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

The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009
The hypernatraemia was recurrent in 10 of the 12 children, usually for a period of about 3
months, although in one it recurred over a period of 45 months. Seven siblings also had a
variety of relevant problems, with salt poisoning in 2, other fabricated illness in 3, failure
to thrive and neglect in 4, physical abuse in 1 and sudden unexpected death at age 1 year
in 1 child.
For ‘at least’ 9 of the children there was either definite or highly probable evidence that
the parent poisoned the child whilst the child was in hospital as well as at home. There
was evidence that one mother tampered with two samples of her breast milk. Two children
yielded ‘extraordinarily’ high sweat concentrations of sodium and chloride (above 1,000
mmol/L) while in the care of their mothers, as did tests in two mothers. One mother
subsequently admitted tampering with the test.
Eleven of the 12 cases did not have detailed descriptions that would allow a reader to form
their own judgement about the certainty of the diagnosis in the individual cases, and did
not permit them to be subjected to peer review. However, the descriptions of the pooled
cases make it virtually certain that the diagnosis was correct in seven of the children,
whose mothers confessed and explained the mechanism.
The doubly reported case 3, 13 was subjected to peer review. Both peer reviewers agreed with
this being likely to be child abuse, one stating “highly likely”, the other “beyond reasonable
doubt”. The lack of detailed biochemical results was noted.
In a case report from Virginia, USA, in 1992 of a fatal ingestion of salt 224 , there was a radioopaque
mass in the stomach due to crystallized salt, which is radio-opaque when formed
into a concretion. The 6-year-old child was originally reported by her adoptive mother
to have voluntarily ingested a small amount of salt. The mother was later arrested and
convicted for force-feeding table salt. No further details of the method of administration
or the basis for the conviction were given. One of the two peer reviewers agreed with the
authors beyond reasonable doubt. The other agreed on the balance of probability because
the authors did not prove that the radioopaque concretion was salt and because although
the mother was convicted after further investigation the evidence on which she was found
guilty is not in the report.
A five year old child reported in 1983 from El Paso, Texas 230 was unusual in that he
eventually admitted that his parents had made him eat salt ‘by the spoonfuls’ for enuresis.
There was a background of previous concerns about child abuse, the boy had scars on his
feet and ankles from burns, and he was subsequently placed in foster care. He had initially
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