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Dr Hasmukh Gala SevenHills Hospital Slide 2 99% of calcium present in bone and teeth Less than 1% of calcium present in blood, intracellular fluid & muscle Serum calcium is tightly regulated Body uses bone as a reservior for, and as a source of calcium to maintain constant concentrations of calcium in blood, muscle & intracellular fluids Slide 3 Bone undergoes continuous remodeling with constant resorption & deposition of calcium The process of bone resorption and formation changes with age Formation > resorption in period of growth in children & adolescent Resorption > Formation in aged individual & post-menopausal women; increasing risk of osteoporosis Slide 4 For growth and mineralisation of growing bones Plays a crucial role in various physiological functions like blood coagulation, neuromuscular transmission, muscle contraction etc. Slide 5 Slide 6 Dairy products like milk, cheese and yoghurt- rich natural sources of calcium Vegetables like spinach, broccoli and cabbage contains calcium- but bioavailability poor Grains contains small amount of calcium Slide 7 Food itemServing sizeCalcium (mg) Milk8 oz291 Yoghurt8 oz274 Yoghurt (low fat)8 oz400 Cheese1 oz150 Artichoke, boiled1 medium135 Broccoli, chopped cup47 Cabbage, boiled cup79 Collards, boiled cup110 Kale, chopped, boiled cup45 Mustard Greens, boiled cup52 Okra, boiled cup77 Peas, boiled cup20 Sweet potato, baked cup32 Onion, chopped, raw1 cup40 Slide 8 Food itemServing sizeCalcium (mg) Black beans, boiled cup23 Chick peas cup38 Kidney beans cup34 Ragi100 gm344 mg Figs, fresh2 medium36 Kiwifruit1 medium20 Orange1 fresh52 Orange juice8 oz22 Papaya, fresh medium36 Banana, chopped1 cup8 Almonds, dried oz (12)37 Sesame seeds, whole, dried 1 tbsp88 Egg, Hens127 Fish, Cod3 oz13 Crab, cooked3 oz50 Slide 9 AgeMaleFemalePregnancyLactation 0-6 months200 mg 7- 12 months260 mg 1-3 years700 mg 4-8 years1000 mg 9- 13 years1300 mg 14- 18 years1300 mg 19- 50 years1000 mg 51- 70 years1000 mg1200 mg 71+ years1200 mg Slide 10 About 30% of calcium in food is absorbed, but it varies with type of food consumed. Efficiency of calcium absorption decreases as intake increases, therefore it is better to take calcium in smaller doses throughout the day Net calcium absorption is as high as 60% in infants and young children, where as it decreases to 15-20% in adults and continue to decrease as people age Slide 11 Phytic and oxalic acid in food can decrease calcium absorption Vitamin D increases calcium absorption Calcium carbonate is best absorbed with meals where as calcium citrate can be given with or without meals Slide 12 Inadequate intake of dietary calcium does not produce any short term adverse effect Over long term, inadequate calcium intake causes osteopenia and ultimately, osteoporosis. Calcium deficiency can also cause rickets, though it mainly results from vitamin D deficiency Blood calcium is tightly regulated and hypocalcemia results mainly from medical conditions or treatment Slide 13 Slide 14 Increase in bone size and bone mass occur throughout the period of growth in childhood & adolescence to reach a peak bone mass at the age of 30. The greater is the peak bone mass, the longer one can delay serous bone loss with increasing age Slide 15 Therefore, everyone should consume adequate amount of calcium and vitamin D throughout childhood, adolescence and early adulthood Other risk factors for osteoporosis are being female, thin, inactive, cigarette smoking, excessive intake of alcohol & family history of osteoporosis Slide 16 Weight bearing exercise helps in making muscles as well as bones stronger Muscle mass is associated with bone strength Weaker muscle can lead to bone breaking accidents Slide 17 In newborn period- prematurity, asphyxia, infants of diabetic mother & IUGR babies- due to transient hypoparathyroidism and delayed intake of milk In infancy- intake of cows milk- due to high phosphorus content of cows milk, which has 956 mg/L of Phosphorus. Slide 18 Hypoparathyroidism Lack of response to PTH Vitamin D deficiency Hyperphosphetemia Inadequate intake of calcium Blood transfusion- Particularly multiple transfusion and exchange transfusion in neonate Slide 19 Mild hypocalcemia is usually asymptomatic Parasthesias, muscle cramps, lethargy, poor apetite, Tetany, Seizure Tetany- Carpopedal spasm, seizure, laryngospasm In infants- seizure may be the first manifestation- brief, recurrent, usually generalised In neonates- tremors, jitteriness, lethargy, seizure Slide 20 Slide 21 Symptomatic hypocalcemia in neonate- 1-2 ml (100- 200 mg)/kg of body wt of 10% calcium gluconate stat and repeated every 6-8 hrly IV or alternately given as continuous IV infusion (500- 750 mg/kg body wt of 10% Cal gluconat) Monitor serum ionised calcium Gradually switch to oral calcium preparation once symptoms resolves Slide 22 Hypocalcemia in infants fed with cows milk is due to hyperphosphetemia Infant formula contains more phosphorus than breast milk Therapy is to lower serum phosphorus and provide calcium supplementation Oral calcium supplement given along with milk feeds helps in decreasing phosphorus absorption and lowering serum phosphorus Slide 23 Starting dose is 50 mg/kg/ day Various enteral preparations Calcium Carbonate- 400 mg Ca/ gm Calcium Glubionate- 64 mg Ca/ gm Calcium Gluconate- 90 mg Ca/ gm Calcium citrate- 210 mg Ca/gm Calcium lactate- 130 mg/gm Slide 24 Calcium supplements produced from unrefined oyster shell, bone meal, dolomite or coral calcium (mainly calcium carbonate) might contain high levels of heavy metals including lead. Permissible upper limit of lead- 7.5 mcg per 1000 mg of elemental calcium Slide 25 If child is on corticosteroids, isonazide or anticonvulsant Has milk allergy Very low birth weight babies Low intake of dietary calcium bellow RDA Slide 26 AgeMaleFemalePregnantLactating 0- 6 months1000 mg 7- 12 months1500 mg 1- 8 years2500 mg 9- 18 years3000 mg 19- 50 years2500 mg 51+ years2000 mg Slide 27 High calcium intake can cause constipation Might interfere with iron and zinc absorption High intake of calcium from supplements, and not food, can increase risk of kidney stone Slide 28 Increased serum ionised calcium level Rarely results from dietary or supplemental calcium intake Hyperparathyroidism, hypervitaminosis D, excess calcium intake Increased release from bone- hypervitaminosis A, thyrotoxicosis, renal osteodystrophy, immobilisation Mild ( 15 mg/dl) Slide 29 Mild to moderate- most patients are asymptomatic Symptoms- vomitting, failure to thrive, pancreatitis, lethargy, hypotonia, coma, psychiatric disturbances, polyuria, nephrolithiasis, renal failure Slide 30 Calcium supplement might increase risk of MI People who need more calcium should first and foremost try to up the dietary intake of this mineral Concluded that calcium supplements should be taken with caution Dr Kuanrong Li, Heart, June 2012 Slide 31 Total of 30 g of Ca accumulates in fetus, most of it during third trimester Low maternal Ca intake can cause lower bone mass in neonates Vitamin D & Ca supplementation in pregnancy increases bone mineral mass in infancy VLBW infants & Premature baby < 32 weeks GA fed on unfortified human milk or full term formula rather than preterm formula are at risk of osteopenia of prematurity Slide 32 Osteopenia of prematurity is mainly due to Ca & Phosphurus deficiency rather than Vit D deficiency All infants with birth weight agemalefemalepregnancylactation 0-12 years400 IU (10 mcg) 400 IU (10 mcg) 1-13 years600 IU (15 mcg) 600 IU (15 mcg) 14-18 years600 IU 19-50 years600 IU 51- 70 years600 IU >70 years800 IU (20 mcg) 800 IU (20 mcg) Slide 39 Approximately 15-20 mins of sun exposure between 10 AM to 3 PM at least twice a week to face, arms, legs or back without sunscreen usually lead to sufficient vitamin D production Individuals with limited sun exposure has to take good sources of vitamin D in the diet or take supplement to achieve recommended level of intake Slide 40 Slide 41 Slide 42 Slide 43 Slide 44 Slide 45 Slide 46 Nmol/LNg/mlHealth status =20Generally adequate for bone and overall health >125>50Associated with potential adverse effect Slide 47 Vit D (IU/L) Calciu m (mg/L) Phosphor us (mg/L) Ca: P Ratio Breast Milk 25- 783501502.3: 1 Cow milk4110319631.2: 1 Buffalo milk 15009601.8: 1 Lactogen 1 3604202401.8: 1 Pediasur e 4809207601.2: 1 Slide 48 Can be asymptomatic Causes bone pain and muscle weakness Low blood levels of vitamin D have been associated with increased risk of cardiovascular disease & certain type of cancer Slide 49 Vitamin D deficiency causes rickets in children and osteomalacia in adults Rickets- failure of bone tissue to properly mineralise leading to soft bones and skeletal deformity Hypocalcemic tetany occasionally accompanies rickets, especially in prolong unrecognized vitamin D deficiency Slide 50 Breast fed infants Should receive vitamin D supplement 400 IU/day starting from first few days after birth People with limited sun exposure Dark skin individuals Fat malabsorption Obese individual with BMI > 30 Slide 51 Vitamin D levels of 1384 children & young adults 64.4% had low levels(less than 20 ng/ml) 26.6% had insufficient levels (20-40 ng/ml) Only 13% had sufficient levels (> 40 ng/ml) recent study by P D Hinduja hospital Slide 52 Slide 53 X ray of wrist S Calcium, S Phosphorus, S Alkaline Phosphatase levels Serum 25- hydroxy vitamin D3 level Slide 54 Slide 55 2000 IU 6000 IU per day of vitamin D3 orally OR 6,00,000 IU as a single dose Healing usually starts in few days and progress to full bone recovery Normal intake of calcium and phosphorus or oral calcium supplements for few days Slide 56 AgeMaleFemalePregnancyLactation 0- 6 months1000 IU (25 mcg) 1000 IU (25 mcg) 7- 12 months1500 IU (38 mcg) 1500 IU (38 mcg) 1- 3 years2500 IU (63 mcg) 2500 IU (63 mcg) 4- 8 years3000 IU (75 mcg) 3000 IU (75 mcg) >= 9 years4000 IU (100 mcg) 4000 IU (100 mcg) 4000 IU (100 mcg) 4000 IU (100 mcg) Slide 57 Excessive intake of vitamin D can result in hypervitaminosis D Symptoms generally starts 1-3 months after excessive intake Hypotonia, polyuria, polydipsia, constipation Hypercalcemia & hypercalciuria, aortic valvar stenosis, osteopetrosis, proteinuria, renal damage, hypertension, retinopathy, clouding of cornea and conjunctiva Slide 58