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

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 The last publication, from France in 1990 225 , describes a 2 year 11 month old child with an initial sodium of 186 mmol/L, in whom there was suspicion of chronic water deprivation. The child was reported by her parents always to be demanding something to drink. She had been observed at preschool to be licking drops of water from windowpanes and from puddles. She improved after removal from her parents. Both peer reviewers agreed (one beyond reasonable doubt, one on the balance of probability) with the authors’ conclusions that the child had been abused. However, they pointed out that the physiology was not well worked out, and considered that the authors had failed to distinguish between water deprivation and salt poisoning. In the adult literature there is a case report of a prisoner who went on a “thirst strike” 242 , with a resulting plasma sodium of 164 mmol/L, a fractional urinary excretion of sodium of 0.21% (suggesting a normal sodium intake and renal function 27 ), and approaching a 20% increase in weight after restoration of hydration. The resulting sodium concentration was not nearly as high as in some of the children described above. It is therefore possible that the children reported as hypernatraemic secondary to water deprivation may also have been administered excessive salt. Evidence statement Although there are credible case reports of significant hypernatraemia in children secondary to water deprivation, at least some of these children may have been administered salt as well [Grade C]. Evidence statement Careful measurement of weight at the time of admission and before restoration of full hydration provides a reliable estimate of the degree of dehydration [Grade B]. This should be undertaken if possible in children presenting with hypernatraemia of uncertain cause [Grade D]. Evidence statement A urine sample for calculation of fractional urinary sodium excretion (for which plasma and urine sodium and creatinine measurements taken at a similar time are required) in the presence of normal renal function should help to ascertain whether the hypernatraemia is secondary to excessive sodium ingestion [Grade D]. Regular urine samples for fractional urinary sodium excretion are recommended in children presenting with hypernatraemia of uncertain cause [Grade D]. 61
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 Evidence statement Postmortem vitreous humour sodium and urea provide a useful guide to plasma sodium and urea concentrations before death [Grade C]. 4.4.4 Associated findings 4.4.4.1 Other evidence of child abuse A number of case reports describe other unexplained or manifestly abusive injuries. In others there is evidence of associated emotional abuse, with evidence of coercion relating to the forced ingestion and/or withholding of fluids. Some case reports may have been published because of the strong evidence of associated abuse. This could mean that there is publication bias, and the actual rate of association with other evidence of child abuse is much lower. The specific association with subdural haemorrhage is dealt with separately below. Evidence statement Some but not all children with hypernatraemia caused by deliberate poisoning have evidence of other forms of child abuse [Grade C]. 4.4.4.2 Psychosocial problems Some case reports include evidence of psychopathology in the mother and of abuse at the hands of substitute carers. These are not surprising findings. For the same reasons as in those children where there was other evidence of abuse, it is not possible to draw conclusions from these. 4.4.4.3 Subdural haemorrhage The common association between subdural haemorrhage in infants and child abuse means that it is crucial to know whether subdural haemorrhage can be a complication of severe hypernatraemia. Laurence Finberg was a world leader in hypernatraemia in infants and produced a large body of work with colleagues in the mid 1950s-60s. In 1959 Luttrell and Finberg presented a series of 3 fatal cases of hypernatraemia in infants of 8 months 62
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