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

More documents

Recommendations

Info

The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 authors’ speculation that the child had ingested salt as a result of his pica, and considered that the child had been abused (one beyond reasonable doubt, the other on the balance of probability). This case therefore should not be used to provide evidence of voluntary salt ingestion by an otherwise normal child, and has been included in the list of case reports of non-accidental salt poisoning as a manifestation of child abuse. There is a second case report in which the authors considered that two otherwise normal young children spontaneously and voluntarily ingested sufficient salt to cause significant hypernatraemia. This case from Ohio, USA 220 , published in 1964, relates to two 14-monthold twin girls who were considered by the authors to have ingested a considerable amount of rock salt, possibly aided and abetted by an older sibling. Their sodium concentrations on admission were 179 and 182 mEq/L. It would be important to be aware that young, otherwise normal children have been reported voluntarily to ingest salt to this extent. This case was cited in a recent review of the evaluation of salt poisoning as a “well-described case of voluntary salt poisoning”. 221 Accordingly, this second case report was peer reviewed by the whole panel of 16 paediatricians. Eight disagreed with the authors on the balance of probability, one disagreed beyond reasonable doubt, and 5 said they could not tell from the publication whether the authors’ conclusions were correct. Only two agreed with the authors on the balance of probability. The following points were made: • This paper was published before the reality of child abuse was recognised, and child abuse was not discussed as a possible diagnosis • The toddler who swallows bleach takes a swig and spills most of it. What they do not do is voluntarily go back for a second helping. It is unlikely that the ingestion response would be much different for salt • The social history given in the case report is inadequate. However, there are some pointers to family stress: • 3rd pregnancy in a 19-year old mother • The mother did not visit for first 24 hours after admission • On a home visit a month after admission a large box of salt was again within easy grasp of the twins • Both the twins were undernourished • At their age, they would be unlikely to have the fine-motor control to ingest large quantities of salt, and could only have ‘finger-fed’ small quantities • Neither child had reportedly eaten or drunk for almost 48hr, nor had they vomited; salt ingestion to cause this degree of hypernatraemia would generate thirst 49
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 • Even had an older sib attempted to feed them, this older sib couldn’t have been much more than 5 years age, and would have struggled to force the twins to consume more than a teaspoon of salt • The salt discovery was only revealed “upon further questioning” • If twin 1 had ingested salt to cause the hypernatraemia of 182mmol/L (and given a normal upper limit of plasma Na of 140mmol/l) she would have needed to have absorbed 8.5 grams [(42*(0.6*body wt))/17.1]. This would amount to 1.75 standard (5 grams) teaspoons. The case report is therefore not credible to a panel of expert paediatricians, and should not be used as evidence that young children will spontaneously and voluntarily ingest significant quantities of salt. There is a report from Denver, USA, in 1985 222 of a 33 year old woman who compulsively ate salt ‘by the shakerful’ (estimated to be around 600mmol per day or ½ pound a week) following a gastric stapling procedure for obesity. Her serum sodium was only slightly elevated at 149 mEq/L. Her 24 hour sodium excretion was 452 mEq/24hrs, and a calculated fractional sodium excretion was 2%. She was found to have iron deficiency anaemia with a haemoglobin of 9.2 g/dl. Treatment with intramuscular iron resulted in rapid resolution of the salt cravings within 2 weeks. The authors concluded that the cause of her hypernatraemia was salt craving rather than an attempt at deliberate self-harm. Although this case is an adult, it raises the possibility in children of compulsive salt ingestion as a rare form of pica. It should however be noted that her serum sodium was relatively low. It was therefore submitted to all the peer reviewers for appraisal. The breakdown of their opinions as to the cause was as follows: • 7 agreed with the authors beyond reasonable doubt • 5 agreed with the authors on the balance of probability • 2 did not consider it was possible to tell from the information given • 2 disagreed with the authors on the balance of probability Those that did not agree considered that the woman may have had some secondary gain from her condition, pointing out her failure to respond to oral iron, the number of previous surgical procedures she had had, and the lack of psychological assessment. 50
Page 1 and 2:
The Differential Diagnosis of Hyper
Page 3 and 4:
The Diagnosis of Salt Poisoning Lea
Page 5 and 6: The Diagnosis of Salt Poisoning Lea
Page 55: The Diagnosis of Salt Poisoning Lea
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?