Shalini Tripathi*, Sunil Taneja**, Samarth Vohra**
Consultant paediatrician, UHM, Hospital, Kanpur and ** Department of Pediatrics, Madhuraj Hospital, Kanpur, India.
|Address for Correspondence|
|Dr Shalini Tripathi, L-30 GSVM campus, Swaroop Nagar, Kanpur, India.|
|hypocalcemia, neonate, seizure, vitamin D.|
|A 2 months old boy was admitted to the intensive care unit of our hospital with convulsions. This child was born of normal vaginal delivery and had a birth weight of 2.9 kg. He was exclusively breast fed. There was no fever or trauma or birth asphyxia. He was admitted to another hospital with generalized convulsions at the age of 1 1/2 months. After treatment for 10 days there, the seizures did not improve and thus the child was referred to our hospital. On admission, the child had generalized tonic clonic convulsions. The child was treated with intravenous phenobarbitone followed by intravenous phenytoin but as the seizures continued and so midazolam infusion was started. On midazolam infusion, seizure episodes were partially controlled. Blood glucose levels were normal on admission. CSF examination was normal. CT scan head was normal. Serum calcium (ionized) was low (2.36 mg/dl). Despite calcium supplementation the repeat calcium levels were also low. On reviewing the antenatal history, mother was not taking any antiepileptic medication and was not on any calcium and multivitamin supplementation. Further investigations in the child showed serum magnesium of 2.6 mg/dl (Normal= 1.2-2.6 mg/dl), serum alkaline phosphatase of 1072 IU/L, serum parathyroid hormone (PTH) level of 696 pg/ml (15-68 pg/ml), serum 25 hydroxy vitamin D of 14.2 nmol/l (Normal = 75-250 nmol/l). X ray wrist showed diffuse rarefaction however there was no cupping at the epiphyseal end. Thus the child was diagnosed to have vitamin D deficiency. Patient was started with oral 1, 25- hydroxy calcitriol with intravenous calcium. After 24 hrs of this treatment seizures were controlled, serum calcium was repeated and became normal on 3rd day after treatment. Mother's serum calcium level was 2.27 mmol/L (normal= 2.19 mmol/L to 2.60 mmol/L), serum 25-hydroxy vitamin D was 13 nmol/l (Normal = 17 nmol/L to 95 nmol/l), serum PTH level was 88 pg/ml (normal=10 - 65 pg/ml). Thus, she was also diagnosed to have vitamin D deficiency.
Vitamin D deficiency in the neonate secondary to maternal deficiency is an important cause of seizures in the newborn period. The appropriate daily allowance of vitamin D during pregnancy and lactation is unknown, although it appears to be greater than the current dietary reference intake of 200-400 IU/day. (1) Maternal diet low in vitamin D with no extra supplementation is an important risk factor for neonatal vitamin D deficiency. Exclusive breast-feeding is recommended up to 6 months of age with all its beneficial effects on child survival. Several studies have concluded that adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D. (1) Most of the vitamin D in a neonate is acquired from maternal transfer, so vitamin D deficiency in mothers is likely to have adverse consequences for their infants. (2-4) The supply of vitamin D in utero, rather than from milk, is the major determinant of vitamin D status in early neonatal life in mammals. (5) Shulman et al published two neonatal cases with hypocalcemic seizures. Following this, the Canadian Paediatric Society guidelines recommend vitamin D supplements for all breastfed babies (400 U/day) to begin at birth and continue until the infant is 12 months of age. For those residing above the 55th parallel, vitamin D intake should be increased to 800 U/day between October and April. (6) Erdeve et al reported a neonate presenting with severe hypocalcemic seizures on day 1 of life due to maternal vitamin D deficiency. (7) Hatun et al analyzed the characteristics of young infants (<3 mo) diagnosed with vitamin D deficiency in Turkey. A total of 42 infants were diagnosed with vitamin D deficiency. The majority (78.7%) presented with seizures. (8) Teaema et al have done a retrospective study on 19 newborns in Qatar with symptomatic hypocalcemia. Vitamin D deficiency with or without relative hypoparathyroidism was the attributed cause. (9)
At present, vitamin D supplementation is not a part of antenatal care/Integrated Management of Neonatal & Childhood Illness (IMNCI) programmes in India. Vitamin D supplementation is done only for low birth babies. Evaluation of vitamin D status should be included into the workup of hypocalcemia in early infancy. Emphasis should be given to prevent vitamin D deficiency by supplementing pregnant women and large studies are needed for vitamin D supplementation of infants who are exclusively breast-fed.
Competing interest- none
|Conflict of Interest|
Last Updated : Sunday, April 01, 2012 Vol 9 Issue 4 Art #25
- Balasubramanian S, Ganesh R. Vitamin D deficiency in exclusively breast-fed infants. Indian J Med Res. 2008; 127: 250-255. [Google Scholar] [Pubmed]
- Maiyegun SO, Malek AH, Devarajan LV, Dahniya MH. Severe congenital rickets secondary to maternal hypovitaminosis D: a case report. Ann Trop Paediatr. 2002; 22: 191-195 [Google Scholar] [Pubmed] [CrossRef]
- Grover SR, Morley R. Vitamin D deficiency in veiled or dark-skinned pregnant women. Med J Aust. 2001; 175: 251-252 [Google Scholar] [Pubmed]
- Thompson K, Morley R, Grover SR, Zacharin MR. Postnatal evaluation of vitamin D and bone health in women who were vitamin D deficient in pregnancy, and in their infants. Med J Aust 2004; 181: 486-488 [Google Scholar] [Pubmed]
- Clements MR, Fraser DR. Vitamin D supply to rat fetus and neonate. J Clin Invest 1988; 81: 1768-1773. [Google Scholar] [Pubmed] [CrossRef]
- Shulman R, O'Gorman CS, Sochett EB. Neonate with seizures and hypocalcemia. Paediatr Child Health. 2008; 13: 197-200 [Google Scholar] [Pubmed]
- Erdeve O, Atasay B, Arsan S, Siklar Z, Ocal Z, Berberoglu M. Hypocalcemic seizure due to congenital rickets in the first day of life. Turk J Pediatr. 2007; 49: 301-303. [Google Scholar] [Pubmed]
- Hatun S, Ozkan B, Orbak Z, Doneray H, Cizmecioglu F, Toprak D, et al. Vitamin D Deficiency in Early Infancy. J Nutr. 135: 279-282 [Google Scholar] [Pubmed]
- Teaema H, Ansari KA. Nineteen Cases of Symptomatic Neonatal Hypocalcemia Secondary to Vitamin D Deficiency: A 2-Year Study. J Trop Pediatr. 2010; 56: 108-110. [Google Scholar] [Pubmed] [CrossRef]
|How to Cite URL :|
|Tripathi S, Taneja S, Vohra S. HYPOVITAMINOSIS D IN AN INFANT WITH HYPOCALCEMIC SEIZURES SECONDARY TO MATERNAL VITAMIN D DEFICIENCY. Pediatric Oncall [serial online] 2012[cited 2012 April 1];9. Art #25. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=475&type=J&tid=&imgid=&reportid=83&tbltype=|