What is the recommended dose of intravenous (IV) calcium gluconate for pediatric patients?

Pediatric Intravenous Calcium Gluconate Dosing

For pediatric patients requiring IV calcium gluconate infusion, the FDA-approved dosing is 200-500 mg/kg/day (equivalent to 18-46.5 mg/kg/day elemental calcium) administered as a continuous infusion or divided doses, with a maximum infusion rate not exceeding 100 mg/minute in children. 1

Standard Dosing by Clinical Indication

Acute Symptomatic Hypocalcemia (Tetany, Seizures)

• Administer 10-20 mg/kg elemental calcium (equivalent to 100-200 mg/kg calcium gluconate or 1-2 mL/kg of 10% solution) as a slow IV bolus over 5-10 minutes with continuous cardiac monitoring 2, 3
• The infusion rate must not exceed 100 mg/minute in pediatric patients to prevent cardiac arrhythmias 1
• Follow the acute bolus with a continuous infusion of 200-500 mg/kg/day calcium gluconate to maintain serum calcium levels 1

Asymptomatic Hypocalcemia

• Provide 40-80 mg/kg/day elemental calcium (equivalent to 400-800 mg/kg/day calcium gluconate) as maintenance therapy 3
• This can be administered as a continuous infusion or divided into multiple doses throughout the day 1

Life-Threatening Hyperkalemia

• Give 100-200 mg/kg/dose calcium gluconate (1-2 mL/kg of 10% solution) via slow IV infusion with ECG monitoring for bradycardia 2
• This dose stabilizes cardiac membranes but does not lower potassium levels 2

Critical Administration Guidelines

Dilution and Preparation

• Always dilute calcium gluconate prior to administration in 5% dextrose or normal saline 1
• For bolus administration: dilute to a concentration of 10-50 mg/mL 1
• For continuous infusion: dilute to a concentration of 5.8-10 mg/mL 1
• Use the diluted solution immediately after preparation 1

Infusion Rate Restrictions

• Maximum rate: 100 mg/minute in all pediatric patients, including neonates 1
• Slower rates (over 5-10 minutes) are preferred for acute symptomatic treatment to minimize cardiac complications 2, 3
• Rapid administration can cause bradycardia, cardiac arrhythmias, and cardiac arrest 1

Monitoring Requirements

• Monitor ECG continuously during bolus administration 2, 1
• Measure serum calcium every 4-6 hours during intermittent infusions 1
• Measure serum calcium every 1-4 hours during continuous infusion 1
• Check serum magnesium levels, as hypomagnesemia must be corrected concurrently for effective calcium repletion 2

Special Populations and Adjustments

Neonates and Preterm Infants

• For early-onset neonatal hypocalcemia: 200-800 mg/kg/day calcium gluconate (equivalent to 18-74 mg/kg/day elemental calcium) 2
• A single dose of 100 mg/kg calcium gluconate effectively raises total and ionized calcium in hypocalcemic preterm infants within 3-6 hours 4
• Very low birth weight infants (<1500g) require lower thresholds for treatment initiation 3

Renal Impairment

• Initiate at the lowest dose of the recommended range for all age groups 1
• Monitor serum calcium every 4 hours in patients with renal impairment 1
• Risk of hypercalcemia is substantially increased with reduced renal function 1

Critical Drug Incompatibilities

Absolute Contraindications

• Never mix calcium gluconate with ceftriaxone—this combination forms fatal precipitates 1
• In neonates ≤28 days, ceftriaxone and IV calcium-containing products are absolutely contraindicated even if given sequentially 1
• In patients >28 days, ceftriaxone and calcium may be given sequentially only if infusion lines are thoroughly flushed between administrations 1

Other Incompatibilities

• Do not mix with bicarbonate-containing fluids—precipitation will occur 1
• Do not mix with phosphate-containing solutions—precipitation will occur 1
• Do not mix with minocycline—calcium complexes and inactivates minocycline 1
• Do not administer through the same IV line as sodium bicarbonate 2

Calcium Gluconate vs. Calcium Chloride

• Calcium gluconate and calcium chloride are equivalent in their ability to raise ionized calcium when given in a 3:1 ratio (by weight) 5
• Calcium gluconate is preferred for peripheral IV administration because calcium chloride causes severe tissue necrosis if extravasation occurs 2
• Calcium chloride provides 3 times more elemental calcium per mL than calcium gluconate (10% calcium chloride = 27.2 mg/mL elemental calcium vs. 10% calcium gluconate = 9.3 mg/mL elemental calcium) 2, 1
• For peripheral access, always use calcium gluconate; calcium chloride should be reserved for central venous administration 2

Common Pitfalls to Avoid

• Failing to dilute calcium gluconate before administration increases the risk of tissue necrosis and cardiac complications 1
• Exceeding the maximum infusion rate of 100 mg/minute in children can cause fatal bradycardia and cardiac arrest 1
• Not monitoring ECG during bolus administration misses life-threatening arrhythmias 2, 1
• Administering through an unsecured IV line risks extravasation and calcinosis cutis 1
• Mixing with incompatible solutions (ceftriaxone, bicarbonate, phosphate) creates dangerous precipitates 1
• Not correcting concurrent hypomagnesemia renders hypocalcemia resistant to treatment 2