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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 53-54

Hypocalcemia and Vitamin D3 deficiency in critically ill children: Does it matter?


Department of Pediatric Critical Care and Emergency Medicine, Rainbow Children's Hospital, Marathahalli, Bengaluru, Karnataka, India

Date of Submission26-Feb-2020
Date of Acceptance08-Mar-2020
Date of Web Publication10-Apr-2020

Correspondence Address:
Dr. Rakshay Shetty
Department of Pediatric Critical Care and Emergency Medicine, Rainbow Children's Hospital, Marathahalli, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_36_20

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How to cite this article:
Shetty R. Hypocalcemia and Vitamin D3 deficiency in critically ill children: Does it matter?. J Pediatr Crit Care 2020;7:53-4

How to cite this URL:
Shetty R. Hypocalcemia and Vitamin D3 deficiency in critically ill children: Does it matter?. J Pediatr Crit Care [serial online] 2020 [cited 2020 Sep 25];7:53-4. Available from: http://www.jpcc.org.in/text.asp?2020/7/2/53/282228



Metabolic derangements are very common in critically ill patients, especially children. Identification and appropriate correction are crucial for the disease management and decreasing mortality and morbidity. Data on the abnormalities of calcium, phosphorus, and Vitamin D in critically ill children admitted to a pediatric intensive care unit (PICU) are scarce, especially from developing countries.

Hypocalcemia has been reported in 12%–90% of critically ill adults and children.[1],[2]

Hypophosphatemia is known to develop during the ICU stay, and the studies have shown that 60%–75% children developed hypophosphatemia during the PICU stay.[3] With Vitamin D deficiency being very common in healthy individuals, studies have reported the incidence of Vitamin D in critically ill children to be 17%–79%.[4],[5]

Abnormality of serum Ca can be due to a variety of causes, e.g., altered Ca binding due to a change in the blood pH, elevation of fatty acids, sepsis, hypoalbuminemia, blood transfusion, renal failure, and hypomagnesemia.[6] Hypophosphatemia is influenced by long-term low intake, decreased absorptive state, intracellular redistribution, and increased renal tubular losses.[7] The frequency and predisposing factors in children are not yet fully understood.

Singhi et al. studied calcium profile in 100 children admitted to a PICU and concluded that hypocalcemia is common in critically ill children admitted to a PICU and is associated with higher mortality.[8] They found hypocalcemia in 35% of the patients at admission and in another 13% during hospital stay. In their study cohort, mortality was significantly higher in hypocalcemic (28.3%) group.

Lodha et al. studied a cohort of 162 children and identified that hypophosphatemia was common in critically ill children and was associated with prolonged length of stay and increased duration of mechanical ventilation.[9] In their study, serum phosphate <2.5 mg/dL was associated with increased mortality.

McNally et al. conducted a systematic review on Vitamin D deficiency in the PICU and found it to be highly prevalent and associated with severity and disease outcome.[10] Sankar et al. studied the prevalence of Vitamin D deficiency and its association to clinical outcome in 196 children admitted to a PICU and found high prevalence of Vitamin D deficiency in critically ill children with increased length of ICU stay.[11]

In this issue, Agarwal et al.[12] reported the findings from a prospective cross-sectional study done in the PICU of a tertiary care hospital. In the study, calcium, phosphorus, and Vitamin D levels of children admitted to PICU were analyzed. Of the 135 children included in the study, 24.4% had hypocalcemia. The study showed a very high incidence of Vitamin D deficiency (85.9%). Their study showed that total and ionized hypocalcemia were significantly more among the nonsurvivors (P = 0.012 and 0.047, respectively). Hypophosphatemia and hyperphosphatemia were also significantly more in the nonsurvivor group (P = 0.048 and 0.018, respectively). They found that mortality was higher in the children with total hypocalcemia (P = 0.006) and ionized hypocalcemia (P = 0.03). They concluded that calcium, phosphate, and Vitamin D abnormalities are common in critically ill children in a developing country and that these abnormalities are associated with poor outcome.

These results are consistent with many studies that emphasize the importance of identifying the metabolic derangements. They analyzed the calcium, phosphorus, and Vitamin D levels together to find a correlation. However, the study population was small and they could not find a relation to Vitamin D levels, probably due to the high incidence of Vitamin D deficiency in the study group. It is difficult to conclude that the low Vitamin D levels are due to the critical illness considering that studies have shown high incidence of Vitamin D deficiency in healthy subjects from the same geographic area.[13]

This study emphasizes the importance of identifying metabolic derangements in a critically ill child. It reinforces that timely recognition and appropriate management are crucial for a favorable outcome in a sick child.

Overall, this study is a welcome addition to the available scant data on calcium, phosphate, and Vitamin D levels in critically ill children. However, further systematic multicenter studies are required to confirm these findings.



 
  References Top

1.
Zivin JR, Gooley T, Zager RA, Ryan MJ. Hypocalcemia: A pervasive metabolic abnormality in the critically ill. Am J Kidney Dis 2001;37:689-98.  Back to cited text no. 1
    
2.
Cardenas-Rivero N, Chernow B, Stoiko MA, Nussbaum SR, Todres ID. Hypocalcemia in critically ill children. J Pediatr 1989;114:946-51.  Back to cited text no. 2
    
3.
de Menezes FS, Leite HP, Fernandez J, Benzecry SG, de Carvalho WB. Hypophosphatemia in critically ill children. Rev Hosp Clin Fac Med Sao Paulo 2004;59:306-11.  Back to cited text no. 3
    
4.
Marwaha RK, Sripathy G. Vitamin D and bone mineral density of healthy school children in Northern India. Indian J Med Res 2008;127:239-44.  Back to cited text no. 4
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5.
Lucidarme O, Messai E, Mazzoni T, Arcade M, du Cheyron D. Incidence and risk factors of Vitamin D deficiency in critically ill patients: Results from a prospective observational study. Intensive Care Med 2010;36:1609-11.  Back to cited text no. 5
    
6.
Chernow B, Zaloga G, McFadden E, Clapper M, Kotler M, Barton M, et al. Hypocalcemia in critically ill patients. Crit Care Med 1982;10:848-51.  Back to cited text no. 6
    
7.
Miller DW, Slovis CM. Hypophosphatemia in the emergency department therapeutics. Am J Emerg Med 2000;18:457-61.  Back to cited text no. 7
    
8.
Singhi SC, Singh J, Prasad R. Hypocalcaemia in a paediatric intensive care unit. J Trop Pediatr 2003;49:298-302.  Back to cited text no. 8
    
9.
Lodha R, Shah S, Irshad M, Gupta N, Kabra S. Hypophosphatemia in critically ill children. Pediatr Crit Care Med 2014;15:60.  Back to cited text no. 9
    
10.
McNally JD, Nama N, O'Hearn K, Sampson M, Amrein K, Iliriani K, et al. Vitamin D deficiency in critically ill children: A systematic review and meta-analysis. Crit Care 2017;21:287.  Back to cited text no. 10
    
11.
Sankar J, Lotha W, Ismail J, Anubhuti C, Meena RS, Sankar MJ. Vitamin D deficiency and length of pediatric intensive care unit stay: A prospective observational study. Ann Intensive Care 2016;6:3.  Back to cited text no. 11
    
12.
Agarwal S, Jhamb U, Kaushik S. Calcium, phosphate, and Vitamin D abnormalities in critically ill children. J Pediatr Crit Care 2020;7:61-8.  Back to cited text no. 12
    
13.
Puri S, Marwaha RK, Agarwal N, Tandon N, Agarwal R, Grewal K, et al. Vitamin D status of apparently healthy schoolgirls from two different socioeconomic strata in Delhi: Relation to nutrition and lifestyle. Br J Nutr 2008;99:876-82.  Back to cited text no. 13
    




 

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