Hypernatraemic DehydrationHypernatraemic DehydrationCase PresentationCase Presentation

Muhammad ZakariyaMuhammad ZakariyaSHO – MKGHSHO – MKGH06/06/201206/06/2012

Baby VB - FemaleDOB: 22/5/2012

12.45 am

15 days old todayCMW Referral

Background

•Mother: 29 years; G2P2; House Wife•Father: 33 years; Product Engineer•Sibling: 4 years; Female•Parents not consanguineous•All in good health

Pregnancy

Uneventful12 wks and 20 wks scans NORMAL

Booking bloods NORMALNo GBS history

Birth

Full term – NVDGood APGAR

Bwt: 2559 grams (2nd – 9th centile)HC: 33cm (9th – 25th centile)

Came to hospital: 10.45 pm (21/5)Delivery: 12.45am )23/5)Discharged: 7am (23/5)

Hospital stay after delivery: 6 hours

Feeding:

Exclusively breast fedFirst feeding: 30 mins after birth

Successive feeding: Every 2 hours lasting for 1 hour

Follow up:

Seen by CMW on:•23/5 – day 0•27/5 – day 5 - Weight: 2.370 kg

(7.3% wt loss)•01/6 – day 10 – Weight: 2.040

(20% weight loss)

Follow up

Day 8 – no UOP for 18 hoursContacted LW

Advised to give waterPassed urine (0n 01/6/2012)

– after 24 hoursPrior to admission on 01/6 child had

passed urine twice in 24 hours

On admission:

Reason for referral: 20% wt lossAdmission weight in PAU: 2.028kg

(20.7% wt loss)Exclusively BF 2-3 hourly lasting for

1 hrNot opened bowels for 48 hrs

Passed urine twice during preceding 24 hours

On admission

No fever; no rash; no lethargy; not irritable;

Vitals on admission

T – 35.5HR – 120RR – 25

Sats – 100%CRT – 3 seconds

BP – not measurable

Clinical signs

Sunken fontanelsSignificantly reduced skin turgor

Cold peripheriesPoor perfusion

Sticky eyesKetotic smell from mouthGood sucking from bottle

Good tone

Clinical signs

Rest of the CVS and Respiratory examination unremarkable

Initial investigation

No urine available immediately for analysisBloods:

FBC - clotted

Na+: 189K+: 3.6Cl: 144HCO3: 17.9

Urea: 48.2Creatinine: 122

Initial investigation

FBC on day2

Hb – 18.5WBC – 17.4PLT – 341N – 11.8

Initial management

2 x 10ml/kg IV Bolus with 0.9% NaCl

Initiated oral feeds at 180 ml/kg/day of EBM+Formula orally

Made HDUPlan made for daily weight and 8

Hourly UENGT sited 12 hours after admission

due to poor sucking

Further Management

USS of kidneys on day 2 of admission:

Abnormal corticomedullary differentiation with hyperechogenic

areas on both kidneys; Some urine in bladder with debris in

it[ Consistent with ATN]

Day 2 progress

Large vomits on 3 hourly feedsPassed urine – 15 mls

Vitals – normalSkin turgor remained reduced

Serum Na+ - 174 mmol/L

Feeds made 1 ½ hourly (30mls)

Further progress

Weight:

day1 day2 day3 day4 day5 day62040

Further progress

Electrolytes:

Na+ 189 185 174 165 158 152

K+ 3.6 4.8 4.4 3.2 4.7 5.0

Ur 48.2 36.2 24.3 8.8 6.3

Cr 122 78 66 41 36

Follow Up

Due for

Repeat USS of kidneysMRI head

Both as out patient

Hypernatraemic Hypernatraemic dehydration in neonates dehydration in neonates

receiving inadequate receiving inadequate breastfeedingbreastfeeding

Introduction

Hypernatraemic dehydration is potentially a lethal condition

Associated with cerebral oedema, intracranial haemorrhage,

hydrocephalus, gangrene and DIC

Introduction

Normal neonatal feeding is usually on demand every 2–4 hours, with a minimum intake of 30 mL/feed over

a period of 5-20 minute

Introduction

It is normal over the first week of life for the neonate to lose as much as 5-7% of its birth weight through normal diuresis

Neonates should regain their birth weight by the tenth day of life

Adequate breast milk intake depends on:

normal mammogenesis (mammary development)normal lactogenesis (unimpeded initiation of Lactation)normal galactopoiesis (sustained ongoing milk synthesis)effective milk delivery to the infant.(effective milk removal)

Introduction

Many underlying factors can interfere with lactation and

breastfeeding, and thus contribute to inadequate breastfeeding

and complications, for example hypernatraemic dehydration

Introduction

HND is more common nowbecause of early infant hospital

discharge withoutadequate follow-up

Cooper WO, Atherton HD, Kahana M, KotagalUR. Increased incidence of severe breast feedingmalnutrition and hypernatremia in a metropolitan

area. Pediatrics 1995;96(5 Pt 1):957– 60.

Aetiology

Commonest causeof hypernatraemic dehydration is

low volume intakeof breast milk

Aetiology

The infant becomes dehydratedwhile the kidneys are mature

enough to retain sodiumions.

Water loss occurs predominantly through the skin

and from the lungs.

Aetieology

Unusually high sodium content of maternal breast milkMay be contributing

Aetiology

The sodium content of breast milkat birth is high and declines rapidly

over the subsequentdays.

Aetiology

Na+ Content of MilkColostrum in the first five days (22±12) mmol/L

Transitional milk from day five to ten (13±3) mmol/L

Mature milk after 15 d is (7±2) mol/L

Aetiology

Women who failed to establishgood breast-feeding did not

experience the normalphysiological drop in breast milk

sodium concentrationcompared to those who had little

difficulty in establishinga good milk flow.

Clinical Presentation

usually around ten days (range : from 3 to 21 d)Symptoms may include:

Reduced UOPReduced bowel motion

Signs may be non-specific, including lethargy and irritability

Clinical Presentation

usual physical signs of dehydration may be unreliable in

neonates

Clinical Presentation

Infants with 10% (100 ml/kg) dehydration may have:

sunken eyes and fontanel,cold and clammy skin,

poor skin turgor and oliguria

Clinical Presentation

Infants with 15% (150ml/kg)dehydration would have signs of

shock (hypotension, tachycardia and weak

pulses) In addition to the above features.

Clinical Presentation

Look for:•Sunken anterior fontanelle •Sunken eyeballs•Lethargic appearance•Dry mucous membranes•Decreased skin turgor ;Doughy skin•Prolonged capillary refill

Clinical Presentation

fullness of the anterior fontanelle may disguise the underlying

dehydration due to cerebral oedema in some cases

Investigations

Serum biochemistry: Serum sodium and plasma

osmolarity would be helpful in theassessment of the hydration

status in an infant

Investigations

Hyponatremia with weight loss suggests sodium

depletion and would merit sodium replacement

Investigations

Hyponatremia with weight gain suggests

water excess and necessitates fluid restriction

Investigations

Hypernatremia with weight loss

suggests dehydration

and would require fluid correction over 48 hours

Investigations

Hypernatremia with weightgain suggests salt and water load

and would be an indication of fluid and sodium

restriction.

Investigations

URINE:Acceptable ranges:

urine output : 1-3 ml/kg/hrspecific gravity: 1.005 - 1.012Osmolarity: 100-400 mosm/L.

Investigations

Blood gas: Not needed routinely for fluid

managementUseful in the acid base

management of patients with poor tissue perfusion and shock

Hypo-perfusion is associated with metabolic acidosis

Investigations

Fractional excretion of sodium (FeNa):

FeNa is an indicator of normal tubular function

(but is of limited value in preterm infants due to developmental tubular

immaturity)

Investigations

Blood Urea and creatinine – good indicators of renal failure

Morbidity and MortalityMorbidity and Mortality

•Apnoeas and bradycardias•Seizures, Facial palsy•Multiple cerebral infacrtions (EEG)•Hypertension, DIC•NEC•Amputation of leg after iliac artery thrombosis•Death

Morbidity and MortalityMorbidity and Mortality

The brain damage may be caused by

•cerebral oedema•intracranial haemorrhages•haemorrhagic infarcts•and thromboses

Morbidity and MortalityMorbidity and Mortality2 examples2 examples

1. Nine days of ageplasma sodium of 191 mmol/Lsuffered seizures, massive intraventricular haemorrhage, multiple dural thromboses and died on day 12.

Morbidity and MortalityMorbidity and Mortality2 examples2 examples

2. Day 13 plasma sodium concentration of 180 mmol/LCT scan: multiple areas of intraventricular, periventricular, and cortical haemorrhage. died on day 16

Morbidity and MortalityMorbidity and Mortality

Some complications, especially seizures, occur

most frequently during treatment

Treatment

mainstay of treatment is to rehydrate

the child very slowly

Treatment

If the child appears well,

Slow rehydration at a rate of 100ml/kg/day can be carried

out using expressed breast milk or proprietary milk or acombination of both.

Treatment

If the child is unwell then rehydration should be

carried out intravenously

Treatment

Infants rehydrated at a rate of 150ml/kg/day were more likely

to develop convulsions and peripheral oedema than the

infants whose fluid intake was restricted to 100 ml/kg/day

Treatment

•A collapsed child:20 mL/kg of colloid or 0.9 %

saline infused over half an hour. •If the child is not in shock,

then rehydration may be commenced intravenously using 0.9 % saline at 100 mL·kg-1·d-1

Conclusion

HND is a preventable condition in most cases:

breast feeding problems are the main risk factors in

NHD incidence and some of them can be diagnosed and

corrected before or after parturition

Conclusion

. To prevent NHD inneonates, continuing weight watch

and monitoring thenumber of urination per day are

strongly recommended

Conclusion

Women should be educated about the signs and

symptoms of dehydration during prenatal visits and

again before discharge after delivery.

Conclusion

Early dischargedemands early follow-up to detect

breastfeedingproblems before the onset of serious and sometimes life-

threatening dehydration.

References1 Kaplan JA, Siegler RW, Schmunk GA. Fatal hypernatremicdehydration in exclusively breast-fed newborn infants due tomaternal lactation failure. Am J Forensic Med Pathol 1998;19: 19-22.2 Chambers TL, Steel AE. Concentrated milk feeds and theirrelation to hypernatraemic dehydration in infants. Arch DisChild 1975; 50: 610-5.3 Clarke TA, Markarian M, Griswold W, Mendoza S.Hypernatremic dehydration resulting from inadequate breastfeeding.Pediatrics 1979; 63: 931-2.4 Rowland TW, Zori RT, Lafleur WR, Reiter EO. Malnutritionand hypernatremic dehydration in breast-fed infants.JAMA 1982; 247: 1016-7.5 Thullen JD. Management of hypernatremic dehydration dueto insufficient lactation. Clin Pediatr 1988; 27: 370-2.6 Jaffe KM, Kraemer MJ, Robison MC. Hypernatremia inbreast-fed newborns. West J Med 1981; 135: 54-5.7 Roddey OF Jr, Martin ES, Swetenburg RL. Critical weightloss and malnutrition in breast-fed infants. Am J Dis Child1981; 135: 597-9

References.8 Marino R, Gourji S, Rosenfeld W. Neonatal metaboliccasebook. Hypernatremia and breast feeding. J Perinatol1989; 9: 451-3.9 Ng PC, Chan HB, Fok TF, Lee CH, Chan KM, Wong W, etal. Early onset of hypernatraemic dehydration and fever inexclusively breast-fed infants. J Paediatr Child Health 1999;35: 585-7.10 Oddie S, Richmond S, Coulthard M. Hypernatraemic dehydrationand breast feeding: a population study. Arch DisChild 2001; 85: 318-20.11 Livingstone VH, Willis CE, Abdel-Wareth LO, Thiessen P,Lockitch G. Neonatal hypernatremic dehydration associatedwith breast-feeding malnutrition: a retrospective survey. CanMed Assoc J 2000; 162: 647-52.12 Cooper WO, Atherton HD, Kahana M, Kotagal UR. Increasedincidence of severe breastfeeding malnutrition andhypernatremia in a metropolitan area. Pediatrics 1995; 96:957-60.

References13 van der Heide PA, Toet MC, Diemen-Steenvoorde JA,Renardel de Lavalette PA, de Jonge GA. Hypertonic dehydrationin “silent” malnutrition of breast-fed infants. NedTijdschr Geneeskd 1998; 142: 993-5.14 Paul AC, Ranjini K, Muthulakshmi, Roy A, Kirubakaran C.Malnutrition and hypernatraemia in breastfed babies. AnnTrop Paediatr 2000; 20: 179-83.15 Harding D, Cairns P, Gupta S, Cowan F. Hypernatraemia:why bother weighing breast fed babies? Arch Dis Child FetalNeonatal Ed 2001; 85: F145.16 Chaudhary R, Twaddle S, Levi R, Haque K. Hypernatremicdehydration in breast-fed infants. Paediatr Today 1998; 6:85-7.17 Pickel S, Anderson C, Holliday MA. Thirsting and hypernatremicdehydration — a form of child abuse. Pediatrics1970; 45: 54-9.18 Banister A, Matin-Siddiqi SA, Hatcher GW. Treatment ofhypernatraemic dehydration in infancy. Arch Dis Child 1975;50: 179-86.