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

Does the use of bisphosphonates during pregnancy affect fetal outcomes? A systematic review

PURPOSE

This systematic review aimed to determine the effects of maternal exposure to bisphosphonates (BPs) during pregnancy on neonatal outcomes. It aimed to disclosfe the impact of BPs on neonates and identify aspects that require further investigation.

METHODS

A comprehensive search of PubMed, Science Direct, LILACS, EMBASE, and Web of Science was conducted until August 2022, with no time restrictions. The selection criteria included studies published in English that evaluated pregnant women who were exposed to BPs.

RESULTS

From an initial pool of 2169 studies, 13 met the inclusion criteria for this systematic review. These studies collectively included 106 women (108 pregnancies) who were exposed to BPs either before orduring pregnancy. A summary of the key characteristics of the selected studies and the risk of bias assessment are provided. Exposure to BPs occurs at various stages of pregnancy, with different indications for BP treatment. The most frequently reported neonatal outcomes were spontaneous abortion, congenital malformations, hypocalcemia, preterm birth, and low birth weight.

CONCLUSION

Although previous reports have linked BPs before or during pregnancy with adverse neonatal outcomes, these associations should be interpreted with caution. Given the complexity of these findings, further research is necessary to provide more definitive insights to guide clinical decisions regarding the use of BPs in pregnant women.

Neonatal Calcinosis Cutis After Treatment of Hypocalcemia with Calcium Gluconate: A Report of 2 Cases

BACKGROUND Calcium gluconate is used to treat neonatal hypocalcemia, severe hyperkalemia, and neonatal convulsions. Calcium gluconate can extravasate into the skin's soft tissues, resulting in redness, skin nodules, and calcification of soft tissue, which can cause tissue necrosis. This report presents 2 cases of neonatal calcinosis cutis following the treatment of hypocalcemia with calcium gluconate. CASE REPORT Case 1. The patient was a 12-day-old male neonate who presented with a mass in the right foot. He was recently discharged from the hospital after evacuation of subdual hematoma triggering his seizures. The swelling was associated with erythema but no discharge. His radiograph showed soft tissue calcification. He had received 2 peripheral intravenous calcium gluconate infusions to manage hypocalcemia during the last hospitalization. Symptomatic treatments were provided, and full resolution of the swelling was reported after 3 weeks. Case 2. The patient was a 1-month-old female infant newly diagnosed with cystic fibrosis who presented with a mass in her left foot. She underwent exploratory laparotomy in another hospital to manage meconium ileus. The mass was not mobile but there was no skin ulceration. Her radiograph showed soft tissue calcification. During her last admission, she had received 3 doses of intravenous calcium gluconate to manage hypocalcemia. The patient was observed and managed symptomatically. After 4 weeks, there was almost complete clinical and radiographic disappearance of the swelling without any skin necrosis. CONCLUSIONS This report has highlighted the importance of monitoring neonates treated with calcium gluconate who may develop skin rashes or nodules due to calcinosis cutis.

The impact of using near-infrared autofluorescence on parathyroid gland parameters and clinical outcomes during total thyroidectomy: a meta-analytic study of randomized controlled trials

BACKGROUND

The added benefit of using near-infrared autofluorescence (NIRAF) during total thyroidectomy (TT) remains controversial. This study investigated whether or not NIRAF results in improved patient outcomes postoperatively.

MATERIALS AND METHODS

We analyzed 1711 TT patients, reported in nine randomized controlled trials, following a systematic search of five databases. NIRAF was compared to the standard of care (naked eye with/without white light). Outcomes included parathyroid gland (PG) and calcium parameters and other clinical outcomes. For dichotomous outcomes, the log odds ratio (logOR) was calculated, and for continuous outcomes, the crude mean difference (MD) was measured. Sensitivity analysis was performed when heterogeneity was significant. The revised Cochrane risk of bias tool was used to assess the methodological quality.

RESULTS

Compared to the standard of care, the use of NIRAF was associated with a significant reduction in postoperative hypoparathyroidism [logOR=-0.31; 95% CI: -0.57: -0.05], inadvertent PG removal [logOR=-0.93; 95% CI: -1.60: -0.26], and postoperative hypocalcemia [logOR=-0.43 mmol/l; 95% CI: -0.77: -0.09]. It was also associated with significantly higher postoperative PTH levels [MD=4.78 pg/ml; 95% CI: 2.13: 7.43], PG identification rate [logOR=1.02; 95% CI: 0.31: 1.72], postoperative serum calcium [MD=0.05; 95% CI: 0.00: 0.09], and operative time [MD=9.38 min; 95% CI: 6.68: 12.09]. No difference was seen regarding PG autotransplantation, length of hospital stay, and hospitalization due to hypocalcemia. Seven trials had low risk and the remainder had some concerns.

CONCLUSION

NIRAF is superior to the naked eye in identifying all four PGs during TT. The reduced risk of postoperative hypoparathyroidism and hypocalcemia reflected this preservation value. However, it was not associated with a change in the length of hospital stay. Although rare, the readmission rate due to hypocalcemia was similar across both methods.

Breastmilk calcium concentrations in Palestinian lactating women

AIM

Breastmilk calcium concentrations can vary between lactating women and over the lactation period. This study assessed breastmilk calcium concentrations among Palestinian lactating women.

METHODS

The demographic and dietary variables of the lactating women were collected using a questionnaire. The women provided a sample of about 5 mL of breastmilk using hand expression. Breastmilk calcium concentrations were quantified using an inductively coupled plasma-mass spectrometric method.

RESULTS

Breastmilk samples were taken from 240 lactating women. The mean breastmilk calcium concentration was 285.4 ± 115.1 mg/L. Lower breastmilk calcium concentrations were associated with age, lactating period, unemployment, dissatisfaction with income and insufficient consumption of vitamins and minerals.

CONCLUSION

Breastmilk calcium concentrations were affected by demographic variables of the lactating women and insufficient consumption of vitamins and minerals. The findings reported in this study are informative to healthcare providers and decision makers who might be interested in improving the health of lactating women and their infants.

Rare cause of recurrent hypocalcaemia and functional hypoparathyroidism due to hypomagnesaemia caused by TRPM6 gene mutation

Magnesium is essential for the functioning and release of parathyroid hormone. Therefore, its deficiency can present as functional hypoparathyroidism. This case report describes a rare inherited disorder called congenital hypomagnesaemia with secondary hypocalcaemia due to TRPM6 gene mutation. This disease clinically and biochemically mimics hypoparathyroidism. However, unlike hypoparathyroidism, it can be treated only by long-term oral magnesium supplements. The patient presented to us with recurrent hypocalcaemic convulsions. The laboratory picture in each admission was similar to that of hypoparathyroidism. However, the hypocalcaemia persisted, and it was noticed to be associated with persistent hypomagnesaemia. A defect in the tubular magnesium reabsorption was postulated and a genetic analysis of the patient was done, which revealed a TRPM6 mutation causing hypomagnesaemia by excessive renal excretion of magnesium. The child responded well to oral magnesium supplements and is currently developmentally appropriate for her age and thriving well.

Neonatal hypocalcaemic seizures unmasking asymptomatic maternal primary hyperparathyroidism

Hypocalcaemia is a common cause of neonatal seizures. Here, we present a breastfed neonate with smooth perinatal transition and no family history of seizures presenting at 3 weeks with recurrent multifocal clonic seizures. On evaluation, the neonate was found to have low iCa and total calcium. 25-hydroxy vitamin D (25(OH)D) level was low and intact parathyroid hormone (iPTH) was inappropriately normal. The maternal evaluation revealed high calcium and low phosphate levels. iPTH was very high and 25(OH)D was very low in the mother. Sestamibi scan showed a left inferior parathyroid adenoma in the mother. Maternal primary hyperparathyroidism causing hypercalcaemia can suppress parathyroid activity in the fetus, resulting in inappropriate parathyroid response to hypocalcaemia after birth causing recurrent hypocalcaemic seizures. So neonatal hypocalcaemic seizures need careful evaluation of the neonate and the mother at times and can help both mother and neonate.

New frontiers in neonatal red blood cell transfusion research

Red blood cell (RBC) transfusions are common in neonates requiring intensive care. Recent studies have compared restricted versus liberal transfusion guidelines, but limitations exist on evaluations of outcomes in populations that never required a transfusion compared to those receiving any transfusion. Although there are well-established risks associated with RBC transfusions, new data has emerged that suggests additional clinically relevant associations, including adverse neurodevelopmental outcomes, donor sex differences, and inflammation or immunosuppression. Further research is needed to delineate the magnitude of these risks and to further improve the safety of transfusions. The goal of this review is to highlight underappreciated, yet clinically important risks associated with neonatal RBC transfusions and to introduce several areas in which neonates may uniquely benefit from alterations in practice.

Changing trend of neonatal Ca/P/Mg status in a Chinese population

Background

Calcium (Ca), phosphorus (P), and magnesium (Mg) are essential elements for keeping the body homeostasis. We aimed to investigate the changing trend of serum levels of Ca/P/Mg in neonates.

Methods

We enrolled 82 premature newborns, 173 neonatal sepsis, 50 neonatal hypoglycemia, 254 neonatal jaundice, 43 neonatal haemolytic disease, and 59 healthy controls in our retrospective study. Serum levels of Ca/P/Mg were collected and expressed in quarters. We analysed the association between neonatal disorders and Ca/P/Mg levels (fourth quarter vs. first quarter) using binary logistic regression analysis. Smooth curve analysis was performed to analyze the non-linear association between birthweight/procalcitonin (PCT) and Ca/P levels. Threshold effect analysis was also performed to yield the turning point of birthweight/PCT in their associations with Ca/P levels.

Results

Binary logistic regression analyses showed that neonatal haemolytic disease, hypoglycemia, sepsis, jaundice, and prematurity were all significantly associated with the fourth quarter of Ca level (P<10-4; P<10-4; P<10-4; P=0.001; and P<10-4, respectively). Neonatal hypoglycemia and prematurity were significantly associated with the fourth quarter of P level (P=0.004; and P=0.003, respectively). Neonatal haemolytic disease, hypoglycemia, sepsis, jaundice and prematurity were not associated with Mg level. Birthweight was significantly associated with Ca level before and after the turning point of 3,220 grams. PCT was significantly associated with Ca level before and after the turning point of 16.8 µg/L. Birthweight was significantly associated with P level before the turning point of 2,990 gram. PCT was significantly associated with P level before the turning points of 3.5 and 34.21 µg/L.

Conclusions

Neonatal disorders demonstrated a decreasing trend of serum Ca/P level. A significantly non-linear association was observed between birthweight/PCT and serum Ca/P levels.

Calcium and Phosphorus: All You Need to Know but Were Afraid to Ask

Inadequate intake of calcium and phosphorus during the perinatal period can result in metabolic bone disease (MBD), characterized by decreased bone mass, altered bone mineralization, and increased risk for fractures. Preterm neonates have higher risk of developing MBD. Treating MBD involves ensuring adequate calcium and phosphorus intake, early fortification, and vitamin D supplementation. Health care providers should closely monitor nutrient intake, postnatal growth, and screening of preterm neonates at risk for MBD. This review summarizes the critical roles of calcium and phosphorus in regulating bone physiology, how they regulate bone formation and resorption, and their influence on overall bone health.

Metal-binding peptides and their potential to enhance the absorption and bioavailability of minerals

Minerals including calcium, iron, zinc, magnesium, and copper have several human nutritional functions due to their metabolic activities. Body tissues require sufficient levels of a variety of micronutrients to maintain their health. To achieve these micronutrient needs, dietary consumption must be adequate. Dietary proteins may regulate the biological functions of the body in addition to acting as nutrients. Some peptides encoded in the native protein sequences are primarily responsible for the absorption and bioavailability of minerals in physiological functions. Metal-binding peptides (MBPs) were discovered as potential agents for mineral supplements. Nevertheless, sufficient studies on how MBPs affect the biological functions of minerals are lacking. The hypothesis is that the absorption and bioavailability of minerals are significantly influenced by peptides, and these properties are further enhanced by the configuration and attribute of the metal-peptide complex. In this review, the production of MBPs is discussed using various key parameters such as the protein sources and amino acid residues, enzymatic hydrolysis, purification, sequencing and synthesis and in silico analysis of MBPs. The mechanisms of metal-peptide complexes as functional food ingredients are elucidated, including metal-peptide ratio, precursors and ligands, complexation reaction, absorbability and bioavailability. Finally, the characteristics and application of different metal-peptide complexes are also described.

Autosomal Dominant Hypocalcemia Type 1 and Neonatal Focal Seizures

Autosomal dominant hypocalcemia type 1 (ADH1) is a rare form of hypoparathyroidism that is characterized by gain-of-function mutations in the CASR gene, which provides instructions for producing the protein called calcium-sensing receptor (CaSR). Hypocalcemia in the neonatal period has a wide differential diagnosis. We present the case of a female newborn with genetic hypoparathyroidism (L125P mutation of CASR gene), hypocalcemia, and neonatal seizures due to the potential correlation between refractory neonatal seizures and ADH1. Neonatal seizures were previously described in patients with ADH1 but not in association with the L125P mutation of the CASR gene. Prompt diagnosis and management by a multidisciplinary and an appropriate therapeutic approach can prevent neurological and renal complications.

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.

Calcium, Potassium, Sodium, and Magnesium Concentrations in the Placenta, Umbilical Cord, and Fetal Membrane from Women with Multiple Pregnancies

Calcium (Ca), potassium (K), sodium (Na), and magnesium (Mg) are the elements responsible for the fundamental metabolic and biochemical processes in the cells of the body. The demand for these elements increases significantly during pregnancy, where an adequate supply protects women from the hypertension common in pre-eclampsia and preterm labor. This study aimed to evaluate the association between macro-elements (Ca, Mg, Na, and K) in the placenta, fetal membrane, and umbilical cord and the morphometric parameters of newborns from multiple pregnancies. The study involved 57 pregnant European women with healthy uncomplicated twin pregnancies (n = 52) and triple pregnancies (n = 5); 40 pairs of dichorionic diamniotic twins, 11 pairs of monochorionic diamniotic twins, 1 pair of monochorionic monoamniotic twins, 3 trichorionic triamniotic triplets, and 2 dichorionic triamniotic triplets. Placentas (n = 107), umbilical cords (n = 114), and fetal membranes (n = 112) were collected immediately following delivery, and then weighed and measured. The levels of Ca, K, Na, and Mg were determined using inductively coupled plasma atomic emission spectroscopy (ICP-OES) in a Thermo Scientific ICAP 7400 Duo (Waltham, MA, USA). The respective mean concentrations of Ca, K, Na, and Mg (mg/kg^-1 dry mass) were: 2466, 8873, 9323, and 436 in the placenta; 957, 6173, 26,757, and 326 in the umbilical cord, and 1252, 7460, 13,562, and 370 in the fetal membrane. In the studied materials from northwestern Poland, we found strong positive correlations between Ca and Mg concentrations in both the umbilical cord (r = 0.81, p = 0.00) and the fetal membrane (r = 0.73, p = 0.00); between K and Mg concentrations in the umbilical cord (r = 0.73, p = 0.00); between Ca and K concentrations in the fetal membrane (r = 0.73, p = 0.00), and we found moderately positive correlations between placental Ca concentration and placental weight (ρ = 0.42, p = 0.00) and between umbilical cord Mg concentrations and the length of the pregnancy (ρ = 0.42, p = 0.00). Negative correlations were found between Na and Ca concentrations in the fetal membrane (r = -0.40, p = 0.00) and Na concentrations in the fetal membrane and Mg concentrations in the placenta (r = -0.16, p = 0.02). Negative correlations were confirmed between the length of pregnancy and head circumference (ρ = -0.42; p = 0.00), infant weight (ρ = -0.42; p = 0.00), infant length (ρ = -0.49; p = 0.00), shoulder width (ρ = -0.49; p = 0.00); and between the infant weight and head circumference (ρ = -0.62; p = 0.00), weight before delivery (ρ = -0.36; p = 0.00), infant length (ρ = -0.45; p = 0.00), shoulder width (ρ = -0.63; p = 0.00), and weight gain during pregnancy (ρ = -0.31; p = 0.01). We found statistically significant correlations between cigarette smoking before pregnancy and the women's weight before delivery (ρ = 0.32, p = 0.00), and a negative correlation between the women's ages and infant head circumference (ρ = -0.20, p = 0.02). This is probably the first study to evaluate Ca, Na, K, and Mg concentrations in the afterbirth tissues of multiple pregnancies. It adds to the knowledge of elemental concentrations in multiple pregnancies and their possible effects on fetal morphometric parameters.

Interrelationship between Vitamin D and Calcium in Obesity and Its Comorbid Conditions

Obesity has been linked to vitamin D (VD) deficiency and low calcium (CAL) status. In the last decade, dietary supplementation of vitamin D and calcium (VD–CAL) have been extensively studied in animal experiments and human studies. However, the physiological mechanisms remain unknown as to whether the VD–CAL axis improves homeostasis and reduces biomarkers in regulating obesity and other metabolic diseases directly or indirectly. This review sought to investigate their connections. This topic was examined in scientific databases such as Web of Science, Scopus, and PubMed from 2011 to 2021, and 87 articles were generated for interpretation. Mechanistically, VD–CAL regulates from the organs to the blood, influencing insulin, lipids, hormone, cell, and inflammatory functions in obesity and its comorbidities, such as non-alcoholic fatty liver disease, cardiovascular disease, and type-2 diabetes mellitus. Nevertheless, previous research has not consistently shown that simultaneous VD–CAL supplementation affects weight loss or reduces fat content. This discrepancy may be influenced by population age and diversity, ethnicity, and geographical location, and also by degree of obesity and applied doses. Therefore, a larger prospective cohort and randomised trials are needed to determine the exact role of VD–CAL and their interrelationship.

Hypocalcemia as a Cause of Complex Febrile Seizures in a Toddler

A 13-month-old boy had suffered three episodes of complex febrile seizures. At this admission, there were signs of hyperexcitability, such as Trousseau sign and QTc prolongation. A point of care blood gas analysis revealed severe hypocalcemia. Therefore, prior to administering intravenous calcium gluconate, we took blood samples to investigate the etiology of this hypocalcemia: magnesium, parathormone, and 25-hydroxyvitamin D. Since both parathormone and phosphate were significantly elevated and 25-hydroxyvitamin D was within the normal range, pseudohypoparathyroidism was diagnosed. After two years of follow-up, serum calcium had normalized in our patient under supplementation of vitamin D and calcium. He had been free of convulsions, although different febrile episodes had occurred.

A retrospective analysis of calcium levels in pediatric trauma patients

Traumatic injury is a major cause of morbidity and mortality in pediatric patients. Hemorrhage is a known but treatable component of these outcomes. Evidence exists that major trauma patients are at high risk for hypocalcemia but the rate of pediatric occurrence is not documented. The purpose of this study was to determine the incidence of hypocalcemia in pediatric trauma patients, as well as to investigate any correlation between hypocalcemia and the need for transfusion and operative intervention. After IRB approval a retrospective analysis was conducted of all pediatric trauma patients seen in our Adult Level One, Pediatric Level Two trauma center. Significance testing for mortality was performed using Pearson's χ² test. For the remaining numeric variables, association was determined one-way analysis of variance (when comparing all classes) or Welch's two-sample t-test (when comparing subsets based on calcium or mortality). In any event, significance was determined using α=0.05. A total of 2,928 patients were identified, 1623 were excluded, primarily due to incomplete data. Patients were predominantly male following blunt trauma. Initial calcium levels were 8.73 mg/dL, 95% CI [4-10.9] and 8.97 mg/dL, 95% CI [6.42-13.1] when correcting for albumin levels. Acute declines were noted when comparing initial and corrected serum calcium levels in patients requiring transfusion (7.99 mg/dL and 8.72 mg/dL) and operative intervention (8.54 mg/dL and 8.91 mg/dL). 456 (34.9%) patients required operative intervention, 138 (10.6%) required transfusion and 29 (2.2%) required massive transfusion. Patients in our cohort arrived with calcium values on the low end of normal, with a trend towards hypocalcemia if operative intervention or blood transfusion was required. This has been previously associated with increased mortality. Patients requiring operative intervention and transfusion are at increased risk for hypocalcemia and recognition of this potential is key for improved outcomes.

The incidence of osteopenia of prematurity in preterm infants without phosphate supplementation: A prospective, observational study

To meet their requirements for bone mineralization, it is recommended that preterm infants receive nutritional support containing calcium and phosphate. There are no clear data on the incidence of osteopenia of prematurity (OFP) in preterm infants without phosphate supplementation.This study aimed to investigate the incidence of OFP in preterm infants without phosphate supplementation and its relationship with the duration of parenteral nutrition (PN).This was a prospective and observational study.This study included 30 infants aged <32 gestational weeks and weighed <1500 g at birth. All infants received PN according to a standard protocol, beginning on day 1 with calcium, without phosphate. Starting from the first day of life, all infants received human milk without fortifiers. Oral vitamin D (400 IU/d) was administered when enteral nutrition reached 100 mL/kg/d.The diagnosis of OFP was based on radiographs that were taken of both wrists. Serum alkaline phosphatase (ALP) was measured 3 times: at the start of PN (ALP 1), at the end of PN (ALP 2), and at discharge or the expected due date (ALP 3). Radiographs were obtained on the same day as ALP 3. The duration of PN was analyzed in the presence of OFP using receiver operating characteristic curve analysis.Among the 30 infants, 13 (43%) were diagnosed with OFP. The duration of PN was significantly longer in the OFP group than in the group without OFP (16 vs 12 days; P < .05). The provision of PN for >15 days significantly increased the risk of OFP (odds ratio, 5.40; 95% confidence interval, 1.12-26.04; P = .035).We found a high incidence of OFP in preterm infants without phosphate supplementation. An association was found between the duration of PN and the incidence of OFP. Further research is needed to prevent the development of osteopenia in preterm infants.

Rapid Cycle Deliberate Practice to Facilitate "Nano" In Situ Simulation: An Interprofessional Approach to Just-in-Time Training

BACKGROUND

Simulation is increasingly used to identify latent threats to patient safety, such as delays in recognition and management of time-sensitive conditions. The Rapid Cycle Deliberate Practice teaching method may facilitate "nano" (brief) in situ simulation training in a critical care setting to improve multidisciplinary team performance of time-sensitive clinical tasks.

OBJECTIVE

To determine whether nano-in situ simulation training with Rapid Cycle Deliberate Practice can improve pediatric intensive care unit team proficiency in identifying and managing postoperative shock in a pediatric cardiac patient.

METHODS

A quality improvement educational project was conducted involving nano-in situ simulation sessions in a combined pediatric and pediatric cardiac intensive care unit. The Rapid Cycle Deliberate Practice method was used with an expert-driven checklist for 30-minute simulation scenarios.

RESULTS

A total of 23 critical care providers participated. The proportion of time-sensitive tasks completed within 5 minutes increased significantly from before to after training (52% [13 of 25] vs 100% [25 of 25]; P ≤ .001). Using a 5-point Likert scale, with higher scores indicating higher levels, the participants reported high degrees of performance confidence (mean, 4.42; SD, 0.20) and satisfaction with the simulation experience (mean, 4.96; SD, 0.12).

CONCLUSION

The Rapid Cycle Deliberate Practice method was used to facilitate nano-in situ simulation training and identify areas requiring additional education to improve patient safety. In situ simulation can educate providers in a cost-effective and timely manner.

Endocrine Diseases of Newborn: Epidemiology, Pathogenesis, Therapeutic Options, and Outcome "Current Insights Into Disorders of Calcium and Phosphate in the Newborn"

The physiology and regulation of bone minerals in the fetus and the newborn is significantly different from children and adults. The bone minerals calcium, phosphate and magnesium are all maintained at higher concentrations in utero to achieve adequate bone accretion. This is an integral component of normal fetal development which facilitates safe neonatal transition to post-natal life. When deciphering the cause of bone mineral disorders in newborns, the potential differential diagnosis list is broad and complex, including several extremely rare conditions. Also, significant discoveries including new embryological molecular genetic transcription factors, the role of active placental mineral transport, and hormone regulation factors have changed the understanding of calcium and phosphate homeostasis in the fetus and the newborn. This article will guide clinicians through an updated review of calcium and phosphate physiology, then review specific conditions pertinent to successful neonatal care. Furthermore, with the advancement of increasingly rapid molecular genetic testing, genomics will continue to play a greater role in this area of fetal diagnostics and prognostication.

Inadequate Weight Gain According to the Institute of Medicine 2009 Guidelines in Women with Gestational Diabetes: Frequency, Clinical Predictors, and the Association with Pregnancy Outcomes

Background: In the care of women with gestational diabetes mellitus (GDM), more attention is put on glycemic control than in factors such as gestational weight gain (GWG). We aimed to evaluate the rate of inadequate GWG in women with GDM, its clinical predictors and the association with pregnancy outcomes. Methods: Cohort retrospective analysis. Outcome variables: GWG according to Institute of Medicine 2009 and 18 pregnancy outcomes. Clinical characteristics were considered both as GWG predictors and as covariates in outcome prediction. Statistics: descriptive, multinomial and logistic regression. Results: We assessed 2842 women diagnosed with GDM in the 1985–2011 period. GWG was insufficient (iGWG) in 50.3%, adequate in 31.6% and excessive (eGWG) in 18.1%; length of follow-up for GDM was positively associated with iGWG. Overall pregnancy outcomes were satisfactory. GWG was associated with pregnancy-induced hypertension, preeclampsia, cesarean delivery and birthweight-related outcomes. Essentially, the direction of the association was towards a higher risk with eGWG and lower risk with iGWG (i.e., with Cesarean delivery and excessive growth). Conclusions: In this cohort of women with GDM, inadequate GWG was very common at the expense of iGWG. The associations with pregnancy outcomes were mainly towards a higher risk with eGWG and lower risk with iGWG.

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.

Investigation and management of hypocalcaemia

Hypocalcaemia is a common clinical scenario in children with a range of aetiological causes. It will often present with common symptoms but may occasionally be identified in an asymptomatic child. An understanding of the physiological regulation of plasma calcium is important in understanding the potential cause of hypocalcaemia and its appropriate management. The age of presentation will influence the likely differential diagnosis. We have presented a stepwise approach to the investigation of hypocalcaemia dependent on the circulating serum parathyroid hormone level at the time of presentation. The acute and long-term management of the underlying condition is also reviewed.