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

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 reviewers agreed (one beyond reasonable doubt, the other on balance of probability) with the authors’ conclusions that the hypernatraemia was due to the misconceived parental actions. A case report from Dallas, USA in 1981 207 described mild hypernatraemia and metabolic alkalosis in a 4 month old associated with the topical use of baking soda by the parents to treat a severe nappy rash. The admission sodium was [apparently, extrapolated from the figure] 152 mEq/L, with serum bicarbonate above 35 mmol/L. The authors acknowledge that there is no direct evidence linking the biochemical findings with the parental actions. Both peer reviewers accepted beyond reasonable doubt the authors’ conclusions as to cause, but commented that the mechanism was far from clear. Sodium bicarbonate as a remedy A case report from Arkansas, USA in 1981 208 described a 4 month old child whose grandmother had admitted adding one tablespoon of baking soda to an 8 oz feed as a home remedy for cold symptoms. The child’s admission sodium was 164 mEq/L. Both peer reviewers agreed with the authors (one beyond reasonable doubt, the other on the balance of probability) that the hypernatraemia was due to the grandmother’s administration of sodium bicarbonate (in the context that this was at the time a popular folk remedy, and therefore given in the mistaken belief of benefit). A case report from Chicago, USA in 1987 209 described a 6 week old infant given water to which baking soda had been added as a treatment for ‘gas’, resulting in a serum sodium of 160 mEq/L, and a bicarbonate of 41 mEq/L. The mother had been adding ‘two pinches’ to each 6oz bottle of tap water for the previous 2 days, and the infant had consumed all 12 oz of this mixture. The peer reviewers agreed with the authors (one beyond reasonable doubt, the other on the balance of probability) that the hypernatraemia was due to the mother’s administration of sodium bicarbonate in the mistaken belief of benefit. A case report from Alabama, USA in 1995 210 described a 6 week old infant whose mother “periodically had been giving the baby ‘a pinch of baking soda in water’ for 2 days as recommended by the patient’s grandmother to help the baby burp.” At admission the serum sodium was 180 mEq/L, and with an anion gap of 49 mEq/L. The mother admitted giving the practice of giving baking soda after an initial denial of having done so. The child recovered and was then followed up for 45
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 4 years with no health problems. The peer reviewers both agreed, on the balance of probability, with the authors’ conclusion that the hypernatraemia and metabolic alkalosis was due to well-intentioned administration of sodium bicarbonate, despite the mother’s initial denial. A 2 month old baby from Philadelphia, USA in 1988 211 , who was given 4 teaspoonfuls of sodium bicarbonate by his mother over 24 hours to treat ‘gas’ developed hypernatraemia (167 mEq/L) and metabolic alkalosis (bicarbonate 39.6 mEq/L). The mother of a 7 week old boy from Baltimore, USA in 1990 212 , “added approximately one-half tablespoon of baking soda to his formula at the time that he felt warm, to ‘help bring up his burps’… [and] two ‘pinches’ of baking soda to the mixture each time she prepares the formula, for the same reason.” His sodium on admission was 155 mEq/L, with a bicarbonate of 29 mmol/L. A case report, from Illinois, USA in 1983 213 , described a 3 year old girl administered sodium bicarbonate as a remedy for mild abdominal pain whose admission sodium was 210 mmol/L. Her serum chloride concentration was very high at 185 mmol/L, and she had a mild metabolic acidosis with a base deficit of 14 mmol/L. She was noted to have “a large contusion over the right orbit and several minor facial lacerations”. There was a delay in the foster parent’s admission that they had been giving the baking soda, and “a formal investigation of the child’s foster parents failed to reveal intentional abuse; evidently they thought sodium bicarbonate was a panacea for abdominal pain.” The child was discharged to a new foster home. The peer reviewers noted that the high chloride concentration and metabolic acidosis were unexplained and both suggested that the girl had been administered salt rather than sodium bicarbonate. The girl’s injuries at the time of admission were not explained. On this basis one of the two peer reviewers disagreed on the balance of probability and considered child abuse was more likely. Evidence statement 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]. 46
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The differential diagnosis of hypernatraemia in children, with ...

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