What is the recommended dosage of calcium gluconate for a pediatric patient with hypocalcemia?

Pediatric Calcium Gluconate Dosing for Hypocalcemia

For symptomatic hypocalcemia in pediatric patients, administer calcium gluconate 50-100 mg/kg IV slowly with continuous ECG monitoring. 1

Acute Symptomatic Hypocalcemia

For immediate treatment of symptomatic hypocalcemia (tetany, seizures, life-threatening arrhythmias):

• Dose: 50-100 mg/kg of calcium gluconate IV 1
• Alternative dosing: 10-20 mg/kg of elemental calcium (equivalent to 1-2 mL/kg of 10% calcium gluconate) 2
• Administration: Slow IV infusion with continuous ECG monitoring for bradycardia 1
• Maximum single dose consideration: 100 mg/kg per dose 3

The FDA-approved labeling confirms individualized dosing within recommended ranges based on severity of symptoms, with specific monitoring requirements during administration 4.

Asymptomatic Hypocalcemia

For asymptomatic pediatric patients with hypocalcemia:

• No immediate intervention is recommended 1
• If treatment is initiated: 40-80 mg/kg/day of elemental calcium for maintenance 2
• This translates to approximately 430-860 mg/kg/day of calcium gluconate (since calcium gluconate contains ~9.3% elemental calcium) 4, 2

Critical Context-Specific Dosing

For hyperkalemia with life-threatening arrhythmias:

• Dose: 100-200 mg/kg/dose of calcium gluconate via slow infusion with ECG monitoring 1
• Do not administer through the same line as sodium bicarbonate 1

For cardiac resuscitation (hypocalcemia, hyperkalemia, hypermagnesemia, calcium channel blocker toxicity):

• Preferred agent: Calcium chloride 20 mg/kg (provides more rapid ionization) 1
• Alternative: Calcium gluconate 60 mg/kg if calcium chloride unavailable 1

Administration Guidelines

Route and monitoring:

• Administer IV bolus slowly or as continuous infusion via secure IV line 4
• For bolus: Give slowly over several minutes to avoid adverse cardiovascular effects 1
• For other indications: Infuse over 30-60 minutes 1
• Central venous access preferred to minimize extravasation risk 1

Monitoring requirements:

• Continuous ECG monitoring during administration 1, 4
• Measure serum calcium every 4-6 hours during intermittent infusions 4
• Measure serum calcium every 1-4 hours during continuous infusion 4
• Stop injection immediately if symptomatic bradycardia occurs 1

Critical Safety Considerations

Avoid calcium administration when:

• Phosphate levels are elevated (risk of calcium-phosphate precipitation and obstructive uropathy) 1
• Consider renal consultation if phosphate is high before treating hypocalcemia 1

Extravasation precautions:

• Extravasation can cause severe tissue necrosis, ulceration, and calcinosis cutis 4
• If extravasation occurs, immediately discontinue infusion at that site 4
• Central line administration strongly preferred over peripheral IV 1

Drug incompatibilities:

• Do not mix with phosphate-containing or bicarbonate-containing fluids (precipitation will occur) 1, 4
• Do not mix with vasoactive amines 1

Calcium Gluconate vs Calcium Chloride

Calcium chloride provides more elemental calcium and faster ionization:

• Calcium chloride: 27% elemental calcium 5
• Calcium gluconate: 9.3% elemental calcium 4, 5
• Both forms produce equivalent cardiovascular effects when dosed to provide equal elemental calcium (approximately 3:1 ratio) 5
• Ionization occurs rapidly (within minutes) for both forms, independent of hepatic metabolism 5
• For critically ill children requiring rapid calcium replacement, calcium chloride is preferred 1

Age-Specific Considerations

Neonates and preterm infants:

• Single dose of 100 mg/kg calcium gluconate effectively raises total and ionized calcium levels within 3-6 hours 3
• Early-onset hypocalcemia (first 24-48 hours) is usually asymptomatic and may not require treatment 1, 2
• Screen high-risk infants (gestational age <32 weeks, small for gestational age, infants of diabetic mothers, severe asphyxia) at 24 and 48 hours after birth 2