ISSN: 2161-0231(ONLINE)
Forced Water Intoxication: A Deadly Form of Child Abuse
Jerrod Brown, Matthew D. Krasowski, and Mario L. Hesse
Introduction
Water intoxication is a dangerous condition that often goes unnoticed until it is too late (Chamberlain,
2012). It is potentially hazardous because it can lead to hyponatremia, a condition that can result in brain
injury or death when sodium levels in the body drop too low (Farrell & Bower, 2003). Literature
suggests that prepubescent children are at a higher risk of developing this rare, and often lethal, condition
(Arieff & Kronlund, 1999). Water intoxication of children may be accidental; however, it is also a
serious and possibly under-recognized form of abuse. Since forced water intoxication is rare, symptoms
are not widely recognized and frequently go undetected or are mistaken for other causes. Improved
education of healthcare providers can help prevent or minimize long-term harm associated with water
intoxication (Verbalis et al., 2013). In order to prevent forced water intoxication abuse, it is necessary to
understand what water intoxication is, how it is used as abuse, and methods of water intoxication
detection and prevention.
Water Intoxication
Water intoxication is the result of excessive water intake that exceeds the kidney’s ability to
eliminate (Arieff, & Kronlund, 1999; Farrell & Bower, 2003; Joo, & Kim, 2013 Rowntree, 1923).
Early signs of water intoxication may include: confusion, vomiting, disorientation, and psychotic
symptoms (Chinn, 1974; Rowntree, 1923; Vieweg, Rowe, David, Sutker, & Spradlin, 1984). Excessive
water intake in turn, can contribute to polyuria, the ejection of heavily diluted urine (Arieff & Kronlund,
1999; Farrell & Bower, 2003; Rowntree, 1923). Excessive water intake resulting from polydipsia (i.e.,
extreme thirst) has been observed in those suffering from medical conditions such as diabetes and
schizophrenia (Radojevic et. al., 2012) and may also be a consequence of abusing certain drugs
(especially methylenedioxy-methamphetamine, MDMA/Ecstasy) (Hall, 1997; Milroy, 2011).
The ingestion of large amounts of water, including flavored drinks and sodas with very low
sodium content, normally results in a compensatory production of very dilute urine. However, excessive
water intake can overwhelm the kidney’s ability to eliminate water (Joo, & Kim, 2013), resulting in
hyponatremia, a reduction in plasma sodium below normal levels, typically defined as 135 mEq/L or less
Verbalis, 1989). Two secondary symptoms of forced water intoxication include hyponatremic
encephalopathy, a symptom affecting the brain, and hypoxemia, an insufficient amount of oxygen in the
blood (Chamberlain, 2012). The brain is very sensitive to sudden shifts in blood sodium. Other more
severe symptoms of hyponatremia include: seizures, brain damage, and even death (Radojevic et al.,
2012). The risk of seizures increases exponentially when plasma sodium falls below 125 mEq/L,
especially when levels drop suddenly (Barber, & Whitefield, 2012). Water intoxication is thus a serious
condition that if left untreated can have extremely negative consequences.
Forced Water Intoxication/Brown. Krasowski, & Hesse
2 Water Intoxication as a Form of Child Abuse
Although water intoxication can occur accidentally, it has been identified as a rare, yet often fatal,
form of child abuse known as “forced water intoxication” (Arieff & Kronlund, 1999). Forced water
intoxication of children is classified as intentional poisoning (Dine & McGovern, 1982). Victims of
previous physical abuse are at greater risk for forced water intoxication (Arieff & Kronlund, 1999). An
example of this type of abuse involved a six-year-old boy forcibly fed water through a garden hose. The
boy repeatedly interrupted his mother by asking for a glass of water. The mother responded by placing a
hose in the child’s mouth and closing his mouth around the hose. Upon seeing this, the child’s playmate
alerted his own parents, who then called the police. The child was found unconscious and frothing at the
mouth, but was resuscitated and reportedly sustained no lasting physical injuries (Radojevic et al., 2012).
In another case, a two-year-old girl presented multiple times with recurrent seizures associated with
hyponatremia, twice requiring resuscitation in the hospital (Barber, & Whitefield, 2012). The etiology
was initially thought to be due to renal salt-wasting disease or adrenal insufficiency before finally being
associated with abuse (i.e., forced water intoxication).
While some incidents of forced water intoxication are the direct result of the abuse, forced water
intoxication is a secondary result of abuse that must also be understood. One example is forced bathtub
emersion (as a form of abuse), which may result in forced water intoxication (Nixon & Pearn, 1977).
Healthcare providers should be equipped to recognize the signs of forced water intoxication, as they are in
the best position to detect it early and are often some of the first people to come into contact with victims
of abuse.
Accidental Water Intoxication
In addition to water intoxication as a form of abuse, healthcare providers must also be aware of the
possibility of accidental water intoxication in children. Although rare, water intoxication may result
among children from common activities such as bottle-feeding, swimming lessons, juice consumption, or
irrigation of the nasal passages (Bruce & Kliegman, 1997; Schulman, 1980). A 2007 study found that
water intoxication might increase for bottle-fed newborns (Ophir et. al., 2007). Risk of water intoxication
may also occur among children who accidentally swallow water during swimming lessons (Goldberg,
Lightner, Morgan, & Kemberling, 1982). Another rare form of accidental water intoxication may occur
from the consumption of large amounts of sweetened beverages, like juice and soda. As with pure water
ingestion, excessive consumption of these beverages (which contain a high percentage of water and very
little sodium) may potentially lead to hyponatremia (Dolezel, 2010; Furth, & Osi, 1993). In the medical
setting, water intoxication can also result from excessive intravenous infusion of solutions that are
hypotonic (i.e., with low amounts of electrolytes). For individuals who have not yet reached puberty,
death or brain damage through acute hyponatremic encephalopathy is the most prominent danger
associated with water intoxication (Arieff & Kronlund, 1999).
Reported cases of accidental water intoxication in adults are often related to the overconsumption
of water by athletes prior to endurance races, military personnel during military basic training, individuals
attempting to dilute urine for a drug test, and persons with schizophrenia (Ristedt, 1999). Cases of water
intoxication by endurance athletes have been reported in endurance activities lasting longer than seven
hours. The athlete voluntarily hyperhydrates with hypotonic solutions and experiences moderate sodium
chloride losses through sweat (Noakes, Goodwin, Rayner, Branken, & Taylor, 1985). Reported cases of
water intoxication in military basic training follow a similar etiology to endurance athlete water
intoxication, with the motivation for hyperhydration being the avoidance of heat injury (Garigan, &
Ristedt, 1999). Water intoxication has also been described following intentional efforts to dilute urine
prior to drug of abuse testing (to hide presence of illicit drugs) by drinking large quantities of water
(Tilley, & Contant, 2011). Self-induced water intoxication has also been reported in some individuals
diagnosed with schizophrenia (de Leon, Verghese, Tracy, Josiassen, & Simpson, 1994; Smith, & Clark,
1980; Vieweg, David, Rowe, Wampler, Burns, & Spradlin, 1985).
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3 Conclusion
Forced water intoxication may be an unfamiliar form of child abuse to many professionals and can
be a potentially lethal form of abuse. The deadly nature of water intoxication is exacerbated by the
public’s lack of awareness about its detection and prevention. Symptoms of water intoxication may go
unnoticed or be mistaken for other ailments, which may indirectly facilitate the onset of hyponatremia,
leading to brain damage and even death. Increasing awareness about forced water intoxication as a form
of child abuse may help to reduce the number of incidents. Healthcare workers should consider forced
water intoxication in the differential diagnosis of otherwise unexplained hyponatremia.
A major step to spread awareness about forced water intoxication is educating healthcare workers
and those working with at-risk populations. Greater awareness of the signs and symptoms of forced water
intoxication is necessary in order to facilitate swift and accurate identification of this potentially fatal
form of abuse. One way healthcare providers could identify incidents of forced water intoxication is by
including queries pertaining to forced water intake in child abuse assessments, as some parents may use
the practice as a misguided form of punishment. Another recommendation is to educate caretakers on the
dangers of forced water intoxication. Medical doctors involved with prenatal and pediatric care should
inform new mothers and caretakers of the risks that water overconsumption can pose. Those who are well
informed about the detection and prevention of water intoxication should collaborate closely with the
community, medical, and mental health providers in order to consider all possible factors in a critical
evaluation.
About the Authors:
Jerrod Brown, MA, MS, MS, MS, is the treatment director for Pathways Counseling Center, Inc. in St.
Paul, Minnesota. Jerrod is also the founder and CEO of the American Institute for the Advancement of
Forensic Studies (AIAFS) and the lead developer and program director for an online graduate degree
program in Forensic Mental Health for Concordia University, St. Paul, Minnesota. Jerrod is also currently
pursuing his doctorate degree in psychology.
Matthew D. Krasowski, MD, PhD, is a pathologist and Director of Clinical Laboratories in the
Department of Pathology at the University of Iowa Hospitals and Clinics.
Mario L. Hesse, PhD, is a professor of Criminal Justice at St. Cloud State University. Dr. Hesse’s areas
of research and teaching focus on: corrections, delinquency, gangs, and media and crime. Mario has been
a review-editor for A Critical Journal of Crime, Law and Society, the Journal of Gang Research and other
journal and periodical publications.
Contributors:
Janina Wresh has 19 years of experience in law enforcement working in forensics crime laboratories,
courts, and adult detention centers. She has served as a deputy sheriff, police officer, domestic abuse
response specialist, crisis intervention specialist, and crime scene technician. Janina also serves as
AIAFS’ Chief Operating Officer.
Erv Weinkauf, MA, is a retired 40-year law enforcement veteran with 19 years of teaching experience.
He currently serves as chairperson of the Concordia University - Criminal Justice Department St. Paul,
Minnesota.
www.jghcs.info [ISSN 2161-­‐0231 (Online) JOURNAL OF LAW ENFORCEMENT/ VOLUME 4, NUMBER 4 Forced Water Intoxication/Brown. Krasowski, & Hesse
4 Julie Anderson, MA, LAMFT, is currently a mental health practitioner at Pathways Counseling Center,
Inc.
Pamela Oberoi, MA, is currently the manager of the refugee mental health program at Pathways
Counseling Center, Inc.
Celesta Harris, Ph.D., received her Ph.D. in Clinical-Forensic Psychology from the California School of
Forensic Studies at Alliant International University.
Ellie Biglow, MA, is currently a mental health practitioner at Pathways Counseling Center, Inc.
Hannah Brown is a volunteer forensic mental health research assistant with the American Institute for
the Advancement of Forensic Studies (AIAFS). She will graduate from Macalester College in 2015 with a
Bachelor of Arts degree in Neuroscience.
References
Arieff, A.I., & Kronlund, B.A. (1999). Child abuse by forced water intoxication. Pediatrics, 103, 12921295.
Ayus, J., Achinger, S. G., & Arieff, A. (2008). Brain cell volume regulation in hyponatremia: Role of sex,
age, vasopressin, and hypoxia. American Journal of Physiology: Renal Physiology, 64, 619-624.
Barber, G. A., & Whitefield, J. S. (2012). Cultivated child abuse: a 2-year-old with hyponatremic
seizures. Pediatric emergency care, 28(11), 1234-1235.
Bruce, R. C., & Kliegman, R. M. (1997). Hyponatremic seizures secondary to oral water intoxication in
infancy: association with commercial bottled drinking water. Pediatrics, 100, 6.
Chamberlain, L. (2012). Hyponatremia caused by polydipsia. Critical Care Nurse, 32, e11-e20.
Chapman, T. H., & Hamilton, M. (2008). Water intoxication presenting as maternal and neonatal
seizures. Journal of medical case reports, 2, 366.
Chinn, T. (1974). Compulsive Water Drinking: A Review of the Literature and an Additional Case.
Journal of Nervous & Mental Disease, 158, 1.
de Leon, J., Verghese, C., Tracy, J. I., Josiassen, R. C., & Simpson, G. M. (1994). Polydipsia and water
intoxication in psychiatric patients: a review of the epidemiological literature. Biological
psychiatry, 35(6), 408-419.
Dine, M., & McGovern, M. (1982). Intentional poisoning of children—An overlooked category of child
abuse: Report of seven cases and review of the literature. Pediatrics, 70, 32-35.
Dolezel, Z., Kopecna, L.D., & Stastna, J. (2010). Baby bottle and the risk of water intoxication. Journal
of Pediatric Sciences, 2, 1-4.
Farrell, D.J., & Bower, L. (2003). Fatal water intoxication. Journal of Clinical Pathology, 56, 803-804.
Goldberg, G., Lightner, E., Morgan, W., & Kemberling, S. (1982). Infantile water intoxication after a
swimming lesson.Pediatrics, 70, 599-600.
Furth, S., & Osi, F. (1993). Hyponatremia and Water Intoxication. Am J Dis Child, 147, 932-933.
Garigan, T. P., & Ristedt, D. E. (1999). Death from hyponatremia as a result of acute water intoxication in
an Army basic trainee. Military medicine, 164(3), 234-238.
Hall, AP. (1997). Hypoantraemia, water intoxication and ‘ecstasy’. Intensive Care Medicine, 23(12),
1289.
Joo, M. A., & Kim, E. Y. (2013). Hyponatremia caused by excessive intake of water as a form of child
abuse. Annals of Pediatric Endocrinology & Metabolism, 18(2), 95-98.
Milroy, C. (2011). 'Ecstasy' associated deaths: what is a fatal concentration? Analysis of a case series.
Forensic Science, Medicine & Pathology, 7(3), 248-252.
www.jghcs.info [ISSN 2161-­‐0231 (Online) JOURNAL OF LAW ENFORCEMENT/ VOLUME 4, NUMBER 4 Forced Water Intoxication/Brown. Krasowski, & Hesse
Nixon, J.& Pearn, J. (1977). Non-accidental immersion in bathwater: Another aspect of child abuse.
British Medical Journal, 29, 271-272.
Noakes, T. D., Goodwin, N., Rayner, B. L., Branken, T., & Taylor, R. K. (1985). Water intoxication: a
possible complication during endurance exercise. Medicine and science in sports and exercise,
17(3), 370-375.
Ophir, E., Solt, I., Odeh, M., & Bornstein, J. (2007). Water intoxication-A dangerous condition in labor
and delivery rooms. Obstetrical and Gynecological Survey, 62, 731-738.
Radojevic, N., Bjelogrlic, B., Aleksic, V., Rancic, N., Samardzic, M., Petkovic, S., & Savic, S. (2012).
Forensics aspects of water intoxication: Four case reports and review of relevant literature.
Forensic Science International, 220, 1-5.
Ristedt, G. (1999). Death from hyponatremia as a result of acute water intoxication in an Army basic
trainee. Military Medicine, 164, 234-238.
Rowntree, L. G. (1923). Water intoxication. Archives of Internal Medicine, 32(2), 157-174.
Schulman, J. (1980). Infantile water intoxication at home. Pediatrics, 66(1), 119-120.
Shivashankar G., Coe, A., Satodia P. (2008). Neonatal seizure due to maternal water intoxication in
labour-a case report. Infant, 4, 196-197.
Siegler, E.L., Tamres, D., Berlin J.A., Allen-Taylor, L., & Strom, B.L. (1995). Risk factors for the
development of hyponatremia in psychiatric inpatients. Arch Intern Med, 155, 953-957.
Smith, W. O., & Clark, M. L. (1980). Self-induced water intoxication in schizophrenic patients. The
American journal of psychiatry, 137(9), 1055-1060.
Tilley, M. A., & Cotant, C. L. (2011). Acute water intoxication during military urine drug screening.
Military Medicine, 176(4), 451-453.
Verbalis, J. G. (1989). 10 Hyponatraemia. Baillière's clinical endocrinology and metabolism, 3(2), 499530.
Verbalis, J. G., Goldsmith, S. R., Greenberg, A., Korzelius, C., Schrier, R. W., Sterns, R. H., &
Thompson, C. J. (2013). Diagnosis, evaluation, and treatment of hyponatremia: Expert panel
recommendations. American Journal of Medicine, 126, S1-S42.
Vieweg, W., Rowe, W., David, J., Sutker, L., & Spradlin, W. (1984). Evaluation of Patients with SelfInduced Water Intoxication and Schizophrenic Disorders (SIWIS). Journal of Nervous & Mental
Disease, 172, 9.
West, C.R., & Harding, J.E. (2004). Maternal water intoxication as a cause of neonatal seizures. Journal
of Pediatrics and Child Health, 40, 709-710.
www.jghcs.info [ISSN 2161-­‐0231 (Online) JOURNAL OF LAW ENFORCEMENT/ VOLUME 4, NUMBER 4 5