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

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 thrashing in his sleep, and when he ‘turned unresponsive’ they initiated CPR and called the emergency services. The child subsequently alleged that his foster mother forced him to drink salt water. The foster parents denied any knowledge of salt ingestion. There was no evidence of iron deficiency. The two peer reviewers both strongly disagreed with the authors’ conclusion 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). They made the following points: 1. There were bilateral subdural haematomas which were chronic and not explained by acute ingestion; 2. The child had a burn which was two weeks old; 3. The child reported foster mother made him drink salt; 4. There was a past history of physical and sexual abuse, presumably before he went into foster care. This case is therefore very likely to represent child abuse rather than voluntary salt ingestion. Evidence statement There are credible case reports of children deliberately and abusively administered salt [Grade C]. These are described from different countries and by different authors. The ages of the children ranged from 6 weeks to 6 years. Evidence statement A sample of gastric contents for analysis of sodium content should be obtained as soon as possible after admission in all children presenting with hypernatraemia of uncertain cause [Grade D]. 4.4.2 One child forced to eat sodium bicarbonate 236 There is a single case report from Wisconsin in 1977 of a 6-year-old child who was forcibly administered sodium bicarbonate, together with vinegar, dishwashing liquid and possibly red pepper. His initial serum sodium was 183 mEq/L and pH was 7.07. He died some days after admission. The following story was recounted: “… the three siblings (ages 12, 11, and 10) began to relate a story. The live-in babysitter, who was in charge of the children while their long-distance truck-driving father was working, had found that the child had begged or stolen other children’s lunches at school. She decided to make him vomit as a method of punishment; she 57
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 gave him large glasses of sodium bicarbonate…. he was forced to drink it and was told he would be hit with a belt if he didn’t…. in an attempt to induce vomiting the babysitter put her foot on the child’s stomach.” The babysitter pleaded guilty to negligent contribution to the death of a minor. Both peer reviewers agreed beyond reasonable doubt with the authors’ conclusions. Evidence statement There is a single, credible case report of deliberate and forcible administration of sodium bicarbonate by a babysitter causing the death of the child [Grade C]. 4.4.3 Children prevented from drinking, “thirsting” 225, 237-239 There have been several reports of hypernatraemia secondary to water deprivation involving 6 children, where there was not thought to be excessive salt administration. All three children in the first case series had good evidence of moderate to severe dehydration at the time of admission. The first case report, from San Francisco, was of three children admitted with hypernatraemia in 1968. 237 The first child aged 2½ years had a serum sodium of 194.5 mEq/L on admission with a 3 day history of vomiting. He had been adopted at 5 months, had developmental delay and had lost weight 2 to 3 months before admission ‘when his parents attempted to teach him to eat vegetables. Subsequently, he regained the weight on his usual diet. His father emphasised that his appetite and intake were usually enormous.’ He had ecchymoses on his cheeks and knees. ‘During his hospital course, it became apparent the patient had been periodically thirsted by his mother while his father was away from home.’ He subsequently demonstrated catch up growth and development. Both peer reviewers agreed on the balance of probability with the authors’ conclusions that this was due to the actions of a psychiatrically disturbed mother, with one pointing out that the additional administration of salt could not be excluded as a contributory cause. The second child, a 3¾ year old, was admitted with a 3-day history of progressive loss of appetite, with increasing irritability and inability to walk or stand. He had had four loose bowel motions a week earlier and weight loss over 3 months. His initial sodium was 201 mEq/L. At the time of admission he had multiple bruises including ‘a 2 x 2 cm bruise on the left cheek, a 3 x 4 cm bruise on the right buttock, and numerous smaller bruises over the lower extremities.’ ‘A baby sitter and the maternal grandfather each made unsolicited telephone calls to say that the patient’s mother had instructed them on numerous occasions 58
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