From the Guidelines
Severe hypocalcemia in pediatric patients should be treated with calcium gluconate 50 to 100 mg/kg IV, administered slowly with EKG monitoring, as recommended by the guidelines for the management of pediatric and adult tumor lysis syndrome 1.
Management of Hypocalcemia
When managing severe hypocalcemia in pediatric patients, it is crucial to consider the potential risks and benefits of treatment. The guidelines suggest that asymptomatic patients do not require intervention, while symptomatic patients may be treated with calcium gluconate 50 to 100 mg/kg IV, administered slowly with EKG monitoring 1.
Key Considerations
Some key considerations when treating severe hypocalcemia in pediatric patients include:
- Monitoring for potential arrhythmias with EKG
- Risk of calcium phosphate precipitation in tissues and consequential obstructive uropathy, particularly if phosphate levels are high
- Potential need for renal consultation if phosphate levels are elevated
Treatment Approach
The treatment approach for severe hypocalcemia in pediatric patients should prioritize prompt intervention with calcium supplementation, while also addressing underlying causes and monitoring for potential complications.
Ongoing Management
Ongoing management should focus on maintaining normal calcium levels, monitoring serum calcium, phosphorus, magnesium, and parathyroid hormone levels, and addressing any underlying conditions that may be contributing to the hypocalcemia.
From the FDA Drug Label
The safety and effectiveness of Calcium Gluconate Injection have been established in pediatric patients for the treatment of acute, symptomatic hypocalcemia. Pediatric approval for Calcium Gluconate Injection, including doses, is not based on adequate and well-controlled clinical studies Safety and dosing recommendations in pediatric patients are based on published literature and clinical experience [see Dosage and Administration (2-2.2)]. Individualize the dose within the recommended range in adults and pediatric patients depending on the severity of symptoms of hypocalcemia, the serum calcium level, and the acuity of onset of hypocalcemia.
The guideline for managing severe hypocalcemia in the pediatric population is to individualize the dose of Calcium Gluconate Injection based on the:
- severity of symptoms of hypocalcemia
- serum calcium level
- acuity of onset of hypocalcemia Dosing recommendations are based on published literature and clinical experience 2.
From the Research
Definition and Diagnosis of Hypocalcemia
- 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.
Management of Hypocalcemia
- The approach to managing hypocalcemia should consider the underlying etiology and the extent to which features of hypocalcemia are present 4.
- Parenteral therapy of hypocalcemia is advisable only in medical emergencies 4.
- The aim of acute management is not to return the serum calcium to normal but rather to ameliorate the acute manifestations of hypocalcemia 4.
- Calcium replacement is the cornerstone of treatment, with elementary calcium replacement of 40 to 80 mg/kg/d recommended for asymptomatic newborns 3.
- For acute treatment of hypocalcemia in patients with symptoms of tetany or hypocalcemic convulsion, elementary calcium of 10 to 20 mg/kg (1-2 mL/kg/dose 10% calcium gluconate) is given as a slow intravenous infusion 3.
Investigation and Monitoring
- Serum total or ionized calcium levels must be monitored in preterm infants with a gestational age <32 weeks, small for gestational age infants, infants of diabetic mothers, and infants with severe prenatal asphyxia with a 1 min Apgar score of <4 3.
- A stepwise approach to the investigation of hypocalcemia dependent on the circulating serum parathyroid hormone level at the time of presentation is recommended 5.
Clinical Considerations
- Ionized hypocalcemia is common in severely ill children, with a prevalence of at least 17.9% 6.
- Patients with ionized hypocalcemia have a higher mortality rate than those with normocalcemia, although this may be due to the severity of illness rather than the hypocalcemia itself 6.
- Functional hypoparathyroidism may occur in critically ill children 6.