Hypocalcemia & Hypercalcemia

Emergency pediatric PICU division

Pediatric Department
Medical Faculty, University of Sumatera Utara
H. Adam Malik Hospital
1
HYPOCALCEMIA
2
Because of potentially severe symptoms such as
laryngospasm and seizures, hypocalcemia needs to be
identified and treated expeditiously
The ionized calcium concentration is low in true hypocalcemia
The total calcium concentration does not accurately predict
the ionized calcium concentration in the patient with
hypoalbuminemia the ionized calcium concentration
should be determined in patients with suspected
hypocalcemia when the patient is hypoalbuminemic and/or is
critically ill

3

SPECIFIC CAUSES IN THE NEONATE
Early neonatal hypocalcemia
Late neonatal hypocalcemia
Maternal hypercalcemia

HYPOPARATHYROIDISM
DiGeorge syndrome (MIM
*
188400)
X-linked hypoparathyroidism (MIM 307700)
Parathyroid hormone (PTH) gene mutations (MIM 168450)
Calcium-sensing receptor mutation (MIM 601199)
Autosomal recessive hypoparathyroidism with dysmorphic features (MIM 241410)
HDR (or Barakat) syndrome (MIM 146255)
Autoimmune polyglandular syndrome type I (MIM 240300)
Kearns-Sayre syndrome (MIM 530000)
Hemochromatosis
Wilson disease (MIM 277900)
Postsurgical hypoparathyroidism
Radioactive iodine ablation of the thyroid gland
Hypomagnesemia
Causes of hypocalcemia
4
LACK OF RESPONSE TO PTH
Pseudohypoparathyroidism type IA (MIM 103580)
Pseudohypoparathyroidism type IB (MIM 603233)
Pseudohypoparathyroidism type II
Hypomagnesemia

VITAMIN D DEFICIENCY
Poor intake
Lack of sunlight
Malabsorption
Increased metabolism (e.g., anticonvulsants)
Failure to form 25-hydroxyvitamin D in the liver
Vitamin Ddependent rickets type 1 (MIM 264700)
Vitamin Ddependent rickets type 2 (MIM 277420)
Renal insufficiency
Causes...
REDISTRIBUTION OF PLASMA CALCIUM
Hyperphosphatemia
Rhabdomyolysis
Tumor lysis syndrome
Blood transfusions
Hungry bone syndrome
Acute pancreatitis
Osteopetrosis, infantile (MIM 259700)

INADEQUATE CALCIUM INTAKE
Calcium-poor diet or TPN
Dietary calcium chelators
Malabsorption

UNKNOWN
Septic shock
Critical illness

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Clinical Manifestation
Mild hypocalcemia is usually asymptomatic
The clinical manifestations are mostly due to neuromuscular irritability
Older children: paresthesias, typically perioral or of the hands and feet
Tetany is the classic manifestation of hypocalcemia, and symptoms may
include carpopedal spasm, laryngospasm, and seizures
Seizures may be the first manifestation of hypocalcemia, especially in
infants
Symptoms of tetany may be provoked in patients with hypocalcemia by
hyperventilation, which by raising the pH causes calcium to bind to
albumin, thereby lowering the ionized calcium concentration

6
Newborn infants with hypocalcemia usually do not have carpopedal
spasm. Along with seizures, manifestations in newborns may include
irritability, muscular twitching, jitteriness, and tremors. Alternatively,
newborns with hypocalcemia may have symptoms suggestive of sepsis,
such as poor feeding, vomiting, and lethargy
The consequences of long-standing hypocalcemia depend on the etiology.
In children with inadequate vitamin D, there is concomitant
hypophosphatemia and secondary hyperparathyroidism. These patients
have inadequate bone mineralization, and consequently develop rickets
Rickets may also occur with severe dietary calcium deficiency
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Chvostek and Trousseau signs
may be elicited in patients with
hypocalcemia
A positive Chvostek sign occurs
if tapping the facial nerve anterior
to the external auditory meatus
elicits a twitch of the upper lip or
entire mouth. This is not a very
specific sign because it is
positive in about 10% of patients
without hypocalcemia

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9
http://www.wrongdiagnosis.com/bookimages/14/4721.1.png
10
Trousseau sign is more specific, but
quite uncomfortable to elicit and
generally not an appropriate test in
a child
A blood pressure cuff is inflated
slightly above the systolic blood
pressure for more than 3 min;
carpopedal spasm occurs if
hypocalcemia is present as a result
of the ischemia of the motor nerves
11
http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe002g/dwe00215g01.gif
Diagnosis & Treatment
Diagnosis of the patient with hypocalcemia
should begin with a thorough history of dietary
intake.
It should also include an investigation of family
history of rickets, hypocalcemia and endocrine
disorders. Physical examination should include
a close evaluation of the bones and joints
12
A primary tenet in the treatment of hypocalcemia is to tailor the therapy to
the cause of hypocalcemia
Calcium may be given IV or orally
Acute symptomatic hypocalcemia: a bolus dose of Ca gluconate (100-
200mg/kg or 9-18 mg/kg elemental Ca to a maximum of 1-3 g in adults)
should be administered over 10-20 mins. A continuous infusion of Ca
gluconate inf may be administered at starting dose of 10-30 mg/kg/hr, the
rate can then be titrated based on serial Ca measurement
All patients receiving IV Ca require close monitoring of total or ionized Ca
levels and cardiac ECG
13
Rogers textbook of pediatric intensive care, 4
th
ed, 2008
For symptomatic hypocalcemia in neonates, calcium gluconate is given
at a dose of 100200 mg/kg (12 mL/kg of a 10% solution; 918 mg of
elemental Ca/kg)
This dose may be repeated every 68 hr until the calcium level
stabilizes
Alternatively, calcium gluconate may be given as a constant
intravenous infusion, with neonates typically requiring 500
750 mg/kg/24 hr of calcium gluconate
14
Nelson Textbook of pediatrics, 17
th
ed, 2004

HYPERCALCEMIA
15
Hypercalcemia is frequently discovered incidentally on a routine
chemistry profile
This is because hypercalcemia is an uncommon electrolyte disorder, and
its clinical manifestations are fairly nonspecific
There are, however, some clinical situations in which hypercalcemia
should be suspected

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EXCESS PARATHYROID HORMONE
Primary hyperparathyroidism
Sporadic adenoma
Familial isolated hyperparathyroidism (MIM
*
145000)
Multiple endocrine neoplasia type I (MIM 131100)
Multiple endocrine neoplasia type II (MIM 171400)
Hyperparathyroidismjaw tumor syndrome (MIM 145001)
Calcium-sensing receptor mutation (MIM 239200)
Transient secondary neonatal hyperparathyroidism
Tertiary hyperparathyroidism

EXCESS VITAMIN D
Hypervitaminosis D
Subcutaneous fat necrosis
Sarcoidosis
Granulomatous diseases
Lymphomas

EXCESS CALCIUM INTAKE
Calcium supplements
Iatrogenic (e.g., total parenteral nutrition)

EXCESS RENAL REABSORPTION OF CALCIUM
Familial benign hypocalciuric hypercalcemia (MIM 145980)
Thiazide diuretics
RELEASE FROM BONE
Thyrotoxicosis
Hypervitaminosis A
Malignancy associated
Ectopic parathyroid hormone (PTH)
PTH-related peptide
Bone metastasis
Other factors
Immobilization
Renal osteodystrophy
Low turnover disease
Aluminum deposition

MISCELLANEOUS
Williams syndrome (MIM 194050)
Hypophosphatemia
Pheochromocytoma
Adrenal insufficiency
Recovery phase of rhabdomyolysis
Jansen metaphyseal chondrodysplasia
(MIM 156400)
Hypophosphatasia (MIM 241500)



Causes of hypercalcemia








Clinical Manifestation
The signs and symptoms of hypercalcemia are related to the magnitude of
the problem
Hypercalcemia is conventionally classified as mild (<12 mg/dL), moderate
(1215 mg/dL), or severe (>15 mg/dL)
Many patients with mild or moderate hypercalcemia are asymptomatic,
with the diagnosis resulting from an incidental laboratory test
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GASTROINTESTINAL
Nausea and vomiting
Poor feeding
Failure to thrive
Constipation
Abdominal pain
Pancreatitis
Peptic ulcer

CARDIAC
Hypertension
Decreased QT interval
Arrhythmias

CENTRAL NERVOUS SYSTEM
Lethargy
Hypotonia
Psychiatric disturbances
Coma
KIDNEY
Polyuria and dehydration
Hypernatremia
Renal failure
Nephrolithiasis


Clinical manifestations of hypercalcemia
Treatment
Dependent on its severity
The initial basic tenets of therapy are to restore intravascular volume and to
enhance renal excretion, which can be accomplished by administration of
normal saline at 2 or 3 times maintenance fluid rate
If the patient is adequately rehydrated and Ca levels do not decrease, loop
diuretics may be administered, but should be done judiciously
Calcitonin and biphosponate are useful adjuncts in hypercalcemia
In severe cases in which hydration and medications fail to reduce serum Ca
levels, hemodialysis using a low Ca dialysate can be performed
Glucocorticoids have been useful in treating hypercalcemia secondary to
sarcoidosis and vit D deficiency
20
Rogers textbook of pediatric intensive care, 4
th
ed, 2008
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