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 Incidence of Erosive Esophagitis as a Complication of Pediatric Diabetic Ketoacidosis.

INTRODUCTION: Gastrointestinal (GI) symptoms commonly occur during diabetic ketoacidosis (DKA) and typically resolve with treatment. However, GI complications can persist after DKA resolves. The incidence of upper GI bleeding during DKA in adults has been described, with erosive esophagitis one of the most common lesions. The incidence of GI bleeding or erosive esophagitis in children with DKA has not been previously reported. We performed a retrospective chart review of DKA admissions in children 0 to <18 years with type 1 diabetes mellitus (T1DM) at a pediatric hospital between January 2009 and July 2016. Among 395 episodes of DKA over 7.5 years, erosive esophagitis occurred during two DKA admissions (0.5%) and there were no episodes of GI bleeding. Case presentations. Both episodes of erosive esophagitis occurred in adolescent males with known T1DM who presented with severe DKA. Both developed odynophagia after resolution of DKA and were readmitted for DKA recurrence. Upper endoscopy for both patients showed erosive esophagitis. Biopsies were negative for infection, though candida was found during one patient's endoscopy. Both had resolution of their esophagitis symptoms with medication management; neither has had recurrence. CONCLUSION: Erosive esophagitis, a rare complication of pediatric DKA, can manifest with odynophagia or substernal chest pain. This complication can lead to DKA recurrence, likely due to increased insulin resistance from inflammation and pain and from reduced oral intake and insulin administration. Patients with odynophagia associated with DKA should be monitored closely to allow timely evaluation and treatment of esophagitis.

Energy expenditure in critically ill children.

OBJECTIVE: To assess the measured resting energy expenditure pattern over time in a group of critically ill children who were admitted to a pediatric intensive care unit and to determine whether a hypermetabolic response, i.e., >10% above predicted, occurred in a pattern similar to that observed in adults. A secondary aim was to compare the accuracy of a newly derived prediction equation specific to the pediatric intensive care unit and the measured resting energy expenditure. DESIGN: A prospective, clinical, observational study. SETTING: A pediatric intensive care unit of a tertiary care medical center. PATIENTS: Forty-four children (29 males, 15 females) ages 2 wks to 17 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the course of their stay in the pediatric intensive care unit, 44 patients' measured resting energy expenditure was assessed using indirect calorimetry 94 times at up to three time points. The first measurement was at a mean time of 25 +/- 10 (+/-sd) hrs after admission, the second at 73 +/- 16 hrs, and the third immediately before discharge, which occurred at a mean of 193 +/- 93 hrs after admission. Measured energy expenditure varied only slightly (7% to 10%) from the first to second and the second to third measurements. Evidence for hypermetabolism was not apparent. Generally, the prediction equations performed well. Mean measured resting energy expenditure for all measurements was 821 +/- 653 kcals/24 hrs. The Schofield equation estimate was 798 +/- 595 kcals/24 hrs and the White equation estimate was 815 +/- 564 kcals/24 hrs (p = not significant). Nineteen (20%) measurements were >110% above the age-appropriate Schofield-predicted equation, and 30 measurements (32%) were <90% below that predicted by Schofield. Consequently, 45% of measured resting energy expenditure measurements were within 90% to 110% of that predicted by the Schofield equation. The White equation was inaccurate (not within 10% of measured resting energy expenditure) in 66 of 94 measurements (70%). The discrepancy was greatest (100%) in children with measured resting energy expenditure <450 kcal/24 hrs. CONCLUSION: The hypermetabolic response apparent in adults was not evident in these critically ill children. Currently available prediction equations cannot substitute for indirect calorimetry measurement of energy expenditure in guiding nutritional support in pediatric intensive care units.

Pitfalls in predicting resting energy requirements in critically ill children: a comparison of predictive methods to indirect calorimetry.

BACKGROUND: Critical illness in children is thought to have profound effects on nutritional status. It is essential to avoid complications associated with inadequate nutrition support and delivery of excess energy. OBJECTIVE: To compare the results of several commonly used methods for predicting energy requirements in a group of critically ill children indirect calorimetry was used to measure energy expenditure in these children. DESIGN: Resting energy expenditures estimated by different prediction methods for energy were compared with measurements of actual resting energy expenditure obtained by indirect calorimetry in 52 children admitted to a pediatric intensive care unit. Agreement between each predictive method and indirect calorimetry was evaluated by Bland-Altman limits of agreement and by whether the methods met the predetermined criterion for accuracy of within 10% of the measured value. RESULTS: None of the equations predicted individual values accurately. Each of the predictive equations gave a wide and variable scatter of predicted values around the median. The recommended dietary allowance for energy was the least accurate and differed significantly even from the other predictive methods, overestimating energy expenditure in 50 of 52 patients. None of the remaining methods stood out as being more precise. CONCLUSIONS: Predictive methods commonly used to estimate energy expenditure in critically ill children are very imprecise and may lead to overprovision or underprovision of nutrition support. Resting energy expenditure should be measured by indirect calorimetry whenever possible.