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

The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009
Eight children were thought to have been abused, of whom two children 224, 235 were
reported to have a subdural haemorrhage. In one child the subdural was thought
to be chronic, in the other its age was not recorded. In one further child 1 of the
33 non-abused children the autopsy report stated “fresh blood was noted in the
subdural space diffusely with marked subarachnoid haemorrhage and congestion
of the dura and pial vessels. There were no bony abnormalities noted.” This
2-year-old child died after reportedly being given a saline emetic by a babysitter
after accidental pill ingestion.
A second child, born preterm at 33 weeks, presented aged 5 weeks with a sodium
of 214 mEq/L associated with a 24 hours history of lethargy, fever, diarrhoea
and vomiting. 252 A right tentorial subdural haematoma, cerebral oedema and
intraventricular haemorrhage were found on cranial CT scan. A diagnosis of
non-accidental injury was considered, but without other skeletal injuries or retinal
haemorrhages the authors attributed the findings to hypernatraemic dehydration.
Analysis of the premixed infant formula and the intravenous fluids used demonstrated
appropriate sodium concentrations. Fractional urinary sodium excretion was not
reported, but there appeared to be a high sodium excretion in the first 15 hours. The
infant died 12 hours after admission; no postmortem findings were reported. Both
peer reviewers agreed on the balance of probability with the authors’ conclusion that
the hypernatraemia was due to dehydration, with the infant being cared for in a hot
room (an error by the parent).
Among the 25 adults with hypernatraemia with similar information about the
presence of a subdural haemorrhage, there was one 35 year old woman 253 with
the following description: “thin covering of blood over an area measuring 5 x 4
cm on the surface of the right temporal lobe”. It is unclear whether this relates
to a subdural haemorrhage. She had died within a few hours following the
administration of a saline emetic as treatment of an overdose.
In the event, therefore, there are two cases 1, 252 where subdural haemorrhage and
hypernatraemia co-exist and there is no other evidence of child abuse. This is not
in itself good evidence that subdural haemorrhage can complicate hypernatraemia,
but does not allow a causal connection to be ruled out.
4
The authors' conclusions as to cause were subjected to peer review, see below.
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