A review of 116 cases of breastfeeding-associated hypernatremia in rural area of central Turkey

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 Due to the infant’s extremely poor prognosis, life support was withdrawn at 19 days of age and the infant expired.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.

Hypernatremic Dehydration in Breast Fed Infants: Lessons from a Baby-Friendly Hospital

AIM

To determine the incidence, presentation and outcome of all neonates admitted to the University Hospital of the West Indies with a diagnosis of breastfeeding associated hypernatremic dehydration during a 15-year period and make comparisons with an earlier study done at the institution.

METHODS

A retrospective review of the files of neonates admitted to the neonatal unit with breastfeeding associated hypernatremic dehydration between January 2002 and December 2016 was conducted. Data on maternal and neonatal demographics, presentation, laboratory results and outcome were extracted and descriptive analyses performed. Statistical significance was taken at the level p < 0.05.

RESULTS

Eighty neonates were entered into the study, 79 were inborn giving an incidence of 2.5 per 1000 live births. Fifty-five (71%) mothers were primiparous, with a mean ± SD age of 29.5 ± 5.6 years and mean ± SD length of hospital stay 2.6 ± 1.5 days. Fifty-six (71%) neonates were exclusively breastfed with a mean ± SD age at presentation of 5.6 ± 3.8 days, mean ± SD percentage weight loss of 16.3% ± 6.1% and a mean serum ± SD sodium of 156.1 ± 8.3 mmol/l. Fifty-four (68%) neonates were admitted from home and 22 (28%) from the postnatal ward. Complications seen included acute kidney injury 6 (8%), seizures 2 (3%), hypotonia 1 (1%) and bradycardia 1 (1%). The neonates were detected earlier, presented with a significantly lower mean serum sodium, urea and creatinine (p < 0.05), had less severe complications and no deaths compared with neonates in the previous study.

CONCLUSION

Early intervention can make a positive impact on the severity and complications of breastfeeding associated hypernatremia.

Neonatal Hypernatremic Dehydration Associated with Lactation Failure

Hypernatremic dehydration secondary to lactation failure remains a potentially life-threatening condition in countries where advanced laboratory investigations are scarce. An 11-day term baby with excessive weight loss (33.6%), reduced urine output, fever, jaundice, doughy skin, opisthotonus posturing, and tachycardia with poor perfusion was presented to our neonatal care. The baby was diagnosed with shock with hypernatremic dehydration. An initial bolus of 20 ml/kg of N/S was repeated 3 times (each over 20 minutes), i.e., a total of 204 ml was given over 1 hr, until the vital signs were normalized to PR-145, RR-45, T-37.2°C, SPO₂-100%, and CRT < 3 seconds, and the baby began to void urine. Free water deficit and sodium excess was managed by gradual and slow correction over 72 hours to prevent cerebral oedema and neurologic sequelae. The baby required reconstituted solutions of 5% D/W + 1/2 N/S at a rate of 27 ml/hr for 72 hrs. Sepsis and hyperbilirubinemia were treated with antibiotics and phototherapy. Management of symptomatic hypernatremic dehydration must be considered in settings with inadequate laboratory facilities.

Predictability of prognosis of infantile hypernatremic dehydration: a prospective cohort study

Background: Infantile hypernatremic dehydration (IHD) is a life-threatening disease with potential cerebral adverse effects.Purpose: This study was conducted to evaluate the prognosis of IHD.Methods/Search strategy: Using convenience sampling 183 term infants with IHD (Na⁺ > 150 mg/dl) were enrolled in a cohort study with 36 months follow-up during 2007-2017. A researcher-made questionnaire was used for data collection. Follow-up visits were performed using the Denver Developmental Screening II test after discharging from hospital. The t-test, chi-square test, regression models, and receiver-operating characteristic curve were performed for data analysis.Findings/results: 17.5% of neonates were diagnosed with abnormal outcomes. Postpartum breast growth, breastfeeding frequency and duration, convulsion, consciousness, urination frequency, urea, Cr, sodium and brain CT scan (p = .000) showed significant differences (p < .05) between the infants with normal and abnormal outcomes. Combination of the above variables had a high predictive power (98.6%) for determining the unfavorable prognosis in infants with IHD.Implications for practice: Sodium, urea and creatinine are high-sensitive/specific determinants of IHD prognosis. Combination of some risk factors is highly predictive for unfavorable prognosis of IHD.Implications for research: Combination of variables such as sodium, urea, creatinine, lethargy, state of fontanels, convulsion, loss of consciousness, state of the breast during postpartum, inverted nipple and brain CT scan has a high predictive power in the determination of unfavorable prognosis in IHD.

Weight loss thresholds to detect early hypernatremia in newborns

OBJECTIVE

The literature indicates a single universal cut-off point for weight loss after birth for the risk of hypernatremia, without considering other factors. The aim of this study was to construct and internally validate cut-off points for the percentage weight loss associated with the risk of hypernatremia, taking into account risk factors.

METHODS

A prospective study with a three-day follow-up was conducted in 165 neonates with a gestational age ≥35 weeks. The main outcome variable was mild or moderate hypernatremia (serum sodium≥145mmol/L). Secondary variables (risk factors) were maternal and infant variables. A multivariate logistic regression model was constructed to predict hypernatremia, obtaining its probability and the optimal discriminant cut-off point for hypernatremia (receiver operating characteristic analysis). Based on this point, threshold weight loss values were obtained according to the other variables. These values were internally validated by bootstrapping.

RESULTS

There were 51 cases (30.9%) of hypernatremia. The mean percentage weight loss for hypernatremic infants was 8.6% and 6.0% for the rest. Associated variables in the multivariate model included greater weight loss, male gender, higher education level, multiparity, and cesarean delivery. The model had an area under the receiver operating characteristic curve of 0.84 (sensitivity=77.6%; specificity=73.2%). Similar values were obtained in the bootstrapping validation. The lowest percentage weight loss was 4.77%, for cesarean delivery in male infants of mothers with a higher education level.

CONCLUSIONS

The weight loss percentage values depended on the type of delivery, parity, newborn gender, and level of maternal education. External studies are required to validate these values.

The Prevalence and Management of Dehydration amongst Neonatal Admissions to General Paediatric Wards in Kenya-A Clinical Audit

An audit of randomly selected case records of 810 patients admitted to 13 hospitals between December 2015 and November 2016 was done. Prevalence of dehydration was 19.7% (2293 of 11 636) [95% CI: 17.1-22.6%], range across hospitals was 9.4% to 27.0%. Most cases with dehydration were clinically diagnosed (82 of 153; 53.6%), followed by excessive weight loss (54 of 153; 35.3%) and abnormal urea/electrolytes/creatinine (23 of 153; 15.0%). Documentation of fluids prescribed was poor but, where data were available, Ringers lactate (30 of 153; 19.6%) and 10% dextrose (18 of 153; 11.8%) were mostly used. Only 17 of 153 (11.1%) children had bolus fluid prescription, and Ringer's lactate was most commonly used for bolus at a median volume per kilogram body weight of 20 ml/kg (interquartile range, 12-30 ml/kg). Neonatal dehydration is common, but current documentation may underestimate the burden. Heterogeneity in practice likely reflects the absence of guidelines that in turn reflects a lack of research informing practical treatment guidelines.

Long-Term Neurodevelopmental Outcome of Neonates with Hypernatremic Dehydration

BACKGROUND

Neonatal hypernatremic dehydration (NHD) is a dangerous condition that can lead to severe weight loss, renal impairment, and central nervous system complications. We aimed to evaluate the consequences of NHD in infants in their second year of life.

MATERIALS AND METHODS

This was a prospective case-control study in Ghaem hospital, Mashhad, Iran. Sixty-five healthy breastfed neonates (serum sodium concentration <150 mmol/L) and 65 hypernatremic (serum sodium concentration ≥150 mmol/L) neonates were followed up from 2008 to 2011. Maternal and neonatal factors were compared between the two groups together with their growth parameters, and developmental milestones (using Denver II developmental assessment scores) were assessed and compared in ages 6, 12, 18, and 24 months, respectively.

RESULTS

The weight of infants at 6 months of age was significantly different between the two groups (7,264 ± 1,089 g vs. 7,596 ± 957 g, p = 0.009). Twenty-five percent of infants in the group who had developed NHD had a delay in development at 6 months of age, with corresponding values of 21% at 12 months, 19% at 18 months, and 12% at 24 months of age. Developmental delay was ∼0.3% for the control group at similar ages. The severity of hypernatremia was strongly correlated with poor developmental outcome at 6 months (p = 0.001). Serum sodium concentration of neonates was 153-195 mg/dL in the NHD group. Median peak serum sodium was 158 ± 16 in case group and 141 ± 9 in control group. Serious complications were cerebral edema (five cases), hemorrhage (five cases), and kidney stones (six cases). Hypernatremic dehydration has an adverse effect on child development especially in the first year of life, their prevalence decreases with advanced age. Growth problems are also present during their first year of life. The major signs and symptoms of infants with poor prognosis on admission were poor feeding (8 infants, 61.5%), seizure (3 infants, 23.1%), hyperthermia (1 infant, 7.7%), and lethargy (1 infant, 7.7%).

CONCLUSIONS

NHD affects growth parameters and developmental milestones of children. Occasionally the child's weight gain was normalized by the end of first year of life; although developmental delay continued, its severity was reduced, with age.

Treatment of Hypernatremia in Breastfeeding Neonates: A Systematic Review

Background/Aims

Hypernatremic dehydration in term neonates is associated with inadequate fluid intake, usually related to insufficient lactation. The use of hypotonic fluids is appropriate to dilute serum sodium (SNa), but cerebral edema may develop when it happens abruptly. Our objective was to clarify how to correct hypernatremic dehydration properly.

Methods

The following databases were searched, limited to studies published until January 31st, 2016: Clinical Trials, MEDLINE/PubMed, EMBASE, LILACS, and the Cochrane Library. We included open-label trials, nonrandomized controlled trials, or prospective and retrospective case series evaluating relevant outcomes. Information regarding the way of administering the treatment, type of fluid used, rates of complications and outcomes, as well as the rate of SNa reduction were collected.

Results

Searches yielded 771 articles: 64 had the full text reviewed and 9 were included. No randomized clinical trials or systematic reviews focusing on treatment of hypernatremic dehydration and its outcomes were found. We found a scarcity of high quality studies and great methodology heterogeneity.

Conclusions

More severe hypernatremia is at greater risk of causing severe adverse effects of treatment. There is no consensus about the optimal rate of SNa drop in this population, but a slower correction appears to be safer. Questions as when parenteral fluids are indicated remain unanswered.

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.

The healthy newborn hydration model: a new model for understanding newborn hydration immediately after birth

The normal small volume of breast milk produced in the first 2 days following birth may raise concerns about adequate hydration in breast-fed newborns. These concerns are further magnified when breast-fed infants lose ≥7% of their birth weight within 2 days postnatally. Weight loss following birth is presumably mostly water loss that could result in hypohydration and subsequent hypernatremic dehydration. However, excess fluid loss immediately following birth is a normal and necessary process. Furthermore, newborns exposed to excess fluid intake during labor may need to lose ≥7% of birth weight in the first 2 days following birth in order to achieve euhydration. Normal newborn fluid loss following birth confounds the use of weight loss as the sole measure of newborn hydration. We thus propose the healthy newborn hydration model that highlights the normalcy of newborn weight loss immediately following birth and the healthy newborn's compensatory mechanisms for preserving adequate hydration. We also recommend the use of serum sodium to measure intravascular osmolarity in addition to monitoring weight loss to obtain a more comprehensive newborn hydration assessment. Research is necessary in healthy newborns to identify relationships among fluids received in utero, newborn weight loss, and hydration, as evaluated with laboratory measures, in the first 2 days following birth. This information will guide clinicians in correctly identifying newborns with inadequate hydration who are in need of supplementary fluids versus newborns with adequate hydration for whom exclusive breast-feeding can be supported and encouraged.

What is the safe approach for neonatal hypernatremic dehydration? A retrospective study from a neonatal intensive care unit

OBJECTIVES

The aims of this study were to evaluate the prevalence, complications, and mortality of hypernatremic dehydration in neonates and to compare the effect of correction rate at 48 hours on mortality and on neurological outcome in the short term.

METHODS

This retrospective study was conducted between January 2007 and 2011 in the neonatal intensive care unit. Term neonates were included. The patients were grouped as follows: group 1 = 150 to 160 mmol/L, group 2 = 161 to 170 mmol/L and group 3 = 171 to 189 mmol/L.

RESULTS

Among 4280 neonates, 81 cases (1.8%) had hypernatremic dehydration. Groups 1, 2, and 3 consisted of 55, 23, and 3 patients, respectively. Mortality rates were as follows: 3.6%, 17.3%, and 66.6%. Mean serum sodium (Na) correction rates at 0 to 24 hours and 24 to 48 hours were 0.48 ± 0.2 versus 0.38 ± 0.31 mmol/L per hour (group 1) and 0.49 ± 0.21 versus 0.52 ± 0.28 mmol/L per hour (group 2), respectively. In 32 patients (58.1%) from group 1 and in 13 patients (56.5%) from group 2, correction rate of 0.5 mmol/L per hour or less was achieved. Twenty-two patients developed convulsions, which was the most common complication during therapy. Serum Na greater than 160 mmol/L at admission (odds ratio, 1.9; 95% confidence interval, 1.3-3.7) and serum Na correction rate of greater than 0.5 mmol/L per hour (odds ratio, 4.3; 95% confidence interval, 1.2-6.5) were independent risk factors for death or convulsion. There was a significant difference between groups 1 and 2 in Denver Developmental Screening Test II results (64.1% vs 30.7 %, P = 0.001).

CONCLUSION

Hypernatremic dehydration is an important problem that should be managed properly to avoid adverse outcomes.

Peripheral gangrene in a breast fed neonate--is hypernatremic dehydration the cause?

Hypernatremic dehydration in breast fed neonates is a rare but increasingly recognized problem. If not identified early, it may lead to potentially life threatening complications. The authors describe a neonate who developed thrombosis and lower limb ischemia secondary to hypernatremic dehydration. Peripheral gangrene, as a result of hypernatremic dehydration is extremely uncommon and has rarely been reported before.

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).