Critical weight loss and malnutrition in breast-fed infants

Hypernatremia in Newborns: A Practical Approach to Management

Hypernatremia is a potentially serious condition in both term and preterm babies, which can lead to severe and permanent neurological damage. There are many physiological changes in sodium homeostasis that occur soon after birth. Understanding this physiological process, early anticipation of hypernatremia and familiarization with the neonatal management of hypernatremia can prevent mortality and long-term morbidity associated with this condition. This review aims to provide a practical and understandable approach to the diagnosis and management of hypernatremia in neonates.

Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalizations for jaundice/hyperbilirubinemia, hypernatremia/dehydration, and hypoglycemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide. Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity. As that new intervention has become increasingly widespread, so too have researchers widely reported associated possible harms of the longer neonatal starvation/deprivation and later infant under-nutrition periods that it creates when breastfeeding is insufficient. Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder. Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers' milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.

Hypernatremia in the Neonate: Neonatal Hypernatremia and Hypernatremic Dehydration in Neonates Receiving Exclusive Breastfeeding

AIMS AND OBJECTIVES

Evaluation of neonatal hypernatremia and hypernatremic dehydration in neonates receiving exclusive breastfeeding.

INTRODUCTION

Neonatal hypernatremia is a serious condition in the newborn period. We present infants with hypernatremic dehydration due to breast milk (BM) hypernatremia. Hypernatremic dehydration in breast-fed newborns is usually secondary to insufficient lactation. We present the neonatal hypernatremia and hypernatremic dehydration encountered between January and December, 2012, its causes and treatment.

METHODOLOGY

This was a retrospective study. We analyzed records of babies admitted to the Neonatal Intensive Care Unit who were investigated and found to have hypernatremia and whose mother's BM sodium (BM Na) was done.

INCLUSION CRITERIA

(1) Babies with serum Na >145 meq/l, (2) euglycemia, (3) normocalcemic, (4) no clinical and lab evidence of sepsis, (5) exclusive breast feeds.

EXCLUSION CRITERIA

Neonates not satisfying any mentioned criterion.

RESULTS

BM Na correlated strongly with neonatal hypernatremia in exclusively breast-fed babies who did not otherwise have any risk factor.

CONCLUSION

Elevated BM Na is an important etiological factor in neonatal hypernatremia.

Breastfeeding-Associated Hypernatremia: A Systematic Review of the Literature

There are increasing reports on hypernatremia, a potentially devastating condition, in exclusively breastfed newborn infants. Our purposes were to describe the clinical features of the condition and identify the risk factors for it. We performed a review of the existing literature in the National Library of Medicine database and in the search engine Google Scholar. A total of 115 reports were included in the final analysis. Breastfeeding-associated neonatal hypernatremia was recognized in infants who were ≤ 21 days of age and had ≥ 10% weight loss of birth weight. Cesarean delivery, primiparity, breast anomalies or breastfeeding problems, excessive prepregnancy maternal weight, delayed first breastfeeding, lack of previous breastfeeding experience, and low maternal education level were significantly associated with breastfeeding-associated hypernatremia. In addition to excessive weight loss (≥ 10%), the following clinical findings were observed: poor feeding, poor hydration state, jaundice, excessive body temperature, irritability or lethargy, decreased urine output, and epileptic seizures. In conclusion, the present survey of the literature identifies the following risk factors for breastfeeding-associated neonatal hypernatremia: cesarean delivery, primiparity, breastfeeding problems, excessive maternal body weight, delayed breastfeeding, lack of previous breastfeeding experience, and low maternal education level.

Influence of breast-feeding on weight loss, jaundice, and waste elimination in neonates

BACKGROUND

The Baby-Friendly Hospital Initiative began promoting exclusive breast-feeding in 2001 in Taiwan; however, few studies have investigated its impact. This study evaluated the influence of breast-feeding on Taiwanese neonates with regard to the frequency of jaundice, body weight loss (BWL), and elimination of both urine and stool.

METHODS

The medical records of 313 healthy mother-neonate pairs admitted at our hospital were reviewed retrospectively and divided into three groups: exclusively breast-feeding (n=161), mixed (breast/formula) feeding (n=80), and exclusively formula feeding (n=72).

RESULTS

Compared with the exclusively formula feeding group, in the exclusively breast-fed neonates, the average total serum bilirubin level at 3 days after birth (p < 0.001) and the rate of significant hyperbilirubinemia ≥ 15 mg/dL (p<0.05) were significantly higher; the average BWLs at 2 and 3 days after birth (p < 0.001, p < 0.001) and the rate of BWL ≥ 10% (p < 0.05) were significantly higher; the average frequency of stool passage at 2 and 3 days after birth (p < 0.001, p < 0.001) and urination at 1, 2, and 3 days after birth (p < 0.001, p < 0.001, p < 0.001) were significantly less. The factors associated with a mother's choice of infant feeding type include maternal age and delivery method.

CONCLUSION

Breast-feeding during the initial days of life has a significant influence on the degree of jaundice, amount of BWL, and the frequency of stool passage and urination.

Five-year neurodevelopmental outcome of neonatal dehydration

OBJECTIVE

To determine the long-term outcome of neonatal dehydration.

STUDY DESIGN

We identified 182 newborns who were rehospitalized with dehydration (weight loss > or =12% of birth weight and/or serum sodium > or =150 mEq/L) and 419 randomly selected controls from a cohort of 106,627 term and near-term infants with birth weight > or =2000 g born between 1995 and 1998 in northern California Kaiser Permanente hospitals. Outcomes data were obtained from electronic records, interviews, questionnaire responses, and neurodevelopmental evaluations performed in a masked fashion.

RESULTS

Follow-up data to age at least 2 years were available for 173 of 182 children with a history of dehydration (95%) and 372 of 419 controls (89%) and included formal evaluation at a mean age (+/-standard deviation) of 5.1 +/- 0.12 years for 106 children (58%) and 168 children (40%), respectively. None of the cases developed shock, gangrene, or respiratory failure. Neither crude nor adjusted scores on cognitive tests differed significantly between groups. There was no significant difference between groups in the proportion of children with abnormal neurologic examinations or neurologic diagnoses. Frequencies of parental concerns and reported behavior problems also were not significantly different in the 2 groups.

CONCLUSIONS

Neonatal dehydration in this managed care setting was not associated with adverse neurodevelopmental outcomes in infants born at or near term.

Reference chart for relative weight change to detect hypernatraemic dehydration

OBJECTIVE

The validity of the rule of thumb that infants may have a weight loss of 10% in the first days after birth is unknown. We assessed the validity of this and other rules to detect breast-fed infants with hypernatraemic dehydration.

DESIGN

A reference chart for relative weight change was constructed by the LMS method. The reference group was obtained by a retrospective cohort study.

PARTICIPANTS

1544 healthy, exclusively breast-fed infants with 3075 weight measurements born in the Netherlands and 83 cases of breast-fed infants with hypernatraemic dehydration obtained from literature.

RESULTS

The rule of thumb had a sensitivity of 90.4%, a specificity of 98.3% and a positive predictive value of 3.7%. Referring infants if their weight change is below -2.5 SDS (0.6th centile) in the reference chart in the first week of life and using the rule of thumb in the second week had a sensitivity of 85.5%, a specificity of 99.4% and a positive predictive value of 9.2%.

CONCLUSIONS

The rule of thumb is likely to produce too many false positive results, assuming that for screening purposes the specificity needs to be high. A chart for relative weight change can be helpful to detect infants with hypernatraemic dehydration.

Dehydration and hypernatremia in breast-fed term healthy neonates

OBJECTIVE

The aim of the study was to determine the incidence of significant weight loss, dehydration, hypernatremia and hyperbilirubinemia in exclusively breast-fed term healthy neonates and compare the incidence of these problems in the warm and cool months.

METHODS

During the study period 496 neonates were recruited.

RESULTS

157 neonates (31.6%) had significant weight loss (> 10 % cumulative weight loss or per day weight loss > 5%). Clinical dehydration was present in 2.2% of neonates. Of these 157 neonates, 31.8% had hypernatremia and 28 % had hyperbilirubinemia.

CONCLUSION

The incidence of the above mentioned problems were higher in the warm months but the difference was not statistically significant.

Acute renal failure in the neonatal period

Acute renal failure (ARF) is a common problem in the neonatal intensive care unit (NICU). In most cases, ARF is associated with a primary condition such as sepsis, metabolic diseases, perinatal asphyxia and/or prematurity. This retrospective study investigated the course of illness, therapeutic interventions, early prognosis and risk factors associated with development of ARF in the neonatal period. A total of 1311 neonates were treated in our NICU during the 42-month study period, and 45 of these babies had ARF. This condition was defined as serum creatinine level above 1.5 mg/dL despite normal maternal renal function. The data collected for each ARF case were contributing condition, cause and clinical course of ARF, gestational age and birth weight, age at the time of diagnosis, treatment, presence of perinatal risk factors and need for mechanical ventilation. The frequency of ARF in the NICU during the study period was 3.4%. Premature newborns constituted 31.1% of the cases. The mean birth weight in the group was 2863 +/- 1082 g, and the mean age at diagnosis was 6.2 +/- 7.4 days. The causes of ARF were categorized as prerenal in 29 patients (64.4%), renal in 14 patients (31.1%) and postrenal in 2 patients (4.4%). Forty-seven percent of the cases were nonoliguric ARF. Asphyxia was the most common condition that contributed to ARF (40.0%), followed by sepsis/metabolic disease (22.2%) and feeding problems (17.8%). Therapeutic interventions were supportive in 77.8% of the cases, and dialysis was required in the other 22.2%. The mortality rate in the 45 ARF cases was 24.4%. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were associated with significantly increased mortality (p<0.05). There were no statistical correlations between mortality rate and perinatal risk factors, oliguria, prematurity or blood urea nitrogen and creatinine levels. The study showed that, at our institution, ARF in the neonatal period is frequently associated with preventable conditions, specifically asphyxia, sepsis and feeding problems. Supportive therapy is effective in most cases of neonatal ARF. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were identified as indicators of poor prognosis in these infants. Early recognition of risk factors and rapid effective treatment of contributing conditions will reduce mortality in neonatal ARF.

[Hypernatremic dehydration associated with breast-feeding]

BACKGROUND

During the last 10 years the number of publications reporting a rise in the incidence of hypernatremia in children who are exclusively breast-fed has increased.

OBJECTIVE

To report the results of a series of cases detected in a district hospital in the last 6 years in order to better delineate the clinical characteristics of infant hypernatremia, its optimal treatment and preventive measures.

MATERIAL AND METHODS

The selection criteria for our study included all neonates aged less than 30 days with serum sodium concentrations equal to or greater than 150 mEq/mL who were exclusively breast fed. Cases were identified through the departmental database.

RESULTS

Twelve newborns were identified who presented the following characteristics: mean gestational age of 39.5 weeks, mean birth weight of 3440 grams, mean percentage of weight loss from birth 13.7 % and mean serum sodium value 152.75 mEg/mL. Five neonates (42 %) were admitted from the maternity unit and seven (58 %) from the emergency department. The presenting complaints included weight loss in nine infants, irritability in six, fever in six, poor feeding in five and jaundice in two. Most of the neonates had more than one symptom. Ten of the mothers (83.33 %) were primiparous and two (16.67 %) were secundiparous.

CONCLUSIONS

Hypernatremia due to breast-feeding is a consequence of inadequate breast-feeding technique in inexperienced mothers. A possible solution would be for health professionals to provide mothers with greater support.

Randomized trial of postpartum care after hospital discharge

OBJECTIVE

Harmful effects of short postpartum hospital stays include dehydration and malnutrition of breastfed infants. These may be prevented by adequate breastfeeding frequency; however, rigorous research to determine the relative effectiveness of various follow-up strategies in supporting breastfeeding frequency is absent. This study addressed the question, "Is there a difference in breastfeeding frequency or infant weight gain for singleton infants discharged within 36 hours' postpartum who received either community nurse (home visit) or hospital nurse (clinic) follow-up?"

METHODS

A randomized, controlled trial was conducted at a university teaching hospital (3700 births/y) and affiliated community health centers. A consecutive sample of 586 healthy mother-infant pairs were recruited from January 1997 to September 1998 before discharge; 513 (87.5%) contributed data on 1 or more outcomes. Forty-eight-hour postpartum telephone contact and day 3 nurse contact in the home (experimental) or at the hospital (control) were provided. The main outcomes measured were breastfeeding frequency and infant weight gain assessed at 2 weeks' postpartum by maternal diary and weight at home by research assistants, masked to group allocation.

RESULTS

No clinically important or statistically significant group differences were found in daily breastfeeding frequency (mean difference experimental minus control = 0.1 feeds [95% confidence interval: -0.1-0.3]) or daily rate of infant weight gain (-1.1 g [-2.5-0.3]) based on intention-to-treat analyses.

CONCLUSIONS

Follow-up by nurses after short postpartum hospital stays, in either the home or a hospital-based clinic, of healthy infants discharged at <36 hours seems associated with satisfactory infant breastfeeding outcomes.

Incidence of dehydration and hypernatremia in exclusively breast-fed infants

OBJECTIVES

To verify in exclusively breast-fed, term infants the incidence of hypernatremic dehydration and identify possible maternal and/or infant factors that interfere with successful breast-feeding.

STUDY DESIGN

We prospectively included all healthy breast-fed neonates referred to our Neonatology Unit between October 1999 and March 2000. All neonates with a weight loss > or = 10% of birth weight had a breast-feeding test and a determination of serum sodium, urea, and base excess. Student t test and chi-square test were used for statistical analysis of the data.

RESULTS

Of 686 neonates, 53 (7.7%) had a weight loss > or = 10% of the birth weight, and 19 also had hypernatremia. These 53 neonates had a significantly higher incidence of caesarean delivery and lower maternal education than neonates with a weight loss < 10%.

CONCLUSION

Our prospective study demonstrates that a weight loss > or = 10% during the first days of life is frequent. Daily weight evaluation, careful breast-feeding assessment, and early routine postpartum follow-up are effective methods to prevent hypernatremic dehydration and promote breast-feeding.

Hypernatraemic dehydration and breast feeding: a population study

As part of a population based regional review of all neonatal readmissions, the incidence of dehydration with hypernatraemia in exclusively breast fed infants was estimated. All readmissions to hospital in the first month of life during 1998 from a population of 32 015 live births were reviewed. Eight of 907 readmissions met the case definition, giving an incidence of at least 2.5 per 10 000 live births. Serum sodium at readmission varied from 150 to 175 mmol/l. One infant had convulsions. The sole explanation for hypernatraemia was unsuccessful breast feeding in all cases. The eight cases are compared with the 65 cases published in the literature since 1979. Presentation, incidence, risk factors, pathophysiology, treatment, and prevention are discussed.

Severe hypernatremic dehydration and death in a breast-fed infant

Breast milk is acknowledged as the best source of nutrition for neonates. We present the case of a full-term newborn who was fed solely breast milk and developed severe dehydration and hypernatremia. The patient developed cerebral edema, transverse sinus thrombosis, and died. The literature on the uncommon entity of breast-feeding hypernatremia and dehydration is reviewed, and management strategies are presented.

Malnutrition and hypernatraemia in breastfed babies

Despite the well-known advantages of breast-feeding to both mother and infant, malnutrition of breastfed infants does occur. We report two term neonates who presented in the 3rd week of life with severe wasting, hypernatraemic dehydration and pre-renal failure while being exclusively breastfed. Breast-milk sodium levels were markedly elevated on admission. Both infants recovered following adequate hydration and showed excellent catch-up growth during follow-up while exclusive breast-feeding was maintained. The critical malnutrition in both cases was detected by the family physician during routine postnatal visits. Both mothers were well motivated toward breast-feeding and were unaware of the severity of the baby's illness.

Underlying illness associated with failure to thrive in breastfed infants

Over a four-year period in a suburban pediatric practice, 38 infants aged six months or less were identified with failure to thrive (FTT) while breast-feeding. In seven cases (18.4%), an associated organic illness was diagnosed. Only 2 of 28 breast-fed neonates (8%) were found to have FTT associated with another illness, as compared to 5 of 10 older infants (50%). Breast-fed infants with FTT, particularly those presenting after the first month of life, should be considered high risk for having other disease. Their clinical evaluation should include an appropriate search for organic illnesses.

The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain

We conducted a prospective study of the associations between several biologic and surgical breast factors and the onset of lactation in 319 healthy, motivated, primiparous women who were breastfeeding term, healthy, appropriate for gestational age or large for gestational age infants. During the last trimester of pregnancy subjects' breasts were examined for surgical incisions, size, symmetry, and nipple protuberance, and women estimated their prenatal breast enlargement. At two visits in the first two weeks postpartum, infants were weighted naked, and mothers reported the magnitude of postpartum breast engorgement when their milk came in. Breastfeeding was evaluated at each visit, and interventions were recommended for problems, with emphasis on maximizing milk yield. Lactation was deemed sufficient when an exclusively breastfed infant achieved an average weight gain of 28.5 g or more per day between the two visits. Infants gaining less than 28.5 g per day with breast milk exclusively, and those requiring formula supplement returned for a third visit at or before 21 days of age, when final lactation outcome was assessed based on weight gain between the second and third visits. Within three weeks postpartum 85 percent of the mothers achieved sufficient lactation, whereas 15 percent had persistent milk insufficiency despite intensive intervention. Of the study population, 6.9 percent had undergone previous breast surgery. Women with periareolar breast incisions were nearly 5 times more likely to have lactation insufficiency than were those without surgery (relative risk [RR] = 4.55; 95 percent confidence interval [CI] = 2.21-9.43; P less than 0.001). Insufficient lactation was significantly associated with minimal prenatal breast enlargement (P less than 0.02) and minimal postpartum breast engorgement when milk came in (P less than 0.001). Although not statistically significant, women with inverted nipples were more likely to have lactation insufficiency compared with those with normal nipples (RR = 2.94; 95% CI 1.05-8.20; P = .07). The findings from this study indicate that certain biologic and surgical breast variables are associated with lactation insufficiency.

Medical management of successful breast-feeding

Despite the present climate of professional and lay enthusiasm for breast-feeding, many women experience problems in the initiation of lactation, either because of misinformation, secondary lactation difficulties, or primary failure of lactation. This article provides pediatricians with practical guidelines for the successful initiation of breast-feeding and the prevention and early detection of problems. Recommendations are made for optimal prenatal preparation for breast-feeding, intrapartum routines that facilitate lactation, appropriate early follow-up of nursing infants, and the management of the full normal course of breast-feeding.

Evolution and infant feeding

The darwinian theory of evolution has been used to justify the statement that breast-milk is ideal for infants. However, a broader interpretation of the theory suggests that the mother-child dyad is the evolutionary unit. For the survival of the species, both mother and child should benefit. Simple arithmetic shows that where there is a conflict of interests, the welfare of the mother outweighs that of the infant. The dyad hypothesis suggests that the maximum evolutionary gain is obtained when protein and energy levels in breast-milk are just high enough to prevent prohibitive infant mortality rates, but low enough to spare the mother. The anti-infective constituents of breast-milk are very small in bulk, so they place a minimum metabolic load on the mother but have a large benefit for the child. The contraceptive effect of breast feeding is pronounced only when the mother is malnourished. A separation of the nutritive from the anti-infective properties of breast-milk suggests that a rational method of infant-feeding for many mothers is to breast-feed for several months to reduce the morbidity rate in the infant, but to give supplementary milks, formulae, and foods when needed to promote the baby's nutritional status.

Successful breast feeding: the mother's dilemma

A content analysis of 141 articles on breast feeding by discipline revealed differences in the factors considered necessary for breast feeding success and in the criteria used to determine success. Whereas medical articles focused on maternal factors prenatally and infant health post-natally, or the length of time breast feeding was maintained, lay articles focused on the relationship of the mother with her infant (the nursing couple) and the mother's ability to manage breast feeding within the family context. The implications of this discrepancy for nursing practice and research are discussed.

Hypernatraemic dehydration and necrotizing enterocolitis

Severe hypernatraemic dehydration developed over the first twelve days of life in a breastfed infant girl. Upon oral rehydration with formula milk, no acute neurological problems arose, but she subsequently developed necrotizing enterocolitis. Intravenous rehydration may be preferred to the oral route in such infants.