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

The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009
4.4 Mechanisms causing hypernatraemia through non-accidental
excessive sodium intake
Clinical question
What agents, mechanisms and circumstances are described in those children with
hypernatraemia who were considered to have been abused?
The following cases are described.
3, 13, 219, 224, 230-235
4.4.1 Twenty children deliberately administered salt
The largest reported series of salt poisoning cases was reported by Meadow, who had
a specialist experience of non-accidental poisoning. 3 These cases had occurred over a
number of years.
The criteria for making the diagnosis were:
• elevated serum and ‘even higher’ urinary sodium concentrations;
• other extensive investigations for natural disease normal/negative;
• cessation of hypernatraemia when separated from probable perpetrator; and
• circumstantial evidence indicating that either the child’s mother or the father was
poisoning the child.
In seven cases the mother confessed to the poisoning and explained how she had done it.
Seven of the children had a combination of problems including failure to thrive/neglect in
4; recurrent apnoea/seizures in 3; other fabricated illness in 3; other drug ingestion in 2;
and physical abuse in 2. Of the 5 cases where there was no parental confession, there was
circumstantial evidence implicating the mother in 3, the father in 1 and implicating the
parents without it being clear who was responsible in 1.
The mode of poisoning was available for 7 children, namely added to a milk drink in 4, to
a fruit drink in 1 child, and administered via a nasogastric tube in 1 child (with a second
child having ‘exceedingly’ high salt concentrations in their stomach). In another case ‘it
is probable that salt solution was introduced by tube into the rectum.’ The normal sodium
concentration of gastric aspirates was stated to be 50-60 mmol/L, with concentrations
of over 200 mmol/L being highly suggestive of salt ingestion. A separate publication 234
found a gastric sodium of 660 mmol/L in a child whose mother subsequently confessed to
administering salt.
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