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

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The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 Evidence statement Subdural haemorrhage occurs only in a small minority of cases of salt poisoning [Grade C]. Evidence statement Most reported cases of coexisting subdural haemorrhage and hypernatraemia are non-accidental, and in several children the evidence suggests that the subdural haemorrhage preceded deliberate salt poisoning [Grade C]. Evidence statement The finding of a subdural haemorrhage in association with hypernatraemia should raise the suspicion that the cause may be non-accidental injury [Grade C]. 4.5 Characteristics of children with hypernatraemia considered to have been abused Clinical question What are the clinical characteristics of children with hypernatraemia reported in the literature in whom child abuse was considered to be the cause? The 29 children in whom the authors considered that child abuse was the cause 5 had the following clinical characteristics: Age at first presentation: Mean 3 years 8 months (range 2 months to 7 years 2 months). All but one of the Meadow cases 3 were under 1 year at first presentation. Sodium at presentation: Mean sodium 196 mmol/L (range 150 to 234 mmol/L). This excludes 5 of Meadow’s cases, where the exact sodium was not reported. The distribution including all cases is shown below: 5 Refs 219, 224, 225, 230-232, 233 (case1), 234-239 67
The Diagnosis of Salt Poisoning Leading to Hypematraemia in Children – September 2009 distribution of initial sodium levels 10 9 8 number of cases 7 6 5 4 3 2 1 0 150-160 160-175 176-190 191-210 above 210 sodium (mmol/L) Other evidence of child abuse was reported in 11 of 17 children in whom this was ascertainable. This is likely to be subject to publication bias, and the overall proportion with other evidence of abuse is not known. Meadow 3 described the following presenting symptoms: • Vomiting (the predominant feature), also present in around half the other cases • Diarrhoea, also present in 3 other cases • Failure to thrive • Drowsiness or coma, also present in 4 other cases • Rigidity, hyper-reflexia • Seizures, also present in 6 other cases • Thirst, also present in 2 other cases Other descriptions of symptoms include being too weak to stand or walk, irritability, headache, fever, and loss of appetite. Evidence statement The common symptoms and signs of deliberate salt poisoning include vomiting, diarrhoea, drowsiness or coma, irritability, seizures, and thirst [Grade C]. Evidence statement Symptoms do not differ from those seen in accidental poisoning [Grade C]. 68
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