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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 The amount of salt that could be fatal to an infant or child is likely to be in the range of 0.75 to 3 grams (approximately 13 to 51 mmol) per kilogram body weight [Grade C]. Post-mortem vitreous humour sodium and urea provide a useful guide to plasma sodium and urea concentrations before death [Grade C]. Associated findings Some but not all children with hypernatraemia caused by deliberate poisoning have evidence of other forms of child abuse [Grade C]. Subdural haemorrhage occurs only in a small minority of cases of salt poisoning [Grade C]. Most reported cases of coexisting subdural haemorrhage and hypernatraemia are non-accidental, and in several children the evidence suggests that the subdural haemorrhage preceded deliberate salt poisoning [Grade C]. The finding of a subdural haemorrhage in association with hypernatraemia should raise the suspicion that the cause may be non-accidental injury [Grade C]. Recommended investigations in children presenting with hypernatraemia A sample of gastric contents for analysis of sodium content should be obtained as soon as possible after admission in all children presenting with hypernatraemia [Grade D]. Careful measurement of weight at the time of admission coupled with a second weight after restoration of full hydration provides a reliable estimate of the degree of dehydration [Grade B]. This should be undertaken if possible in children presenting with hypernatraemia [Grade D]. A urine sample for calculation of fractional urinary sodium excretion (for which plasma and urine sodium and creatinine measurements taken at a similar time are required) in the presence of normal renal function should help to ascertain whether the hypernatraemia is secondary to excessive sodium ingestion [Grade D]. Regular urine samples for fractional urinary sodium excretion are recommended in children presenting with hypernatraemia [Grade D]. Measurement of bicarbonate, calcium and phosphate concentrations as well as sodium and chloride concentrations should assist in distinguishing the different sodium containing substances [Grade D]. 7
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 In a child with hypernatraemia a urine osmolality can assist in excluding diabetes insipidus [Grade D]. It is best interpreted in conjunction with a simultaneous serum osmolality. Differential diagnosis of salt poisoning As well as the causes of excessive sodium intake there are a number of other causes of significant hypernatraemia, all due to water depletion. Although hypernatraemia may occur with mineralocorticoid excess, this is mild and it is rarely, if ever, severe enough to constitute a clinical problem. Lack of water intake: 1. Inadequate breast milk resulting in inadequate water intake 2. Unconscious or mentally impaired (described in adults) 3. Essential hypernatraemia without structural abnormality of the hypothalamus 4. Adipsia secondary to structural abnormalities involving the hypothalamus 5. Deliberate water restriction 6. Lost in the desert or at sea with lack of available water combined with increased evaporative water loss. Case reports of osmoreceptor dysfunction are all in association with other endocrine or structural brain abnormalities. There are no case reports of otherwise normal children presenting with isolated hypernatraemia being due to abnormal osmostats [Grade C]. Increased water loss Increased renal loss 1. Central diabetes insipidus 2. Nephrogenic diabetes insipidus 3. Renal medullary damage Increased gastrointestinal loss Hypernatraemic dehydration secondary to diarrhoea 8
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The differential diagnosis of hypernatraemia in children, with ...

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