CALCIUM

99% of body Ca ( in bones) , 1%( soluble) , 0.5% ( ionized (for all ca function , clotting , nerve impulse ,
muscle contraction , Hormonal secretion .
Nutritional ca def main presentations are due to hypocalcemia (tetany , seizure , stridor )
Normal level (8.5-11mg/dl)- Preterm (7 )- Term (8 ) , Lab sample : morning & fasting
Hypocalcemia Consider hypocalcemia if (total < 7 in PT , < 8 in term , < 8.8 in children )
Adjusted Ca = Total serum Ca (mg/dl)+ 0.8 [ 4- albumin (g/dl) ] =-----------------(N>8.4)
Natural source ‫االلبان ومنتجاتها والحبوب والخضروات‬
Ca concentration Breast milk 35 , cows 115 , term formula 39-66 preterm formula 77-110/dl
Yogurt 1cup (350) , milk 1cup ( 300mg) , cheder cheese 1 oz (204)
Absorption ↑: VitD , protein, acidity , lactose (change to lactic acid w/help absorption)
↓: phytate (salt) , oxalate(salt), fats(soap) , excess phosphorus, alkalinity
‫ السبانخ‬- ‫المشروبات الغازية – الردة‬
Recommended ‫ مجم في اليوم‬500 ‫أقل من‬
dietary allowance ‫فوق السنة‬
per day ‫يسبب لين عظام بنقص الكالسيوم‬
< 6mo : 200
< 6 mo (200mg) ,> 6mo (260mg) , > 1 (500mg) ( another opinion )
Daily needs mg/day:<6 mo-(200),>6mo-(260),1-3y(700),4-8y(1000) ,9-13y(1300)
1-3 yrs ( 700 mg → Nido1+500ml ) , 4-8 yrs ( 1000 mg→ cows milk 750 ml )
Needed with vitD& phosphorus for bone mineralization (NB dietary phosphorus
deficiency is very rare)
Ca supply @30-50 mg elemental /kg/day ( divided 2-3 doses)
@Minimum 500mg/day in conjunction of vit D therapy .
@From dietary sources or supplement for 2 to 4 weeks, until vitamin D doses have been
reduced to maintenance levels
@Calcium supplementation is mandatory along with vitamin D replacement.
@Ca citrate can be taken without food and ca carbonate (bioavailability 40%) should be taken with food.
IV ca gluconate 10%:1-2 ml/kg dil. with saline( don’t mix with bicarb, ceftriaxone, digitalis, quinolone )
PO calcium : 40-80mg elemental /kg/day divided , premeal ( better ca carbonate or citrate)
Associated with vit D for Tx of rickets, in hypocalcemia
Side effect: constipations & GIT upset
Preparations of Ca
Hical syrup (78mg/5ml)= 2.5-5ml /kg/day (3),
Hical forte (115 mg/5ml)= 2- 3.5 ml/kg/day(3)
Cal Sandoz (110 mg/5ml)= 2- 3.5 ml/kg/day(3)
Depa Ca syrup : Ca 250mg,Mg 50mg, D3 200:( 1-1.5 ml/kg/ day )
D-CAL-C syrup : ca 250mg + Mg 25mg + D3 100 IU) >6mo( 1-1.5 ml/kg/ day)
Osteocare syrup : Ca 150 mg, Mg 75mg,D3 75 , Zn 3mg (1.5- 2.5 ml/kg/ day)>4y (contains sorbitol)
Jolical syrup : Ca 150 mg ,Mg 75mg,D3 200 , Zn 3mg ‫ جنيه مصري‬35
Cal mag forte : Ca 200 mg ,Mg 100 mg,D3 165 IU , Zn 3mg ( LIPOSOMAL ) >3y 5ml ‫ جنيه‬75
Capregomix syrup : Ca 150 mg,Mg 75mg, D3 200 , Zn 3mg
Osteo zad syrup : Ca 150mg , Mg 75 mg ,D3 75 IU , Zn 3 mg (1.5-2.5 ml/kg/day)
Cal D3 syrup : Ca 400mg, D3 500 , Zn 25mg (0.5- 1ml/kg/ day)
Maxical D syrup : Ca 150mg,Mg 50mg, D3 100 (1.5- 2.5ml/kg/ day)
Caldin zinc syrup: Ca 150mg,Mg 75mg,D3 200Iu ,Zinc 3 mg (1.5-2.5 ml/kg/day)> 6mo
Sanso cal-D liquid : Ca : 150mg , Mg: 75 mg , Zn: 3mg , VitD: 75 IU ( 70 e pound)
CalCao pieces : Ca carbonate(500mg), D3 ( 400 U) , Whey Ptn (300 mg) – OD
Calcium eff sachets (500mg)
Calcichelate sachets: CA 250mg, D400U ,K2 20mcg, C,B12, B7, < 1y ( ½ sachet /day)> 1y (1 sachet/day)

1
 ‫كمية الكالسيوم المطلوبة يوميا ‪WHO‬‬ ‫السن‬
‫‪ 6-0‬شهور ‪ 200‬مجم‬
‫‪ 12-6‬شهر ‪260‬‬
‫‪ 3-1‬سنوات ‪700‬‬
‫‪ 8-4‬سنوات ‪1000‬‬
‫‪ 13-9‬سنة ‪1300‬‬
‫فيجب اضافة الكالسيوم مع فيتامين ‪ D‬كالسابق ‪-‬نقص الكالسيوم سيؤدى الى لين العظام بغض النظر عن فيتامين د‬
‫الجرعات الوقائية لفيتامين د ‪ 400 :‬وحدة خالل السنة االولى ‪ 600 ،‬وحدة فيمابعد‬
‫بعض اآلراء األخرى ( من عدة بلدان )‪ :‬فوق السنة ‪ 500‬مجم ‪/‬اليوم يكفى ‪ ،‬أقل من ‪ 300‬مجم‪ /‬اليوم معرض لإلصابة ب لين العظام‬

‫‪Food rich in ca‬‬

‫‪2‬‬
Lab Other tests Diagnosis
N (low) Ca + Low Pi + High ALP Normal vitD25 + Normal PTH Familial hypophosphatemic rickets
N Ca + low Pi + high ALP Low vitD25 + compensatory ↑ PTH Initial VitD deficiency
Low ca + Low Pi + high ALP Low vitD25 + compensatory High PTH Severe VitD deficiency
Low ca + N Pi + high ALP Low vitD25 + compensatory High PTH Healing vitD deficiency
Low Ca + high Pi+ N ALP Low PTH Hypoparathy., Pi overload, Mg def.
Low Ca + high Pi+ N ALP High PTH Pseudohypoparathyroidism
Normal Ca + high Pi Renal disease , Pi overload , GH ++
Rickets of prematurity: required high vitD + Ca + phosphorus ( VitD alone is insufficient )
In familial hypophosphatemic rickets : PTH is normal since Ca is usually normal
In initial Vit D deficiency, Low vitD, result in low Pi reabsorption, there is compensatory ↑of PTH that
temporarily normalize Ca
In severe vitD deficiency low ca & low phosphorus due to poor absorption from gut
In healing vitD deficiency: phosphorus is the first to return to normal
Liver dysfunction leads to ↓bile salts in gut → low absorption of VitD → vitD deficiency
Pi = phosphorus , ALP = alkaline phosphatase , ++ excess , N normal
Normal range
Ionized ca Pi Mg ALP PTH D-25 U Ca/Cr ratio
1.15-1.35 1.4-2.8 0.7-0.12 82-383 10-65 10-55 <0.2
mmol/L mmol/L mmol/L U/L pg/ml ng/ml

Ca deficiency rickets
Causes :
• Low intake , children < 200 mg , adolescents < 500mg
• Malabsorption : phytate
Biochemistry :
➢ Ca low
➢ PO4 N
➢ 25-D normal to low
Ca P 25-D 1-25D PTH Urine P
N /↓ ↓ N ↑ ↑
Treatment: Oral ca : 1000-1500mg/daily + vitD 600 IU/day for 3mo may be more