Calcium gluconate and calcium citrate in pediatrics
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Calcium Gluconate vs. Calcium Citrate in Pediatrics
Overview: Key Properties
| Property | Calcium Gluconate | Calcium Citrate |
|---|---|---|
| Elemental Ca content | 9.3% (93 mg/g) | 21% (211 mg/g) |
| Available routes | IV, PO | PO only |
| Primary pediatric use | IV treatment of hypocalcemia, tetany, cardiac arrest | Oral supplementation / chronic hypocalcemia |
| Acid requirement for absorption | No | No (advantage over carbonate) |
| Preferred in achlorhydric patients | — | Yes |
Calcium Gluconate
Formulations (Harriet Lane, 23rd ed.)
- Injection: 100 mg/mL (10%) — 0.465 mEq Ca/mL — in 10, 50, 100 mL vials
- Ready-to-use injection: 20 mg/mL in sodium chloride
- Oral: Tabs 50 mg; Caps 500 mg
- Each 1 g of salt = 4.65 mEq = 93 mg elemental Ca
- ⚠️ May contain aluminum — relevant in renal impairment and premature infants (>4–5 mcg/kg/24 hr associated with CNS and bone toxicity)
Pediatric Dosing
Maintenance / Hypocalcemia:
| Age group | IV dose | PO dose |
|---|---|---|
| Neonate | 200–800 mg/kg/24 hr ÷ Q6h | — |
| Infant | 200–500 mg/kg/24 hr ÷ Q6h | 400–800 mg/kg/24 hr ÷ Q6h |
| Child | 200–500 mg/kg/24 hr ÷ Q6h | 200–500 mg/kg/24 hr ÷ Q6h |
Acute symptomatic hypocalcemia (neonates & infants):
- 10% calcium gluconate, 1 mL/kg (= 9 mg elemental Ca/kg) IV over 10 min at 1 mL/min — repeat as needed with monitoring — Brenner and Rector's The Kidney, p. 3164
Tetany (neonates, infants, children):
- 100–200 mg/kg/dose IV over 5–10 min; repeat at 6 hr if needed; max 500 mg/kg/24 hr
Cardiac arrest:
- Infant/child: 60 mg/kg/dose (max 3000 mg/dose) IV Q10–20 min PRN
- Adult: 1.5–3 g/dose IV Q10 min PRN
Continuous infusion:
- 1 mg elemental Ca²⁺/kg/hr following acute correction
Maximum IV Administration Rates
- IV push: do not exceed 100 mg/min (over 10–20 sec in cardiac arrest)
- IV infusion: do not exceed 200 mg/min; max concentration 50 mg/mL
Calcium Gluconate vs. Calcium Chloride for IV Use
Calcium gluconate is preferred for IV use because it is less irritating to veins. However, in critically ill children, calcium chloride may be preferred because it produces a more rapid rise in ionized calcium (calcium chloride does not require hepatic metabolism to release free calcium). — Katzung, p. 1222; Harriet Lane, p. 1051
Use in Cardiac Arrest
Routine calcium use during pediatric cardiac arrest is not recommended. Three pediatric studies associated routine calcium administration with decreased survival and/or worse neurologic outcomes. Calcium is only indicated when a specific cause is present:
- Documented hypocalcemia
- Calcium channel blocker overdose
- Hypermagnesemia
- Hyperkalemia — Miller's Anesthesia, 10th ed., p. 11291
Key Contraindications / Warnings
- Contraindicated in ventricular fibrillation
- Use with caution in renal impairment (risk of hypercalcemia; aluminum accumulation in premature infants)
- Avoid peripheral infusion — extravasation causes tissue necrosis; do not administer via scalp veins, IM, or SC routes
- Do not mix IV form with bicarbonate or ceftriaxone (precipitates)
- Risk of arrhythmia in digitalized patients
- Oral route reduces absorption of fluoroquinolones, tetracyclines, and iron
Calcium Citrate
Formulations (Harriet Lane, 23rd ed.)
- Oral only (no IV formulation)
- Caplets: Citracal Petites (200 mg elemental Ca + 250 IU D3), Citracal Maximum Plus (325 mg elemental Ca + 500 IU D3)
- Chewable tabs: Citracal Gummies (250 mg elemental Ca + 500 IU D3)
- Each 1 g of salt = 10.5 mEq = 211 mg elemental Ca
- Doses expressed as mg of elemental calcium; to convert to mg of salt, divide by 0.21
Pediatric Dosing (Hypocalcemia, oral elemental calcium)
| Age group | Dose |
|---|---|
| Neonate | 50–150 mg/kg/24 hr ÷ Q4–6h PO; max 1 g/24 hr |
| Child | 45–65 mg/kg/24 hr PO ÷ QID |
| Adult | 1–2 g/24 hr PO ÷ BID–TID |
Advantages of Calcium Citrate
- Does not require gastric acid for absorption — preferred in achlorhydric patients and when H2 blockers or PPIs are used
- Better absorbed than calcium carbonate in some patients
- Available combined with vitamin D
Side Effects
Constipation, hypercalcemia, hypophosphatemia, hypomagnesemia, nausea, vomiting, headache, confusion
— Harriet Lane Handbook, 23rd ed., p. 1051
Monitoring During Treatment (Brenner & Rector, p. 3165)
- Fasting total and ionized serum calcium
- Serum phosphate
- Spot urine Ca:Cr ratio
- Goal: keep 24-hour urinary calcium <4 mg (0.1 mmol)/kg/day to prevent hypercalciuria and nephrocalcinosis
- Serum magnesium at least annually
Summary: When to Use Which
| Clinical Scenario | Preferred Agent |
|---|---|
| Acute symptomatic hypocalcemia (IV) | Calcium gluconate (less vein irritation) |
| Critically ill child, rapid ionized Ca correction needed | Calcium chloride (but gluconate widely used) |
| Tetany, neonatal seizures | Calcium gluconate IV |
| Cardiac arrest (with documented indication) | Calcium gluconate IV |
| Chronic/oral supplementation | Calcium citrate (or carbonate) |
| Achlorhydric patient, concurrent PPI use | Calcium citrate (acid-independent absorption) |
| Asymptomatic hypocalcemia in infant | Calcium carbonate PO (first choice); citrate acceptable |
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