INTRODUCTION Calcium deficiency means a condition of low level of calcium in the blood (hypocalcemia) which can make the

nervous system highly irritable causing tetany (spasms of the hands and feet, muscle cramps, abdominal cramps, and overly active reflexes). Hypocalcemia is defined as a total serum calcium concentration of less than 2.1 mmol/L (8.5 mg/dL) in children, less than 2 mmol/L (8 mg/dL) in term neonates, and less than 1.75 mmol/L (7 mg/dL) in preterm neonates (Singhal, 2010). Hypocalcemia in children may be asymptomatic or there may be a wide range of signs and symptoms. Because very young patients cannot accurately verbalize symptoms, they are more likely to present with signs such as weakness, feeding problems, facial spasm, jitteriness or seizures. In addition, features of conditions known to be associated with hypocalcemia may be identified (Dawrant, 2007). There are multiple causes of hypocalcemia in children, thus, diagnosis must follow a systematic approach. Since pediatric hypocalcemia can represent the first manifestation of a genetic disorder, a definitive diagnosis may eventually require further testing at a specialized centre (Dawrant, 2007). Once diagnosis of hypocalcemia has been made, a systematic workup that includes a panel of blood tests can help sort out what may otherwise be a confusing clinical picture. Hypocalcemia in children can be an early presentation of a genetic syndrome, and a systematic approach can facilitate referral for definitive diagnosis and treatment (Dawrant, 2007).

CHAPTER II PEDIATRIC CALCIUM DEFICIENCY 2.1 results Etiology in hypocalcemia because of inadequate 1-hydroxylation of 25-

Overall, one of the most common causes of hypocalcemia is renal failure, which hydroxyvitamin D and hyperphosphatemia due to diminished glomerular filtration (Singhal, 2010). Although hypocalcemia is most commonly observed among neonates, it is frequently reported in older children and adolescents, especially in PICU settings. The causes of hypocalcemia can be classified by the child's age at presentation (Singhal, 2010). The first classification is early neonatal hypocalcemia (within 48-72 h of birth). The possible causes are prematurity, birth asphyxia, diabetes mellitus in the mother, intrauterine growth retardation (IUGR). In premature infants, the possible mechanisms include poor intake, decreased responsiveness to vitamin D, increased calcitonin, and hypoalbuminemia leading to decreased total but normal ionized calcium (Singhal, 2010). In infants with birth asphyxia, delayed introduction of feeds, increased calcitonin production, increased endogenous phosphate load, and alkali therapy all may contribute to hypocalcemia (Singhal, 2010). The presence magnesium depletion in the mother with diabetes mellitus causes hypomagnesemic state in the fetus. This hypomagnesemia induces functional hypoparathyroidism and hypocalcemia in the infant. A high incidence of birth asphyxia and prematurity in infants of diabetic mothers are also contributing factors (Singhal, 2010). Infants with IUGR may have hypocalcemia if they are also preterm or have had perinatal asphyxia (Singhal, 2010). The second classification is late neonatal hypocalcemia (3-7 d after birth, though occasionally as late as age 6 week). The possible causes are exogenous phosphate load, magnesium deficiency, transient hypoparathyroidism of newborn, hypoparathyroidism due to other causes and gentamicin uses. Exogenous phospate

load-related hypocalcemia is most commonly seen in developing countries. The identified cause is feeding with phosphate-rich formula or cows milk. Whole cows milk has 7 times the phosphate load of breast milk (956 vs 140 mg/L in breast milk) (Singhal, 2010). The third classification is hypocalcemia in infants and children. The major causes are hypoparathyroidism, abnormal vitamin D production or action, and hyperphosphatemia (Singhal, 2010).

REFERENCES Singhal, Abhay. Hypocalcemia. [cited 2010 March]. http://emedicine.medscape.com/article/921844-overview. Available from:

Dawrant, Jonathan and Daniele Pacaud. Pediatric Hypocalcemia: Making The Diagnosis. CMAJ. 2007;177(12);1494-1497.