Thread by @NEPHKIDS1

#NEPHTWEETORIAL #NEPHKIDS2020 LET'S TALK HYPOCALCEMIA!Ever wonder why we supplement 👶🏽 with Calcium while we're correcting Vitamin D deficiency/insufficiency?🤔More on that at the end of tweetorial! Let's deep-dive into physiology now!🏊🏽‍♂️🔽 @nikhil_Lohiya @jpsugumar @IPNA_PedNeph

99% of calcium is in 🦴. Of the tightly regulated serum calcium, 45% is albumin-bound 🤝, 55% is diffusible 💥(ionized Ca2, complex with HCO3 & Citrate). onlinelibrary.wiley.com/doi/abs/10.100…

Calcium homeostasis is intimately regulated by
🌜Parathyroid Hormone (PTH)
🌜Calcitonin
🌜Active Vitamin D
Whenever there's a drop⚠️⏬ in Calcium levels, 🦇 signal is sent out by Parathyroid glands to osteoclasts to release calcium from 🦴 via PTH.

And this is how it goes! @grepmeded #Hypocalcemia

💁‍♀️Understanding physiology helps with a better understanding of etiopathology.
Causes of hypocalcemia can be classified, as depicted.👇

Ca has a key role in nerve conduction⚡️ & muscle function💪. So ☠️acute hypocalcemia manifests with the following symptoms 👇

Chronic hypocalcemia can present as
🤪Personality disturbances
😠Irritability
🧠Nonspecific EEG changes
🪨 Basal ganglia calcification
👀Subcapsular cataracts
👁‍🗨Papilloedema
🦷Dental enamel hypoplasia

Now that we've learned the symptomatology, let's move on to the treatment!⏭️
🔑here is to identify whether the child has exhibited symptoms of hypocalcemia!
Symptoms➕▶️Establish venous access ▶️Collect samples as mentioned▶️ Rx it as an emergency! Don't wait for reports!⚠️

Acute Rx - 💉Give IV 10% Calcium Gluconate 0.5mL/kg (5 mg/kg, max of 20 mL) over 5–10 min under 💟monitoring▶️If symptoms persist repeat once▶️f/b continuous IV infusion of 40mg/kg (max 350mg) over 24 hrs☠️
(10% calcium gluconate contains 9mg/ml of elemental Ca)

When asymptomatic the etiology of hypocalcemia should be established - The treatment will be guided according to the etiology! 👇Table sums up the biochemical findings in various etiologies!

This algorithmic approach will help you identify the key investigations, laboratory findings, and inherent diagnoses you need to consider while dealing with #Hypocalcemia.

Now, let's answer the Q posed at the beginning! 🧐
A few weeks after initiation of 25-OH Vitamin D therapy the calcium starts moving from 🩸to 🦴leading to hypocalcemia. This happens due to normalization of PTH. This is called as "Hungry bone syndrome".

💁‍♀️To avoid this adequate calcium intake (30-75 mg/kg per day) should be ensured and is supplemented.
💁‍♀️Calcium supplementation should be continued till the vitamin D therapy is reduced to daily maintenance.

Oral Calcium should be supplemented in all causes of hypocalcemia at a dose of 30-75 mg/kg/day in two-three divided doses.

Dietary intake of dairy products should be encouraged!

Here's the IAP guidelines for the Prevention and Treatment of Vitamin D and Calcium Deficiency in. Children and Adolescents!
indianpediatrics.net/july2017/567.p…

We leave you here at the end of this #NEPHTWEETORIAL! Do join us for the next one on Nov 10! -@jpsugumar Do Tag and ask @nikhil_Lohiya for tweetorial related queries!! @IPNA_PedNeph @ASianPNA @ISNeducation