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

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
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