Treatment of Hypernatremia in Breastfeeding Neonates: A Systematic Review

Too Much Salt to My Taste: An Entity to Think about in Neonatal Hypernatremia: A Case Report and Review of the Literature

In exclusively breastfed newborns, hypernatremic dehydration is associated with a free water deficit secondary to insufficient fluid intake. Failure of newborns to regain their birth weight by the 10th day of life should be investigated urgently. In this report, we present a case of a 2 -week-old girl who presented to our institution for 30% weight loss and was found to have severe hypernatremic dehydration associated with acute renal failure (creatinine 4 mg/dL). Upon further investigation, the breast milk sodium content was found to be extremely elevated (90 mEq/L). To our knowledge, the following reported case of severe neonatal hypernatremic dehydration associated with acute renal failure has the most elevated breast milk sodium content, serum sodium, and serum creatinine levels described in the literature. Thus, hypernatremic dehydration secondary to elevated breast milk content should always be borne in mind and investigated whenever suspected.

Hypernatremia in Newborns: A Practical Approach to Management

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

Evaluation of Term Newborn Patients With Hypernatremic Dehydration

Aim

We aimed to evaluate the demographic, clinical, and laboratory findings and the management of newborns with hypernatremic dehydration (HDH).

Materials and Methods

A total of 85 term newborns with serum sodium (Na) levels higher than 145 mEq/L who admitted to our hospital between January 2011 and December 2018 were included in this study.

Results

Among all cases, 54.1% were female infants with the mean birth weight, weight loss ratio, and median age at diagnosis of 3095 ± 540 g, 13.6 ± 10%, and 8 (2-24) days, respectively. The most common presenting complaints were breastfeeding difficulties (90.5%), fever (63.5%), decreased urination (43.5%), jaundice (22.3%), and convulsion (15.3%). The mean sodium and potassium, and median blood urea and creatinine levels on admission were 167.9 ± 13.4 mEq/L, 5.4 ± 2.8 mmol/L, 213 mg/dL (11-476 mg/dL), and 2.4 mg/dL (0.52-9.96 mg/dL), respectively. There was metabolic acidosis in 67% and acute renal failure in 74.4% of patients, while peritoneal dialysis was performed in 12 of them. There was a positive correlation between weight loss ratio and admission age, serum urea, and creatinine levels; there was a negative correlation between weight loss and blood pH. Eight patients died (9.4%).

Conclusions

In our study, serum urea, creatinine, potassium, metabolic acidosis levels, convulsion, and dialysis requirements at the time of admission of the newborns with HDH were found to be higher in those who died compared to those who survived. Convulsion was a presenting complaint, and it was also observed during the treatment.

Correction of hypernatremic dehydration in neonates with supervised breast-feeding: A cross-sectional observational study

BACKGROUND

Hypernatremic dehydration is an uncommon but a serious cause of readmission in neonates especially in the ones on exclusive breast-feeding. The management of such neonates is challenging as serious complications can occur both because of hypernatremic dehydration and its rapid correction. The aim was to study the clinical profile of neonates with hypernatremic dehydration and determine the outcome of these neonates after appropriate management.

METHODS

This is a prospective cross-sectional observational study of neonates readmitted with hypernatremic dehydration in a tertiary care hospital in a 12-month period from March 2017 to February 2018. The inclusion criterion was as follows: all neonates with serum sodium >145 mEq/l. The exclusion criteria were as follows: neonates with hypoglycemia, positive sepsis screen and any other congenital diseases. Neonates with serum sodium between 145 and 160 mEq/l were treated with supervised quantified oral feeds at 150 ml/kg/day, unless they had features of shock. Neonates who had serum sodium ≥160 mEq/l were given intravenous (IV) fluids initially.

RESULTS

A total of 2412 deliveries took place during the study period. Hypernatremic dehydration was reported in 46 (1.9%) of them, which required admission. We found that all these neonates were exclusively breast-fed, with 81.3% neonates born to primigravidae. One neonate presented with seizures, and one, with metabolic acidosis. More than 50% neonates had acute kidney injury (AKI) on admission. No neonates in our study developed central nervous system (CNS) complications such as cerebral venous thrombosis, convulsions or intracranial haemorrhage, and complete recovery from AKI was documented in all neonates.

CONCLUSION

Hypernatremic dehydration can be a serious problem even in term healthy neonates especially in exclusively breast-fed neonates born to primiparous women. Our study shows that quantified oral feeding is effective in successful management of hypernatremic dehydration and not associated with the dreaded CNS complications due to rapid correction.

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.].