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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