Long-Term Neurodevelopmental Outcome of Neonates with Hypernatremic Dehydration

Evaluating the relationship between aEEG findings and two-year prognosis in neonates with severe hyperbilirubinemia

OBJECTIVE

Identifying factors that can better predict the prognosis of neonates with hyperbilirubinemia is important. In this study, we aimed to evaluate the relationship between electroencephalography (EEG) findings and two-year prognosis in neonates with severe hyperbilirubinemia.

METHODS & MATERIALS

In a cohort prospective study, we studied neonates with a total serum bilirubin level of higher than 18 mg/dL, who were admitted to the neonatal intensive care unit (NICU) of Ghaem hospital, Mashhad, Iran. EEG was recorded upon admission, for all neonates. Patients' data, including demographic characteristics, admission information, and pregnancy and birth data were gathered by obtaining history from parents and studying case files. Also, the relationship between initial EEG findings and final developmental status was assessed.

RESULTS

Mean and standard deviation age of patients were 5.46 ± 3.13 days and average serum total bilirubin level was 23.97 ± 4.34 mg/dL at admission. Our findings revealed a significant correlation between the presence of trace alternant on EEG and developmental delay (P = .001). Presence of trace alternant waves on initial EEG at admission was significantly associated with developmental delay in the two year (P = .005).

CONCLUSION

These results indicate a relationship between developmental prognosis and the severity of hyper bilirubinemia in neonates. Also, our findings show that the presence of trace alternate waves on the initial EEG is significantly associated with developmental delay of the neonate in the future.

Clinical Profile and Outcome of Young Infants With Hypernatremic Dehydration Presenting to the Emergency Department

OBJECTIVES

The aim of this study was to evaluate the clinical profile and outcome of young infants presenting to the pediatric emergency department with hypernatremic dehydration.

METHODS

A prospective observational study was conducted at a tertiary care teaching hospital over a period of 18 months. All outborn sick young infants aged 2 months or younger who presented to the emergency department with symptoms and signs of possible sepsis and/or dehydration were screened, and those with hypernatremia were enrolled in the study. Those infants born at less than 37 weeks of gestation and gross congenital anomaly were excluded. Hypernatremic dehydration was defined as serum sodium levels (Se Na+)higher than 145 mEq/L. Variables used in the study were defined as per standard definitions. Acute kidney injury was defined and staged using serum creatinine as per modified neonatal Kidney Disease Improving Global Outcome guidelines. Clinical presentation, laboratory parameters, and comorbidities were compared among outcome groups (survived and died).

RESULTS

Of 1124 outborn young infants who met the eligibility criteria for screening, 63 were diagnosed to have hypernatremic dehydration and 55 were enrolled. The hospital-based period prevalence of hypernatremic dehydration in young infants was 4.89%. The median age of presentation was 17 days (10-30). Male-to-female ratio was 1.1:1. Seventy-three percent were first in birth order. Feeding pattern showed 61.8%, 30.9%, and 7.3% of infants were exclusively breastfed, top fed, and mixed fed, respectively. The median serum sodium at the time of admission was 160 (153.5-167) mg/dL. Three (5.5%) infants had mild, 39 (70.9%) had moderate, and 13 (23.6%) had severe hypernatremic dehydration. There was statistically significant correlation between median platelet count with severity of hypernatremic dehydration. The mean time taken to correct serum sodium level was 3.30 ± 1.60 days. The case fatality rate was 41.8%. Those who died had statistically more severe hypernatremic dehydration, acute kidney injury, sepsis, and need for ventilation.

CONCLUSIONS

Acute kidney injury stage 3, shock, and need for ventilation are associated with poor outcome in infants with hypernatremic dehydration.

Comparison of prognosis between hyperbilirubinemic infants with and without hypernatremia

OBJECTIVES

Hypernatremia may facilitate the diffusion of bilirubin through the blood-brain barrier and increase the risk of bilirubin encephalopathy. This study was conducted to compare the prognosis of jaundice infants with those with jaundice and hypernatremia.

METHODS

A total of 615 term infants with idiopathic jaundice with or without hypernatremia were enrolled in this cohort study with 24-months follow-up at Ghaem Hospital, Mashhad, Iran, between 2010 and 2022. An in-house questionnaire including the laboratory evaluation and neonatal characteristics was used as the data collection tool. The follow-up of neonatal development status was performed using the Denver test II at 6, 12, 18, and 24 months after discharging from hospital.

RESULTS

Normal outcomes were seen in 555 (90.2%) out of 615 studied infants, while 60 cases (9.8%) showed abnormal outcomes. Serum levels of sodium (P = 0.017), bilirubin (P = 0.001), urea (P = 0.024), and creatinine (P = 0.011) as well as hyperthermia (P = 0.046) and unconsciousness (P = 0.005) showed significant differences between the two groups. Approximately 16% of the newborns with both jaundice and hypernatremia, and 9% of those with only jaundice had unfavorable prognoses. Also, bilirubin level had the most predictive power (91.3%).

CONCLUSIONS

Our results suggest that hypernatremia or jaundice alone, may affect the prognosis of infants aged 2 years; but jaundice and hypernatremia together, will intensify the developmental problems in jaundice infants. However, the role of hyperbilirubinemia in the incidence of complications is more than hypernatremia.

Fatal Hypernatremic Dehydration in a Term Exclusively Breastfed Newborn

Hypernatremic dehydration in term newborns has steadily increased in incidence with increasing efforts to promote exclusive breastfeeding before hospital discharge, a key metric of the Baby-Friendly Hospital Initiative. The following report details a case of a term newborn infant who had evidence of poor intake while exclusively breastfeeding during his hospital stay that may not have been recognized by health care providers. The infant was discharged home and was subsequently found by the parents in cardiac arrest 12 h after discharge and was found to have hypernatremic dehydration. Although return of spontaneous circulation was achieved after fluid resuscitation, the infant sustained extensive hypoxic-ischemic brain injury due to cardiovascular collapse. Due to the infant’s extremely poor prognosis, life support was withdrawn at 19 days of age and the infant expired. This sentinel case demonstrates multiple pitfalls of current perceptions of normal vs. abnormal newborn feeding behavior, weight loss percentages, elimination patterns, and acceptable clinical thresholds believed to be safe for neonates. Newer data have shown that hypernatremia occurs commonly in healthy, term breastfed newborns at weight loss percentages previously deemed normal by most health professionals and hospital protocols. In-hospital strategies to prevent excessive weight loss and screening for hypernatremia in response to signs of inadequate feeding have the potential to prevent tens of thousands of readmissions for feeding complications a year, as well as hundreds of millions in health care costs.

The Impact of Hypernatremia in Preterm Infants on Neurodevelopmental Outcome at 18 Months of Corrected Age

OBJECTIVE

The study objective was to assess the correlation between hypernatremia during the first week of life and neurodevelopmental outcomes at 18 months of corrected age in premature infants.

STUDY DESIGN

A retrospective observational study of preterm infants born at less than 32 weeks of gestation who had a neurodevelopmental assessment with the Bayley scales of infant and toddler development III at 18 ± 6 months of corrected age. Serum sodium levels from birth through 7 days of life were collected. The study cohort was divided into two groups: infants with a peak serum sodium of >145 mmol/L (hypernatremia group) and infants with a peak serum sodium level of <145 mmol/L (no hypernatremia group). Prenatal, intrapartum, and postnatal hospital course and neurodevelopmental data at 18 ± 6 months were collected. Logistic regression analysis was used to assess the correlation between neonatal hypernatremia and neurodevelopment with adjustment for selected population characteristics.

RESULTS

Eighty-eight preterm infants with complete neurodevelopmental outcome data at 18 ± 6 months of corrected gestational age were included in the study. Thirty-five neonates were in the hypernatremia group and 53 were in the no hypernatremia group. Maternal and neonatal characteristics were similar between the two groups except that the hypernatremia group had a significantly lower average birth weight and gestational age. Comparison of the mean neurodevelopmental scores between the two groups showed that patients in the hypernatremia group as compared with those in the no hypernatremia group had significantly lower neurodevelopmental scaled scores in the fine motor domain (p = 0.01). This difference remained significant (p = 0.03, odds ratio [OR] = 0.8, 95% confidence interval [CI]: 0.6-0.97) when adjusted for birth weight and gestational age.

CONCLUSION

Preterm infants born at less than 32 weeks of gestation with hypernatremia in the first week of life have lower fine motor scores at 18 months of corrected age.

KEY POINTS

· Hypernatremia is a common electrolyte disturbance in preterm neonates.. · Hypernatremia may be associated with long-term neurodevelopmental outcomes in preterm infants.. · Hypernatremia is a potentially modifiable risk factor..

Importance of Early Genetic Sequencing in Neonates Admitted to NICU with Recurrent Hypernatremia: Results of a Prospective Cohort Study

OBJECTIVES

The genetic characteristics in neonates admitted to the NICU with recurrent hypernatremia remained unknown. We aimed to implement early genetic sequencing to identify possible genetic etiologies, optimize the treatment, and improve the outcome.

METHODS

We prospectively performed exome sequencing or targeted panel sequencing on neonates diagnosed with recurrent hypernatremia (plasma sodium ≥150 mEq/L, ≥2 episodes) from January 1, 2016, to June 30, 2020.

RESULTS

Among 22,375 neonates admitted to the NICU, approximately 0.33% (73/22,375) developed hypernatremia. The incidence of hypernatremia >14 days and ≤14 days was 0.03% and 0.3%, respectively. Among 38 neonates who had ≥2 hypernatremia episodes, parents of 28 patients consented for sequencing. Genetic diagnosis was achieved in 25% neonates (7/28). Precision medicine treatment was performed in 85.7% (6/7) of the patients, including hydrochlorothiazide and indomethacin for 57.1% (4/7) with arginine vasopressin receptor 2 (AVPR2) deficiency-associated congenital nephrogenic diabetes insipidus; a special diet of fructose formula for 1 patient with solute carrier family 5 member 1 deficiency-associated congenital glucose-galactose malabsorption (1/7, 14.3%); and kallikrein-inhibiting ointment for 1 patient with serine protease inhibitor of Kazal-type 5 deficiency-associated Netherton syndrome (1/7, 14.3%). Only hypernatremia onset age (adjusted odds ratio 1.32 [1.01-1.72], p = 0.040) independently predicted the underlying genetic etiology. The risk of a genetic etiology of hypernatremia was 9.0 times higher for neonates with a hypernatremia onset age ≥17.5 days (95% confidence interval, 1.1-73.2; p = 0.038).

CONCLUSIONS

Single-gene disorders are common in neonates with recurrent hypernatremia, and >50% of cases are caused by AVPR2 deficiency-associated congenital nephrogenic diabetes insipidus. Early genetic testing can aid the diagnosis of unexplained recurrent neonatal hypernatremia and improve therapy and outcome.

Weight loss monitoring reduces the occurrence of neonatal hypernatremic dehydration in breastfeeding neonates

Background

Excessive weight loss enhances the incidence of neonatal hypernatremic dehydration (NHD). We compared the effect of a new breastfeeding policy against an old breastfeeding policy on neonatal weight change and the incidence of NHD.

Methods

This was a QA project between two sets of breastfeeding (BF) protocols for exclusively BF newborns. Under our old BF policy, a number of neonates had a significant loss of weight after birth and were admitted to the NICU due to NHD. We implemented a new BF policy that was used when a newborn loses>5% of previously recorded weight within a 24-h interval. Two groups were compared: the preintervention group (old BF policy) and postintervention group (new BF policy). Additionally, characteristics of newborns admitted to NICU were separately compared with the subgroup of pre- and post intervention dehydration groups.

Results

Preintervention = 1320 and postintervention = 1450. Neonates with weight loss of ≥ 5% within the first 24-h time interval were higher in the postintervention group (19.7%) as compared to the preintervention group (10.2%) (P < .05). However, the number of infants diagnosed to have NHD was lower in the postintervention group (0.68%) than in the preintervention group (1.66%), (P < .03). Neonatal characteristics were comparable between subgroups of dehydration.

Conclusion

An intervention at ≥ 5% neonatal weight loss markedly reduces the incidence of NHD-associated NICU admissions.

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.

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.].

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