Hypocalcemia in the newborn

Neonatal polycythemia: prevalence, risk factors and predictors of severity

BACKGROUND

Polycythemia is a disorder with several causes and risk factors. The clinical presentation is variable, ranging from asymptomatic newborns to cases with severe physiological changes. The aim of this study was to assess the prevalence, risk factors and predictors of severity of polycythemia in a Portuguese level III Neonatal Intensive Care Unit (NICU).

METHODS

Case-control study of all term newborns with the diagnosis of polycythemia admitted to the NICU of the São João Universitary Hospital Center, Porto, Portugal, from January 1, 1999 to December 31, 2019; and who met one of the following inclusion criteria were eligible for the study: 1) Hct>65% or Hb>22 g/dL; and 2) Hb≥21 g/dL with clinical manifestations of polycythemia.

RESULTS

A total of 53 newborns fulfilled the inclusion criteria and were included in the study, corresponding to a prevalence of 0.57%. Birth outside the hospital was the only risk factor with statistical significance. Of 53 cases, 51 (96.23%) had symptomatic polycythemia. The most frequent symptoms were: hyperbilirubinemia (69.81%), hypoglycemia (52.83%), thrombocytopenia (50.94%), cardiorespiratory (33.96%), and neurological symptoms (33.96%). Of the 53 newborns evaluated, 41 (77.36%) needed treatment. The only risk factors that influenced the hematocrit value were maternal diabetes and fetal growth restriction.

CONCLUSIONS

The best way to improve the prognosis of polycythemia is to identify the risk factors present throughout pregnancy and make an early diagnosis and treatment. Out-of-hospital births should be avoided. The diagnosis should not be excluded, even if hemoglobin and hematocrit are within normal limits.

Impact of advanced maternal age on neonatal morbidity: a systematic review

OBJECTIVE

This systematic review aimed to understand the impact of advanced maternal age (AMA) on the neonatal morbidity, based on the available scientific evidence.

METHODS

A systematic search was conducted on 22 November 2021, using the PubMed and Scopus databases to identify studies that compared the morbidity of neonates delivered to AMA mothers with that of neonates delivered to non-AMA mothers.

RESULTS

Sixteen studies that evaluated the effect of AMA on the neonatal morbidity were included in this review. Nine of these studies found some association between AMA and increased neonatal morbidity (with two of them only reporting an increase in asymptomatic hypoglycemia, and one only reporting an association in twins), six found no association between AMA and neonatal morbidity and one study found a decrease in morbidity in preterm neonates. The studies that found an increase in overall neonatal morbidity with AMA considered older ages for the definition of AMA, particularly ≥40 and ≥45 years.

CONCLUSION

The current evidence seems to support a lack of association between AMA and the neonatal morbidity of the delivered neonates. However, more studies focusing on the neonatal outcomes of AMA pregnancies are needed to better understand this topic.

Relationship between vitamin D deficiency and neonatal hypocalcemia: a meta-analysis

We aimed to explore the associations of neonatal hypocalcemia with neonatal vitamin D deficiency and maternal vitamin D deficiency. A comprehensive systematic literature search using PubMed and web of science was performed for relevant articles from inception to February 17th, 2023. We used odds ratio (OR) and 95 % confidence interval (CI) as effect sizes for our meta-analysis. Publication bias was evaluated using funnel plot, Begg's test, and Egger regression test. All the statistical analyses were performed using Stata 14.0. A total of 11 studies were included and analyzed, including 452 newborns with hypocalcemia and 2,599 newborns with normal serum calcium level. Our research results revealed that vitamin D deficiency in newborns may be related to the higher prevalence of hypocalcemia (OR: 2.87, 95 % CI: 1.17-7.04). In addition, maternal vitamin D deficiency might also be a risk factor for neonatal hypocalcemia (OR: 7.83, 95 % CI: 3.62-16.92). There was a significant correlation between vitamin D deficiency and neonatal hypocalcemia.This meta-analysis indicates that newborns with vitamin D deficiency have a higher risk of hypocalcemia, and maternal vitamin D level play a crucial role in this association. Vitamin D supplementation may have a positive effect in reducing the prevalence of neonatal hypocalcemia.

A Case of Severe Neonatal Hypocalcemia Treated With Continuous Enteral Calcium

Background/Objective

Hypocalcemia is a common, treatable cause of neonatal seizures. The rapid repletion of calcium is essential for restoring normal calcium homeostasis and resolving seizure activity. The accepted approach to administer calcium to a hypocalcemic newborn is via peripheral or central intravenous (IV) access.

Case Report

We discuss a case of a 2-week-old infant who presented with hypocalcemia and status epilepticus. The etiology was determined to be neonatal hypoparathyroidism secondary to maternal hyperparathyroidism. Following an initial dose of IV calcium gluconate, the seizure activity abated. However, stable peripheral intravenous access could not be maintained. After weighing the risks and benefits of placing a central venous line for calcium replacement, it was decided to use continuous nasogastric calcium carbonate at a rate of 125 mg of elemental calcium/kg/d. Ionized calcium levels were used to guide the course of the therapy. The infant remained seizure-free and was discharged on day 5 on a treatment regimen that included elemental calcium carbonate, calcitriol, and cholecalciferol. He remained seizure free since discharge and all medications were discontinued by 8 weeks of age.

Discussion

Continuous enteral calcium is an effective alternate therapy for restoration of calcium homeostasis in a neonate presenting with hypocalcemic seizures in the intensive care unit (ICU).

Conclusion

We propose that continuous enteral calcium be considered as an alternative approach for calcium repletion in neonatal hypocalcemic seizures, one that avoids the potential complications of peripheral or central IV calcium administration.

The role of dietary calcium in the etiology of childhood rickets in the past and the present

For more than two centuries, lack of sunlight has been understood to cause vitamin D deficiency and documented as a primary cause of rickets. As such, evidence of rickets in the archeological record has been used as a proxy for vitamin D status in past individuals and populations. In the last decade, a clinical global consensus has emerged wherein it is recognized that dietary calcium deficiency also plays a role in the manifestation of rickets and classic skeletal deformities may not form if dietary calcium is normal even if vitamin D is deficient. This disease is now clinically called "nutritional rickets" to reflect the fact that rickets can take calcium deficiency-predominant or vitamin D deficiency-predominant forms. However, there are currently no paleopathological studies wherein dietary calcium deficiency is critically considered a primary etiology of the disease. We review here the interplay of calcium, vitamin D, and phosphorous in bone homeostasis, examine the role of dietary calcium in human health, and critically explore the clinical literature on calcium deficiency-predominant rickets. Finally, we report a case of rickets from the late Formative Period (~2500-1500 years ago) of the Atacama Desert and argue the disease in this infant is likely an example of calcium deficiency-predominant rickets. We conclude that most archeological cases of rickets are the result of multiple micronutrient deficiencies that compound to manifest in macroscopic skeletal lesions. For clinicians, these factors are important for implementing best treatment practice, and for paleopathologists they are necessary for appropriate interpretation of health in past communities.

The Effect of Gestational Diabetes on Depression and Breastfeeding Self-Efficacy in Pregnancy and Postpartum Period

Objective: The purpose of this study was to explore the effect of gestational diabetes mellitus (GDM) on depression and breastfeeding self-efficacy during pregnancy and the postpartum period. Methods: This descriptive study was conducted in Obstetrics and Perinatology clinics of two university hospitals in Turkey between July 2016 and June 2017. Women were followed up two times. The first follow-up was performed face-to-face in the gestational week 34th to 38th and the second one was performed by telephone in the 8th week of the postpartum period. In the first follow-up, 104 pregnant women with GDM and 133 pregnant with non-GDM women were interviewed. In the second follow up, 30 women could not be reached in both groups. Data were collected by the Individual Description Form, Edinburgh Postpartum Depression Scale, and Breastfeeding Self-Efficacy Scale-Short Form. Descriptive statistics, repeated measures analysis of variance and correlation analysis were used in the data analysis. Results: The depression risk of mothers with GDM was found higher compared to non- GDM mothers. No significant difference was found between the depression and breastfeeding self-efficacy mean scores in the antenatal and postpartum period of women by the presence of GDM. There was no significant difference between the depression and breastfeeding self-efficacy mean scores in the antenatal and postpartum period by the presence of GDM and some confounding variables. As the breastfeeding self-efficacy level of mothers with GDM both in the antenatal and postpartum period increased, the depression risk decreased. Conclusion: In the study, it has been concluded that GDM does not have an impact on depression and breastfeeding self-efficacy during pregnancy and in the postpartum period.

Transient neonatal hypocalcaemia caused by maternal hyperparathyroidism

Hypocalcaemia in neonates can range from asymptomatic to a potentially life-threatening condition. We present a case of a 36 weeks gestational age boy, admitted to our neonatal intensive care unit for jitteriness, mild hypotonia and breastfeeding difficulties. By the ninth day of life, he presented with late-onset hypocalcaemia, hypomagnesaemia, low 25-OH-vitamin D and inappropriately normal parathyroid hormone. Further investigation revealed maternal hypercalcaemia with high parathyroid hormone. Maternal asymptomatic hyperparathyroidism was diagnosed and admitted as the cause of neonatal hypocalcaemia. There was a clinical improvement and calcium levels stabilisation after treatment with calcium gluconate and vitamin D3 This case highlights the importance of careful evaluation of neonatal late-onset hypocalcaemia in uncovering asymptomatic maternal hyperparathyroidism.

Syndromic and non-syndromic etiologies causing neonatal hypocalcemic seizures

BACKGROUND

The diagnosis of neonatal hypocalcemic seizures (HS) in newborns is made based on clinical signs and serum calcium level. Their etiology is broad and diverse, and timely detection and initiation of treatment is essential.

METHODS

We retrospectively reviewed 1029 patients admitted to the neonatal intensive care unit. Neonatal HS were diagnosed in 16 patients, and we compared etiologies and clinical outcomes, including clinical seizures and neurodevelopment at least over 1 year old.

RESULTS

The etiologies can be broadly categorized into 5 syndromic and 11 non-syndromic neonatal HS. Syndromic neonatal HS included 3 Digeorge syndrome, 1 Kleefstra syndrome and 1 Alström syndrome. Non-syndromic neonatal HS included 8 vitamin D deficiency, 1 hypoparathyroidism, and 2 hypoxic-ischemic encephalopathy. Patients with syndromic neonatal HS were found to have worse clinical outcomes than those with nonsyndromic HS. In eight patients with vitamin D deficiency, neurodevelopment was normal. Five of five patients (100%) with syndromic HS used two or more antiseizure drugs. However, among patients with non-syndromic neonatal HS, only one of 11 (9.1%) used more than one drug (p = 0.001).

CONCLUSION

This finding highlighted that syndromic hypocalcemic seizures in newborns have worse neurodevelopmental outcomes and are more often difficult to manage, and would benefit from a genetic diagnostic approach.

A rare case report of neonatal calcinosis cutis induced by distant and delayed extravasation of intravenous calcium gluconate

A 3,480 g male neonate showed tachypnea symptom with a serum ionized calcium level of 0.66 mmol/L by routine clinical analysis. He was injected calcium gluconate intravenously through femoral vein catheter to treat the hypocalcemia. On second day after the injection, he started to show erythema in the flank area. The lesion became firm and changed into whitish crust consist of small crystals. Abdominal X-ray and ultrasonography showed the accumulation of calcium deposit in the subcutaneous layer of the lesion. Surgical debridement was performed to remove the crust with calcium deposit and acellular fish skin graft rich in omega-3 (Kerecis) was applied to the defect site for secondary intention of the defect wound. After 2 months, the skin and soft tissue defect were fully covered with healthy normal skin without depression or contracture. This report is a first case of iatrogenic calcinosis cutis without extravasation symptom.

Tubular calcium, magnesium, and phosphate excretion during therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy: A prospective study

OBJECTIVES

Hypocalcemia, hypomagnesemia, and hyperphosphatemia are common electrolyte disturbances in perinatal asphyxia (PA). Different reasons have been proposed for these electrolyte disturbances. This study investigated the effect of the urinary excretion of calcium (Ca), magnesium (Mg), and phosphorus (P) on the serum levels of these substances in babies who were treated using therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE) caused by PA. This study sheds light on the pathophysiology that may cause changes in the serum values of these electrolytes.

METHODS

This study included 21 healthy newborns (control group) and 38 patients (HIE group) who had undergone therapeutic hypothermia due to HIE. Only infants with a gestational age of 36 weeks and above and a birth weight of 2000 g and above were evaluated. The urine and serum Ca, Mg, P, and creatinine levels of all infants were evaluated at 24, 48, and 72 h.

RESULTS

The lower serum Ca value and the higher serum P value of the HIE group were found to be statistically significant compared to the control group (p<0.05). There was no significant difference in serum Mg values between the groups. However, hypomagnesemia was detected in five patients from the HIE group. The urine excretion of FeCa and FeMg at 24 h, and FeP excretion at 48 and 72 h were found to be significantly higher in the HIE group compared to the control group.

CONCLUSIONS

This study determined that the urinary excretion of Ca, Mg, and P has an effect on the serum Ca, Mg, and P levels of infants with HIE.

A neonate with late-onset hypocalcemia due to unrecognized maternal hyperparathyroidism and a systematic overview of similar cases

Objective: Neonatal seizures are alarming manifestations of an underlying significant disorder demanding immediate attention and intervention. Hypocalcemia, although rare, must be considered in the differential diagnosis of neonatal seizures. Method: We present an unusual case of a 10-day-old infant with unexplained symptomatic hypocalcemia, experiencing multiple episodes of focal tonic-clonic seizures, born by an entirely asymptomatic mother. Moreover, we conducted a systematic search in PubMed and Scopus databases to present a clinical overview of all similar cases. Result: Maternal laboratory investigation revealed markedly increased calcium levels with concomitant high parathyroid hormone levels due to a parathyroid adenoma, undiagnosed during antenatal checkup. Conclusion: This is one of the few cases in the literature where neonatal symptomatology led to the diagnosis of undiagnosed maternal hyperparathyroidism. Early detection and appropriate management of neonatal hypocalcemia could eliminate serious maternal and fetal morbidity.

Neonatal Hypocalcemia in the Infant of a Diabetic Mother

Neonatal hypocalcemia (NHC) is one of the most common disorders of calcium metabolism in infants admitted to the NICU. Presentation can range from asymptomatic to generalized seizures or tetany. In this case study, an infant with NHC is presented along with an overview of the pathophysiology, prevalence, diagnosis, and management of NHC for neonatal clinicians.

新生儿血钙水平与围生期因素的关系及与智能尿检系统检测的尿钙水平的关系

OBJECTIVE

To study the association of neonatal blood calcium levels with perinatal factors and neonatal urinary calcium levels measured by an intelligent urine test system.

METHODS

The medical data of 96 full-term singleton neonates with mild diseases were collected by a cross-sectional survey, who were hospitalized in the Department of Neonatology, The First Affiliated Hospital of Xi'an Jiaotong University, from June to August 2018. Urinary calcium levels measured by an intelligent urine test system, total blood calcium levels, ionized calcium levels, and the mother's calcium and vitamin D supplementation during pregnancy were recorded.

RESULTS

Compared with the group without vitamin D supplementation for the mother (17 neonates), the group with vitamin D supplementation for the mother (79 neonates) had significantly higher levels of total blood calcium and ionized calcium (P < 0.05).The group with both vitamin D and calcium supplementation for the mother (68 neonates) had significantly higher levels of ionized calcium than controls (28 neonate) (P=0.05). There was no significant difference in the levels of total blood calcium and ionized calcium between the group with calcium supplementation for the mother (74 neonates) and the group without calcium supplementation for the mother (22 neonates) (P > 0.05). The hypothermia group (5 neonates) had a significantly lower level of total blood calcium than the normal body temperature group (91 neonates) (P < 0.05). There was a significantly positive correlation between the maternal blood total calcium level and the neonatal blood total calcium and ionized calcium levels (r=0.881 and 0.703 respectively; P < 0.05). The neonatal urinary calcium level measured by the intelligent urine test system was significantly correlated with the blood ionized calcium level (r=0.526, P=0.025).

CONCLUSIONS

Vitamin D supplementation during pregnancy can increase the blood levels of total calcium and ionized calcium in neonates, and calcium supplementation alone cannot increase the blood levels of total calcium or ionized calcium in neonates. Hypothermia in neonates might cause the reduction in blood calcium levels. The urinary calcium level measured by the intelligent urine test system is positively correlated with the blood level of ionized calcium.

Exchange transfusion safety and outcomes in neonatal hyperbilirubinemia

OBJECTIVE

To characterize the prevalence of exchange transfusion (ET), clinical characteristics of infants receiving ET, and ET-associated morbidity and mortality.

STUDY DESIGN

We conducted a multicenter cohort study of infants ≥23 weeks of gestational age (GA) with hyperbilirubinemia who underwent ET within 30 days of birth from 1997 to 2016. We examined clinical characteristics and adverse events after ET. We used multivariable logistic regression to examine the association between clinical risk factors and death.

RESULT

A total of 1252 infants were included; 4% died within 7 days of ET and 6% died before discharge. Compared with infants ≥37 weeks of GA, infants ≤29 weeks of GA had greater odds of death (adjusted odds ratio [95% confidence interval] = 20.08 [7.32, 55.07]).

CONCLUSIONS

Infants ≤ 29 weeks of GA had greater odds of death following ET compared with term infants. These data will support clinicians in evaluating risks and prognosis for infants who require ET.

Idiopathic Primary Hypoparathyroidism Presenting as Focal Seizures in a Neonate: A Rare Occurrence

Focal seizures in neonates presenting to the emergency department can be potentially dangerous and life-threatening. Hypoparathyroidism is an exceedingly rare but treatable cause of focal neonatal seizures. Due to its weak association with neonatal seizures, hypoparathyroidism often remains undetected as a potential cause. We hereby elucidate a rare case of idiopathic hypoparathyroidism presenting as right-sided focal seizures in a 12-day-old female neonate with an uneventful birth history. Despite the administration of antibiotics and phenobarbitone, the seizures remained unabated. Laboratory workup revealed the diagnosis of late-onset hypocalcemia with severe hypoparathyroidism. The patient was subsequently treated with calcium supplements and alfacalcidol. Thereafter, the frequency of seizures gradually decreased and the same treatment regimen was continued until the patient was seizure-free. The patient continues to do well to date with complete remission of his clinical symptoms.

Exchange transfusion in neonatal hyperbilirubinemia: A single Centre experience from Northern India

OBJECTIVE

To determine the indication, efficacy and adverse events related to exchange transfusion (ET) with reconstituted blood (RB) in neonatal hyperbilirubinemia (NNH).

METHODS

Blood bank records of neonates who underwent double volume ET for NNH from January 2013 to July 2018 were retrospectively reviewed. Demographic details, cause of NNH, details of ET and ET related adverse events were recorded.

RESULTS

A total of 23 ET (average: 1.64/neonate) were performed in 14 neonates (9 males; 5 females) with a mean age of 9.8 ± 7.6 days. Ten (71.4%) neonates underwent 1 session of ET, while 4 (28.6%) underwent repeated sessions (average: 3.25/neonate). A total of 5912 ml of RB was transfused (average: 422 ml/neonate). A statistically significant reduction was noted in total serum bilirubin (TSB) level post-ET (p < 0.001) with overall TSB reduction/procedure being 46%. Of the 14 neonates with NNH, 11 (78.6%) had Rh haemolytic disease of foetus and new-born (HDFN), 2 (14.3%) had ABO HDFN and 1 (7.1%) had hyperbilirubinemia due to prematurity. Of the 11 neonates with Rh HDFN, only 5 underwent intrauterine transfusion (average: 1.8/neonate). Post-ET, top-up transfusions were noted in 8 (57.1%) neonates with packed red blood cell and/or platelet concentrate. ET related adverse were noted in 5 (21.7%) procedures only.

CONCLUSION

Rh HDFN was the most common cause of NNH in our study population.Exchange transfusion is a safe treatment modality for treating NNH, as it results in the rapid elimination of serum bilirubin, thus, lowering the risk of kernicterus in these patients.

Clinical features of neonatal listeriosis in Taiwan: A hospital-based study

BACKGROUND

Neonatal listeriosis is a major cause of mortality in newborn; however, there is limited information about this disease in Taiwan. The aim of our study was to identify the outcome determinants, clinical features, and incidence of pregnancy-associated listeriosis, which includes both neonatal and maternal listeriosis.

METHODS

We retrospectively analyzed the medical records of neonatal and maternal patients with pregnancy-associated listeriosis at two hospitals in Taiwan from January 2000 to December 2018. Listeriosis was indicated by positive Listeria monocytogenes culture.

RESULTS

Our study examined 18 neonates and 19 mothers. The neonatal and fetal death rate was 24%. All five cases of fetal losses or neonatal deaths occurred before 29 weeks of gestational age. The annual incidence of confirmed neonatal listeriosis increased significantly from 0.94/10,000 neonatal inpatients in 2000-2011 to 5.45/10,000 neonatal inpatients in 2012-2018 (p = 0.026). Clinical presentations of neonatal listeriosis included respiratory distress (85%), leukocytosis or leukopenia (77%), bandemia (69%), thrombocytopenia (77%), hypocalcemia (100%) and elevated C-reactive protein (CRP) levels (92%). Lower gestation correlated with a higher fatality rate (p = 0.002). Among the maternal cases investigated, 67% had a diagnosis of listeriosis, and 72% presented with fever. However, only 21% of the 19 mothers received complete antepartum ampicillin treatment.

CONCLUSIONS

The incidence of neonatal listeriosis is increasing, especially in preterm neonates. Maternal listeriosis should be adequately treated with appropriate empirical antibiotics.

An unusual case of neonatal seizures as manifestation of asymptomatic maternal hypoparathyroidism

Neonatal hypoparathyroidism is one of the rare causes of hypocalcaemia. Several cases of neonatal hypoparathyroidism secondary to maternal hyperparathyroidism have been reported. In this case report, we have a term neonate with normal birth history who presented with late onset hypocalcemic seizures. After excluding polyendocrinopathies and related syndromes, hypocalcaemia seizures were secondary to maternal asymptomatic hypoparathyroidism. Since this is one variety of unusual case of maternal and fetal hypoparathyroidism, further testing was mandatory to confirm familial origin. This focuses on the need for every clinician to test maternal metabolic status in case of neonatal manifestations.

Clinical Approach to Hypocalcemia in Newborn Period and Infancy: Who Should Be Treated?

Introduction

Hypocalcemia is a common metabolic problem in newborn period and infancy. There is consensus on the treatment of the symptomatic cases while the calcium level at which the treatment will be initiated and the treatment options are still controversial in asymptomatic hypocalcemia.

Methods

This review article will cover hypocalcemia with specific reference to calcium homeostasis and definition, etiology, diagnosis, and treatment of hypocalcemia in newborn and infancy period.

Results

Hypocalcemia is defined as total serum calcium <8 mg/dL (2 mmol/L) or ionized calcium <4.4 mg/dL (1.1 mmol/L) for term infants or preterm infants weighing >1500 g at birth and total serum calcium <7 mg/dL (1.75 mmol/L) or ionized calcium <4 mg/dL (1 mmol/L) for very low birth weight infants weighing <1500 g. Early-onset hypocalcemia is generally asymptomatic; therefore, screening for hypocalcemia at the 24th and 48th hour after birth is warranted for infants with high risk of developing hypocalcemia. Late-onset hypocalcemia, which is generally symptomatic, develops after the first 72 h and toward the end of the first week of life. Excessive phosphate intake, hypomagnesemia, hypoparathyroidism, and vitamin D deficiency are commonest causes of late-onset hypocalcemia. Hypocalcemia should be treated according to etiology. Calcium replacement is the cornerstone of the treatment. Elementary calcium replacement of 40 to 80 mg/kg/d is recommended for asymptomatic newborns. Elementary calcium of 10 to 20 mg/kg (1–2 mL/kg/dose 10% calcium gluconate) is given as a slow intravenous infusion in the acute treatment of hypocalcemia in patients with symptoms of tetany or hypocalcemic convulsion.

Conclusion

Since most infants with hypocalcemia are usually asymptomatic, serum total or ionized calcium levels must be monitored in preterm infants with a gestational age <32 weeks, small for gestational age infants, infants of diabetic mothers, and infants with severe prenatal asphyxia with a 1 min Apgar score of <4. The treatment of hypocalcemia should be initiated immediately in infants with reduced calcium levels while investigating the etiology.

Intrauterine Growth Restriction: Postnatal Monitoring and Outcomes

Intrauterine growth restriction (IUGR) is an important cause of fetal, perinatal and neonatal morbidity and mortality. IUGR occurs because of multiple reasons. Neonates with IUGR experience acute problems in the perinatal and early neonatal period that can be life-threatening. The unfavorable uterine environment causing growth restriction results in programming that predisposes IUGR infants to long-term health issues such as poor physical growth, metabolic syndrome, cardiovascular disease, neurodevelopmental impairment and endocrine abnormalities, warranting careful monitoring. It is imperative to strike the balance between achieving optimal catch-up to promote normal development, while preventing the onset of cardiovascular and metabolic disorders in the long-term.

Three cases of transient neonatal pseudohypoparathyroidism

Neonatal hypocalcemia is defined as serum calcium (S-Ca) < 2.0 mmol/l in full-term newborns and <1.75 mmol/l in preterm newborns. Neonatal hypocalcemia is either early onset (<3 days of age) or late onset (>3 days of age). Newborns with hypocalcemia are often asymptomatic but may present with hypotonia, apnea, poor feeding, jitteriness, seizures, and cardiac failure. Signs of hypocalcemia rarely occur unless S-Ca drops below 1.75 mmol/l. Neonatal hypocalcemia can be a result of hypoparathyroidism (transient or primary), increased serum calcitonin, sepsis, asphyxia, hepatopathy, hypomagnesemia, high phosphate load, transient hypoparathyroidism, and, rarely, transient neonatal pseudohypoparathyroidism [transient resistance to biological actions of parathyroid hormone (PTH)]. We present the case of three boys (two with gestational age 39 weeks, one 36 weeks; none of them with either asphyxia or sepsis) with mild hypotonia, where S-Ca in the range of 1.67-1.9 mmol/l was detected within the first 3 days of life, together with hyperphosphatemia [serum phosphate (P) 2.5-2.6 mmol/l], normomagnesemia [serum magnesium (S-Mg) 0.77-0.88 mmol/l], normal alkaline phosphatase (ALP) activity (2.8-4.5 μkat/l), and high serum PTH (40-51 pg/ml; normal = 5-28). In spite of the gradual increase of S-Ca, the elevated serum PTH persisted beyond days 3, 4, and 6 in all three boys, together with normal or low-to-normal S-Ca, high or normal-to-high serum P, and no increases in serum ALP. The mothers S-Ca, P, Mg, ALP, and PTH levels were within normal reference ranges. With regard to laboratory results, the diagnosis of transient neonatal pseudohypoparathyroidism (due to immaturity of PTH-receptors) is highly probable in these three neonates.

Neonatal hypocalcemia and its relation to vitamin D and calcium supplementation

OBJECTIVES

To assess the prevalence of hypocalcemia in outpatient clinic neonates and its relation to vitamin D and calcium supplementation.  Methods: This cross-sectional analytical study was conducted at the University Teaching Hospital from May to October 2016. Data were collected from 100 neonates by interviewing mothers using a structured questionnaire; which included socio-demographic information, maternal and neonatal history; in addition to investigations of serum calcium total and ionized and serum vitamin D level. Results: The prevalence of hypocalcemia was 76%, late hypocalcemia represent 52% of hypocalcemic neonates. The prevalence of hypovitaminosis D was 38%. Hypocalcemia was found more prevalent among neonates with no history of vitamin D supplementation (98.7%), no history of maternal calcium supplementation (57.9%), while they had a history of neonatal jaundice on phototherapy (46.1%) which increased to 53.8% with late hypocalcemia. Conclusion: Neonatal hypocalcemia is widely prevalent in Fayoum governorate with significant association with a history of neonatal jaundice on phototherapy, not receiving maternal calcium or neonatal vitamin D supplementation.

Maternal and Neonatal Outcome in Mothers with Gestational Diabetes Mellitus

INTRODUCTION

Gestational diabetes mellitus (GDM) is common and is accompanied with other comorbidities. Challenges to treatment exist at our institute as it serves women with low income. This study assessed the burden of comorbidities and the outcome of GDM.

METHODS

This was a prospective, observational study of women with gestational diabetes attending the obstetrics department from September 2012 to April 2014. GDM was diagnosed based on the International Association of Diabetes and Pregnancy Study Groups criteria. Medical comorbidities were noted, and lipid profile was done. All the women were followed up till delivery, and the complications were recorded. Age- and parity-matched pregnant women with normal oral glucose tolerance test were recruited as controls.

RESULTS

One hundred and thirty-nine women were followed up till delivery. The average age was 28 years. Eighteen percent had bad obstetric history. The average body mass index was 28.8. Twenty-five percent had gestational hypertension (HTN), and 6.4% had chronic HTN. Thirty percent had hypothyroidism. 65% women received insulin. The glucose values were within the recommended range in 60% of the women. Maternal hypoglycemia occurred in 7 (5%) women. Forty-four percent of the women required cesarean section and 34% had complications either during pregnancy or labor. Three neonates had macrosomia. Twenty-six neonates (20%) required admission to the Neonatal Intensive Care Unit. Four neonates (3%) died. Newborns of mothers whose GDM optimally treated had less complications.

CONCLUSION

Gestational diabetes is associated with HTN, hypothyroidism, obesity, and lipid abnormalities. The majority of women required insulin for treatment and optimal control of blood glucose resulted in lower neonatal complications.

HYDROCEPHALY, SCHIZENCEPHALY, SPONDYLOCOSTAL DYSPLASIA, AND HYPOPARATHYROIDISM IN AN INFANT OF A DIABETIC MOTHER

CONTEXT

Diabetes mellitus is the most frequent chronic complication in pregnancy and continues to contribute to increased perinatal morbidity and mortality in newborns. Macrosomia, respiratory distress syndrome, metabolic and electrolytic disturbances, and increased rates of congenital structural defects are well-known neonatal complications associated with maternal diabetes, even if well-controlled.

CASE REPORT

A macrosomic infant born from an insulin-dependent mother, with uncontrolled diabetes and lack of adequate prenatal care, prenatally diagnosed with hydrocephaly showed a complicated postnatal course. Initial respiratory distress syndrome and transient hypoglycemia, rapidly corrected under treatment, were followed by persistent hypocalcemia and hyperphosphatemia due to hypoparathyroidism and evolving hydrocephaly. Ventriculoperitoneal shunting was followed by resolution of hypocalcemia, but seizures associated with schizencephaly and recurrent respiratory tract infections, aggravated by spondylocostal dysplasia, concurred to infant's demise at the age of 5 months.

CONCLUSIONS

The reported case is rare due to multiple aspects: persistent hypoparathyroidism, uncommon association of schizencephaly, and even rarely association with spondylocostal dysplasia, all these conditions requiring a multidisciplinary therapeutic approach. Also, the reported case is evocative for challenges associated with infants born from diabetic mothers.

Life-threatening Dilated Cardiomyopathy Induced by Late-onset Neonatal Hypocalcemia

Neonatal seizures caused by hypocalcemia may be associated with cardiopulmonary dysfunction and may require specific management other than calcium supplementation. Severe dilated cardiomyopathy is an extremely rare complication in neonatal hypocalcemia and often results in high morbidity and mortality. We report here a 14-day-old neonate presenting with a gradually increasing frequency of tonic seizures. After admission, arterial desaturation was found despite supplying oxygen (4 L/min) through nasal prongs and the patient developed life-threatening respiratory distress and heart failure secondary to dilated cardiomyopathy. His critical cardiopulmonary derangements rapidly improved after respiratory support, the administration of diuretic and inotropic drugs, and the correction of his hypocalcemia and hypomagnesemia. The patient responded to treatment and was well during the 1-year follow-up period. We present this unique case history of seizure, respiratory distress, and heart failure induced by transient hypocalcemia to remind clinicians about the importance of this rare, life-threatening, but reversible, disorder.

Hypocalcemia in jaundiced neonates receiving phototherapy

OBJECTIVE

To determine the frequency of hypocalcemia in term neonates with jaundice receiving phototherapy.

METHODS

This was a cross sectional study conducted at Neonatal intensive care unit, National Institute of Child Health, Karachi from 1st January 2014 to 30th December 2014. A total of 123 term neonates with jaundice of either gender managed by phototherapy were enrolled in the study. Gestational age was assessed through modified Ballard scoring. Duration of phototherapy was recorded. A sample of 3 ml of blood was sent to the laboratory for serum calcium level before initiating phototherapy and after 24 hours of continued phototherapy. All the data were recorded in the preformed proforma. Data was analyzed using SPSS version 19. P value <0.05 was taken as significant.

RESULTS

The mean age of the neonates was 8.35±6.74 days. Mean gestational age at the time of birth was 39.08±1.37 weeks. Mean duration of jaundice was 2.4±1.20 days. Mean duration of phototherapy was 1.74±0.98 days. Serum calcium level before and after 24 hours of initiating phototherapy was 8.73±0.68 mg/dl and 7.47±0.82mg/dl respectively Frequency of hypocalcemia in term jaundiced neonates receiving phototherapy were observed in 22.76% (28/123).

CONCLUSIONS

The frequency of hypocalcemia is significant in the jaundiced neonates treated with phototherapy. One needs to be vigilant in dealing neonates in this context while serial monitoring for hypocalcemia and its complications should be considered in institutional policy and research priority.

Intrauterine growth restriction - part 2

Small for gestational age (SGA) infants have been classically defined as having birth weight less than two standard deviations below the mean or less than the 10th percentile of a population-specific birth weight for specific gestational age, whereas intrauterine growth restriction (IUGR) has been defined as a rate of foetal growth that is less than normal for the population and for the growth potential of a specific infant. SGA infants have more frequent problems such as perinatal asphyxia, hypothermia, hypoglycaemia, polycythaemia and many more when compared with their appropriate for gestational age counterpart. They too have growth retardation and various major and subtle neurodevelopmental handicaps, with higher rates of perinatal and neonatal mortality. With the advent of newer technologies, even though the perinatal diagnosis of these SGA/IUGR foetuses has increased, but still perinatal morbidity and mortality rates are higher than normal foetuses and infants. In this part, we have covered neonatal IUGR classification, postnatal diagnosis, short-term and long-term complications faced by these IUGR infants.

Neonatal idiopathic primary hypoparathyroidism: A rare cause of neonatal seizures

Etiology of neonatal seizures (NNS) is diverse and hypocalcemia is one of the treatable causes. Neonatal hypocalcemia (NHC) due to congenital hypoparathyroidism, either permanent or transient, is extremely rare. Its biochemical abnormalities include hypocalcemia, hyperphosphatemia and low levels of intact parathyroid hormone (PTH). Isolated congenital hypoparathyroidism in which deficiency of PTH has no association with maternal, syndromic or endocrine defects is a very rare entity. We are reporting a case of a newborn who presented with seizures on the 5th day of life and later on investigations revealed hypocalcaemia due to isolated congenital hypoparathyroidism.

Prevalence of hypocalcemia after phototherapy among neonates who underwent phototherapy in Koodakan Hospital in Bandar Abbas in 2013

Introduction

Hyperbilirubinemia is one of the most common problems in newborns, and it is reported in about 60% of infants. Phototherapy is used extensively to treat these patients, and hypocalcemia is one important side effect of the phototherapy. The aim of this study was to determine the prevalence of hypocalcemia after phototherapy in full-term newborns that underwent phototherapy in Koodakan Hospital in Bandar Abbas in 2013.

Methods

This cross-sectional study was conducted on 100 neonates admitted to Koodakan Hospital in Bandar Abbas. All of the newborns were full-term, healthy, weighed more than 2,500 g, and were candidates for phototherapy. The newborns were divided into two groups, i.e., 1) those who were more than three days old and 2) those who were less than three days old. Serum bilirubin and calcium levels were measured for each newborn before phototherapy and 48 hours after phototherapy, and the before and after levels were compared. The data were analyzed using IBM SPSS 21.0 statistical software. The Fisher Exact test, the independent samples t-test, and the paired t-test were used to test the research hypothesis.

Results

Among the 100 newborns studied, 54% had decreased calcium levels after phototherapy. The prevalence of hypocalcemia was 9% in this study, and the prevalence was not significantly different in the two age groups (P = 0.217).

Conclusion

Phototherapy does not increase the risk of hypocalcemia in healthy, full-term neonates. Therefore, prophylactic calcium is not recommended for healthy, full-term neonates who have undergone phototherapy.

Cystic multiglandular maternal hyperparathyroidism diagnosed by neonatal hypocalcemic seizures

A 7-day-old male infant born to a healthy 33-year-old female at 37 weeks of gestation was brought to the local emergency department (ED) with sudden-onset tonic–clonic seizures. Laboratory testing revealed extreme hypocalcemia (ionized calcium of 3.2 mg/dl) and undetectable parathyroid hormone (PTH <10 pg/ml). Concomitant evaluation of the mother revealed both elevated ionized calcium (5.9 mg/dl) and PTH (116 pg/ml). The mother underwent preoperative ultrasound localization and sestamibi scan, followed promptly by parathyroidectomy. Given the cystic appearance and presence of multiglandular disease, evaluation for familial cystic parathyroid adenomatosis (hyperparathyroidism-jaw bone-tumor syndrome) and MEN 1 were undertaken. The infant was stabilized and discharged home. He returned to the ED with seizures at 1 month of age. After increasing calcium supplementation appropriately, he was monitored with weekly office visits. This represents a unique case of undiagnosed maternal primary hyperparathyroidism manifesting with intrauterine parathyroid suppression and hypocalcemic seizures in the newborn.

The many etiologies of neonatal hypocalcemic seizures

Seizures during the neonatal period have a broad differential diagnosis. Unlike in developing countries where hypovitaminosis D and hypocalcemia constitutes a major cause of infantile seizures, the number of neonatal seizures attributed to hypocalcemia in developed countries has decreased dramatically due to the improvement of infant formulas and vitamin D supplementation. In these countries, most infants that present with hypocalcemic seizures have underlying endocrinological etiologies rather than dietary insufficiencies. Here, we describe 3 cases of neonatal seizures due to hypocalcemia. Although the symptoms and calcium concentrations at presentation were similar in all 3 cases, the course of the disease and the final diagnosis for each were distinct. The cases are presented along with a brief review of the pathophysiology, differential diagnosis, and treatment of neonatal hypocalcemia.

Correlation of hypocalcemia with serum parathyroid hormone and calcitonin levels in pediatric intensive care unit

OBJECTIVES

To investigate factors involved in causing hypocalcemia in critically ill patients.

METHODS

The patients aged 1 mo to 18 y, admitted to PICU at Nemazee Hospital, from May through November 2012, were reviewed. Those with impaired calcium hemostasis or on vitamin-D supplement were excluded. Calcitonin and parathyroid hormone levels were checked if ionized calcium level was less than 3.2 mg/d. Patient's demographic data, length of stay, Pediatric Risk of Mortality-III (PRISM-III) score, the need for mechanical ventilation, inotropic drug administration and outcome were recorded.

RESULTS

Among the 294 patients enrolled in the study, the incidence of ionized hypocalcemia was 20.4 %. The mortality rate was 45 % in hypocalcemic groups and 24.8 % in normocalcemic patients. Highly significant negative correlations were found between serum ionized calcium, PRISM-III score (r = -0.371, P = 0.004), and calcitonin level (r = -0.256, P = 0.049), but no significant correlation between hypocalcemia and parathyroid hormone level (P = 0.206) was found. A significant difference was observed between survivor and non-survivor groups regarding PRISM-III score (P = 0.00), ionized calcium (P = 0.00), and calcitonin (P = 0.022) but not parathyroid hormone level (P = 0.206).

CONCLUSIONS

Hypocalcemia was associated with increased mortality rate in PICU patients. A negative correlation was found between ionized calcium level and calcitonin. There was also a link between PTH level and severity of illness. It can therefore be concluded that evaluating serum ionized calcium, calcitonin, and PTH levels can be used as prognostic factors in critically ill patients.

Prevalence of hypocalcaemia and its associated features in 22q11·2 deletion syndrome

BACKGROUND

22q11.2 deletion syndrome (22q11.2DS) is a relatively common yet under-recognized genetic syndrome that may present with endocrine features. We aimed to address the factors that contribute to the high prevalence of hypocalcaemia.

METHODS

We investigated hypocalcaemia in a well-characterized sample of 138 adults with 22q11.2DS (65 m, 73 F; mean age 34.2, SD 11.8, years) using laboratory studies and lifelong medical records. Logistic regression modelling was used to identify features associated with lifetime prevalence of hypocalcaemia.

RESULTS

Of the total sample, 111 (80.4%) had a lifetime history of hypocalcaemia. Eleven (84.6%) of 13 subjects with neonatal hypocalcaemia had documented recurrence of hypocalcaemia. Lifetime history of hypocalcaemia was associated with lifetime prevalence of hypoparathyroidism (P < 0.0001) and hypothyroidism (P = 0.04), as statistically independent factors. Hypomagnesaemia was associated with concurrent hypocalcaemic measurements, especially in the presence of concurrent hypoparathyroidism (P = 0.02).

CONCLUSIONS

The results suggest that, in addition to the major effect of hypoparathyroidism, hypothyroidism may play a role in hypocalcaemia in 22q11.2DS and that there is a high recurrence rate of neonatal hypocalcaemia. Hypomagnesaemia may contribute to hypocalcaemia by further suppressing parathyroid hormone (PTH). Although further studies are needed, the findings support regular lifelong follow-up of calcium, magnesium, PTH and TSH levels in patients with 22q11.2DS. At any age, hypocalcaemia with hypoparathyroidism and/or hypothyroidism may suggest a diagnosis of 22q11.2DS.

Neonatal Late-onset Hypocalcemia: Is There Any Relationship with Maternal Hypovitaminosis D?

PURPOSE

Neonatal late-onset hypocalcemia is defined as hypocalcemia developed after postnatal 3 days and associated with hypoparathyroidism, high phosphate diets and vitamin D deficiency. We experienced the increment of neonatal late onset hypocalcemia over 1 year. We tried to evaluate the relationship between late onset hypocalcemia and maternal hypovitaminosis D.

METHODS

The medical records in the neonates with late-onset hypocalcemia during January 2007 to July 2008 were retrospectively reviewed. Among those patients, 17 paired sera of mothers and neonates had collected. The levels of 25-OH vitamin D (25OHD) and intact parathyroid hormone (iPTH) were measured and were compared with neonate and the mother.

RESULTS

The mean gestational age was 38(+1) weeks, and the mean body weight was 2,980 g. The onset time of hypocalcemia was 5.9 days of age. Most of them (88.2%) were feeding with formula and no one was only breast milk feeding. Of the 17 patients, 13 were born in spring or in winter. The median levels of calcium, phosphorus, alkaline phosphatase, iPTH and 25OHD were 7.0 mg/dL, 8.6 mg/dL, 191.0 U/L, 57.2 pg/mL and 24.0 ng/mL in neonates. The levels of 25OHD of 6 neonates were <20 ng/mL. A total of 16 mothers were considered vitamin D-deficient (<20 ng/mL), and vitamin D insufficient (20<25OHD<30 ng/mL).

CONCLUSION

Neonatal late-onset hypocalcemia in our study seems to be influenced by maternal vitamin D deficiency and insufficiency. Sun tanning and vitamin D supplements from winter to spring would be helpful to prevent maternal vitamin D deficiency, one of the causes of neonatal late-onset hypocalcemia.

Stridor in an 11-year-old child

Stridor in older children can be due to diverse aetiology that includes infections, anaphylaxis and rarely systemic conditions leading to hypocalcaemia. We report the case of a previously asymptomatic 11-year-old girl who presented to the casualty with stridor due to hypocalcaemia. The aetiological investigations for hypocalcaemia uncovered previously undetected chronic renal failure, possibly due to a rare autosomal recessive condition called nephronophthisis. We report this case to highlight the importance of widening the diagnostic focus for children presenting with stridor, especially when they fall outside the usual age group for infections like croup, or when the history is atypical.

Hemodynamic correlates of low umbilical cord vitamin D and ionized calcium

Vitamin D deficiency and hypocalcemia are associated with gestational hypertension. Therefore, we hypothesized that umbilical cord [Ca(2+)] and [vitamin D] are correlated with perinatal blood pressures. Mothers and newborns comprised vitamin D sufficient (vitamin D ≥ 50 nM, range 52-111 nM, n = 14), and vitamin D deficient groups (vitamin D < 50 nM, range 13-49 nM, n = 29). Cord [Ca²⁺] was negatively correlated with maternal systolic pressure (SBP) (r = -0.56, p < 0.01) and positively correlated with neonatal SBP (r = +0.55, p < 0.01) in the vitamin D deficient group. We conclude that low umbilical cord [vitamin D] and [Ca²⁺] may predispose mothers to higher and newborns to lower blood pressures.

Neonatal seizures: soothing a burning topic

Neonatal seizures are a potentially life-threatening pediatric problem with a variety of causes, such as birth trauma, asphyxia, congenital anomalies, metabolic disturbances, infections, and drug withdrawal or intoxication. Thorough and timely evaluations of such patients are necessary to identify and treat the underlying etiology, therefore reducing potential morbidity and mortality. We review neonatal seizures and hypocalcemia and present the case of a 6-day-old male infant who presented to a tertiary pediatric emergency department with seizure-like episodes. He was found to have markedly low serum calcium, magnesium, and parathyroid hormone concentrations, as well as a significantly elevated serum phosphate concentration. The etiology of these abnormalities was found to be maternal ingestion of extremely high doses of calcium carbonate during the third trimester of her pregnancy, an occurrence that has been reported only once in the literature. Education pertaining to the dangers of excessive calcium carbonate intake during pregnancy may be an important piece of anticipatory guidance for pregnant mothers with symptoms of gastroesophageal reflux, and questioning the mother of a neonate presenting with seizures about such over-the-counter medications may help to elucidate the diagnosis.

Neonatal seizure as a manifestation of unrecognized maternal hyperparathyroidism

Maternal hypercalcemia suppresses parathyroid activity in the fetus resulting in impaired parathyroid responsiveness to hypocalcemia after birth. Resultant hypocalcemia may be severe and prolonged and rarely may lead to convulsions. Here, we present a newborn infant admitted to the pediatric emergency department at age two weeks with recurrent tonic convulsions due to asymptomatic maternal hyperparathyroidism and vitamin D deficiency. Physicians should be aware that undiagnosed maternal hyperparathyroidism can cause severe hypocalcemia in the newborn.