neonatal hy po calcemia
DESCRIPTION
One of lectures presented in our Port said fifth neonatology conference 23-24 October 2014, presented by prof Olfat Fawzy, M.D, M.Sc.,Professor of Endocrinology Al Azhar universityTRANSCRIPT
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• Hypocalcemia is a common metabolic problem in newborns.
• The diagnosis, cl inical manifestations, and treatment of neonatal hypocalcemia will be reviewed.
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• Patient born preterm at 34 weeks• Normal spontaneous vaginal
delivery• Birth Weight: 2050 g• APGAR 8
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• 28 year old G1P0• Irrelevant medical History• Denies smoking• No medication use• No HTN, no DM• Negative serologic studies
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• Irritable, with weak cry• +ve hypertelorism• jaw held tightly closed• cleft palate• CV: RR, systolic murmur• Extremities: hypertonic
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• CBC: WNL• CMP: WNL except Ca• Ca: 6.0 mg/dL • P: 9.2 mg/dL (4.5-9.0)• Mg: 1.5 mEq/L (1.3-2.0)• PTH: 44 pg/mL (N 40-100)
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•2D Echo reveals a small VSD•Hypoplastic thymus
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•Hypocalcemia•Hypoparathyroidism•VSD•Hypoplastic thymus
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• Plasma calcium totals 2.4 mM (9.4 mg/dl)– Free calcium is 1.2 mM
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– Albumin
– Blood pH
– Serum phosphate
– Serum magnesium
– Serum bicarbonate
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Hormone Effect Bone Gut Kidney
PTH Ca Po4 Increases Osteoclasts
Indirect via Vit. D
Ca reabPo4 exr.
Vit D3 Ca Po4 No direct action
Ca Po4 absorption
No direct effect
Calcitonin Ca Po4 Inhibits Osteoclasts
No direct effect
Ca & Po4 excretion
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• Ca messenger system – regulates cell function
• Activates cellular enzyme cascades
• Smooth muscle and myocardial contraction
• Nerve impulse conduction
• Secretory activity of glands
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• Neuromuscular excitabil ity
• Tetany• Seizures• Stridor or cyanosis
from laryngospasm• Hypotension• Impaired cardiac
contractil ity
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• May be unspecific– Asymptomatic– Lethargy– Poor feeding– Vomiting– Abdominal distention
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• Fetus: Ca and P concentration higher than mother plasma, s Ca falls at 24 hrs.
• Neonates: Ca lower than children at 2 n d and 3th day
• Return to normal by 5-10 days
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•Total serum Ca less than:– 7.0 mg/dL in Preterm infants– 8.0 mg/dL in Term newborns– 8.8 mg/dL in children
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Early neonatal hypocalcemia (48-72 hours)Prematurity
Poor intake, hypoalbuminemia, ↓ responsiveness to vit D
Birth asphyxiaDelayed feeding, ↑ calcitonin, endogenous
phosphate load , alkali therapy
Infant of diabetic motherMg depletion functional hypoparathyroidism → →
↓ CaIUGR
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Late neonatal hypocalcemia (Full term)
•Exogenous phosphate load•Mg deficiency
•Transient hypoparathyroidism of newborn
•Congenital Hypoparathyroidism
•Maternal Vit D deficiency•Maternal Hyperparathyroidism•Gentamycin
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Bicarbonate infusion → metabolic alkalosis
Transfusion with citrated blood→ formation of Ca complexes, ↓ Ca++
Lipid infusions → Ca complexes with FFAs → ↓ Ca++
Phototherapy for hyperbil irubinemia Acute renal failure →
hyperphosphatemiaRotavirus infection
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• ↓ Mg → impaired PTH secretion & resistance to PTH → hypocalcemia
• Usually idiopathic & transient
• May be secodary to disorders of intestinal and/or renal tubular Mg transport
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• Antagonizes PTH secretion or actions → ↑ Ca & P deposition in bones → hypocalcemia.
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Cardiac defects, Abnormal facies, Thymic hypoplasia, Cleft palate, and Hypocalcemia caused by Chromosome 22 deletion
DiGeorge Syndrome is a severe phenotype of this group of related disorders.
FISH establishes the diagnosis.
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• What is the diagnosis?
• How could we confirm the diagnosis?
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• Total Ca• Ionized Ca• Phosphorus• Magnesium
• PTH • Vitamin D • Liver function• Renal function
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Only in infants with risk factors
Measure Ca at 24, and 48 hrs of age.
Measure Ca in infants with congenital heart ds.
Ionized Ca should be the primary measurement.
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1. Depends on underlying cause & severity
2. Mild asymptomatic : ↑ dietary Ca by initiating early feeding
3. For infants who require parenteral nutrit ion, Ca is added to the solution .
4. If symptomatic: treat immediately
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– Ca gluconate:10 mg/kg (1 ml/kg of 10% solution) Slowly IV
– Start oral Calcium as soon as possible
– Early neonatal hypocalcaemia normalizes in 2-3 d
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Late neonatal hypocalcemia– Associated with ↑ S-phosphate
–Decrease phosphate intake– Give calcium containing phosphate
binder – Oral calcium gluconate 100
mg/kg/dose 4 hourly
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– Tissue necrosis/calcif ication if extravasates
– Calcium can inhibit sinus node → bradycardia + arrest
– Avoid complete correction of hypocalcemia
– Give Ca before correcting acidosis
– If ↓ Mg – f irst treat & correct hypomagnesemia
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