PRESENTATION ON NEONATAL HYPOCALCEMIA,

HYPOGLYCEMIA, HYPOMAGNESAEMIA

PRESENTED BY :MISS GNANA JYOTHI

MSC(N) II YEAR

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 hypocalcemiaLate 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

Management1 ml of Ca.gluconate (10%) -9 mg elemental ca.EARLY NEOANTAL HYPOCALCEMIA:Patients at increased risk of hypocalcemiaPatients diagnosed –asymptomaticPatients 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 minContin. Infusion-----80mg/kg/day -----48hrs50% 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 statesVit . 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 supply-Mg loss

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

HYPOGLYCEMIA

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 FACTORS1.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 HYPOGLYCORRHACHIAHead acheMental confusion, Staring, behavioral changesDifficulty concentratingVisual disturbancesDysarthriaSeizuresAtaxiaSomnolenceComa 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/dLBS remains <45 mg/dLEnteral 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 6hrsOral 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