What is the treatment for hypocalcemia (low calcium levels) in neonates (newborns)?

From the Guidelines

Hypocalcemia in neonates should be treated promptly with calcium supplementation, typically using calcium gluconate 10% solution at a dose of 100-200 mg/kg (1-2 mL/kg) administered intravenously over 10-20 minutes with cardiac monitoring, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment approach for hypocalcemia in neonates involves prompt calcium supplementation to prevent complications such as seizures, cardiac arrhythmias, and poor feeding.

• The recommended dose for calcium gluconate is 100-200 mg/kg (1-2 mL/kg) administered intravenously over 10-20 minutes with cardiac monitoring.
• For maintenance therapy, calcium can be given as a continuous infusion at 500-800 mg/kg/day (5-8 mL/kg/day of 10% calcium gluconate) 1.
• Oral calcium supplementation may be used for less severe cases or as follow-up therapy at 50-75 mg/kg/day of elemental calcium divided into 4-6 doses.

Additional Considerations

• Vitamin D supplementation is also essential, typically with calcitriol 0.05-0.1 mcg/kg/day or ergocalciferol 800-1000 IU daily.
• Magnesium levels should be checked and corrected if low, as hypomagnesemia can impair calcium regulation.
• Frequent monitoring of serum calcium, phosphate, and magnesium levels is necessary during treatment.
• Calcium should never be mixed with bicarbonate solutions as precipitation may occur.

Goal of Treatment

The goal of treatment is to maintain ionized calcium in the normal range (1.1-1.4 mmol/L) to prevent complications such as seizures, cardiac arrhythmias, and poor feeding, which can occur with untreated hypocalcemia in this vulnerable population 1.

From the FDA Drug Label

For bolus intravenous administration: Dilute the dose of Calcium Gluconate Injection in 5% dextrose or normal saline to a concentration of 10-50 mg/mL prior to administration. Administer the dose slowly and DO NOT exceed an infusion rate of 200 mg/minute in adults or 100 mg/minute in pediatric patients, including neonates.

Table 1 provides dosing recommendations for Calcium Gluconate Injection in mg of calcium gluconate for neonates, pediatric and adult patients.

The treatment for hypocalcemia in neonates involves administering Calcium Gluconate Injection intravenously. The dose should be individualized based on the severity of symptoms, serum calcium level, and acuity of onset.

• The recommended infusion rate for neonates is 100 mg/minute or less.
• Table 1 in the drug label provides specific dosing recommendations for neonates, but the exact dosage is not specified in the provided text.
• It is essential to monitor patients' vitals, calcium levels, and electrocardiograph (ECG) during administration 2.
• Concomitant use of ceftriaxone and Calcium Gluconate Injection is contraindicated in neonates (28 days of age or younger) due to reports of fatal outcomes associated with the presence of lung and kidney ceftriaxone-calcium precipitates 2.

From the Research

Definition and Diagnosis of Hypocalcemia in Neonates

• Hypocalcemia is defined as total serum calcium <8 mg/dL (2 mmol/L) or ionized calcium <4.4 mg/dL (1.1 mmol/L) for term infants or preterm infants weighing >1500 g at birth 3
• For very low birth weight infants weighing <1500 g, hypocalcemia is defined as total serum calcium <7 mg/dL (1.75 mmol/L) or ionized calcium <4 mg/dL (1 mmol/L) 3
• Screening for hypocalcemia at the 24th and 48th hour after birth is warranted for infants with high risk of developing hypocalcemia, such as preterm infants, infants of diabetic mothers, and infants with severe prenatal asphyxia 3, 4

Treatment of Hypocalcemia in Neonates

• Calcium replacement is the cornerstone of the treatment of hypocalcemia in neonates 3, 5
• Elementary calcium replacement of 40 to 80 mg/kg/d is recommended for asymptomatic newborns 3
• For symptomatic hypocalcemia, elementary calcium of 10 to 20 mg/kg (1-2 mL/kg/dose 10% calcium gluconate) is given as a slow intravenous infusion 3
• A single dose of calcium gluconate (100 mg/kg) can raise total and ionized serum calcium and decrease clinical signs of hypocalcemia in preterm infants 5
• Treatment of hypocalcemia should be initiated immediately in infants with reduced calcium levels while investigating the etiology 3

Etiology and Management of Hypocalcemia

• Excessive phosphate intake, hypomagnesemia, hypoparathyroidism, and vitamin D deficiency are common causes of late-onset hypocalcemia 3
• Hypocalcemia should be treated according to etiology 3
• Management of chronic hypocalcemia requires knowledge of the factors that influence the complex regulatory axes of calcium homeostasis in a given disorder 6
• Treatment and management options for chronic hypocalcemia vary depending on the underlying disorder, such as hypoparathyroidism or disorders that disrupt the metabolism of vitamin D 6