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Rapid and appropriate investigation and treatment of severe hypocalcaemia.
Peripheral IV infusion of calcium gluconate


Hypocalcaemia is a symptom complex, and can be regarded as:

  • Biochemical
  • Mildly symptomatic (distal parasthesia)
  • Severely symptomatic (tetany, seizures)

All children with symptomatic OR severe biochemical hypocalcaemia (usually Ca2+ < 1.7-1.8 mmol/L) should be discussed with and admitted under the Paediatric Endocrinology Team.


Hypocalcaemia itself in children is potentially life-threatening due to cardiac arrhythmias and stridor (usually at values of total Calcium <1.6 mmol/l) - hence the need for cardiac monitoring.

Calcium is vital for most biological functions and hence the serum calcium level is maintained within a narrow range, at the expense of sequestration of bone (potentially leading to rickets), and retention of calcium by kidneys at the expense of phosphate loss. Hypocalcaemia in this setting is therefore a late presentation of a chronic disease process and indicates that a child has significant total body calcium depletion (termed bone hunger).

Large and continuous doses of calcium are normally required for replacement; weaning of calcium infusion is usually over 48 hours as oral calcium is initiated, and stopping infusions usually results in rebound hypocalcaemia. But weaning can normally start once serum Ca2+ is >1.8

Common Causes of Infant and Childhood Hypocalcaemia

Causes  Features
   PO4  ALP  PTH  25(OH)D3
Vitamin D deficiency  ↓  ↑  ↑  ↓↓
Hypoparathyroidism (transient or permanent)  =  N/↓  N/↓  N
Pseudohypoparathyroidism     N/↓  ↑  N


Blood tests

Critical to draw at time of hypocalcaemia

Serum calcium, ionised calcium, phosphate, ALP, albumin, creatinine, urea, magnesium, PTH, & 25(OH)D3 (25 hydroxyvitaminD)


Calcium, calcium/creatinine ratio & phosphate

In Neonates

Check maternal PTH, 25 hydroxyvitamin D, calcium, phosphate, ALP & HbA1c (maternal diabetes)

Principles of Management

  1. To stabilize serum calcium to a safe range (>1.7 - 1.8 mmol/L total Calcium or >1.0 mmol/l ionised) quickly and maintain it while transitioning to oral therapy.
  2. To avoid complications of treatment: in particular extravasations of IV calcium infusion (must have a close watch of IV site).
  3. To establish the underlying cause.

Management Details

  • Obtain blood for appropriate investigations before commencing treatment. 
  • Bolus or infusions of IV calcium should ONLY be given in CED, PICU, 23B or 26A HDU with continuous cardiac monitoring, and frequent checks of iv site due to high risk of extravasation. 
  • Do not give calcium with phosphate or bicarbonate as precipitation will occur.

Symptomatic Hypocalcaemia (Seizures / Tetany / Stridor)

1 Always perform ABC and basic resuscitation if necessary
2 Treat seizures with anti-epileptics as per seizure protocol
3 Continuous cardiac monitoring - if arrhythmia discuss with Cardiologist 

Treat hypocalcaemia with IV calcium (See below for dosing) 

5 If serum Mg2+ is ≤ 0.6 mmol/L consider IV magnesium sulphate (2 mmol/mL). 
Dose: 0.2 - 0.4 mmol/kg every 12 hours as slow iv infusion. See Paediatric Medication Administration Guideline ADHB intranet only. 


  • Check Ca2+ level at 6 hours to ensure improvement, then 12 hourly as indicated
  • Aim to keep Ca2+ >1.9 mmol/L, and then gradually wean the infusion as GI absorption of Ca2+ improves
  • Stopping the calcium infusion is likely to result in a rapid fall in serum Ca2+ level due to uptake into bone ("bone hunger"). Suggest reducing infusion in 10-20% increments as Calcium normalises.

 Oral Therapy (Assuming Vitamin D deficient rickets or hypoparathyroidism)

  • Commence oral calcium and vitamin D supplementation early as it takes 2-3 days to increase absorption from the GI system.
  • Calcium gluconate (gluconate and carbonate as Calcium Sandoz® brand) 100 mg/kg/day of elemental in 4 divided doses (1000mg per tablet), or similar sources of oral Ca2+
  • 1, 25-dihydroxycholecalciferol = calcitriol (as Rocaltrol® brand) 0.03-0.06 micrograms/kg/day (max. 1-2 micrograms /day) or One Alpha drops (1 drop/kilo)
This is the most active from of Vitamin D; increases absorption of calcium in 1-2 days.

Calcium Infusion via peripheral IV


  • Calcium gluconate comes as a 10% standard stock solution.
  • For peripheral infusions always make calcium to a 1% solution as follows: 1 part 10% calcium gluconate diluted to 9 parts with "water for injection".
  • Also compatible with 5% glucose (makes it less irritant), 0.9% sodium chloride, and glucose saline solutions.
  • More concentrated solutions may be used via central lines.
  • Only administer if secure IV access is obtained

    BOLUS IV calcium
    Six (6) mL/kg of 1% Calcium gluconate solution (diluted as above) over 2 hours

    Ensure cardiac monitoring, followed by an continuous infusion (see below). 
    This bolus dose equates to ~ 0.13 mmol/kg.
    This will ameliorate tetany for ≥ 15 minutes to several hours.
    Can repeat if required. 
    NB: Seizures need treating with anticonvulsants
      See Concentrations of calcium gluconate.


    As above always make calcium to a 1% solution for peripheral administration:

    Sixty (60) mL/kg/DAY of the 1% Calcium gluconate solution (diluted as above)
    • Ensure cardiac monitoring
    • Repeat Calcium levels at 8 hours then 8-12 hourly accordingly
    • Adjusting calcium total to >1.7 - 1.8 mmol/l to start weaning

Monitoring and observation

  • Monitor ECG in case of arrythmia: unusual with this protocol
  • Monitor the IV site for local reaction/redness - must be directly observed regularly as risk of tissue necrosis if any extravasation
  • Review IV site if patient complains of pain
  • Monitor Blood pressure
  • Monitor serum calcium's as described above


  • Do not add any other medications as calcium precipitation may occur

Concentrations of Calcium gluconate

  1. 10% calcium gluconate = calcium gluconate 100 mg/mL = elemental Ca of 0.22 mmol/mL = elemental Ca of 8.9 mg/mL
  2. The daily elemental calcium estimation requirement is ~73 mg/kg.
  3. If IV calcium gluconate not available can use calcium chloride:
    10% CaCl (100 mg/mL) (elemental Ca = 0.68 mmol/mL; 27 mg/mL). This is 3X more elemental calcium.


Sperling MA. Pediatric Endocrinology. 2nd Edition.

Lifshitz F. Pediatric Endocrinology. 3rd Edition.

Hospital for Sick Children Resuscitation Card 2003-2004

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Document Control

  • Date last published: 26 January 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Endocrinology
  • Author(s): Craig Jefferies
  • Owner: Craig Jefferies
  • Editor: Greg Williams
  • Review frequency: 2 years

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