Incidence of dehydration and hypernatremia in exclusively breast-fed infants

Time to adequate weight gain and predictors among low-birth-weight preterm neonates at Neonatal Intensive Care Unit of hospitals in Bahir-Dar

Weight gain in low birth-weight babies remains a challenge to the management of the neonatal period in low and middle-income countries like Ethiopia. Therefore, this study aimed to determine the time to adequate weight gain and its predictors among low-birth-weight preterm neonates admitted to neonatal intensive care unit of public hospitals in Bahir Dar City. An institution-based retrospective follow-up study was conducted from March 4 to April 3, 2023, using three years of data. About 344 low-birth-weight preterm babies were recruited and followed up until 28 days of age. Model goodness-of-fit was checked by Cox Snell residuals test. The Cox-Proportional Hazards Model was used to assess predictors of weight gain with a statistically significant level of P-value < 0.05. The median weight gain time was 15 days with an overall incidence density rate of 6.3 per 100 person-day of observation (95% CI 0.055, 0.071). Absence of medical problems of mothers (AHR: 1.63, 95% CI 1.015, 4.614), spontaneous vaginal mode of delivery (AHR: 1.53, 95% CI 1.028, 2.593), and long duration of labor (AHR: 3.18, 95% CI 1.579, 6.413) were significant predictors. The time of adequate weight gain was long. Early detection and management of significant predictors is recommended.

Peritoneal dialysis for term neonates in a neonatal intensive care unit

BACKGROUND

This study aimed to evaluate the indications, complications, and outcomes of peritoneal dialysis (PD) in term neonates from a state hospital.

METHODS

The demographic, clinical, and laboratory data of 67 newborn term infants who underwent PD within the first 4 weeks of life between June 2014 and June 2019 were retrospectively analyzed.

RESULTS

Twenty-five patients (37.3%) were male, 42 (63.7%) were female. The mean gestational age was 38.3 ± 0.8 (range: 37-40) weeks and mean birthweight 3,100 ± 504.9 g (range: 1,800-5,000 g). The mean age of patients at the start of dialysis was 7.97 ± 8.34 days (range:1-44 days) and the mean duration for dialysis was 3 ± 5.42 days (range 1-40 days). The majority of patients who underwent PD had inborn error of metabolism (59.7%). The most common complication was dialysate leakage. Thirty-three neonates (49.2%) died during PD process because of underlying disease, 17 patients (25.4%) were referred to other centers, and 17 patients (25.4%) were discharged. There were seven acute kidney injury patients associated with hypernatremic dehydration. There were statistically significant differences between non-survivors and survivors in terms of dialysis duration, birthweight, weight at admission, requirements for mechanical ventilation, and inotrop agent, and also the renal angina index.

CONCLUSIONS

In our region, hypernatremic dehydration is still a one of the major cause for acute kidney injury (AKI) in newborns. In state hospitals, pediatric specialists must be present in neonatal intensive care units in order not to refer unstable patients to other centers and to provide high-quality patient care.

Hypernatremic Dehydration Risk Factors in Newborns: Prospective Case-Controlled Study

BACKGROUND

The prevalence of hypernatremic dehydration (HND) has increased in recent years most likely due to insufficient intake of breast milk as the most important factor. This study aimed to investigate risk factors of HND.

METHODS

In this study, 47 neonates whom were diagnosed to have HND were included in the study group and 96 healty neonates whom were included in the control group. While demographic data of the patients were recorded, mothers were asked to fill out the sociodemographic/ psychosocial data form, Edinburgh Postpartum Depression Scale(EPDS) and STAI I and II State and Trait Anxiety Scale. Breast milk sodium concentrations were studied from mothers of all infants. The relationship between the development of neonatal HND and risk factors affecting this condition were evaluated.

RESULTS

Being the first-born baby of the family was found to be a significant risk factor for HND. Breast milk sodium concentration was 25.8±7.9 mmol/L in the HND group which was significantly higher than the control group. Median depression score was similar in both groups and there was no statistical difference in terms of groups. The anxiety score was higher in the control group compared to the study group. There was no difference in terms of other sociodemographic / psychosocial data of mothers.

CONCLUSION

Primiparity or insufficient breastfeeding may result in elevated breast milk sodium levels and related neonatal HND. Breastfeeding support should principally target primiparous women to improve breastfeeding outcomes like as especially HND.

Term Infant with Cerebral Venous Sinus Thrombosis

Hypernatremic dehydration in neonates is a common condition in an exclusively breastfed infant but often underdiagnosed. Any newborn who has lost more than 10% of birthweight should be carefully evaluated and monitored for clinical features of dehydration. Efforts such as frequent follow-up for weight check, and formula supplementation, if needed, should be provided to a neonate at risk of developing complications of dehydration. Adequate lactation consultation, both inpatient and outpatient, should also be provided, especially to the primigravida mother. Here, we present a case of a neonate with severe hypernatremic dehydration caused by inadequate lactation in a primigravida mother, which resulted in cerebral venous sinus thrombosis leading to significant intracerebral hemorrhage. The infant suffered permanent neurologic damage and was sent home on technological devices (tracheostomy and gastrostomy tubes). Further, we provide a brief review of hypernatremic dehydration and sinus venous thrombosis in neonates.

Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks' gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Neonatal weight loss and gain patterns in caesarean section born infants: integrative systematic review

There is evidence that caesarean section delivery can impact on neonatal weight loss and weight gain patterns in the first 5 days of life. We conducted an integrative systematic review to examine the association of mode of delivery on early neonatal weight loss. Pubmed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Excerpta Medica dataBASE, and Medical Literature Analysis and Retrieval System Online were searched for relevant papers published before June 2019. Reference lists from the relevant papers were then backwards and forwards searched. As neonatal weight loss was reported in different formats, a meta-analysis could not be carried out. Most studies did not distinguish between elective and emergency caesarean sections or instrumental and nonassisted vaginal deliveries. Seven papers were included. All papers except one found that caesarean section was associated with higher weight loss in the early days of life. Two papers presented data from studies on babies followed up to 1 month. One study found that on day 25, babies born by caesarean section had significantly higher weight gain than those born vaginally, while another found that by day 28, babies born vaginally gained more weight per day (11.9 g/kg/day) than those born by caesarean section (10.9 g/kg/day; p = .02). Overall, infants born by caesarean section lost more weight than those born vaginally, but due to the small number of studies included, more are needed to look at this difference and why it may occur. This discrepancy in weight between the two groups may be corrected over time, but future studies will need larger sample sizes and longer follow-up periods to examine this.

Determinants of excessive weight loss in breastfed full-term newborns at a baby-friendly hospital: a retrospective cohort study

Background

Excessive weight loss in newborns is associated with neonatal complications such as jaundice and dehydration, which cause renal failure, thrombosis, hypovolemic shock, and seizures. The identification of the risk factors for excessive weight loss will help to discover preventive measures. The aim of this study was to determine the factors associated with excessive weight loss, defined as weight loss of ≥10%, in breastfed full-term newborns in Japan.

Methods

The present retrospective study, which was performed in a tertiary perinatal center accredited as a Baby-Friendly Hospital, included neonates who were born alive with a gestational age of ≥37 weeks. Cases of multiple births, admission to the neonatal intensive care unit (NICU), referral to another facility, or exclusive formula feeding were excluded. Multivariate logistic regression analyses were performed to assess the association between maternal or neonatal characteristics and excessive weight loss.

Results

We studied 399 newborns, of whom 164 (41%) had excessive weight loss. According to the adjusted multiple regression analysis, the factors associated with excessive weight loss were an older maternal age, primiparity, and antepartum Caesarean section, with adjusted odds ratios (95% Confidence Intervals [CIs]) of 1.07 (1.02, 1.11), 2.72 (1.69, 4.38), and 2.00 (1.09, 3.65), respectively.

Conclusions

Close monitoring of infants born to older mothers, primiparous mothers, or infants delivered by antepartum Cesarean section is recommended, and earlier supplementation with artificial milk may be considered.

Neonatal Hypernatremic Dehydration

Hypernatremic dehydration in exclusively breast-fed neonates is associated with a free water deficit secondary to inadequate fluid intake. It is a common but underrecognized problem in the primary care setting, as the degree of dehydration can be underestimated due to fluid shifts. Neonates of primiparous mothers and those who experience greater weight loss in the first week of life are at higher risk of developing hypernatremic dehydration and most often present for care between 6 and 10 days of life. No consensus treatment guidelines exist, but most experts recommend a goal reduction rate of serum sodium levels of 0.5 mEq/L per hour with correction over 48 hours. Serum sodium level greater than 160 mEq/L is a risk factor for morbidity and mortality. Complications of hypernatremic dehydration, with seizure being most common, usually occur during improper correction. Several small studies have documented varying degrees of neurodevelopmental delay on long-term follow-up of patients admitted for hypernatremic dehydration treatment as a neonate. [Pediatr Ann. 2019;48(5):e197-e200.].

Exclusive breast-feeding and postnatal changes in blood sodium, ketone, and glucose levels

BACKGROUND

Blood sodium and ketone are parameters of dehydration and fasting, respectively. Little is known, however, about the postnatal changes in these parameters in healthy, term, exclusively breast-fed neonates.

METHODS

Capillary blood sodium, β-hydroxybutyrate (β-OHB), and glucose levels in 628 samples obtained from 392 healthy, term, exclusively breast-fed neonates during the first 12-143 h of life were examined.

RESULTS

Blood sodium and β-OHB gradually increased and reached a peak at 48-59 h of life (mean blood sodium, 142.3 ± 2.8 mEq/L; mean blood sodium increase, 3.3 mEq/L; mean β-OHB, 1.16 ± 0.46 mmol/L; mean β-OHB increase, 0.65 mmol/L), and then gradually decreased and reached a nadir at 120-143 h of life. Blood glucose gradually decreased and reached a nadir at 48-59 h of life (mean, 62.4 ± 12.2 mg/dL; mean decrease, 4.7 mg/dL), and then gradually increased and peaked at 120-143 h of life. These changes were synchronized with changes in weight-loss percentage.

CONCLUSIONS

The postnatal changes in blood sodium, ketone, and glucose levels during the first 12-143 h of life are described in healthy, term, exclusively breast-fed neonates. The parameters seemed to be associated with the sufficiency of the breast-milk supply. These results can serve as normal reference values for healthy, term, exclusively breast-fed neonates during the early postnatal period.

Differentiating Normal Newborn Weight Loss From Breastfeeding Failure

There is increasing concern for the risk of hypernatremic dehydration in infants breastfeeding poorly. It is important to differentiate normal weight changes as infants adapt to extrauterine life from excessive weight loss from breastfeeding failure or mismanagement. We review recent data on normal weight changes in exclusively breastfeeding infants and those at risk for hypernatremic dehydration to help health professionals determine when infants require further scrutiny and supplementation. The data suggest that perinatal practices influence infant weight changes. Protecting normal birth and early initiation of breastfeeding should reduce the incidence of excessive weight loss and risk of hypernatremic dehydration

Association Between Dehydration and Fever During the First Week of Life

BACKGROUND

Trying to differentiate serious bacterial infection (SBI) from a self-limiting illness in febrile infants seen in the pediatric emergency department (PED) is a significant challenge. The aim of the study was to determine the prevalence of dehydration and its relationship to SBI in febrile full-term newborns under 1 week of age seen in a PED.

METHODS

A retrospective observational study was carried out on all children younger than 8 days of age with fever who presented to a single, tertiary care, PED from January 2009 to April 2014. Dehydration was defined as plasma sodium >150 mmol/L or >10% loss of birth weight. SBI was defined by the presence of a positive culture in the blood, urine, cerebrospinal fluid; osteoarticular infection; bacterial enteritis; or pneumonia. The primary analysis was the proportion of children with dehydration. A secondary analysis compared proportion of infection according to hydration status.

RESULTS

Of the 895 children under 8 days of age who visited the PED, 69 consulted for fever. Seven patients were excluded because they were transferred from another hospital. Sixty-two eligible patients were included in the final analysis. Of these, 17 (27%) were dehydrated according to our definition. Only 2 patients had an SBI while 2 others had a final diagnosis of viral myocarditis and encephalitis, respectively. None of the 4 children with serious infection fulfilled our definition of dehydration, and all had a plasma sodium level lower than 145 mmol/L.

CONCLUSIONS

Dehydration is frequently associated with fever in infants younger than 8 days of age seen in a PED. Early identification of dehydration may be useful in limiting the aggressive intervention in some of these infants.

Life Threatening Severe Hypernatraemic Dehydration in Neonates: A Report of Two Cases

Hypernatraemic dehydration in neonates may lead to potentially lethal consequences like cerebral oedema, intracranial haemorrhage, hydrocephalus and gangrene. In the light of increase in the infants presenting with hypernatraemic dehydration, there is a definitive need to heighten the awareness and have a high degree of suspicion in diagnosis for this potentially lethal condition. We report two neonates of severe hypernatraemia with dehydration highlighting its diagnosis and management. Treatment of hypernatraemic dehydration involves correction of electrolyte imbalance by careful restoration of fluids and ensuring appropriate intake of calories. Promoting, protecting and supporting breastfeeding by careful breastfeeding assessment and including an early post partum follow up in the hospital protocol to detect any unusual weight loss in the newborn period plays a significant role in preventing this condition.

Pulmonary hypertension and right heart failure due to severe hypernatremic dehydration

INTRODUCTION

Neonates are at risk of developing hypernatremic dehydration and its associated complications, such as stroke, dural sinus thrombosis and renal vein thrombosis. Pulmonary hypertension has not been described as a complication of hypernatremia.

CASE REPORT

We report a case of a seven-day-old neonate with severe hypernatremic dehydration who went on to develop pulmonary hypertension and right heart failure needing extracorporeal membrane oxygenation (ECMO).

DISCUSSION

Normal or high anion gap metabolic acidosis commonly accompanies hypernatremic dehydration. The presence of acidosis and/or hypoxia can delay the normal drop in pulmonary vascular resistance (PVR) after birth, causing pulmonary hypertension and right ventricular failure.

CONCLUSION

A high index of suspicion is paramount to diagnose pulmonary hypertension and aggressive correction of the acidosis and hypoxia is needed. In the presence of severe right ventricular failure, ECMO can be used as a bridge to recovery while underlying metabolic derangements are being corrected.

Severe Hypernatremic Dehydration and Lower Limb Gangrene in an Infant Exposed to Lamotrigine, Aripiprazole, and Sertraline in Breast Milk

BACKGROUND

Hypernatremic dehydration is well described in exclusively breastfed neonates, although life-threatening complications are rarely reported.

MATERIALS AND METHODS

The present article describes a case of severe hypernatremic dehydration in a previously healthy term neonate. Other published cases of severe complications of hypernatremic dehydration are discussed.

RESULTS

The exclusively breastfed neonate described had severe hypernatremic dehydration because of inadequate milk intake, with disseminated intravascular coagulation and right lower limb gangrene that required amputation of all five toes and surgical debridement of the metatarsals. The usual etiology of hypernatremic dehydration in this age group is insufficient breast milk intake. Here, the infant's mother was treated for bipolar disorder with lamotrigine 250 mg orally once daily, aripiprazole 15 mg orally once daily, and sertraline 100 mg orally once daily.

CONCLUSIONS

Awareness of these complications should prompt close follow-up of the infant with poor weight gain. The role of maternal medication as a risk factor for hypernatremic dehydration among exclusively breastfed infants needs to be further explored.

Hypernatremic Dehydration in Breastfed Term Infants: Retrospective Evaluation of 159 Cases

OBJECTIVES

The aim of this study was to reveal the frequency, presenting complaints, risk factors, complications, and ways for prevention of hypernatremic dehydration (HD) among term breastfed infants.

METHODS

The files of 159 breastfed term infants hospitalized because of HD between the years 2009 and 2014 were examined retrospectively in the Neonatal Intensive Care Unit of Sivas State Hospital, Turkey. The patients were classified according to serum sodium (Na) levels, group 1 (Na: 146-149 mEq/L, n = 68) and group 2 (Na ≥150 mEq/L, n = 91).

RESULTS

The most common complaint was fever (67.9%), and the most common physical finding was oral mucosal dryness (76%). There were positive correlations between serum Na levels and weight loss, hospital stay, admission age, admission to neonatal unit after discharge, serum urea levels, and body temperature (p < 0.05). The normalization period of Na levels was significantly longer (21.7 ± 8.8 versus 29.3 ± 17.8 hours, p = 0.03), and Na reduction rate was faster in group 2 (0.41 ± 0.3 versus 0.50 ± 0.3 mEq/L/hour, p = 0.02). Bradycardia was seen more commonly in group 2 (1.5% versus 16.5%, p = 0.002).

CONCLUSIONS

HD is a significant condition that should be treated appropriately to avoid serious complications.

Evidence Based Weighing Policy during the First Week to Prevent Neonatal Hypernatremic Dehydration while Breastfeeding

BACKGROUND

Neonatal hypernatremic dehydration is prevented by daily neonatal weight monitoring. We aim to provide evidence-based support of this universally promoted weighing policy and to establish the most crucial days of weighing.

METHODS

Weight measurements of 2,359 healthy newborns and of 271 newborns with clinical hypernatremic dehydration were used within the first seven days of life to simulate various weighting policies to prevent hypernatremic dehydration; its sensitivity, specificity and positive predictive value (PPV) of these policies were calculated. Various referral criteria were also evaluated.

RESULTS

A policy of daily weighing with a cut-off value of -2.5 Standard Deviation Score (SDS) on the growth chart for weight loss, had a 97.6% sensitivity, 97.6% specificity and a PPV of 2.80%. Weighing at birth and only at days two, four and seven with the same -2.5 SDS cut-off, resulted in 97.3% sensitivity, 98.5% specificity and a PPV of 4.43%.

CONCLUSION

A weighing policy with measurements restricted to birth and day two, four and seven applying the -2.5 SDS cut-off seems an optimal policy to detect hypernatremic dehydration. Therefore we recommend to preferably weigh newborns at least on day two (i.e. ~48h), four and seven, and refer them to clinical pediatric care if their weight loss increases below -2.5 SDS. We also suggest lactation support for the mother, full clinical assessment of the infant and weighing again the following day in all newborns reaching a weight loss below -2.0 SDS.

Excessive weight loss in exclusively breastfed full-term newborns in a Baby-Friendly Hospital

OBJECTIVE

To determine the risk factors for weight loss over 8% in full-term newborns at postpartum discharge from a Baby Friendly Hospital.

METHODS

The cases were selected from a cohort of infants belonging to a previous study. Healthy full-term newborns with birth weight ≥2.000g, who were exclusively breastfed, and excluding twins and those undergoing phototherapy as well as those discharged after 96 hours of life, were included. The analyzed maternal variables were maternal age, parity, ethnicity, type of delivery, maternal diabetes, gender, gestational age and appropriate weight for age. Adjusted multiple and univariate Cox regression analyses were used, considering as significant p<0.05.

RESULTS

We studied 414 newborns, of whom 107 (25.8%) had excessive weight loss. Through the univariate regression, risk factors associated with weight loss >8% were caesarean delivery and older maternal age. At the adjusted multiple regression analysis, the model to explain the weight loss was cesarean delivery (relative risk: 2.27 and 95% of confidence interval: 1.54 to 3.35).

CONCLUSIONS

The independent predictor for weight loss >8% in exclusively breastfed full-term newborns in a Baby-Friendly Hospital was the cesarean delivery. It is possible to reduce the number of cesarean sections to minimize neonatal excessive weight loss and the resulting use of infant formula during the first week of life.

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.

A new approach to estimating weight change and its reference intervals during the first 96 hours of life

AIM

We aimed to apply a novel model to estimate weight change and its reference intervals during the first 96 h of life and the time of weight nadir.

METHODS

This study involved 1288 full-term singletons, from the Generation XXI birth cohort. Recruitment occurred between 2005 and 2006 in all five public units providing obstetrical and neonatal care in Porto, Portugal. Birthweight was abstracted from clinical records, and the subsequent newborn anthropometrics were obtained by trained examiners. Longitudinal models to estimate postnatal weight were tested and the weight ratio was calculated as the weight during 96 h of life divided by birthweight.

RESULTS

The chosen model was (weight(t)~ 3241.442 + (-9.378) × t + 0.119 × t(2) + 0.000 × t(3) + b0i + b1i × t, where t represented the newborn infant's age in hours and bi represented the random coefficients. The curve inflection point (nadir) was achieved at 52.3 h of life, corresponding to a loss of 218 g and a weight ratio of 0.933. We estimated that at six, 12, 24 and 36 h of life the mean weight ratio and 10th-90th percentiles were 0.978 (0.968-0.988), 0.968 (0.953-0.983), 0.951 (0.928-0.974) and 0.939 (0.909-0.969), respectively.

CONCLUSION

This model allows a more accurate estimate of newborn weight change and its reference intervals, and estimated the nadir at 52.3 h of life, corresponding to a weight ratio of 0.933.

Determinants of weight changes during the first 96 hours of life in full-term newborns

BACKGROUND

Newborn weight loss (NWL) in the first 3 days of life is around 6 percent of birthweight (BW). We aim to describe the determinants of an excessive and insufficient NWL in the first 96 hours of life.

METHODS

A sample of 1,288 full-term singletons without congenital abnormality belonging to Generation XXI birth cohort was selected. Newborns were recruited in 2005-2006 at all public units providing obstetrical and neonatal care in Porto, Portugal. Information was collected by face-to-face interview and additionally abstracted from clinical records. Anthropometrics were obtained by trained examiners and newborn weight change (NWC) was estimated as (weight-BW)/BW × 100. We categorized NWL as excessive (below 10th percentile of the sample distribution of NWC: ≤-9.4% of BW), normal (between 10th and 90th percentiles: -9.3 to -4.2%) and insufficient (above 90th percentile: ≥ -4.1%). Adjusted odds ratios (OR) and 95 percent confidence intervals (CI) were calculated using multinomial regression models.

RESULTS

Excessive NWL was positively associated with maternal age ≥40 years (OR = 3.32, 95%CI 1.19-9.25), maternal education (OR = 1.04, 95% CI 1.00-1.09), cesarean delivery (OR = 2.42, 95% CI 1.12-5.23), and phototherapy-treated jaundice (OR = 1.69, 95% CI 1.00-2.87). Insufficient NWL was positively associated with low BW (OR = 2.68, 95% CI 1.13-6.33), and formula/mixed feeding (OR = 1.74, 95% CI 1.13-2.66).

CONCLUSION

Excessive NWL was positively associated with maternal age and education, cesarean delivery, and phototherapy-treated jaundice. Insufficient NWL reflected child's feeding. As breastfed newborns did not lose weight excessively, but newborns with formula/mixed feeding had insufficient NWL, our study supports that breastfeeding provides excellent nutrition during this period.

Charts for weight loss to detect hypernatremic dehydration and prevent formula supplementing

BACKGROUND

Most breast-fed newborns get the milk they need. However, very rarely milk intake is insufficient mostly as a result of poor breastfeeding techniques. Dramatic weight loss and hypernatremic dehydration may occur. Our aim was to construct charts for weight loss.

METHODS

A case-control study was performed. Charts with standard deviation score (SDS) lines for weight loss in the first month were constructed for 2,359 healthy breast-fed term newborns and 271 cases with breastfeeding-associated hypernatremic dehydration with serum sodium level > 149 mEq/L. Day 0 was defined as the day of birth.

RESULTS

Many cases with (or who will develop) hypernatremic dehydration (84%; +1 SDS line) fell below the -1 SDS line at day 3, the -2 SDS line at day 4, and the -2.5 SDS line at day 5 in the chart of the healthy breast-fed newborns. Weight loss of cases with permanent residual symptoms was far below the -2.5 SDS.

CONCLUSIONS

Already at an early age, weight loss differs between healthy breast-fed newborns and those with hypernatremic dehydration. Charts for weight loss are, therefore, useful tools to detect early, or prevent newborns from developing, breastfeeding-associated hypernatremic dehydration, and also to prevent unnecessary formula supplementing.

Disorders of sodium and water balance

Dysnatremias occur simultaneously with disorders in water balance. The first priority is to correct dehydration; once the patient is euvolemic, the sodium level can be reassessed. In unstable patients with hyponatremia, the clinician should rapidly administer hypertonic saline. In unstable patients with hypernatremia, the clinician should administer isotonic intravenous fluid. In stable patients with either hyponatremia or hypernatremia, the clinician should aim for correction over 24 to 48 hours, with the maximal change in serum sodium between 8 to 12 mEq/L over the first 24 hours. This rate of correction decreases the chances of cerebral edema or osmotic demyelination syndrome.

First-day weight loss predicts eventual weight nadir for breastfeeding newborns

OBJECTIVE

To examine the relationship between high (≥5%) weight loss during the first 24 h after birth and eventual excess weight loss (EWL) of ≥10% of birth weight.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Northern California hospitals.

PATIENTS

63 096 infants born at ≥36 weeks in 2009-2010, of whom 59 761 (94.5%) had a weight subsequent to birth weight measured at <24 h.

MAIN PREDICTOR MEASURE

Per cent of birth weight lost by 24 h of age.

MAIN OUTCOME MEASURE

Weight nadir, defined as the lowest recorded inpatient or outpatient weight in the first 30 days after birth, expressed as a percentage of birth weight.

RESULTS

Among infants who breastfed at least once, mean (±SD) weight nadir was 6.3±3.5% below birth weight, and 9.6% of the newborns lost ≥10% of birth weight. Among 2670 infants who lost ≥5% of their birth weight in the first 24 h, 782 (29%) eventually developed EWL, compared with 4840 (8%) of 57 109 infants who lost <5% (p<0.0005). In multivariate analysis, ≥5% first-day weight loss predicted eventual EWL (≥10%) with an OR of 4.06 (95% CI 3.69 to 4.46) after adjusting for gestational age, method of delivery, maternal race/ethnicity and hospital of birth.

CONCLUSIONS

High first-day weight loss predicts eventual weight nadir and can be used to identify infants who might benefit from targeted interventions to support breastfeeding and prevent EWL.

Severe neonatal hypernatraemia: a population based study

AIMS

To describe incidence, presentation, treatment and short term outcomes of severe neonatal hypernatraemia (SNH, sodium ≥160 mmol/l).

METHODS

Prospective, population based surveillance study over 13 months using the British Paediatric Surveillance Unit. Cases were >33 weeks gestation at birth, fed breast or formula milk and <28 days of age at presentation.

RESULTS

Of 62 cases of SNH reported (7, 95% CI 5.4 to 9.0 per 1 00 000 live births), 61 mothers had intended to achieve exclusive breast feeding. Infants presented at median day 6 (range 2-17) with median weight loss of 19.5% (range 8.9-30.9). 12 had jaundice and 57 weight loss as a presenting feature. 58 presented with weight loss ≥15%. 25 babies had not stooled in the 24 h prior to admission. Serum sodium fell by median 12.9 mmol/l per 24 h (range 0-30). No baby died, had seizures or coma or was treated with dialysis or a central line. At discharge, babies had regained 11% of initial birth weight after a median admission of 5 (range 2-14) days. 10 were exclusively breast fed on discharge from hospital.

CONCLUSIONS

Neonatal hypernatraemia at this level, in this population, is strongly associated with weight loss. It occurs almost exclusively after attempts to initiate breast feeding, occurs uncommonly and does not appear to be associated with serious short term morbidities, beyond admission to hospital.

Changes in the body weight of term infants, born in the tropics, during the first seven days of life

BACKGROUND

Identifying unwell neonates, particularly in the first week of life, is often subjective. If normal values are known, calculating the weight lost or gained from birth weight can be a useful adjunct in the evaluation of the health of a neonate.

METHODS

Serial body weights of well, term, breast fed infants who were attending for routine follow up, were recorded at the Shoklo Malaria Research Unit clinic in Maela Camp for displaced persons on the Thailand Myanmar border. Newborn examination was routine. Weight loss, expressed as percent weight lost from birth weight, and weight gain, expressed as a velocity (g/kg/day), was calculated for the first seven days of life. The results from normal birth weight infants, low birth weight infants (<2.5 kg) and small for gestational age infants (SGA) were examined.

RESULTS

In the first week of life there were no significant differences in weight gained or lost across the three study groups. The maximum weight lost was 4.4% (95% CI 4.1 - 4.6%), which occurred on day three. Weight gain ranged from 13 g/kg/day [95% CI 10 - 16] on day four to 18 g/kg/day [95% CI 15 - 20] on days six and seven.

CONCLUSIONS

Use of these normal values for weight gain and loss, allows infants falling outside of the expected range (95% CI) to be easily identified and subsequently highlighted as needing further medical review.

Impact and feasibility of breast crawl in a tertiary care hospital

OBJECTIVE

To determine the impact of breast crawl on breast feeding and its feasibility and acceptability in a busy labor room.

STUDY DESIGN

A prospective, single blinded, randomized controlled clinical trial. Impact of breast crawl was studied in one group and the outcome was compared with the other group where breast crawl was not performed. Feasibility and acceptability was determined by analysis of questionnaire given to obstetricians and nurses. Descriptive statistics and χ(2)-analysis was applied to evaluate the questionnaire and to compare the outcome in the two groups.

RESULT

Breast crawl had a significant positive impact on the onset of lactation (P=0.0005) as well as extent of neonatal weight loss on day 3 (0.032).

CONCLUSION

Our study adds to the body of evidence that breast crawl results in positive short-term breast feeding outcome but acceptability of breast crawl as a routine in a busy labor room remains a major issue.

Acute peritoneal dialysis in neonates with acute kidney injury and hypernatremic dehydration

OBJECTIVE

We aimed to evaluate the efficacy of acute peritoneal dialysis (PD) and clinical outcomes in neonates with acute kidney injury (AKI) and hypernatremic dehydration. ♢

METHODS

The medical records of 15 neonates with AKI and hypernatremic dehydration who were treated with acute PD were reviewed. The diagnoses were AKI with hypernatremic dehydration with or without sepsis in 13 patients and AKI with hypernatremia and congenital nephropathy in 2 patients. The main indications for PD were AKI with some combination of oligoanuria, azotemia, hyperuricemia, and metabolic acidosis unresponsive to initial intensive medical treatment. ♢

RESULTS

The mean age of the patients at dialysis initiation was 11.9 ± 9 days, and the mean duration of PD was 6.36 ± 4.8 days. In 7 patients (46.7%), hypotension required the use of vasopressors, and in 6 patients (40%), mechanical ventilation was required. Peritoneal dialysis-related complications occurred in 7 patients (46.7%), the most common being catheter malfunction (n = 6). Four episodes of peritonitis occurred in the 15 patients (26.7%), 2 episodes in patients with congenital renal disease and 2 episodes in patients with sepsis and multiorgan failure, who did not survive. Congenital renal disease, septicemia, and the need for mechanical ventilation were important factors influencing patient survival. All patients with no pre-existing renal disease or sepsis recovered their renal function and survived. ♢

CONCLUSIONS

In neonates with AKI and hypernatremic dehydration, PD is safe and successful, and in patients without congenital renal disease or sepsis, the prognosis is good. Peritoneal dialysis should be the treatment of choice in neonates with AKI and hypernatremic dehydration who do not respond to appropriate medical treatment.

[Use of supplementation for breast-fed neonates in the maternity ward]

OBJECTIVES

The aim of this study was to evaluate our practices regarding the use of supplementation for breast-fed neonates.

METHODS

A descriptive and prospective study conducted between 22/05/2010 and 23/03/2010 comprising breast-fed, healthy, singleton infants at the Maternity University Hospital of Tours. Indications for supplementation were collected prospectively by paramedics.

RESULTS

The study included 281 breast-fed neonates, of whom 99 (35 %) received supplementation. Supplemented neonates were more often children of primiparae (61.6 % versus 44%; P=0.005), or born to mothers without experience of breast-feeding (69.7% versus 48.9%; P=0.001), born by cesarean section (21.2% versus 10.4%; P=0.01), or were small for gestational age (10.1 % versus 6.6%; P=0.003). The main indications were: to prevent additional weight loss, hunger of the newborn, hypoglycemia, and difficulty to breast-feed. Twenty-nine percent of the neonates were given supplements without medical indication.

CONCLUSION

One third of breast-fed infants receive supplementation, not always medically justified. A better understanding of medical indications would avoid supplementation being given to breast-fed infants.

Impact of early weight loss on growth of Caesarean delivered babies: how long does it last?

BACKGROUND

We hypothesized that Caesarean delivered babies might experience excessive weight loss during neonatal period.

AIM

To investigate amount of weight loss among Caesarean delivered babies with exclusive breastfeeding and to identify role of relative weight change (RWC) in early postnatal period on the growth of infants in subsequent months.

METHODS

We studied healthy infants born ≥36 completed weeks, by Caesarean section between September 2008 and August 2009, with Apgar scores >7. Weight measurements were performed at birth, at 24 h postpartum and at days 2, 4, 7, 14, 30 and monthly up to 6 months. Predictive roles of RWC at each assessment on detecting excessive weight loss and poor weight gain in 1st month, as well as bodyweight z scores in subsequent months were assessed.

RESULTS

We studied 160 infants (88 female, 72 male) with a mean gestational age of 38.01 ± 1 weeks and birthweight of 3239 ± 421 g. Overall, 22.5% of infants lost >10% of birthweight; 11.9% at day 2, 16.9% at day 4 and 6.6% at day 7. Degree of weight loss was not related with parity, gestational age, birthweight or type of anaesthesia. Predictive values of RWCs in detecting poor weight gain in 0-30 days were: 2nd day; limit =-9.4%, specificity = 91.5%, 4th day; limit =-10.2%, specificity = 89.4%, 7th day; limit =-6.3%, specificity = 85%, sensitivity = 78%, 14th day; limit =+0.8%, specificity = 91.5%, sensitivity = 83.3%. Adjusting for birthweight z scores, RWC at 14th day had a significant influence on 1st and 2nd month bodyweight z scores. Bodyweight z scores were significantly correlated with the z scores of bodyweight in 1-5 months but not with that of 6 months.

CONCLUSION

Incidence of excessive weight loss is very high among Caesarean delivered babies. RWC at earlier measurements proves satisfactory in predicting poor infant growth. Management strategies based on identifying infants at risk could prevent excessive weight loss and improve future growth of those infants.

Weight loss in exclusively breastfed infants delivered by cesarean birth

BACKGROUND

Rates of exclusive breastfeeding during the postpartum hospital stay are a key measure of quality maternity care. Often, however, concern for excessive in-hospital weight loss leads to formula supplementation of breastfed infants. The American Academy of Pediatrics defines 7% weight loss as acceptable for breastfed newborns regardless of mode of delivery. Typical weight loss in exclusively breastfed infants delivered by cesarean birth has not been studied nor have possible correlates of greater weight loss in this population.

OBJECTIVES

To determine average weight loss in a cohort of exclusively breastfed infants delivered by cesarean birth and to identify correlates of greater than expected weight loss.

METHODS

We performed a retrospective chart review of exclusively breastfed infants delivered via cesarean birth at a Baby-Friendly hospital between 2005 and 2007. Average weight loss was calculated, and multivariate regression analysis was performed.

RESULTS

Average weight loss during the hospital stay in our cohort of 200 infants was 7.2% ± 2.1% of birth weight, slightly greater than the American Academy of Pediatrics guideline of 7%. Absence of labor prior to delivery was significantly associated with a greater percentage of weight loss (P = .0004), as were lower gestational age (P = .0004) and higher birth weight (P < .0001). Maternal age, gravity, parity, infant sex, Apgar scores, and prior cesarean birth were not significantly associated.

CONCLUSIONS

We conclude that for exclusively breastfed infants delivered by cesarean birth in a Baby-Friendly hospital, absence of labor prior to cesarean birth may be a previously unreported risk factor for greater than expected weight loss.

Neonatal weight loss at a US Baby-Friendly Hospital

Few if any studies have examined weight loss among term newborns by weighing infants daily for the first week of life. Perhaps because so few data exist, there is no standard in the United States for normal newborn weight loss. Our objective was to investigate normal newborn weight loss among infants born in a US Baby-Friendly hospital, by weighing infants daily for the first week of life. Using a prospective cohort design, infants born at an urban Boston, MA, hospital were enrolled within 72 hours of delivery and weighed daily for the first week of life. In hospital, infant weight was obtained from the medical record; post discharge, a research assistant visited the home daily and weighed the baby. All feeds in week 1 of life were recorded. Birth-related factors potentially affecting weight loss were abstracted from the medical record. Complete data were collected on 121 infants. Mean weight loss was 4.9% (range=0.0% to 9.9%); 19.8% (24 of 121) of infants lost >7% of their birth weight; no infant lost >10%. Maximum percent weight loss was significantly associated with feeding type: exclusively and mainly breastfed infants lost 5.5%, mainly formula-fed infants lost 2.7% and exclusively formula-fed infants lost 1.2% (P<0.001). Type of delivery and fluids received during labor were not associated with weight loss. Clinical practices at a Baby-Friendly hospital, which support and optimize breastfeeding, appear to be associated with only moderate weight loss in exclusively and mainly breastfed infants.

An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss

BACKGROUND

Newborn weight measurements are used as a key indicator of breastfeeding adequacy. The purpose of this study was to explore non-feeding factors that might be related to newborn weight loss. The relationship between the intravenous fluids women receive during parturition (the act of giving birth, including time in labour or prior to a caesarean section) and their newborn's weight loss during the first 72 hours postpartum was the primary interest.

METHODS

In this observational cohort study, we collected data about maternal oral and IV fluids during labour or before a caesarean section. Participants (n = 109) weighed their newborns every 12 hours for the first three days then daily to Day 14, and they weighed neonatal output (voids and stools) for three days.

RESULTS

At 60 hours (nadir), mean newborn weight loss was 6.57% (SD 2.51; n = 96, range 1.83-13.06%). When groups, based on maternal fluids, were compared (≤1200 mls [n = 21] versus > 1200 [n = 53]), newborns lost 5.51% versus 6.93% (p = 0.03), respectively. For the first 24 hours, bivariate analyses show positive relationships between a) neonatal output and percentage of newborn weight lost (r(96) = 0.493, p < 0.001); and b) maternal IV fluids (final 2 hours) and neonatal output (r(42) = 0.383, p = 0.012). At 72 hours, there was a positive correlation between grams of weight lost and all maternal fluids (r(75) = 0.309, p = 0.007).

CONCLUSIONS

Timing and amounts of maternal IV fluids appear correlated to neonatal output and newborn weight loss. Neonates appear to experience diuresis and correct their fluid status in the first 24 hours. We recommend a measurement at 24 hours, instead of birth weight, for baseline when assessing weight change. Because practices can differ between maternity settings, we further suggest that clinicians should collect and analyze data from dyads in their care to determine an optimal baseline measurement.

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.

Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance

OBJECTIVES

The objectives were to describe weight loss in a multiethnic population of first-born, predominantly breastfed, term infants and to identify potentially modifiable risk factors for excess weight loss (EWL).

METHODS

Data on prenatal breastfeeding intentions, demographic characteristics, labor and delivery interventions and outcomes, breastfeeding behaviors, formula and pacifier use, onset of lactogenesis, and nipple type and pain were collected prospectively. Logistic regression analyses identified independent predictors of EWL (≥10% of birth weight) by using a preplanned theoretical model.

RESULTS

EWL occurred for 18% of infants who received no or minimal (≤60 mL total since birth) formula (n = 229), including 19% of exclusively breastfed infants (n = 134) and 16% of infants who received minimal formula (n = 95). In bivariate analyses, EWL was associated (P < .05) with higher maternal age, education, and income levels, hourly intrapartum fluid balance, postpartum edema, delayed lactogenesis (>72 hours), fewer infant stools, and infant birth weight. In multivariate logistic regression analysis, only 2 variables predicted EWL significantly, namely, intrapartum fluid balance (adjusted relative risk for EWL of 3.18 [95% confidence interval [CI]: 1.35-13.29] and 2.80 [95% CI: 1.17-11.68] with net intrapartum fluid balance of >200 and 100-200 mL/hour, respectively, compared with <100 mL/hour) and delayed lactogenesis (adjusted relative risk: 3.35 [95% CI: 1.74-8.10]).

CONCLUSIONS

EWL was more common in this population than reported previously and was independently related to intrapartum fluid balance. This suggests that intrapartum fluid administration can cause fetal volume expansion and greater fluid loss after birth, although other mechanisms are possible.

Early severe weight loss in newborns after discharge from regular nurseries

AIMS

To study incidence and risk factors of early neonatal dehydration in a Norwegian population based cohort.

METHODS

Term neonates admitted to a paediatric department during 2002-2008 with a weight loss > or = 12% within three weeks of age were identified retrospectively through review of medical records. For each patient a sex-matched control group of two full-term infants was selected to assess risk factors for dehydration.

RESULTS

A total of 38 of 37 321 infants (1.0 per thousand) were admitted at a median age of 6 (interquartile range 5-12) days, and the admission rate increased during the study period (p for trend = 0.008). Simultaneously, mean nursery stay decreased from 3.5 to 2.7 days (p = 0.022). Mean weight loss was 15.0% of birth weight and 17 of 29 (58.6%) had serum sodium above 145 mmol/L. The only significant difference between patients and controls was that mothers of patients were older (32.3 +/- 5.0 vs. 29.4 +/- 5.4 years, p = 0.005).

CONCLUSION

Short nursery stay may be a risk factor for dehydration in newborn infants.

HIV-negative status is associated with very early onset of lactation among Ghanaian women

This is a longitudinal cohort study investigating the association between maternal HIV status and the reported onset of lactation. The Research to Improve Infant Nutrition and Growth project recruited 442 mothers from 3 antenatal clinics in the eastern region of Ghana, based on positive, negative, and unknown HIV status. Onset of lactation was assessed by maternal perception and validated with 2 subsamples: measurement of infant breast milk intake (n = 40) and daily infant weight measurement for 2 weeks (n = 150). Multivariate logistic regression was used to identify predictors of very early onset of lactation (onset of lactation < 6 hours). Predictors of very early onset of lactation include HIV-negative status (odds ratio = 2.68; P = .014), multiparity (odds ratio = 2.93; P = .009), vaginal delivery (odds ratio = 2.55; P = .035), and having a male child (odds ratio = 1.86; P = .032). The findings indicate an association between maternal HIV status and very early onset of lactation.

Risk factors for early lactation problems among Peruvian primiparous mothers

The aim of this study was to determine the incidence and risk factors for early lactation problems [suboptimal infant breastfeeding behaviour (SIBB), delayed onset of lactogenesis (OL) and excessive neonatal weight loss] among mother-infant pairs in Lima, Peru. All primiparous mothers who gave birth to a healthy, single, term infant at a government hospital in a peri-urban area of Lima during the 8-month recruitment period were invited to participate in the study. Data were collected at the hospital (day 0) and during a home visit (day 3). Infant breastfeeding behaviour was evaluated using the Infant Breastfeeding Assessment Tool; SIBB was defined as < or = 10 score. OL was determined by maternal report of breast fullness changes; delayed OL was defined as perceived after 72 h. Excessive neonatal weight loss was defined as > or = 10% of birthweight by day 3. One hundred seventy-one mother-infant pairs participated in the study. SIBB prevalence was 52% on day 0 and 21% on day 3; it was associated with male infant gender (day 0), < 8 breastfeeds during the first 24 h (days 0 and 3), and gestational age < 39 weeks (day 3). Delayed OL incidence was 17% and was associated with infant Apgar score < 8. Excessive neonatal weight loss occurred in 10% of neonates and was associated with maternal overweight and Caesarean-section delivery. Early lactation problems may be influenced by modifiable factors such as delivery mode and breastfeeding frequency. Infant status at birth and maternal characteristics could indicate when breastfeeding dyads need extra support.

Growth of breastfed infants

Understanding normal growth for the healthy breastfed infant is an important component of promoting and supporting child health in general and breastfeeding in particular. In this article, we summarize what is known regarding differences in growth between breastfed and formula-fed infants; we describe the development and use of infant growth references and growth standards; we introduce the new World Health Organization growth velocity standards for early infancy (which provide standards for gain in g/day during the first weeks of life); and, in closing, we present a snapshot of recent data from a cohort of breastfed newborns in Sacramento, CA, and examine how their early weight gain compares to the new growth velocity standards.

Hydration status of exclusively and partially breastfed near-term newborns in the first week of life

An in-hospital prospective, observational cohort study was conducted to assess the effects of type of feeding (exclusively breastfed [EBF] vs partially breastfed [PBF]) on the hydration status of near-term newborns in the first week of life. A total of 205 babies of 35 to 37 weeks of completed gestation were enrolled (82 in the EBF group and 123 in the PBF group). The overall incidence of significant weight loss (>or=10%) was 18% with no significant difference between EBF and PBF groups (18.3% vs 17.9%, P=.94). The incidence of hypernatremia (serum NA>or=150 meq/L) was 2.4% in the EBF group and 5.7% in the PBF group (P=.32). The factors associated with significant weight loss in the total cohort were having a mother with previous negative breastfeeding experience (adjusted odds ratio [OR]=16.5, 95% confidence interval [CI]=2.1-115.7), exposure to phototherapy (adjusted OR=9.0, 95% CI=2.5-31.8), and cesarean delivery (adjusted OR=6.7, 95% CI=2.3-19.7).

Prevention of hypernatraemic dehydration in breastfed newborn infants by daily weighing

Hypernatraemic dehydration, which predominantly appears in breastfed neonates, can cause serious complications, such as convulsions, permanent brain damage and death, if recognised late. Weight loss > or = 10% of birth weight could be an early indicator for this condition. In this prospective cohort study from October 2003 to June 2005 in the postnatal ward of the University Hospital Zurich, Switzerland, all term newborns with birth weight > or = 2,500 g were weighed daily until discharge. When the weight loss was > or = 10% of birth weight, serum sodium was measured from a heel prick. Infants with moderate hypernatraemia (serum sodium = 146-149 mmol/l) were fed supplementary formula milk or maltodextrose 10%. Infants with severe hypernatraemia (serum sodium > or = 150 mmol/l) were admitted to the neonatal unit and treated in the same way, with or without intravenous fluids, depending on the severity of the clinical signs of dehydration. A total of 2,788 breastfed healthy term newborns were enrolled. Sixty-seven (2.4%) newborns had a weight loss > or = 10% of birth weight; 24 (36%) of these had moderate and 18 (27%) severe hypernatraemia. Infants born by caesarean section had a 3.4 times higher risk for hypernatraemia than those born vaginally. All newborns regained weight 24 h after additional fluids.

CONCLUSION

In our study, one out of 66 healthy exclusively breastfed term neonates developed hypernatraemic dehydration. Daily weight monitoring and supplemental fluids in the presence of weight loss > or = 10% of birth weight allows early detection and intervention, thereby preventing the severe sequellae of hypernatraemic dehydration.

Hypernatremic dehydration due to concentrated infant formula: report of two cases

Hypernatremic dehydration is a rare but serious clinical condition in newborns and small infants. It is usually caused by diarrhea, improperly prepared infant formula, decreased fluid intake, or exclusive breastfeeding. Symptoms are usually masked until neurological symptoms occur. We report two infants who presented with fever and hypernatremic dehydration caused by concentrating infant formula to alleviate symptoms of constipation, and careless formula preparation due to confusion over spoon sizes, respectively. In the first case, status epilepticus occurred during early treatment, despite close serum sodium monitoring, though the infant was asymptomatic and thriving 4 years after discharge, with no identified neurodevelopmental deficits. The course of treatment was smooth in the second case, and no neurological complications developed. The practice of concentrating infant formula to relieve symptoms of constipation, although temporarily effective, is hazardous to newborns or young infants and can cause hypernatremic dehydration. Spoon sizes supplied with commercial infant formulas (30 mL/spoonful or 60 mL/spoonful) should be unified to avoid mistakes during preparation, especially by inexperienced and teenage mothers.