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

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 Evidence statement 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]. Evidence statement 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]. 4.3 Characteristics of children with hypernatraemia in whom accident was the likely cause Clinical question What are the characteristics of children reported in the literature in whom an accident was the likely cause? There are reports of 24 newborn infants less than 4 weeks of age who received excessive amounts of salt in their feeds, with 3 separate errors occurring in Binghamton, USA 8, 150 ; Sydney, Australia 151 ; and Graz, Austria 152, 153 . Five infants between 4 weeks and 7 months 151,159 (case 2), 161, 167, received either salt in their feeds or incorrect oral rehydration solutions. 169 Eleven children between 13 months and 14 years received salt, most commonly as an emetic. 1, 159 (case 1), 167, 181, 200-203,223 The three age groups’ symptoms are reported separately. The 14 term infants in Binghamton had the following symptoms and signs reported: • Vomiting (13/14) • Convulsions or muscular twitching (11/14) • Fluttering of eyelids or facial muscles (7/14) • Refusing feeds • Avid thirst • Respiratory distress • Fever None of the 4 low birth weight, ‘premature’ babies (gestations not specified, BW between 1.36 and 2.35 kilogram) in Sydney had convulsions, and one had muscular twitching. They had somewhat different symptoms: 51
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 • Vomiting and diarrhoea • Peripheral circulatory failure • Sunken eyes • Respiratory depression • GI and heel prick bleeding Two of the 5 infants between 4 weeks and 7 months had refused feeds, one with accompanying weight loss of 10% of his body weight with clinical dehydration. One was reported as showing intense thirst. Two were drowsy and lethargic; three became comatose (one further was found dead). Two infants vomited. Three were seen to fit, have extensor spasms or be “on the verge of fitting”. The ten children in whom symptoms are described all became comatose, some very quickly (one within 15 minutes of receiving the saline emetic). Eight had seizures. Six had documented pyrexia. Three were documented as having vomited, one further child complained of feeling nauseated. Three had circulatory shock. Three had some degree of respiratory distress. One had bloody, fluid stools. There are 10 case reports in the literature in which a patient has been documented to receive salt or saline, and a blood glucose on admission is available. Patients were excluded with preexisting conditions such as diabetes or Cushing’s disease, as well as those in whom additional 158, 161, 167, 202, 223-229. glucose was also given (e.g. glucose in oral rehydration solutions). The average blood glucose on admission was 9.4 mmol/L, with a standard deviation of 3.5 mmol/L. Seven of the 10 had a blood glucose above 8.0 mmol/L. The highest blood glucose was 17.3 mmol/L in a child whose mother had added salt instead of sugar to two yoghurts. The average sodium was 193 mmol/L, range 166 to 212 mmol/L. Evidence statement The onset of coma can be rapid following salt ingestion [Grade C]. Evidence statement Some children poisoned with salt have a modestly raised blood glucose [Grade C]. 52
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The differential diagnosis of hypernatraemia in children, with ...

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