The differential diagnosis of hypernatraemia in children, with ...

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 Side effect of parental practices • Saline used as an emetic following accidental ingestion • Excessive quantities of oral rehydration solution • Application of salt to the skin in a healthy baby to promote health • Application of salt crystals to burned skin • Topical use of sodium bicarbonate for nappy rash • Baking soda added to feeds to treat cold symptoms or wind There are well described credible instances where errors by parents and professionals have led to significant, sometimes fatal, hypernatraemia secondary to salt, sodium bicarbonate or sodium phosphate administration [Grade C]. The judgements as to whether these episodes were accidental rather than abusive or neglectful are based on the context and circumstances, not the biochemical findings [Grade C]. In many of the case reports of infants and children being fed inappropriately concentrated feeds the true cause cannot be ascertained with any degree of confidence. There remains the alternative possibility of abuse or neglect [Grade C]. Some medical interventions involving the administration of additional sodium to children have on occasion resulted in fatal hypernatraemia [Grade C]. There are credible reports of well-intentioned actions by parents or carers that have resulted in hypernatraemia [Grade C]. Some parents have initially denied their actions, and although this should raise suspicions of possible non-accidental injury, this may also occur for other reasons [Grade C]. Accidental or voluntary ingestion by children The existing evidence suggests that young but otherwise healthy children in the UK do not spontaneously and voluntarily ingest sufficient salt to cause significant hypernatraemia [Grade C]. The one existing case report involving two healthy young children does not provide credible evidence that otherwise healthy young children spontaneously and voluntarily ingest sufficient salt to cause significant hypernatraemia [Grade C]. 5
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 Additional mechanisms involving excess sodium ingestion described in adults • Deliberate self-harm using Soy sauce • Accidental ingestion of salt by adults with learning difficulties or dementia • Accidental ingestion of flavour intensifier containing sodium chloride and sodium glutamate by a young adult with learning difficulties • Inadvertent ingestion of sea water in near drowning • Deliberate administration of saline in exorcism ritual • Substitution of Milton for Eusol used for postoperative wound irrigation The diagnosis of salt poisoning Clinical findings in salt poisoning The following symptoms and signs are reported in accidentally poisoned infants and children: 1. Vomiting 2. Convulsions or muscular twitching 3. Fluttering of eyelids or facial muscles 4. Refusing feeds 5. Avid thirst 6. Respiratory distress 7. Fever 8. Diarrhoea 9. Peripheral circulatory failure 10. Drowsiness and coma The onset of coma can be rapid following salt ingestion [Grade C]. The common symptoms and signs of deliberate salt poisoning include vomiting, diarrhoea, drowsiness or coma, irritability, seizures, and thirst [Grade C]. Symptoms do not differ from those seen in accidental poisoning [Grade C]. Some children poisoned with salt have a modestly raised blood glucose [Grade C]. When calculating the amount of sodium required to raise the serum sodium by a specified amount, the total body water (approximately 65% of the child’s weight) should be used to determine the volume of distribution. [Grade D] 6
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The differential diagnosis of hypernatraemia in children, with ...

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