What is the appropriate dose of calcium gluconate for a 0.91 kilogram neonate?

Calcium Gluconate Dosing for a 0.91 kg Neonate

For a 0.91 kg neonate with hypocalcemia, administer calcium gluconate 60 mg/kg as an initial dose, which equals 54.6 mg (approximately 0.55 mL of 10% calcium gluconate solution), given as a slow intravenous bolus not exceeding 100 mg/minute, followed by a continuous infusion of 60-120 mg/kg/hour if needed. 1, 2

Initial Bolus Dosing

• The pediatric dose for acute hypocalcemia is 60 mg/kg of calcium gluconate (equivalent to 0.28 mEq/kg of elemental calcium) 1, 2
• For your 0.91 kg patient, this calculates to 54.6 mg of calcium gluconate 1, 2
• Since 10% calcium gluconate contains 100 mg/mL, administer approximately 0.55 mL 2
• Critical safety requirement: Dilute this dose in 5% dextrose or normal saline to achieve a concentration of 10-50 mg/mL before administration 2
• Administer slowly at a rate not exceeding 100 mg/minute in neonates (the FDA label specifies this pediatric maximum rate) 2

Continuous Infusion (If Required)

• If hypocalcemia persists or is severe, initiate a continuous infusion at 60-120 mg/kg/hour 1, 2
• For your 0.91 kg patient, this equals 54.6-109.2 mg/hour (approximately 0.55-1.1 mL/hour of 10% solution) 1, 2
• Dilute to a concentration of 5.8-10 mg/mL for continuous infusion 2

Essential Monitoring Requirements

• Measure ionized calcium every 4-6 hours during intermittent bolus administration 1, 2
• During continuous infusion, measure ionized calcium every 1-4 hours 2
• Continuous ECG monitoring is mandatory during calcium administration to detect bradycardia or arrhythmias 2
• Monitor vital signs continuously during administration 2

Target Calcium Levels

• Maintain ionized calcium in the normal range of 1.15-1.36 mmol/L (4.6-5.4 mg/dL) 1
• Do not exceed 1.5-2 times the upper limit of normal for ionized calcium 1

Critical Safety Considerations

Administration Route

• Use a secure intravenous line to prevent extravasation, which causes calcinosis cutis and tissue necrosis 2
• Central line administration is preferred in neonates to minimize extravasation risk 1

Drug Incompatibilities

• Absolutely contraindicated: Do not mix with ceftriaxone in neonates ≤28 days old due to fatal precipitation 2
• Never mix with fluids containing bicarbonate or phosphate (causes precipitation) 2
• Never mix with minocycline (calcium inactivates it) 2

Infusion Rate Warnings

• Never exceed 100 mg/minute in neonates (slower than the 200 mg/minute adult maximum) 2
• Rapid administration causes bradycardia, cardiac arrhythmias, and cardiac arrest 2

Special Considerations for This Extremely Low Birth Weight Infant

• At 0.91 kg, this patient is an extremely low birth weight (ELBW) infant requiring meticulous fluid management 1
• Consider that ELBW infants may have nonoliguric hyperkalemia, so verify urine output before adding potassium to any maintenance fluids 1
• The small blood volume in ELBW infants means frequent calcium monitoring is essential but must be balanced against iatrogenic blood loss 1, 2

Common Pitfalls to Avoid

• Do not use undiluted 10% calcium gluconate as a bolus—always dilute first 2
• Do not administer through the same line as ceftriaxone in this neonate 2
• Do not rely solely on total calcium levels—ionized calcium is the gold standard for monitoring 1, 3
• Do not assume hypocalcemia is corrected after one dose—persistent hypocalcemia requires continuous infusion 1, 2