Dr Hasmukh Gala SevenHills Hospital

 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

 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

 For growth and mineralisation of growing bones  Plays a crucial role in various physiological functions like blood coagulation, neuromuscular transmission, muscle contraction etc.

 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

Food itemServing sizeCalcium (mg) Milk8 oz291 Yoghurt8 oz274 Yoghurt (low fat)8 oz400 Cheese1 oz150 Artichoke, boiled1 medium135 Broccoli, chopped½ cup47 Cabbage, boiled½ cup79 Collards, boiled½ cup110 Kale, chopped, boiled½ cup45 Mustard Greens, boiled½ cup52 Okra, boiled½ cup77 Peas, boiled½ cup20 Sweet potato, baked½ cup32 Onion, chopped, raw1 cup40

Food itemServing sizeCalcium (mg) Black beans, boiled½ cup23 Chick peas½ cup38 Kidney beans½ cup34 Ragi100 gm344 mg Figs, fresh2 medium36 Kiwifruit1 medium20 Orange1 fresh52 Orange juice8 oz22 Papaya, fresh½ medium36 Banana, chopped1 cup8 Almonds, dried½ oz (12)37 Sesame seeds, whole, dried 1 tbsp88 Egg, Hen’s127 Fish, Cod3 oz13 Crab, cooked3 oz50

AgeMaleFemalePregnancyLactation 0-6 months200 mg months260 mg 1-3 years700 mg 4-8 years1000 mg years1300 mg years1300 mg years1000 mg years1000 mg1200 mg 71+ years1200 mg

 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

 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

 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

 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

 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

 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

 In newborn period- prematurity, asphyxia, infants of diabetic mother & IUGR babies- due to transient hypoparathyroidism and delayed intake of milk  In infancy- intake of cow’s milk- due to high phosphorus content of cow’s milk, which has 956 mg/L of Phosphorus.

 Hypoparathyroidism  Lack of response to PTH  Vitamin D deficiency  Hyperphosphetemia  Inadequate intake of calcium  Blood transfusion- Particularly multiple transfusion and exchange transfusion in neonate

 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

 Symptomatic hypocalcemia in neonate- 1-2 ml ( mg)/kg of body wt of 10% calcium gluconate stat and repeated every 6-8 hrly IV or alternately given as continuous IV infusion ( mg/kg body wt of 10% Cal gluconat)  Monitor serum ionised calcium  Gradually switch to oral calcium preparation once symptoms resolves

 Hypocalcemia in infants fed with cow’s 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

 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

 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

 If child is on corticosteroids, isonazide or anticonvulsant  Has milk allergy  Very low birth weight babies  Low intake of dietary calcium bellow RDA

AgeMaleFemalePregnantLactating 0- 6 months1000 mg months1500 mg 1- 8 years2500 mg years3000 mg years2500 mg 51+ years2000 mg

 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

 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)

 Mild to moderate- most patients are asymptomatic  Symptoms- vomitting, failure to thrive, pancreatitis, lethargy, hypotonia, coma, psychiatric disturbances, polyuria, nephrolithiasis, renal failure

 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

 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

 Osteopenia of prematurity is mainly due to Ca & Phosphurus deficiency rather than Vit D deficiency  All infants with birth weight <1500 g should receive fortified human milk or preterm formula  After hospital discharge, these infants should receive preterm formula (with high mineral content) or additional Calcium and Phosphurus supplementation in breast fed babies

 All babies < 1500 gm should receive mg/kg/day of Ca, mg/kg/day of P, 400 IU/ day of vitamin D  They should be screened for OOP by biochemical tests (Ca, P, ALP), x-ray, DEXA scan

 Helps in calcium absorption from GI tract  Helps in maintaining adequate S Ca and P level for adequate mineralization of bone  Maintains bone growth and bone remodeling by osteoblast and osteoclast

 Sun exposure  Flesh of fatty fish (Salmon, Tuna, Meckerel)  Fish liver oil  Cheese & egg yolk  Some mushrooms  Vitamin D fortified foods

agemalefemalepregnancylactation 0-12 years400 IU (10 mcg) 400 IU (10 mcg) 1-13 years600 IU (15 mcg) 600 IU (15 mcg) years600 IU years600 IU years600 IU >70 years800 IU (20 mcg) 800 IU (20 mcg)

 Approximately 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

Nmol/LNg/mlHealth status <30<12Vit D deficiency, associated with rickets and osteomalacia Generally considered inadequate for bone and overall health >= 50>=20Generally adequate for bone and overall health >125>50Associated with potential adverse effect

Vit D (IU/L) Calciu m (mg/L) Phosphor us (mg/L) Ca: P Ratio Breast Milk : 1 Cow milk : 1 Buffalo milk : 1 Lactogen : 1 Pediasur e : 1

 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

 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

 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

 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

 X ray of wrist  S Calcium, S Phosphorus, S Alkaline Phosphatase levels  Serum 25- hydroxy vitamin D3 level

 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

AgeMaleFemalePregnancyLactation 0- 6 months1000 IU (25 mcg) 1000 IU (25 mcg) 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)

 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