Hypernatraemic dehydration in Jamaican breastfed neonates: a 12-year review in a baby-friendly hospital

Early Fluid and Nutritional Management of Extremely Preterm Newborns During the Fetal-To-Neonatal Transition

During the fetal-to-neonatal transitional period, extremely preterm newborns undergo significant intrabody fluid shifts and resulting weight loss due to increased insensible fluid losses due to immature skin, kidneys, among other factors. These ongoing physiologic changes make fluid and nutritional management complex in the neonatal-to-fetal transitional time period for extremely premature newborns. However, limited literature exists to guide optimal practices for providers caring for this population. Here, we review the evidence on optimal fluid and nutritional management during the fetal-to-neonatal transition of extremely preterm newborns.

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 Due to the infant’s extremely poor prognosis, life support was withdrawn at 19 days of age and the infant expired.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

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.

Breast-feeding-associated hypernatremia: retrospective analysis of 169 term newborns

BACKGROUND

The aim of the present paper was to define the incidence, complications, morbidity and mortality of hypernatremic dehydration due to inadequate breast-feeding in a neonatal intensive care unit.

METHODS

A retrospective study was carried out between 2002 and 2005, to identify the term breast-fed neonates with serum sodium level > or =150 mEq/L at the Ministry of Health Ankara Diskapi Children's and Research Hospital.

RESULTS

The incidence of hypernatremic dehydration secondary to inadequate breast-feeding was 4.1%, occurring in 169 term infants among 4136 hospitalized term neonates with the following characteristics: mean gestational age, 39.1 weeks (37-42 weeks); birthweight, 3352 g (2200-4500 g); mother's age, 26.1 years (17-38 years); weight loss, 15.9% (5.4-32.7%); proportion of spontaneous vaginal deliveries, 75.7%; and proportion of first-time mothers, 74.6%. Major presenting symptoms were neonatal jaundice (47.3%) and poor infant suck (29.6%). The median sodium; blood urea nitrogen (BUN); and creatinine levels on admission were 155 mmol/L (150-194 mmol/L), 35 mg/dL (7-253 mg/dL), and 0.9 mg/dL (0.2-10 mg/dL), respectively. Major complications were as follows: acute renal failure, 82.8%; elevated liver enzymes, 20.7%; disseminated intravascular coagulation, 6.5%; brain edema, 5.2%; intracranial hemorrhage, 3.6%; cavernous sinus thrombosis, 1.2%; and bilateral iliac artery thrombosis, 0.6%. Ten patients (5.9%) developed seizure within the first 24 h of rehydration therapy with a mean sodium decrease of 11.9 mmol/L per day (4-19 mmol/L per day). Two patients (1.2%) died. There were positive correlation between weight loss and serum sodium, BUN, bilirubin levels (P < 0.01); there was no correlation between weight loss and mothers' age, education level, delivery route, or first-born status (P > 0.05).

CONCLUSIONS

Hypernatremic dehydration in neonates due to inadequate breast-feeding is a serious, potentially devastating and life-threatening disorder, and can damage the central nervous system. Follow up of infants for adequate breast-feeding is important. Pediatricians must maintain a high level of suspicion, especially in cases of pathologic infant weight loss after delivery.