NEONATAL HYPOCALCEMIA,
HYPOGLYCEMIA,
HYPOMAGNESAEMIA
HYPOCALCEMIA
Children – is defined as a total serum calcium
concentration less than 2.1 mmol/L (8.5
mg/dL).
Term infants -less than 2 mmol/L (8 mg/dL) or
ionized fraction of less than 1.1 mmol/L (4.4
mg/dL)
Pre term -less than 1.75 mmol/L (7 mg/dL)
Normal calcium values
• Cord = 9-11.5 mg/dl
• Newborn, 3-24 hours = 9-10.6 mg/dl
• Newborn, 24-28 hours = 7-12 mg/dl
• Newborn, 4-7 days = 9-10.9 mg/dl
Anatomy & physiology
Epidemiology
Late onset hypoglycemia –common (developing
countries)
Age related demographics -:
-Mostly new borns
-older children : associated with
#critical illness
#acquired hypoparathyroidism
#mutations in calcium – sensing receptor
#defect in Vit.D supply or metabolism
INCIDENCE
• 30% VLBW (<1500 g)
• Infants of diabetic mother
Etiology
• In neonates :
Early onset neonatal hypocalcemia
Late onset neonatal hypocalcemia
• In infants and children :
Hypoparathyroidism,
Abnormal vitamin d production or action, and
Hyperphosphatemia
PATHOPHYSIOLOGY
DIAGNOSTIC FINDINGS
• History collection
• Physical examination
• Lab .findings
Lab . Findings
• Total and ionized serum calcium
levels
• Serum magnesium levels
• Serum electrolyte and glucose
levels
• Phosphorus levels
• Parathormone levels
• Vitamin D metabolite (25-
hydroxyvitamin D and 1,25-
dihydroxyvitamin D) levels
• Urine calcium, magnesium,
phosphorus, and creatinine levels
• Serum alkaline phosphatase
levels
Additional tests:
• Malabsorption workup
• Total lymphocyte and T-cell
subset analyses
• Chest radiography
• Ankle and wrist
radiography
• Electrocardiography
• Karyotyping
Management
1 ml of Ca.gluconate (10%) -9 mg elemental ca.
EARLY NEOANTAL HYPOCALCEMIA:
Patients at increased risk of hypocalcemia
Patients diagnosed –asymptomatic
Patients diagnosed – symptomatic
Patients at increased risk of hypocalcemia
• -pre term + sick (DM) + perinatal asphyxia
= 40 mg/kg/day
• -infants (oral feeds)
calcium PO=q.6 hrly
• -therapy – continued ---3 days
Patients diagnosed –asymptomatic
• -80 mg/kg/day elemental calcium – 48 hrs
• Tapered 50% --------for another 24 hrs
• -oral feeds---------PO calcium
Patients diagnosed – symptomatic
Bolus ---2ml/kgldose -----5% D-----10 min
Contin. Infusion-----80mg/kg/day -----48hrs
50% dropped-----next 24 hrs-----discontinued
Late Neonatal Hypocalcemia
• Hypomagnesaemia
• High phosphate load
• Hypoparathyroidism
• Vit .D deficiency
Hypomagnesaemia
• Symptomatic hypocalcemia- unresponsive
= due tohypomagnesaemia
• 2 doses ---0.2 ml/kg----50% MgSO4 inj(12 hrs)
deep IM
• Maintenance dose----0.2 ml/kg/day---3 days
High phosphate loads
• EBM-----encouraged
• Phosphate binding gels---avoided
Hypoparathyroidism
• Hyperphosphatemic & hypocalcemic---
normal renal functions
• Ca. supple…----50mg/kg/day----3 divided
doses
• Vit . D3-----0.5-1 µg/day
• Syrup shelcal------250 mg/5ml
Vit .D deficiency states
Vit . D3 supple…30-60 ng/kg/day
NURSING MANAGEMENT
• Assessment
• Identify the infants at risk
• Administer supp. Ca, vit .D, phos.
• Monitor during infusion
• Nutritional supplementation
DIAGNOSIS
• Risk for injury r/t seizures secondary to
hypocalcemia
• Ineffective airway clearance r/t laryngospasm
sec. to hypocalcemia
• Impaired skin integrity r/t infiltration of
calcium infusion
• Ineffective perfusion r/t rapid infusion of
calcium
Hypomagnesaemia
Definition
Hypomagnesemia occurs when serum
concentrationsfall below 0.66mmol/L
(1.6mg/dL)
ETIOLOGY
-Decreased
-Mg loss mg supply
CLINICAL MANIFESTATIONS
NEONATALPERIOD –
• Malabsorption syndrome
• Intractable hypocalcemic
seizures
Management (medical)
• Should not be treated with Ca.or Vit.D
• Mg. salts ----can be given
• 50% solution of MgSO4, 0.005 to 0.1 mL/kg
(0.1 to 0.2 mmol/kg or 2.5 to 5.0 mg /
kg )
slow IV 30-60 MIN
……..Repeated doses-q 8-12 hrs
• Concominant oral Mg suppl
• if Mal absorption- 1mg/kg/day PO (daily)
• Serum Mg. conc. Measured
• Oral MgSO4 --- are not well absorbed---
diarrhoea
• Well
titrated
Nursing management
• Assessment
-fluid balances
-wt changes
-skeletal muscle strength(weakness)
-cardiac rhythm(arrythmia)
-cerebral func.(LOC)
-GI func(bowel sounds)
-neuro muscular excitability
• Monitor serum Mg. levels
• Monitor BP
• Monitor RR & depth
• Monitor deep tendon reflexes
• Admin. Drugs
• Monitor electrolyte balances
• Parent education
Complications
• Hypotonia
• Respiratory depression
• Hypotension
• Cardiac arrythmias
HYPOGLYCEMI
A
DEFINITION:
Neonatal Hypoglycemia is defined as a plasma
glucose level of less than mg/dL ( mmol/L)
in the first 24 hrs of life and less than 45
mg/dL (2.5 mmol/L) .
INCIDENCE
• Differs ----population, method & timing
of feeding
• Early feeding ------decreases incidence
• IBM :
CHO metabolism disorders(>1:10,000)
Fatty acid oxidation disorders(1:10,000)
Hereditary fructose intolerance (1:20,000/50…)
Glycogen storage diseases(1:25,000)
Galactosemia
RISK FACTORS
1.Decreased substrate availability
•Intra-uterine fetal growth restriction
•Glycogen storage disease
•Inborn errors (e.g., fructose intolerance)
• Prematurity
•Prolonged fasting without IV glucose
2.Hyperinsulinemia
• Infant of diabetic mother
•Islet cell hyperplasia
• Erythroblastosis fetalis
•Exchange transfusion
•Beckwith-Wiedemann Syndrome
•Maternal ß-mimetic tocolytic agents
•”High” umbilical arterial catheter
•Abrupt cessation of IV glucose
3.Other endocrine abnormalities
•Pan-hypopituitarism
•Hypothyroidism
•Adrenal insufficiency
4.Increased glucose utilization
•Cold stress
•Increased work of breathing
•Sepsis
• Perinatal asphyxia
5.Miscellaneous condition
• Polycythemia
•Congenital heart disease
•CNS abnormalities
GLUCOSE PHYSIOLOGY IN FETUS &
NEW BORN
CLINICAL MANIFESTATIONS
• Infants ---1st/ 2nd day of life ------asymptomatic
• Hypotonia
• Lethargy
• Poor feeding
• Jitteriness, seizures
• CHF
• Cyanosis
• Apnea
• Hypothermia
C/M ---ASSOCIATED WITH ANS
• Anxiety, tremulouness
• Diaphoresis
• Tachycardia
• Pallor
• Hunger, nausea, & vomiting
C/M ---OF HYPOGLYCORRHACHIA
Head ache
Mental confusion,
Staring, behavioral changes
Difficulty concentrating
Visual disturbances
Dysarthria
Seizures
Ataxia
Somnolence
Coma
Stroke
Diagnostic findings
• Serum or plasma glucose levels
• Serum insulin
• Urine for ketone bodies
• Screening for metabolic errors
• Angiography
Management
• Screening-------1,2,4,6,9,12 hrs
• At risk neonates-----2,6,12,24,48,72hrs
• Sick babies, sepsis,
asphyxia, shock 6-8 hrs
Asymptomatic babies
---with BS 20-40 mg/dL
–after 1 hr of oral feed
-later q 6 hrs till 48 hrs ( if BS > 50 mg/dL)
----with BS levels < 20 mg/dL
-after 1 hr of starting IV fluids & then q hr
----BS <40 mg/dL-(even after 1 hr of oral feeds)
- q 6h for 48 hrs
To calculate rate of glucose
administration
• % glucose x mL/kg/d = glucose infusion rate
(mg/kg/min)
144
Or
• % glucose x mL/h = glucose infusion
rate (mg/kg/min)
• 6 x body weight (kg)
Asymptomatic hypoglycemia
• Are at risk for neurodevelopment
• Initially feed---BM/ formula---spoon or gavage
• Check BS-----30-60 min-before next feed
• If >45mg/dL---2-3 hrly feed ---q 4-6 hr monitor
for 48hrs
• IV Infusion if :
BS < 25 mg/dL
BS remains <45 mg/dL
Enteral feed –contra..
Baby becomes –
sympt..
Symptomatic hypoglycemia
• Can result in high incidence ----neural inj.
• Bolus 2mL/kg –10%D—IV
• Following –IV dextrose (6mg/kg/min)
• BS –rechecked—after 15-30 min
• If BS 45 mg/dL ---hrly ---for 4-6 hrly
• If BS- remains < 45 mg/dL
GIR---increased 2mg/kg/min q 15-30
min… (+) checked
• Tappering glucose infusion –
Once BS values >45 mg/dL stabilized 24
hrs infusion is tappered.
Infusion is tappered @ 2mg/kg/min-q 6hrs
Oral feeds ca be started if not
contraindicated
Nursing management
• Assessment
-maternal history
-immunization
-family history
-sepsis
-enteral feeding
-use of corticosteroids
-drug addiction
-cancer
Nursing Diagnosis
• Risk for complications related to lower plasma
glucose levels such as mental disorders,
behavioral disorders, autonomic nerve
function disorders, hypoglycemic coma
Nursing Diagnosis
• Risk for infection related to a decrease in
endurance
