Clinical fi ndings and treatment recommendations of hypernatremic dehydration due to breast milk

Öz

Objectives: In this study, we aimed to assess the incidence, presenting complaints, risk factors of hypernatremic dehydration (DH), and to stage the degree of hypernatremic DH among term, exclusively breast feeding infants, and to suggest a therapy for hypernatremic DH. Methods: Term, exclusively breast feeding neonates admitted to our neonatology policlinics, with a more than 7% weight loss, serum sodium concentrations of ≥147 mEq/L were allocated for the study. ‘Maternals and infants\' medical history, examination, including presenting complaints, risk factors, stool- urine frequency, weight loss, the duration of the treatment, the rate of sodium decrease by hourly was calculated and recorded. Percentage of weight loss by taking into account, degree of DH (mild, moderate, severe) was created. Results: Dehydration were determined in 126 of 3642 patients (3.5%). Patients were allocated as Group 1, mild DH (n=59, 47%), group 2, moderate DH (n=43, 34%), group 3, severe DH (n=24, 19%). Relevant clinical fi ndings on admission were jaundice (46.8%), fever (42%), poor oral feeding (36.5%), reduction in the amount of stool- urination (32.5%). Clinical fi ndings of dehydration were more frequent than other groups in group 3. On the admission day, postnatal age, blood urea, creatinine levels, duration of the therapy, sodium levels were higher than other groups in group 3. Intravenous (IV) fl uid requirement was over than other groups in group 3. Only two patients had seizures in the severe DH group. Positive correlation was determined between percentage of weight loss and serum sodium, urea and creatinine levels Conclusion: Diagnosis of hypernatremic DH is delayed, because of no obvious signs of dehydration is present in the early period. There is no specifi c sign to determine the degree of DH. Weight loss is the most prominent fi nding, accompanied by jaundice, fever, a decrease in urine and stool frequencies. Creation of a common treatment protocol is the solution of questions in minds.

Anahtar Kelimeler

• Hypernatremia, dehydration, newborn, treatment

Anne sütüne bağlı hipernatremik dehidratasyonun klinik bulguları ve tedavi önerileri

Öz

Amaç: Sadece anne sütü ile beslenen term bebeklerde hipernatremik dehidratasyon (DH) sıklığını, eslik eden sikâyetleri, risk faktörlerini değerlendirmek, dehidratasyon derecesini evrelemek, hipernatremik DH tedavisi için öneride bulunmak amaçlanmıstır. Gereç ve Yöntem: Yenidoğan Polikliniğimize başvuran term, sadece Anne sütüyle beslenen, %7\'den fazla kilo kaybı olan ve serum sodyum değeri ≥147 mEq/L olanlar çalısmaya alındı. Anneye, bebeğe ait tıbbi öykü, eslik eden sikâyetler, risk faktörleri, gayta-idrar sıklığı, fi zik muayene, laboratuar bulguları, kilo kaybı, tedavi süresi, saatlik sodyum düsüs hızı hesaplanarak kayıt edildi. Yüzde kilo kayıplarına göre DH dereceleri hafi f, orta, ağır olarak belirlendi. Bulgular: 3642 hastadan 126\'sında (%3.5) DH saptandı.Hastalar Grup 1, hafi f DH (n=59, %47), grup 2, orta DH (n=43, %34), grup 3, ağır DH (n=24, %19) olarak belirlendi. Eslik eden klinik bulgular sarılık (%46.8), ates (%42), zayıf beslenme (%36.5), dıskı ve idrar miktarında azalma (%32.5) idi. Dehidratasyona ait bulgular gurup 3\'te diğer gruplara göre daha fazlaydı. Gurup 3\'te basvurudaki postnatal yas, hastanede kalma süresi, kan üre, kreatinin değerleri, sodyum değeri diğer gruplara göre belirgin yüksekti. Grup 3\'te intravenöz sıvı desteği diğerlerine göre daha fazla yapıldı. Gruplar arasında sodyum düsme hızı aynıydı. Ağır DH grubunda 2 hastada könvülziyon görüldü. Yüzde kilo kayıplarıyla serum sodyum, üre, kreatinin değeri arasında pozitif korelasyon vardı. Sonuç: Erken dönemde DH\'u gösteren bulgularının belirgin olmaması hipernatremik DH tanısını geciktirmektedir. Dehidratasyon derecesini belirleyecek spesifi k bulgu mevcut değildir. En belirgin bulgusu olan kilo kaybına sarılık, ates, idrar- dıskı çıkısında azalma eslik etmektedir. Tedaviyle ilgili ortak bir protokolün olusturulması kafalardaki soruların çözümü olacaktır.

Anahtar Kelimeler

• Hipernatremi, dehidratasyon, yenidoğan, tedavi

Kaynakça

1. American Academy of Pediatrics Breastfeeding and the use of human milk. Work Group on Breastfeeding. Pediatrics 1997;100:1035-9.
2. Çağlar MK, Altugan FŞ, Özer I. Exclusively Breastfeeding and Hypernatremic Dehydration. Iranian J Publ Health 2005;34.1-11.
3. Scariati PD, Grummer-Strawn LM, Fein SB. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics 1997; 99: E5.
4. Reynolds A. Breastfeeding and brain development. Pediatr Clin North Am 2001;48:159-71.
5. Laing IA, Wong CM. Hypernatremia in the Ş rst few days: Is the incidence rising? Arch Dis Child Fetal Neonatal Ed 2002; 87.158-62.
6. Neiffert MR . Prevention of breastfeeding tragedies. Pediatr Clin North Am 2001;48:273-97.
7. Smith RG. Severe hypernatremic dehydration in a newborn infant. Pediatr Child Health 1998; 3: 413-5.
8. Kapkan JA, Siegler RW, Schmunk GA. Fatal hypernatremic dehydration in exclusively breastfed newborn infants due to maternal lactation failure. Am J Forensic Med Pathol 1998;19:19-22

9. Neville M, Morton J. Physiology and endocrine changes underlying human lactogenesis II. J Nutrition 2001;131: 3005-8.
10. Modi N. Avoiding hypernatraemic dehydration in healthy term infants. Arch Dis Child 2007;92;474-5.
11. Livingstone VH, Willis CE, Abdel-Wareth LO, Thiessen P, Lockitch G. Neonatal hypernatremic dehydration associat- ed with breastfeeding malnutrition: a retrospective survey. CMAJ 2000;162:647-52.
12. Catherina MD, Ira DD. Fluid and Electrolyte Therapy. In: Richard J. Martin, Avroy A. Fanaroff, Michele C Walsh, eds. Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant, 8th edn. St. Louis Elsevier Mosby, 2006:695-702.
13. Gartner LM, Morton J, Lawrence RA, et al. American Acad- emy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.
14. Oddie S, Richmond S, Coulthard M. Hypernatraemic de- hydration and breast feeding: A population study. Arch Dis Child 2001;85: 318-32.
15. Michael ML, Manole MD, Bogen DL, Ayus JC. Breastfeed- ing-associated hypernatremia: Are we missing the diagno- sis? Pediatrics 2005;116: 343-7.
16. Uras N, Karadag A, Dogan G, Tonbul A, Tatli MM. Mod- erate hypernatremic dehydration in newborn infants: retro- spective evaluation of 64 cases. J Matern Fetal Neonatal Med 2007;20:449-52.
17. Unal S, Arhan E, Kara N, Uncu N, Aliefendioğlu D. Breast- feeding-associated hypernatremia: Retrospective analy- sis of 169 term newborns. Pediatrics International 2008; 50:29-34.
18. Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed 2003; 88: 472-6.
19. Manganaro R, Mami C, Marrone T, Marseglia L, Gemelli M. Incidence of dehydration and hypernatremia in exclu- sively breastfed infants. J Pediatr 2001; 139: 673-5.
20. Neville MC, Allen JC, Archer PC, et al. Studies in human lactation: milk volume and nutrient composition during weaning and lactogenesis. Am J Clin Nutr 1991;54.81-92.
21. Caglar MK, Ozer I, Altugan FS. Risk factors for excess weight loss and hypernatremia in exclusively breast-fed in- fants. Braz J Med Biol Res 2006;39:539-44.
22. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breast-feeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112: 607.
23. Salariya E, Easton P, Cater J. Duration of breast-feeding after early initiation and frequent feeding. Lancet 1978;2: 1141-3.
24. Chapman DJ, Pérez-Escamilla R. Maternal perception of the onset of lactation is a valid, public health indicator of lactogenesis stage II. J Nutrition 2000;130: 2972-80.
25. Chen DC, Nommsen-Rivers L, Dewey KG, Lonnerdal B. Stress during labor and delivery and early lactation perfor- mance. Am J Clin Nutr 1998;68:335-44.
26. Neifert MR. The optimization of breastfeeding in the peri- natal period. Clin Perinatol 1998; 25: 303-26.
27. Yaseen H, Salem M, Darwich M. Clinical presentation of hypernatremic dehydration in exclusively breast-fed neo- nates. Indian J Pediatr 2004;71:1059-62.
28. Zachariassen G, Juvonen P. Neonatal dehydration (dehy- dration fever) in newborn infants. Ugeskrift for Laeger 2002;164:4930-4.
29. Chilton L A. Prevention and management of hypernatremic dehydration in breastfed infants. West J Med 1995;163: 74-6.
30. Moritz ML, Manole MD, Bogen DL. Breastfeeding-associ- ated hypernatremia: are we missing the diagnosis? Pediat- rics 2005;116:343-7.
31. Bhat SR, Lewis P, David A, Liza SM. Dehydration and hy- pernatremia in breast-fed term healthy neonates. Indian J Pediatr 2006;73:39-41.
32. Van Amerongen RH, Moretta AC, Gaeta TJ. Severe hyper- natremic dehydration and death in a breast-fed infant. Pe- diatr Emerg Care 2001;17:175-80,
33. Gebara BM, Everett KO. Dural sinus thrombosis complicat- ing hypernatremic dehydration in a breastfed neonate. Clin Pediatr 2001;40:45-8.
34. Musapasaoglu H, Agildere AM, Teksam M, Tarcan A, Gu- rakan B. Hypernatraemic dehydration in a neonate: brain MRI fi ndings. Br J Radiol 2008; 81: 57-60.
35. Molteni KH. Initial management of hypernatremic dehydra- tion in the breastfed infant. Clin Pediatr 1994;33:731-40.
36. Banister A, Matin-Siddiqi SA, Hatcher GW. Treatment of hypernatraemic dehydration in infancy. Arch Dis Child 1975;50:179-86.
37. Morton JA. The clinical usefulness of breast milk sodium in the assessment of lactogenesis. Pediatrics 1994;93:802-6.