be su""icient6 =itamin , in one o" its $arious "orms, is also indicated de!ending on the metabolic abnormalit% !resent6 (owe$er, the use o" $itamin "ormulations in newborns to !re$ent h%!ocalcemia has not been e""ecti$e6 >he most im!ortant as!ect o" management is resolution o" the !rimar% cause )eg, h%!er!hos!hatemia, h%!omagnesemia*6 rug Categor%: Calcium compounds AA Calcium is the most abundant mineral in the human bod%6 ,t is essential "or blood coagulation and the de$elo!ment and3or "unction o" bone, teeth, ner$es, and muscles6 Calcium also

"unctions as an enz%matic co"actor and a""ects endocrine secretor% "unction6 +u!!lements are used to increase serum calcium concentrations in !atients with h%!ocalcemia6 Oral !re!arations are !rescribed to reduce !hos!hate absor!tion "rom the intestine in !atients with h%!er!hos!hatemia6 &r,$ Name Calcium, intra$enous AA Calcium gluconate 10< )ie, 100 mg3m7* ,= solution contains ;68 mg3m7 )06@9 mE53m7* elemental calcium6 Calcium chloride 10< )ie, 100 mg3m7* contains 2: mg3m7 )16@ mE53m7* elemental calcium6 Calcium chloride is more irritating to the $eins and ma% a""ect !(1 there"ore, it is t%!icall% a$oided in !ediatric !atients6 Ad,lt &ose 200A1900 mg )as elemental calcium* ,= o$er 2@ h )ediatric &ose 10A20 mg3/g elemental calcium )1A2 m7 calcium gluconate3/g* ,= slowl% o$er 9A10 min to control seizures1 ma% be continued b% 90A:9 mg3/g3d ,= in"usion o$er 2@ h 'ontraindications Renal calculi1 h%!ercalcemia h%!o!hos!hatemia1 $entricular "ibrillation during cardiac arrest, digitalis to?icit% Interactions 'a% cause arrh%thmias in !atients ta/ing digo?in1 !reci!itates in solution with sodium bicarbonate 'a% decrease e""ects o" tetrac%clines, atenolol, salic%lates, iron salts, and "luoro5uinolones1 antagonizes e""ects o" $era!amil1 large inta/es o" dietar% "iber ma% decrease calcium absor!tion and le$els )re$nancy 0 A -suall% sa"e but bene"its must outweigh the ris/s6 )reca,tions -se e?treme care in !eri!heral in"usion because e?tra$asation can cause se$ere tissue necrosis1 ra!id ,= in"usion ma% cause brad%cardia and h%!otension1 ma% cause li$er necrosis i" administered in an umbilical $enous catheter lodged in a branch o" !ortal $ein1 !rolonged use o" calcium chloride ma% lead to h%!erchloremic acidosis &r,$ Name Calcium glubionate )NeoACalglucon* AA Calcium su!!lement "or #O use6 >he glubionate salt )1800 mg39 m7* contains 119 mg elemental calcium39 m76 Ad,lt &ose 1A2 g3d )as elemental calcium* #O di$ided tid35id )ediatric &ose 90A:9 mg3/g3d )as elemental calcium* #O di$ided 56A8h 'ontraindications Renal calculi1 h%!ercalcemia h%!o!hos!hatemia1 $entricular "ibrillation during cardiac arrest, digitalis to?icit% Interactions 'a% decrease e""ects o" tetrac%clines, atenolol, salic%lates, iron salts, and "luoro5uinolones1 large inta/es o" dietar% "iber ma% decrease calcium absor!tion and le$els )re$nancy 0 A -suall% sa"e but bene"its must outweigh the ris/s6 )reca,tions -se with caution in small neonates because o" high osmolar load1 ma% cause diarrhea in older children &r,$ Name Calcium carbonate )O%stercal, Caltrate, >ums, OsACal* AA +u!!lement "or #O use6 ,n man% wa%s, the calcium su!!lement o" choice because it !ro$ides @0< elemental calcium6 >hus, 1 g o" calcium carbonate !ro$ides @00 mg o" elemental calcium6 Eell absorbed orall% and unli/el% to cause diarrhea6 A$ailable in tab and li5uid "orms6 Ad,lt &ose 1A2 g3d )as elemental calcium* #O di$ided tid35id

)ediatric &ose Neonates: B0A190 mg3/g3d #O di$ided 5id1 ma% be added to "ormula )eg, +imilac #' 603@0 to ma/e a calciumA!hos!horous ratio o" @:1* Children: 20A69 mg3/g3d #O di$ided bid35id 'ontraindications Renal calculi1 h%!ercalcemia h%!o!hos!hatemia1 $entricular "ibrillation during cardiac arrest, digitalis to?icit% Interactions 'a% decrease e""ects o" tetrac%clines, atenolol, salic%lates, iron salts, and "luoro5uinolones1 large inta/es o" dietar% "iber ma% decrease calcium absor!tion and le$els )re$nancy 0 A -suall% sa"e but bene"its must outweigh the ris/s6 )reca,tions (%!ercalcemia or h%!ercalcuria ma% occur when thera!eutic amounts are gi$en rug Categor%: Vitamin D metabolites AA >he acti$e "orms o" $itamin regulate calcium absor!tion and its uses in the bod%6 >he% increase calcium le$els b% !romoting absor!tion o" calcium in intestines and retention in /idne%s6 &r,$ Name Calcitriol )Rocaltrol* AA Acti$e metabolic "orm o" $itamin )ie, 1,29Adih%dro?%cholecalci"erol*6 Es!eciall% use"ul in im!aired li$er or renal "unction causing inabilit% to h%dro?%late $itamin to its acti$e "orms6 4enerall% is ra!idl% acting1 howe$er, ma% act more slowl% in neonates )B6A@8 h*6 #reterm in"ants ma% be resistant to its actions6 Also used to treat acute h%!ocalcemia6 Ad,lt &ose 0629 mcg #O 5d initiall%1 ma% increase b% 0629 mcg e$er% BA @ w/1 t%!ical range 069A2 mcg3d )ediatric &ose 0601A0609 mcg3/g3d ,= 5d3bid1 ad2ust dosage until normocalcemia is attained 'ontraindications ocumented h%!ersensiti$it%1 h%!ercalcemia, h%!ercalciuria, malabsor!tion s%ndrome Interactions Cholest%ramine and colesti!ol decrease absor!tion o" calcitriol1 magnesiumAcontaining antacids and thiazide diuretics can increase calcitriol e""ects )re$nancy C A +a"et% "or use during !regnanc% has not been established6 )reca,tions 'a% cause h%!ercalciuria1 gi$e with calcium salts to attain o!timum results1 ma% add h%drochlorothiazide to regimen to control h%!ercalciuria &r,$ Name ih%drotach%sterol ) (>, (%ta/erol* AA +%nthetic analog o" $itamin , which does not re5uire acti$ation b% renal 1 h%dro?%lase "or acti$it%6 Also a$ailable in li5uid "orm "acilitating administration o" $ariable doses in in"ants and %oung children6 1 mg e5ui$alent to 120,000 - )ie, B mg* $itamin A26 Ad,lt &ose 06:9A269 mg3d #O "or 2AB d initiall%1 maintain with 061A2 mg3d )ediatric &ose Neonates: 0609A061 mg3d #O Children: 069A2 mg3d #O 'ontraindications ocumented h%!ersensiti$it%1 h%!ercalcemia1 h%!ercalcuria1 malabsor!tion s%ndrome Interactions None re!orted )re$nancy C A +a"et% "or use during !regnanc% has not been established6

)reca,tions 'a% cause h%!ercalciuria1 gi$e with calcium salts to attain o!timum results1 ma% add h%drochlorothiazide to regimen to control h%!ercalciuria
ion 7 o 1!

F,rt#er Inpatient 'are: 'ost babies with h%!ocalcemia are !reterm and ha$e alread% been admitted to the neonatal intensi$e care unit )N,C-*6

An% newborn in"ant with h%!ocalcemia should be monitored in the N,C-6 An% child with s%m!tomatic h%!ocalcemia should be admitted to the hos!ital unless the diagnosis is h%!er$entilation6

F,rt#er O,tpatient 'are: Regular "ollowAu! monitoring o" serum calcium concentration and a!!ro!riate monitoring o" the underl%ing disease )eg, #>( concentration in h%!o!arath%roidism* is necessar%6

>his monitoring is im!ortant because no de"initi$e measures e?ist to determine whether an in"ant has transient h%!o!arath%roidism that ma% last "or se$eral %ears or is at ris/ "or recurrence o" h%!o!arath%roidism and h%!ocalcemia1 recurrence has been re!orted as late as adolescence6

In1O,t )atient Meds: 'agnesium administration is necessar% to correct an% h%!omagnesemia because h%!ocalcemia does not res!ond until the low magnesium le$el is corrected6

#hos!hateAlowering agents ma% be necessar% i" h%!ocalcemia is associated with h%!er!hos!hatemia6

&eterrence1)re8ention: 7ateAonset h%!ocalcemia in neonates, which is t%!icall% caused b% h%!er!hos!hatemia, can be !re$ented b% a$oiding highA!hos!hate diets )eg, regular cow&s mil/*6 Ensuring ade5uate $itamin stores in mothers during !regnanc% also !re$ents late h%!ocalcemia6

Deeding a lowA!hos!hate diet such as human mil/ or +imilac #' 603@0 "ormula ma% !re$ent h%!ocalcemia in h%!er!hos!hatemic states, such as renal "ailure, h%!o!arath%roidism, and endogenous !hos!hate loading6 Enhancing the calciumA!hos!horus ratio to @:1 in the diet )b% adding calcium su!!lements to a lowA!hos!hate diet* also reduces intestinal absor!tion o" !hos!hate6

)ro$nosis:

'ost cases o" earl% neonatal h%!ocalcemia resol$e within @8A:2 hours without an% signi"icant se5uelae6 7ate neonatal h%!ocalcemia secondar% to e?ogenous !hos!hate load and magnesium de"icienc% also res!onds $er% well to !hos!hate restriction and magnesium re!letion6 Ehen caused b% h%!o!arath%roidism, h%!ocalcemia re5uires continued thera!% with $itamin metabolites and calcium salts6 >he !eriod o" thera!% de!ends on the nature o" the h%!o!arath%roidism, which can be transient, last se$eral wee/s to months, or be !ermanent6

SLLAN-OUS tion 9 o 1! Medical1Le$al )it alls: ,ntra$enous in"usion with calciumAcontaining solutions can cause se$ere tissue necrosis6 >his can cause contractures and ma% re5uire s/in gra"ting6 ,ntegrit% o" the intra$enous site should be ascertained be"ore administering calcium through a !eri!heral $ein6

Necrosis o" li$er can occur "ollowing calcium in"usion through an umbilical $ein catheter !laced in a branch o" the !ortal $ein6 >he !osition o" all umbilical $ein catheters must be con"irmed radiologicall% be"ore in"using calciumAcontaining solutions6 Ra!id in"usion o" calciumAcontaining solutions through arterial lines can cause arterial s!asm and, i" administered $ia an umbilical arter% catheter, intestinal necrosis6

RA#(0ibiliogra!h%

4ertner H': isorders o" Calcium and #hos!horus (omeostasis6 #ediatric Clinics o" North America 1;;01 B: )6*: 1@@1A 1@69I'edlineJ6 4uise >A, 'und% 4R: E$aluation o" h%!ocalcemia in children and adults6 Hournal o" clinical endocrinolog% and metabolism 1;;91 80)9*: 1@:BA 1@:8I'edlineJ6

/I/LIO+RA)H: