Is calcium chloride used in pediatric patients?

Calcium Chloride Use in Pediatric Patients

Calcium chloride is NOT routinely used in pediatric cardiac arrest, but it IS indicated for specific life-threatening conditions including documented hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker toxicity. 1

When Calcium Chloride Should NOT Be Used

Routine administration of calcium during pediatric cardiopulmonary arrest is NOT recommended and may cause harm (Class III: Harm recommendation). 1 The evidence is clear on this point:

• Multiple studies demonstrate no improvement in survival to hospital discharge when calcium is given during cardiac arrest without specific indications 1
• Data from the National Registry of Cardiopulmonary Resuscitation showed children receiving calcium had an adjusted odds ratio of survival to discharge of only 0.6 1
• One multicenter study found calcium administration was an independent predictor of hospital mortality with an odds ratio of 2.24 1
• The 2020 American Heart Association guidelines explicitly state this as a Class III: Harm recommendation with B-NR level of evidence 1

Specific Indications Where Calcium Chloride IS Used

Calcium chloride is appropriate in pediatric patients for these documented conditions:

Life-Threatening Hyperkalemia

• Administer 20 mg/kg (0.2 mL/kg of 10% calcium chloride) IV/IO by slow push during cardiac arrest 1
• For symptomatic hyperkalemia with ECG changes, give 100-200 mg/kg/dose via slow infusion with continuous ECG monitoring 1, 2
• Calcium stabilizes the myocardial cell membrane but does not lower potassium levels—must be combined with therapies that shift potassium intracellularly (insulin/glucose, bicarbonate, albuterol) 2
• In hyperkalemia treatment sequences, calcium should be administered first, followed by sodium bicarbonate, then insulin with dextrose 3

Documented Hypocalcemia

• Only treat symptomatic hypocalcemia 1, 4, 2
• Asymptomatic hypocalcemia does NOT require treatment 1, 4, 2
• Dose: 20 mg/kg (0.2 mL/kg of 10% calcium chloride) infused over 30-60 minutes for non-arrest situations 1

Calcium Channel Blocker Toxicity

• Administer 20 mg/kg (0.2 mL/kg of 10% calcium chloride) by slow push for cardiac arrest 1
• For non-arrest CCB poisoning: infuse over 5-10 minutes, followed by continuous infusion of 20-50 mg/kg per hour 1
• Monitor serum ionized calcium to prevent hypercalcemia 1

Hypermagnesemia

• Use calcium chloride 20 mg/kg during cardiac arrest associated with documented hypermagnesemia 1

Critical Administration Considerations

Route and Monitoring

• Central venous catheter administration is strongly preferred 1
• Peripheral IV extravasation can cause severe skin and soft tissue injury 1
• Continuous ECG monitoring is mandatory during administration 1, 4, 2
• Stop injection immediately if symptomatic bradycardia occurs 1, 4

Calcium Chloride vs. Calcium Gluconate

• Calcium chloride is preferred in critically ill children because it results in more rapid increase in ionized calcium concentration 1, 4
• Calcium gluconate (60 mg/kg) may be substituted if calcium chloride is unavailable 1
• In cardiac arrest situations specifically, calcium chloride is the preferred formulation 4

Drug Interactions and Contraindications

• Never administer calcium and sodium bicarbonate through the same IV line—risk of precipitation 1, 2
• Administer very cautiously to digitalized patients due to additive cardiac effects 5

Dosing Specifics from FDA Label

The FDA-approved pediatric dosing for hypocalcemic disorders is 2.7 to 5.0 mg/kg of hydrated calcium chloride (equivalent to 0.027 to 0.05 mL/kg of 10% calcium chloride injection) 5. Textbook references recommend repeat dosing every 4-6 hours if needed 5. The 10% concentration provides 27 mg (1.4 mEq) of elemental calcium per mL 5.

Important Clinical Pitfalls

• Do not confuse calcium chloride with calcium gluconate dosing—they are NOT equivalent on a mg-per-mg basis 1
• In tumor lysis syndrome with hyperphosphatemia, calcium administration increases risk of calcium phosphate precipitation and obstructive uropathy—consider renal consultation first 1, 2
• Medication preparation for hyperkalemia takes significantly longer in smaller children (median 16.3 minutes for 4 kg patients vs. 6.8 minutes for 50 kg patients) 3
• Dosing errors occur in 42% of medication preparations for hyperkalemia treatment 3