What is the treatment for hypocalcemia (low calcium level) in a six-year-old child?

Treatment of Hypocalcemia in a Six-Year-Old Child

For symptomatic hypocalcemia in a six-year-old child, administer calcium gluconate 50-100 mg/kg IV slowly with ECG monitoring; for asymptomatic hypocalcemia, no immediate intervention is required but the underlying cause must be identified and treated. 1

Immediate Management Based on Symptoms

Symptomatic Hypocalcemia

• Administer calcium gluconate 50-100 mg/kg IV slowly with continuous ECG monitoring for bradycardia. 1
• Symptoms requiring immediate treatment include tetany, seizures, muscle cramps, paresthesias, tremors, rigidity, or cardiac arrhythmias (including QT prolongation). 1
• Calcium chloride (20 mg/kg or 0.2 mL/kg of 10% solution) provides more rapid increase in ionized calcium than calcium gluconate and is preferred for critically ill children, though calcium gluconate (60 mg/kg) may be substituted if calcium chloride is unavailable. 1
• Central venous administration is preferred as extravasation through peripheral IV can cause severe skin and soft tissue injury. 1

Asymptomatic Hypocalcemia

• No immediate intervention is recommended for asymptomatic patients. 1
• However, treatment should be initiated while investigating the underlying etiology, as hypocalcemia can become symptomatic unpredictably. 2

Identify and Treat the Underlying Cause

Essential Diagnostic Workup

• Measure serum calcium (total and ionized), albumin, intact parathyroid hormone (iPTH), 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, phosphorus, magnesium, blood urea nitrogen, and creatinine. 3
• The iPTH level is the most important initial test to distinguish PTH-dependent from PTH-independent causes. 3

Common Etiologies in Children

Hypoparathyroidism:

• Most common cause of chronic hypocalcemia in children, often associated with genetic syndromes like 22q11.2 deletion syndrome (DiGeorge syndrome). 1
• Approximately 60% of children with 22q11.2DS have hypocalcemia, which can recur during periods of biological stress (illness, surgery, puberty). 1
• Treatment requires daily calcium and vitamin D supplementation with careful titration. 1
• Active vitamin D metabolites (calcitriol or alfacalcidol) are typically required for hypoparathyroidism management. 1, 4

Vitamin D Deficiency:

• A major cause of hypocalcemia in children worldwide. 5, 4
• Supplement with native vitamin D (cholecalciferol or ergocalciferol) if deficiency is documented. 1

Hypomagnesemia:

• Can impair PTH secretion and cause hypocalcemia. 1, 4
• Magnesium supplementation is indicated when hypomagnesemia is present, as hypocalcemia will not resolve without correcting magnesium levels. 1

Long-Term Management Considerations

Chronic Supplementation

• Daily calcium supplementation should provide adequate elemental calcium based on age-appropriate reference daily intake. 1
• For hypoparathyroidism, treatment typically includes calcium supplements and active vitamin D (calcitriol 20-30 ng/kg/day or alfacalcidol 30-50 ng/kg/day). 1
• Carefully titrate calcium and vitamin D to avoid hypercalcemia, hypercalciuria, nephrocalcinosis, and renal dysfunction. 1

Monitoring Requirements

• Regular monitoring of serum calcium, phosphorus, magnesium, and renal function is essential. 1
• Monitor urine calcium/creatinine ratio to detect hypercalciuria, which can lead to nephrocalcinosis. 1
• Keep calciuria levels within normal range by ensuring regular water intake, considering potassium citrate administration, and limiting sodium intake if hypercalciuria develops. 1

Critical Pitfalls to Avoid

• Do not administer calcium if phosphate levels are severely elevated, as this increases risk of calcium-phosphate precipitation in tissues and obstructive uropathy. 1
• Renal consultation may be necessary when treating hypocalcemia in the presence of hyperphosphatemia. 1
• Avoid over-correction, which can result in iatrogenic hypercalcemia, renal calculi, and renal failure. 1
• In patients with 22q11.2DS or other genetic syndromes, avoid multivitamin preparations containing vitamin D in early childhood and use vitamin D supplementation with caution. 1
• Monitor for increased risk of hypocalcemia during periods of biological stress including surgery, acute illness, or decreased oral intake. 1