Neonatal Hypocalcemia
Content
NEONATAL HYPOCALCEMIA
INTRODUCTION
Both calcium and maternal parathyroid hormone cross the placenta.
There is an active transport of calcium and phosphorous to the fetus from
maternal sources and fetal concentrations of calcium are about 1.0mg/dl
higher than the maternal. Most of placental transport of calcium takes place
during last trimester of pregnancy so that prematurely born infants have
deficient stores of calcium. Small for dates infants usually have normal
serum calcium levels and stores of calcium in the body. Serum calcium levels
falls after birth especially in preterm babies and a state of physiological
hypocalcaemia is achieved during 24 to 36 hours of age.
DEFINITION
Neonatal hypocalcaemia is defined as a total serum calcium concentration
less than 7.0 mg/dl and an ionized calcium concentration less than 4
mg/dl.Lowest level in term babies occurs at 24-48 hours of age and in
preterm’s at 12 hours of age.
ETIOLOGY
1. EARLY-ONSET HYPOCALCEMIA
Immaturity
There is a direct correlation between birth weight and
serum calcium. About 50 % of infants weighing less than 2500gm and
75%of those weighing less than 1500gm may show transient selflimited hypocalcaemia during first 24 hours of life. Various factors
which Predispose low birth weight babies to develop hypocalcaemia
include low calcium stores due to early birth, delayed feeding, renal
immaturity and reduced immaturity and GFR rate leading to retention
of phosphates,hypoproteinemia,frequent administration of sodium
bicarbonate solution and respiratory distress syndrome.
2. MATERNAL DIABETES MELLITUS
About 25 to 50 % of babies born to diabetic mothers may develop
hypocalcaemia which is believed to be due to immaturity and
hypercorticism though the evidence for latter is controversial.
3. COMPLICATIONS DURING DELIVERY
Perinatal hypoxia, difficult and prolonged delivery, emergency CS
especially following a trial of labour, toxemia and APH are associated
with incidence of hypocalcaemia.
4. LATE-ONSET
NEONATAL
HYPOCALCEMIA
(CLASSICAL
TETANY)
It is characterized by onset of tetany at the age of 5 to 10 days in
healthy term babies receiving artificial feeding. The ingestion of milk
with high phosphate content or low calcium/phosphorous ratio leads to
hyperphosphatemia and hypocalcaemia in the neonate.
UNCOMMON CAUSES
Maternal hypoparathyroidism
Hypomagnesaemia
Di george’s syndrome
phototherapy
Exchange transfusion
Renal disorders
CLINICAL MANIFESTATIONS
Usually, there are no specific features of hypocalcaemia especially in preterm
babies. Many cases are asymptomatic and transient. Convulsions are usually
seen in late onset hypoglycemia.Jitteriness, apnea, increased extensor tone,
clonus,hyperreflexia,stridor,high pitched cry larygospasm is seen in some
cases.
DIAGNOSIS
History of familial hypocalcemia,maternal complications during pregnancy,
birth asphyxia and type of milk intake should be asked in all suspect cases.
Babies should be weighed, gestational age determined and clinical features
should be looked for.
Serum level of calcium should be determined in all suspect cases.
Prophylactic monitoring of serum calcium levels at 12,24 and 48 hours
should be done in
All preterms<1500grams
All sick and stressed newborns
Infants of IDDM mothers
Electrocardiography is very reliable for diagnosis and monitoring.
TREATMENT
Parenteral calcium therapy is required in presence of extreme irritability,
convulsions or apneic spells when other causes have been ruled out. Calcium
gluconate 10%solution should be injected slowly at a rate of 1ml/min
monitoring heart rate. Magnesium and vitamin D should be given in
unresponsive cases. Calcium and phosphorous supplementation is required
in preterm babies<1500grams.210 mg/kg of calcium and 100mg/kg of
phosphorous should be supplemented using oral preparation containing
calcium and phosphorous in ratio 2:1. The supplementation should continue
till 40 weeks postconceptional age.
PROGNOSIS
Prognosis of hypocalcemic seizures is good. Development of child is usually
normal. Prognosis in cases of natal complications depends on nature and
severity of associated complications.
NURSING DIAGNOSIS
1. Impaired breathing pattern dyspnea related to poor lung maturity
secondary to respiratory distress.
Baby should be positioned with neck extended
Tackling stimulation by sole flaring can be provided to
stimulate respiratory effort
Do gentle suctioning to remove the secretion
Baby’s respiratory rate,rhythum,signs of distress,oxygen
saturation etc to be monitored at frequent intervals
2. Impaired nutrition less than body requirement related to poor
sucking reflex
If the baby is able to suck encourage breast milk
If baby is unable to suck provide expressed breast milk with
the help of palada.
If aspiration is evident then give through NG tube.
Early enteral feeding should be started as soon as the baby is
stable.
Administer 10% glucose through IV
3. High risk for infection related to poor immunity
The baby should be observed for respiration,skin
temperature,heart rate and skin colour,activity,feeding
behavior,passage of meconium or stool and urine,condition of
umbilical cord,oral cavity
Any abnormal signs like edema,bleeding vomiting should be
noted.
One person as to handle the baby
Wash hands before touching each baby
SUMMARY
In
this
seminar
I
had
dealt
with
neonatal
hypoglycemeia,hypocalcemia.hypomagnesemia its definition,etiology,clinical
symptoms,prognosis,prevention,management and treatment.
CONCLUSION
A common metabolic disorder due to inability to maintain glucose
homeostasis resulting from an imbalance between systemic organ
requirement and the production of glucose essentially due to a metabolic
transition from regular supply of nutrients in intrauterine life to intermittent
meal intake in the postnatal life.
BIBLIOGRAPHY
Dorothy R Marlow,Barbara A Redding,Textbook of Pediatric
Nursing 6th edition,2009
D.C.Dutta’s,Textbook of obstetrics,6th edition,2004,Page
no:480-481.
Nelson Text book of Paediatrics,7 th edition,Sunders
Publishers,Page no:287,442.
Mehaban Singh,Textbook on Care of the newborn360-365.
Annamma Jacob,A comprehensive Textbook on midwifery
and
gynaecological
nursing,1st
edition,2005,Jaypee
publishers.
Arvind Sali,challenges in Neonatology,1st edition,jaypee
.publications.Page No:17-25
JOURNALS
The Indian journal of Paediatrics Dr.Varma I C,Volume
79/number 2/March 2012 Page Number 58-61.
The Indian journal of Paediatrics Dr.Varma I C,Volume
79/Number 12/March 2010 Page No:97-99.
INTERNET
www.scribd.com
www.wikipedia.com
INTRODUCTION
Both calcium and maternal parathyroid hormone cross the placenta.
There is an active transport of calcium and phosphorous to the fetus from
maternal sources and fetal concentrations of calcium are about 1.0mg/dl
higher than the maternal. Most of placental transport of calcium takes place
during last trimester of pregnancy so that prematurely born infants have
deficient stores of calcium. Small for dates infants usually have normal
serum calcium levels and stores of calcium in the body. Serum calcium levels
falls after birth especially in preterm babies and a state of physiological
hypocalcaemia is achieved during 24 to 36 hours of age.
DEFINITION
Neonatal hypocalcaemia is defined as a total serum calcium concentration
less than 7.0 mg/dl and an ionized calcium concentration less than 4
mg/dl.Lowest level in term babies occurs at 24-48 hours of age and in
preterm’s at 12 hours of age.
ETIOLOGY
1. EARLY-ONSET HYPOCALCEMIA
Immaturity
There is a direct correlation between birth weight and
serum calcium. About 50 % of infants weighing less than 2500gm and
75%of those weighing less than 1500gm may show transient selflimited hypocalcaemia during first 24 hours of life. Various factors
which Predispose low birth weight babies to develop hypocalcaemia
include low calcium stores due to early birth, delayed feeding, renal
immaturity and reduced immaturity and GFR rate leading to retention
of phosphates,hypoproteinemia,frequent administration of sodium
bicarbonate solution and respiratory distress syndrome.
2. MATERNAL DIABETES MELLITUS
About 25 to 50 % of babies born to diabetic mothers may develop
hypocalcaemia which is believed to be due to immaturity and
hypercorticism though the evidence for latter is controversial.
3. COMPLICATIONS DURING DELIVERY
Perinatal hypoxia, difficult and prolonged delivery, emergency CS
especially following a trial of labour, toxemia and APH are associated
with incidence of hypocalcaemia.
4. LATE-ONSET
NEONATAL
HYPOCALCEMIA
(CLASSICAL
TETANY)
It is characterized by onset of tetany at the age of 5 to 10 days in
healthy term babies receiving artificial feeding. The ingestion of milk
with high phosphate content or low calcium/phosphorous ratio leads to
hyperphosphatemia and hypocalcaemia in the neonate.
UNCOMMON CAUSES
Maternal hypoparathyroidism
Hypomagnesaemia
Di george’s syndrome
phototherapy
Exchange transfusion
Renal disorders
CLINICAL MANIFESTATIONS
Usually, there are no specific features of hypocalcaemia especially in preterm
babies. Many cases are asymptomatic and transient. Convulsions are usually
seen in late onset hypoglycemia.Jitteriness, apnea, increased extensor tone,
clonus,hyperreflexia,stridor,high pitched cry larygospasm is seen in some
cases.
DIAGNOSIS
History of familial hypocalcemia,maternal complications during pregnancy,
birth asphyxia and type of milk intake should be asked in all suspect cases.
Babies should be weighed, gestational age determined and clinical features
should be looked for.
Serum level of calcium should be determined in all suspect cases.
Prophylactic monitoring of serum calcium levels at 12,24 and 48 hours
should be done in
All preterms<1500grams
All sick and stressed newborns
Infants of IDDM mothers
Electrocardiography is very reliable for diagnosis and monitoring.
TREATMENT
Parenteral calcium therapy is required in presence of extreme irritability,
convulsions or apneic spells when other causes have been ruled out. Calcium
gluconate 10%solution should be injected slowly at a rate of 1ml/min
monitoring heart rate. Magnesium and vitamin D should be given in
unresponsive cases. Calcium and phosphorous supplementation is required
in preterm babies<1500grams.210 mg/kg of calcium and 100mg/kg of
phosphorous should be supplemented using oral preparation containing
calcium and phosphorous in ratio 2:1. The supplementation should continue
till 40 weeks postconceptional age.
PROGNOSIS
Prognosis of hypocalcemic seizures is good. Development of child is usually
normal. Prognosis in cases of natal complications depends on nature and
severity of associated complications.
NURSING DIAGNOSIS
1. Impaired breathing pattern dyspnea related to poor lung maturity
secondary to respiratory distress.
Baby should be positioned with neck extended
Tackling stimulation by sole flaring can be provided to
stimulate respiratory effort
Do gentle suctioning to remove the secretion
Baby’s respiratory rate,rhythum,signs of distress,oxygen
saturation etc to be monitored at frequent intervals
2. Impaired nutrition less than body requirement related to poor
sucking reflex
If the baby is able to suck encourage breast milk
If baby is unable to suck provide expressed breast milk with
the help of palada.
If aspiration is evident then give through NG tube.
Early enteral feeding should be started as soon as the baby is
stable.
Administer 10% glucose through IV
3. High risk for infection related to poor immunity
The baby should be observed for respiration,skin
temperature,heart rate and skin colour,activity,feeding
behavior,passage of meconium or stool and urine,condition of
umbilical cord,oral cavity
Any abnormal signs like edema,bleeding vomiting should be
noted.
One person as to handle the baby
Wash hands before touching each baby
SUMMARY
In
this
seminar
I
had
dealt
with
neonatal
hypoglycemeia,hypocalcemia.hypomagnesemia its definition,etiology,clinical
symptoms,prognosis,prevention,management and treatment.
CONCLUSION
A common metabolic disorder due to inability to maintain glucose
homeostasis resulting from an imbalance between systemic organ
requirement and the production of glucose essentially due to a metabolic
transition from regular supply of nutrients in intrauterine life to intermittent
meal intake in the postnatal life.
BIBLIOGRAPHY
Dorothy R Marlow,Barbara A Redding,Textbook of Pediatric
Nursing 6th edition,2009
D.C.Dutta’s,Textbook of obstetrics,6th edition,2004,Page
no:480-481.
Nelson Text book of Paediatrics,7 th edition,Sunders
Publishers,Page no:287,442.
Mehaban Singh,Textbook on Care of the newborn360-365.
Annamma Jacob,A comprehensive Textbook on midwifery
and
gynaecological
nursing,1st
edition,2005,Jaypee
publishers.
Arvind Sali,challenges in Neonatology,1st edition,jaypee
.publications.Page No:17-25
JOURNALS
The Indian journal of Paediatrics Dr.Varma I C,Volume
79/number 2/March 2012 Page Number 58-61.
The Indian journal of Paediatrics Dr.Varma I C,Volume
79/Number 12/March 2010 Page No:97-99.
INTERNET
www.scribd.com
www.wikipedia.com
