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

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 old or less, one of whom (case 3), “a neglected one-month-old”, had intradural and subarachnoid haemorrhages with an initial serum sodium of 180 mEq/l. 243 One peer reviewer could not tell the cause of the hypernatraemia from the publication. The other peer reviewer agreed on the balance of probability with the authors’ conclusion that this was secondary to hypernatraemic dehydration. The same year the authors used clinical observation 244 and experimental studies 245 to add weight to the evidence that hypernatraemia may be a cause of subdural haemorrhage. The clinical paper included 7 cases of hypernatraemia with a subdural effusion, one of which was bloody and one xanthochromic. A major limitation of the clinical study is that most of the subdurals were chronic, and very little detail is given of all but one of the cases. Subdural tap may in itself cause bleeding, and in the one case where 5mls of grossly bloody fluid was obtained on subdural tap subsequent exploration showed no membrane or large haematoma. The one case described in detail was of a 5-week-old infant with evidence of a chronic subdural hygroma, and acute presentation with salt poisoning, thought by the authors to be accidental. The mother made up the infant’s formula while in the home of the child’s grandmother, and “it was subsequently learned that sugar and salt were kept in identical canisters and that salt had inadvertently been substituted for sugar. The patient took between 360 and 600 ml of this mixture…” The timing of the poisoning and the chronicity of the subdural fluid collection excludes hypernatraemia as the cause. Both peer reviewers agreed, one on the balance of probability and the other beyond reasonable doubt, with the authors’ conclusion in this case that this was due to an error making up the feed with salt instead of sugar. These studies were also conducted before the widespread recognition of nonaccidental injury in children, first highlighted in 1962 by the landmark article outlining the features of ‘Battered-Child Syndrome’. 246 As stated by Kempe, “subdural haemorrhage with or without a skull fracture in our experience is an extremely frequent finding even in the absence of fracture of the long bones” and it was recommended that ‘Battered-Child Syndrome’ should be considered in any child with a subdural haemorrhage. Therefore the lack of available neuroimaging techniques, coupled with the lack of appreciation of child abuse in the late 1950’s makes it very difficult to interpret Finberg’s findings. 63
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 Although Finberg predicted that subdural haemorrhages would occur in salt poisoning, when the Binghamton disaster then occurred (also reported by Finberg 8 ) no child on whom a post mortem was conducted actually had a subdural haemorrhage. If the only cases where both occurred had other evidence of child abuse (not simply evidence in the form of subdural haematomas), then one might reasonably conclude that the evidence suggests that subdural haematoma does not complicate hypernatraemia. A more recent publication looking critically at the issue of subdural haemorrhage and its association with hypernatraemia 247 (evidence level 4) approached the topic from four different perspectives: 1. Chart review of hypernatraemic infants at autopsy (9 cases, multiple causes of death): none had a subdural haemorrhage. 2. Hospitalised children (aged
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The differential diagnosis of hypernatraemia in children, with ...

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