Pathophysiology of Hyponatremia in Children

A well child with prolonged oral thrush: an unexpected diagnostic journey

Oral thrush is a familiar presentation in both general practice and paediatrics, and is usually responsive to treatment in the community. Here, we present the diagnostic journey of a previously well boy aged 3 years who presented with treatment-resistant thrush and describe how 'unexpected' results led to eventual diagnosis and management. This intriguing case was managed jointly by district hospital general paediatric team and tertiary hospital specialist teams.

Efficacy and safety of isotonic versus hypotonic intravenous maintenance fluids in hospitalized children: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Iatrogenic hyponatremia is a common complication following intravenous maintenance fluid therapy (IV-MFT) in hospitalized children. Despite the American Academy of Pediatrics' 2018 recommendations, IV-MFT prescribing practices still vary considerably.

OBJECTIVES

This meta-analysis aimed to compare the safety and efficacy of isotonic versus hypotonic IV-MFT in hospitalized children.

DATA SOURCES

We searched PubMed, Scopus, Web of Science, and Cochrane Central from inception to October 1, 2022.

STUDY ELIGIBILITY CRITERIA

We included randomized controlled trials (RCTs) comparing isotonic versus hypotonic IV-MFT in hospitalized children, either with medical or surgical conditions. Our primary outcome was hyponatremia following IV-MFT. Secondary outcomes included hypernatremia, serum sodium, serum potassium, serum osmolarity, blood pH, blood sugar, serum creatinine, serum chloride, urinary sodium, length of hospital stay, and adverse outcomes.

STUDY APPRAISAL AND SYNTHESIS METHODS

Random-effects models were used to pool the extracted data. We performed our analysis based on the duration of fluid administration (i.e., ≤ 24 and > 24 h). The Grades of Recommendations Assessment Development and Evaluation (GRADE) scale was used to evaluate the strength and level of evidence for recommendations.

RESULTS

A total of 33 RCTs, comprising 5049 patients were included. Isotonic IV-MFT significantly reduced the risk of mild hyponatremia at both ≤ 24 h (RR = 0.38, 95% CI [0.30, 0.48], P < 0.00001; high quality of evidence) and > 24 h (RR = 0.47, 95% CI [0.37, 0.62], P < 0.00001; high quality of evidence). This protective effect of isotonic fluid was maintained in most examined subgroups. Isotonic IV-MFT significantly increased the risk of hypernatremia in neonates (RR = 3.74, 95% CI [1.42, 9.85], P = 0.008). In addition, it significantly increased serum creatinine at ≤ 24 h (MD = 0.89, 95% CI [0.84, 0.94], P < 0.00001) and decreased blood pH (MD = -0.05, 95% CI [-0.08 to -0.02], P = 0.0006). Mean serum sodium, serum osmolarity, and serum chloride were lower in the hypotonic group at ≤ 24 h. The two fluids were comparable in terms of serum potassium, length of hospital stay, blood sugar, and the risk of adverse outcomes.

LIMITATIONS

The main limitation of our study was the heterogeneity of the included studies.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Isotonic IV-MFT was superior to the hypotonic one in reducing the risk of iatrogenic hyponatremia in hospitalized children. However, it increases the risk of hypernatremia in neonates and may lead to renal dysfunction. Given that the risk of hypernatremia is not important even in the neonates, we propose to use balanced isotonic IV-MFT in hospitalized children as it is better tolerated by the kidneys than 0.9% saline.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42022372359. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

Postoperative free water administration is associated with dysnatremia after congenital heart disease surgery in infants

Dysnatremia after congenital heart disease (CHD) surgery is common. European guidelines on intraoperative fluid therapy in children recommend isotonic solutions to avoid hyponatremia, but prolonged cardiopulmonary bypass and administration of high sodium-containing solutions (i.e., blood products and sodium bicarbonate) are associated with postoperative hypernatremia. The aim of the study was to describe fluid composition prior to and during the development of postoperative dysnatremia. A retrospective observational, single-center study including infants undergoing CHD surgery. Demographics and clinical characteristics were registered. Highest and lowest plasma sodium values were recorded and associations with perioperative fluid administration, blood products, crystalloids, and colloids were explored in relation to three perioperative periods. Postoperative dysnatremia occurred in nearly 50% of infants within 48 h after surgery. Hypernatremia was mainly associated with administration of blood products (median [IQR]: 50.5 [28.4-95.5] vs. 34.5 [18.5-61.1] mL/kg; p = 0.001), and lower free water load (1.6 [1.1-2.2] mL/kg/h; p = 0.01). Hyponatremia was associated with a higher free water load (2.3 [1.7-3.3] vs. 1.8 [1.4-2.5] mL/kg/h; p = 0.001) and positive fluid balance. On postoperative day 1, hyponatremia was associated with higher volumes of free water (2.0 [1.5-2.8] vs. 1.3 [1.1-1.8] mL/kg/h; p < 0.001) and human albumin, despite a larger diuresis and more negative daily fluid balance. Postoperative hyponatremia occurred in 30% of infants despite restrictive volumes of hypotonic maintenance fluid, whereas hypernatremia was mainly associated with blood product transfusion. Individualized fluid therapy, with continuous reassessment to reduce the occurrence of postoperative dysnatremia is mandatory in pediatric cardiac surgery. Prospective studies to evaluate fluid therapy in pediatric cardiac surgery patients are warranted.

Hyponatremia and its associated factors in children admitted to the pediatric intensive care unit in eastern Ethiopia: a cross-sectional study

BACKGROUND

Hyponatremia is a serious problem that leads to substantial increases morbidity and mortality in critically ill children. The identification of risk factors, implementation of preventive measures, and timely diagnosis and management are crucial to reduce adverse events related to hyponatremia. Despite the higher burden of the problem in Ethiopia, evidence related to the risk factors for hyponatremia among children in Ethiopia is limited; in particular, no study has been identified in eastern Ethiopia. Therefore, we aimed to determine the magnitude of hyponatremia and its associated factors in children admitted to the pediatric intensive care unit at the Hiwot Fana Comprehensive Specialized University Hospital.

METHODS

A facility-based cross-sectional study was conducted using 422 medical records of pediatric patients admitted to the pediatric intensive care unit at Hiwot Fana Comprehensive Specialized University Hospital from January 2019 to December 2022. Medical records were reviewed to collect data. Data were analyzed using a statistical package for social sciences (SPSS) version 26. A binary logistic regression model with an adjusted odds ratio (aOR) and a 95% confidence interval (CI) was used to identify factors associated with the outcome variable. Statistical significance was set at p < 0.05.

RESULTS

The magnitude of hyponatremia was 39.1% (95% CL: 34.4-43.8%). The age of the child (aOR = 2.37;95% CL:1.31-4.31), diagnosis of sepsis (aOR = 2.33; 95% CL:1.41-3.84),   surgical procedures (aOR = 2.39; 95% CL:1.26-4.56), nutritional status (aOR = 2.60; 95% CL:1.51-4.49), and length of hospital stay (aOR = 3.04; 95% CL: 1.73-5.33) were factors significantly associated with hyponatremia.

CONCLUSIONS

Four out of ten children admitted to pediatric intensive care units had hyponatremia. Hyponatremia was significantly associated with the age of the child, malnutrition, sepsis, surgical procedures, and length of hospital stay. To reduce the burden of hyponatremia and associated mortality, attention should be focused on improving the care of malnourished children, and those with sepsis, and the quality of postoperative monitoring services. Moreover, intervention strategies aimed at reducing the burden of hyponatremia should target the identified factors.

Clinical and pathophysiological aspects of impaired water and sodium metabolism in newborns and neurological complication

This literature review covers the pathophysiological features of water and sodium exchange in newborns. The main mechanisms regulating fluid and electrolyte balance in newborns are poorly studied. The volume and composition of the extracellular fluid are provided by the functional activity of the kidneys under the control of the neuroendocrine system. The antidiuretic hormone plays the main role in the regulation of water excretion by the kidneys. The volume of intracellular fluid depends on the passive water transport with the participation of aquaporins. Lability of water and electrolyte metabolism in newborns may be accompanied by hyponatremia. For various pathological conditions in the neonatal period, certain types of hyponatremias are characteristic. Correction of hyponatremia should be carried out taking into account its pathophysiological type. Hyponatremia is a common complication associated with severe neonatal brain damage. Hyponatremia contributes to brain damage as an independent factor. The study of indicators of water and electrolyte balance in the neonatal period has an important prognostic value for early detection of damage to the central nervous system.

Controls of Central and Peripheral Blood Pressure and Hemorrhagic/Hypovolemic Shock

The pressure exerted on the heart and blood vessels because of blood flow is considered an essential parameter for cardiovascular function. It determines sufficient blood perfusion, and transportation of nutrition, oxygen, and other essential factors to every organ. Pressure in the primary arteries near the heart and the brain is known as central blood pressure (CBP), while that in the peripheral arteries is known as peripheral blood pressure (PBP). Usually, CBP and PBP are correlated; however, various types of shocks and cardiovascular disorders interfere with their regulation and differently affect the blood flow in vital and accessory organs. Therefore, understanding blood pressure in normal and disease conditions is essential for managing shock-related cardiovascular implications and improving treatment outcomes. In this review, we have described the control systems (neural, hormonal, osmotic, and cellular) of blood pressure and their regulation in hemorrhagic/hypovolemic shock using centhaquine (Lyfaquin^®) as a resuscitative agent.

The accuracy of serum osmolarity calculation in small children

Background

Serum osmolality can be measured (Omeas) or calculated (Ocal). Many formulas for Ocal have been already published, but data regarding the most accurate equation in small babies is not available. Thus, we aim to compare Omeas and Ocal obtained by different formulas in newborns and small children.

Methods

The study included 280 serum samples taken from children, from the first day of life to 2 years (mean age 8.2 ± 7.6 months) treated in the University Children's Hospital in Krakow. The serum osmolality was measured by osmometer and calculated by 8 common formulas.

Results

The mean value of Omeas (2 8 5 .8 ± 5 .1 mOsm/kgH2O) was significantly different as compared to the mean values of Ocal (p< 0.01) for all formulas, except Ocal obtained by the formula: 1.86*(N a + K) +1.15*Glu + Urea + 14. According to Bland-Altman analysis, this formula showed the best performance for estimating osmolality. In children under 3 months of life Passing-Bablok regression indicated both systematic and proportional error for results obtained by each formula compared to the measured values.

Conclusions

To calculate osmolarity in children aged between 3 months and 2 years old the following equation: 1 .86*(N a + K) + 1.1 5*G lu+ U rea+ 14 might be used, whereas serum osmolality in children up to 3 month of life should be measured.

Serum electrolyte abnormalities in pediatric patients presenting to an emergency department with various diseases: Age-related differences

BACKGROUND

This study evaluated the prevalence and frequency of serum electrolyte abnormalities (SEAs) in children presenting to a pediatric emergency department (PED) with various diseases.

METHODS

Pediatric patients (≤18 years) with blood electrolyte panels obtained in the PED of Lin-Kou Chang Gung Memorial Hospital, Taiwan, in the 5 years from January 1, 2016, to August 31, 2021, were enrolled in this retrospective observational study. Patients were divided into three age groups: Group A, < 4 years; Group B, 4-11 years; and Group C, 12-18 years. The associations between SEAs and clinical diseases in children and age-related differences were assessed.

RESULTS

This study included 182,058 pediatric patients visiting our PED over a 5-year period. A total of 250 (0.14%) patients with SEAs were included in the analysis. The study population consisted of 127 boys and 123 girls with a median (IQR) age of 9.0 (3.2-14.1) years. Hospital admission was required in 86.4% (n = 216) of the patients, and 32.4% (n = 81) of them were admitted to the pediatric intensive care unit (PICU). The median (IQR) hospital stay and PICU stay was 6.5 (4.0-11.0) and 4.0 (3.0-8.0) days, respectively. The PICU stay was longer in Group A (p < 0.05) and shorter in group C (p < 0.05). Hyponatremia was the most common SEA in group A (46.3%, n = 31), while hypokalemia was common in groups B (54.2%, n = 52) and C (32.2%, n = 28). Gastrointestinal, renal, and endocrine diseases were common clinical conditions associated with SEAs in pediatric patients in our PED.

CONCLUSION

The detection rate of SEAs in patients in the PED was 0.14%. Hyponatremia was a common SEA in pediatric patients aged <4 years, while the most common electrolyte disorder in those >4 years old was hypokalemia. In infants and young children, SEAs were associated with a longer PICU stay.

Clinical characteristics of pediatric intussusception and predictors of bowel resection in affected patients

Background

Surgery is required for the treatment of intussusception when enema reduction is unsuccessful, or when the patient develops peritonitis, bowel perforation, or intestinal damage. We aimed to evaluate the clinical and laboratory parameters that may be used to predict the need for bowel resection in children with intussusception.

Methods

This observational retrospective study included children who were admitted to the pediatric emergency department with intussusception. Univariate and multivariate logistic regression models were used to evaluate factors associated with bowel resection.

Results

In total, 584 children with intussusception were admitted to the pediatric emergency department; 129 of these children underwent surgery. Multivariate analysis revealed the following independent predictors of bowel resection for intussusception: symptoms for at least 2 days before surgery (OR = 6.863; p = 0.009), long intussusception (OR = 5.088; p = 0.014), pathological lead point (OR = 6.926; p = 0.003), and intensive care unit admission (OR = 11.777; p = 0.001) were factors independently associated with bowel resection.

Conclusion

Symptoms for at least 2 days before surgery, long intussusception, pathological lead, and intensive care unit admission were predictors of bowel resection in children with intussusception. These findings can be used to identify patients at high risk of needing surgery and bowel resection.

Giant cystic hypothalamic hamartoma in an infant associated with persistent syndrome of inappropriate antidiuretic hormone secretion

BACKGROUND

A giant hypothalamic hamartoma (GHH) is a rare congenital malformation only reported in a few cases in the literature and is often associated with precocious puberty, gelastic seizures, or less commonly, Pallister-Hall syndrome. Persistent syndrome of inappropriate antidiuretic hormone secretion (SIADH) is very rare in infancy, and most patients with GHH do not develop persistent SIADH, usually only transient electrolyte disturbances postoperatively. Previous cases of GHH have not been associated with persistent derangements in antidiuretic hormone levels.

CASE DESCRIPTION

A 7-month-old male infant presented to our hospital with a history of an intracranial cystic lesion diagnosed at 23 weeks gestational age (GA), later impressed as a solid-cystic mass at 37 weeks GA by ultrasound prenatally. Postnatal MRI after birth showed a large mass with a dorsal cyst occupying the hypothalamus, causing hydrocephalus and brainstem compression. The patient started to have subtle seizures on the seventh day after birth and eventually developed dacrystic seizures. Hyponatremia with persistent SIADH was observed at 3 months of age before surgery. He received long-term oral sodium supplementation, polytherapy of anti-epileptic medications, ventriculocystostomy for progressive enlargement of the cystic cavity, and later surgical treatment for disconnection and partial resection which confirmed a histological diagnosis of hypothalamic hamartoma.

CONCLUSION

In this case study, we present a novel association of GHH with persistent SIADH and a rare presentation of a cystic component at the dorsal part of the tumor. Clinicians should be aware of this potential endocrine derangement and provide emergent treatment.

Risk Factors for Benign Convulsions With Mild Gastroenteritis

Objective

To investigate the risk factors for benign convulsions with mild gastroenteritis (CwG) and provide a basis for the early identification and diagnosis.

Method

We selected children with CwG and acute gastroenteritis in the same period who attended the pediatric department of the Liyang People's Hospital from June 2018 to June 2021. A retrospective analysis of the general data, clinical characteristics, and laboratory test results of the two groups was performed. Finally, we conducted a multifactorial logistic regression analysis to derive the risk factors for CwG.

Results

A total of 82 children were included in the CwG and 93 children were included in the acute gastroenteritis group. Univariate analysis showed no significant differences in gender, age, vomiting, diarrhea, neutrophil, lymphocyte, hemoglobin, platelets, and serum calcium. Statistically significant differences were found in onset season, rotavirus, white blood cells, aspartate aminotransferase, alanine transaminase, serum sodium, and uric acid. Finally, multifactorial logistic regression analysis showed rotavirus (OR, 3.042, 95% CI, 1.116-8.289, p = 0.030), serum sodium (OR, 0.811, 95% CI, 0.684-0.962, p = 0.016) and uric acid (OR, 1.018, 95% CI, 1.012-1.024, p = 0.000) to be independent risk factors.

Conclusion

Characteristics of gastroenteritis symptoms such as vomiting and diarrhea cannot be used to predict the onset of CwG. Rotavirus is an independent risk factor for CwG, and decreased serum sodium and increased uric acid can be used as early warning indicators for CwG.

Diagnosis and management of hypernatraemia in children

Hypernatraemia is most commonly caused by excessive loss of solute-free water or decreased fluid intake; less often, the aetiology is salt intoxication. Especially infants, young children and individuals with a lack of access to water are at risk of developing hypernatraemia. Diagnosis is based on detailed history, physical examination and basic laboratory tests. Correction of hypernatraemia must be slow to prevent cerebral oedema and irreversible brain damage. This article reviews the aetiology, differential diagnosis and management of conditions associated with paediatric hypernatraemia. Distinguishing states with water deficiency from states with salt excess is important for proper management of hypernatraemic patients.

Prevalence, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19

Hyponatraemia is frequently encountered in adults with coronavirus disease 2019 (COVID-19) and is associated with poor prognosis. This review aims to describe for the first time the prevalence, aetiology, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19, taking into account all relevant studies published in PubMed and Cochrane Library studies until 26th September 2021. Literature search did not detect any studies evaluating the prevalence and prognostic value of sodium disorders in paediatric patients with COVID-19. A broader literature review showed a high prevalence of hyponatraemia in children with bacterial pneumonia, while some studies have reported that hyponatraemia is relatively common in Multisystem Inflammatory Syndrome in Children (MIS-C). In adults with COVID-19, an inverse association between sodium and interleukin-6 levels has been found, indicating that hyponatraemia could be used as a surrogate marker for the risk of cytokine storm and may facilitate the identification of patients who could benefit from immunomodulatory agents. Studies are urgently needed to evaluate the frequency and prognostic impact of electrolyte abnormalities in children with COVID-19. In the meantime, clinicians are urged to consider hyponatraemia in children with COVID-19 as a potential red flag, investigate the cause and administer fluids and other therapies accordingly.

Vasopressin-Dependent Disorders: What Is New in Children?

Arginine vasopressin (AVP)-mediated osmoregulatory disorders, such as diabetes insipidus (DI) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) are common in the differential diagnosis for children with hypo- and hypernatremia and require timely recognition and treatment. DI is caused by a failure to concentrate urine secondary to impaired production of or response to AVP, resulting in hypernatremia. Newer methods of diagnosing DI include measuring copeptin levels; copeptin is AVP's chaperone protein and serves as a surrogate biomarker of AVP secretion. Intraoperative copeptin levels may also help predict the risk for developing DI after neurosurgical procedures. Copeptin levels hold diagnostic promise in other pediatric conditions, too. Recently, expanded genotype and phenotype correlations in inherited DI disorders have been described and may better predict the clinical course in affected children and infants. Similarly, newer formulations of synthetic AVP may improve pediatric DI treatment. In contrast to DI, SIADH, characterized by inappropriate AVP secretion, commonly leads to severe hyponatremia. Contemporary methods aid clinicians in distinguishing SIADH from other hyponatremic conditions, particularly cerebral salt wasting. Further research on the efficacy of therapies for pediatric SIADH is needed, although some adult treatments hold promise for pediatrics. Lastly, expansion of home point-of-care sodium testing may transform management of SIADH and DI in children. In this article, we review recent developments in the understanding of pathophysiology, diagnostic workup, and treatment of better outcomes and quality of life for children with these challenging disorders.

Hyponatremia in childhood urinary tract infection

Acute urinary tract infection (UTI) is the most common bacterial infection in childhood. Although hyponatremia was described in ~ 2/3 of these children, its clinical significance is still unclear. Herein, we evaluated the prevalence and clinical implications of hyponatremia in children hospitalized with a UTI. Medical records of previously healthy children hospitalized between January 2011 and December 2016 with UTI were retrospectively reviewed. Patients (median age 5.5 months) were divided into two groups according to their sodium levels: normonatremia (Na ≥ 135 mEq/L) and hyponatremia (Na < 135 mEq/L). Hyponatremia diagnosed on admission was found in 114/219 children (49%). Hyponatremic patients experienced a more severe disease manifested by a longer hospital stay (3.8 vs 3.4 days, p = 0.003), a higher prevalence of abnormal findings on renal ultrasound (10 vs 2, p = 0.01), higher C-reactive protein (CRP) levels (8.6 vs 3.4 mg/dl, p = <0.001), and a negative correlation between sodium levels and CRP (r = - 0.38, p < 0.001).Conclusion:Hyponatremia occurs frequently in children hospitalized with UTI and is associated with elevated inflammatory markers and a more severe disease course. What is Known: • Hyponatremia, one of the most common electrolyte abnormalities, occurs in approximately 1/3 of hospitalized children and in 2/3 of children with pyelonephritis. • In certain cases of various medical conditions, hyponatremia has been shown to correlate with disease severity. What is New: • Hyponatremia in hospitalized children with UTI correlates with elevated inflammatory markers and a more severe disease course.

Lower serum sodium levels predict poor clinical outcomes in patients with insomnia

Background

The association between lower serum sodium levels and the clinical outcomes of insomnia patients remains unclear. We explored whether lower serum sodium is associated with poor clinical outcomes in patients with insomnia.

Methods

We retrospectively enrolled patients with a diagnosis of insomnia from January 2011 to December 2012. We divided participants into three groups according to initial serum sodium level: tertile 1 (< 138 mmol/L), tertile 2 (138.0–140.9 mmol/L), and tertile 3 (≥ 141.0 mmol/L). To calculate the relative risk of death, hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained using Cox proportional hazard models.

Results

A total of 412 patients with insomnia were included, of whom 13.6% (n = 56) had hyponatremia. Patients with lower serum sodium concentrations were older and had lower hemoglobin, calcium, phosphorus, and albumin levels. At the median follow-up of 49.4 months, 44 patients had died and 62 experienced acute kidney injury (AKI). Kaplan-Meier analysis showed significantly higher mortality in patients in the lowest tertile for serum sodium. The lowest tertile of the serum sodium level and the AKI were associated with all-cause mortality. However, the lowest tertile of the serum sodium level was not significantly associated with AKI.

Conclusions

The lowest tertile of the serum sodium level was associated with a higher mortality rate in insomnia patients. Our results suggest that the serum sodium level could serve as a prognostic factor in insomniacs; patients with lower sodium levels require particular care.

Clinical Approach to Sodium Homeostasis Disorders in Children with Pituitary-Suprasellar Tumors

Children with pituitary-suprasellar tumors are at high risk of developing sodium metabolism disorders since the tumoral mass itself or surgical and medical treatment can damage AVP release circuits. Additional risk factors are represented by the use of hypotonic fluids, the young age, total parenteral nutrition, and obstructive hydrocephalus secondary to tumor pathology. The most frequent hyponatremic disorders related to AVP in these patients are the syndrome of inappropriate ADH secretion and the cerebral/renal salt wasting syndrome, while hypernatremic conditions include central diabetes insipidus (CDI) and adipsic CDI. The main challenge in the management of these patients is to promptly distinguish the AVP release disorder at the base of the sodium imbalance and treat it correctly by avoiding rapid sodium fluctuations. These disorders can coexist or follow each other in a few hours or days; therefore, careful clinical and biochemical monitoring is necessary, especially during surgery, the use of chemotherapeutic agents, or radiotherapy. This monitoring should be performed by experienced healthcare professionals and should be multidisciplinary, including pediatric endocrinologists, neurosurgeons, and oncologists since maintaining sodium homeostasis also plays a prognostic role in terms of disease survival, therapeutic response, hospitalization rate, and mortality. In this review, we analyze the management of sodium homeostasis disorders in children with pituitary-suprasellar tumors and discuss the main challenges in the diagnosis and treatment of these conditions based on literature data and over 30 years of clinical experience at our Department of Pediatric Endocrinology.

Prevalence and Clinical Significance of Hyponatremia in Pediatric Intensive Care

A retrospective chart review was conducted to estimate the prevalence and severity level of hyponatremia on admission at the pediatric intensive care unit (PICU) in a Saudi tertiary hospital. Hyponatremia was highly prevalent (67.2%) and severe hyponatremia was frequent among patients with Pediatric Risk of Mortality score > 10%. Severe hyponatremia was also associated with increased length of stay ( p  = 0.04) and a trend of increased mortality ( p  = 0.054). However, disease severity was not an independent risk factor of mortality in PICU, but might confound other risk factors that render the children requiring prolonged hospital stay, mechanical ventilation, and increased health costs.

Unilateral renal artery stenosis presented with hyponatremic-hypertensive syndrome - case report and literature review

Background

Renal artery stenosis is one of the secondary causes of pediatric hypertension. Cases with critical unilateral renal artery stenosis manifesting with the hyponatremic hypertensive syndrome are rare and a comprehensive description of this disorder in the pediatric population is lacking in the literature.

Case presentation

We describe a 4-year-old boy who presented with severe hypertension, profound hyponatremia, hypokalemia, nephrotic range proteinuria, and polyuria. Distinctly, the diagnosis of hyponatremic hypertensive syndrome secondary to unilateral renal artery stenosis was confirmed in light of laboratory and radiographic findings of severe natriuresis, elevated renin, and unilateral small kidney. Two weeks following nephrectomy, there was resolution of hyponatremia, hypokalemia, nephrotic range proteinuria and hypertension.

Conclusions

Findings of hyponatremia, hypokalemia, hypertension, polyuria, and unilateral renal hypoplasia can be attributed to a unifying pathology of unilateral renal artery stenosis.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1246-9) contains supplementary material, which is available to authorized users.

A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures

A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient's final diagnosis.

Mortality in children with classic congenital adrenal hyperplasia and 21-hydroxylase deficiency (CAH) in Germany

BACKGROUND

Adrenal crises in children with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) are life-threatening and have the potential to death.

METHODS

A survey was performed among Paediatric Endocrinologists in Germany to report on deceased children with CAH. Our survey covered the whole of Germany.

RESULTS

The participating centres reported 14 cases of death (9 female, 5 male) from 1973 until 2004, but no deaths thereafter. 11 children had the SW form and 3 the simple virilizing (SV) form. All patients were on glucocorticoid replacement, and the SW forms additionally on mineralocorticoid replacement. The age at death varied between 6 weeks and 16.5 years. Seven children died before introduction of general neonatal screening, and 7 children thereafter. Before death, the clinical signs of impending crisis were nonspecific. Five patients developed hypoglycaemia and convulsions with cerebral oedema. Half of the deceased patients died at home. The hydrocortisone dosage was only doubled in two of the 14 cases.

CONCLUSIONS

According to the assessments by the attending centres, almost all deaths could be related to an inadequate administration of stress doses of hydrocortisone. Since no deceased CAH children were reported in Germany from 2005 on, we assume the effectiveness of educational programs over the past years.