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

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 The cause of this very mild hypernatraemia in patients with primary hypoaldosteronism appears to be a slight upward resetting of the osmostat. 147, 148 These two studies describe carefully investigated cases, whilst a third 149 is a review with a commentary. Most patients with mineralocorticoid excess therefore have sodium concentrations in the normal range, with a few having mild hypernatraemia up to just above 150 mmol/L, in itself of little or no clinical significance. Dangerous, potentially lethal hypernatraemia is never seen in these conditions. 4.2 Mechanisms causing hypernatraemia through accidental excessive sodium intake Clinical question What other agents, mechanisms and circumstances are described in those children with hypernatraemia who were not considered to have been abused? A number of scenarios have been reported in which a variety of agents administered to 119 children have caused hypernatraemia, sometimes fatal. None of these was considered by the authors to be due to child abuse. 4.2.1 Errors by professionals 4.2.1.1 Accidental substitution of salt for glucose in newborn infants One of the earliest reports was of the accidental making up of babies’ feeds with salt instead of sugar in Binghamton Hospital, USA, in 1962. 8,150 There are now two additional reports of similar occurrences from different countries. In Binghamton fourteen babies were affected, and six died. The problem was recognised when the sixth baby was found to be hypernatraemic (sodium 244mEq/L), the first five not having had serum sodium measured. A further eight babies with sodium concentrations of between 162 and 274mEq/L all survived. All eleven infants who were symptomatic had either seizures or muscular twitching. All but one vomited, and all displayed avid thirst until too ill to feed. Five infants had respiratory distress. In 1967 there was a report from Sydney 151 of a similar occurrence in a neonatal nursery. Five babies, all but one premature, aged 1 to 4 weeks were affected, with three deaths. All but one vomited and two had diarrhoea. 33
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 More recently in 1984 was reported a series of five term newborn babies in Austria 152, 153 who all died following accidental intravenous infusion of 10% saline instead of 10% dextrose. They had serum sodium concentrations between 159 and 247mmol/L. They were reported to have ‘cramps’ and oedema. In all three occurrences there had been an error in the pharmacy either in preparing the feeds, or in the third case in incorrect labelling of the infusion. These reports were not subjected to peer review. 4.2.1.2 Other errors by professionals in making up feeds or ORS In 1983 154 , a baby in Canada developed hypernatraemia (sodium 182 mmol/L) having received an excessive amount of salt in a chicken meat-based formula whilst in hospital. The authors did not discuss who made up the feed, apart from stating “care… must be exercised in formula preparation, even in a hospital setting.” The two peer reviewers, whilst agreeing that this appeared to be the mechanism, therefore felt they were unable to determine who had caused the error or why. A case report from Spain in 1989 155 reported a fatal outcome in an infant of 7 months in whom double strength oral rehydration solution was made up and initiated in clinic, with a resulting hypernatraemia of 189 mEq/L. It was not clear who made the error, and the two peer reviewers came to different conclusions though both considered beyond reasonable doubt that the hypertonic ORS was the cause. A case report from Seattle in 1967 156 described an infant of 6 weeks whose mother had for some time made up double strength feeds, and who was admitted with a sodium of 174 mEq/L following the development of a mild diarrhoeal illness. The mother reported that the doctor had advised making up the feeds at this strength. The doctor had thought the infant was receiving a different formula. Both peer reviewers agreed (one beyond reasonable doubt, the other on the balance of probability) with the authors’ conclusions that this was due to the doctor’s mistaken instructions, noting the lack of detail in the report to substantiate the findings. 4.2.1.3 Inadvertent administration of concentrated intravenous saline A 12 year old with type 1 diabetes was inadvertently given 500mls of 5% saline intravenously instead of 0.9% saline for treatment of diabetic ketoacidosis. 157 His serum sodium reached 172mEq/L. He complained of headache, vomited, developed seizures, then became comatose and died 4 days later. 34
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The differential diagnosis of hypernatraemia in children, with ...

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