Color profile: Disabled
Composite Default screen
CASE REPORT
Severe hypernatremic dehydration
in a newborn infant
R Garth Smith MBBS FRCPC, Consultant Pediatrician, Chatham, Ontario*
RG Smith. Severe hypernatremic dehydration in a newborn infant.
Paediatr Child Health 1998;3(6):413-415.
La déshydratation hypernatrémique grave chez un
nouveau-né
A female infant presented with severe hypernatremic dehydration and
failure to thrive two weeks after birth. The diagnosis and management of
the infant are described, highlighting the need for follow-up and support
after early discharge of newborns.
RÉSUMÉ : Une fillette de deux semaines se présente à l’hôpital
atteinte de déshydratation hypernatrémique et de retard
staturopondéral. Cet article décrit le diagnostic et le traitement du
nourrisson et souligne le besoin d’un suivi et d’un soutien après le
congé précoce des nouveau-nés.
Key Words: Dehydration, Early discharge, Escherichia coli, Failure to
thrive, Neonates, Sepsis
T
make an appointment if the situation worsened or did not
improve. The baby began sneezing and coughing, had an
increasing reluctance to nurse and became quite irritable.
The mother had reported that the baby was “not urinating well from the beginning”, but despite this, weight
was actually 2.55 kg on day seven, a gain of 0.195 kg postdischarge.
On day 14 of life, the baby was brought in for a routine
follow-up at the request of the family physician. The baby
weighed 1.845 kg at that time and appeared “moribund”
according to the family physician. The baby was immediately transferred to the local community hospital paediatric ward where the author was asked to see the baby in
consultation.
The baby appeared markedly wasted (Figure 1) with
clinical evidence of severe dehydration. She was lethargic,
with moaning respirations that were shallow; breath rate
was 48 breaths/min. Heart rate was 180 to 200
beats/min, and she responded to stimulation with a weak
moan. Blood pressure was attempted but could not be
obtained. Oxygen saturation monitoring was attempted
but, with poor perfusion (capillary refill approximately 4
s), was difficult to achieve. Supplementary oxygen was,
therefore, prophylactically administered, and the baby
placed under a radiant warmer. The baby’s colour was
his report describes an infant with severe hypernatremic dehydration, failure to thrive and Escherichia
coli sepsis, who presented to a community hospital in
Chatham, Ontario, at two weeks of age.
CASE PRESENTATION
A female baby was born at 38 weeks’ gestation, birth
weight 2.625 kg to a gravida 2 para 2 married 34-year-old
mother. The pregnancy was described as ‘uneventful’,
and the mother was group B streptococcus negative. The
birth was by spontaneous vaginal delivery and was “uncomplicated”. Apparently nursing was initiated “with
some difficulty” and required “considerable assistance”
from the lactation nurse consultant. Despite problems
with nursing, the baby and mother were discharged after
two days in hospital. The discharge weight was 2.355 kg
– a weight loss of 0.270 kg from birth. The mother was
given strict instructions to nurse at least every 3 h, and
an early post discharge follow-up appointment was made
for seven days after discharge. However, no homecare
nurse follow-up was arranged.
Approximately two to three days after discharge, the
baby developed a purulent eye discharge and was taken
into the family physician on about day seven. Antibiotic
eye drops were prescribed, and the mother was told to
*Dr Smith was working in Chatham when this patient presented for treatment.
Correspondence and reprints: Dr R Garth Smith, Department of Pediatrics, Child Development Centre, Hotel Dieu Hospital, 166 Brock Street,
Kingston, Ontario K7L 5G2. Telephone 613-544-3400 ext 3135, fax 613-545-3557, e-mail [email protected]
Paediatr Child Health Vol 3 No 6 November/December 1998
413
1
G:\PAEDS\1998\Vol3No6\smith.vp
Mon Dec 14 12:26:55 1998
Color profile: Disabled
Composite Default screen
Smith
dosage of cefotaxime 115 mg was administered along
with ampicillin 115 mg. A minibolus of 10 mL/kg of normal saline was administered over about 10 to 15 mins simultaneously with the initiation of 5% dextrose solution
with 0.45% saline at just above maintenance. Potassium
chloride 20 MEq/L was added after the first void. A second minibolus of normal saline was administered once
the initial blood results were obtained, and the miniboluses were repeated until hemodynamic stability was
achieved.
Measurement of electrolytes was repeated along with
measurement of arterial blood gas at approximately 3 h
after the first result. It should be noted that measurement
of arterial blood gas had been unsuccessfully attempted
with the initial bloodwork. The results of the repeat
bloodwork are shown in Table 1.
Once hemodynamically stable, the baby was transferred
to a tertiary institution for further management, given concerns about the potential complications and management
challenges that were anticipated with this infant.
At approximately 18 h after transfer the blood culture
came back positive for E coli. Urine was latex agglutination negative and culture negative. A spinal tap was perfomed at the tertiary institution and was negative (clear). An
eye swab grew large quantities of Haemophilus influenzae biotype III, beta-lactamase positive.
At the tertiary hospital, the baby was rehydrated over
appropriately 48 to 72 h, and the hypernatremia slowly
corrected over several days. At discharge sodium was
144 mmol/L, chloride 110 mmol/L, potassium 4.5 mmol/L,
urea 1.5 mmol/L and creatinine 25 mmol/L. She received
a 10-day course of ampicillin and cefotaxime for the
Gram-negative sepsis. She was discharged home from the
tertiary hospital on formula.
Follow-up: The baby was followed very closely by the
author and a developmental team at the local rehabilita-
Figure 1) Picture of a 14-day old patient upon admisson to hospital. The
baby appeared markedly wasted with clinical evidence of severe dehydration
sallow, the anterior fontanelle was small but sunken, and
there was marked tenting of the skin with a wrinkled appearance and paucity of subcutaneous fat.
The abdomen was scaphoid. The baby’s eyelids were
stuck together with exudate (a culture was done), but there
was no apparent nasal discharge. Neurologically, she was
extremely lethargic, with a weak cry and marked hypotonia. Rectal temperature at that time was 36°C.
An intravenous line was started shortly thereafter,
and, at the same time, blood was drawn for culture, electrolytes, urea (blood urea nitrogen), creatinine, bilirubin,
liver function tests, random glucose, complete blood
count and calcium. The results of the tests were returned
within 10 to 15 mins (tests were confirmed in the laboratory where they were repeated) (Table 1).
Before obtaining the blood results, an intravenous
TABLE 1: Acute blood results of patient
Time
Blood results
14:33
17:17
Liver enzymes
14:33
Arterial blood gas
17:17
Complete blood count
14:33
Test results
Na
(mmol/L)
197
198
K
(mmol/L)
5.8
4.9
Cl
(mmol/L)
150
152
TC02
(mmol/L)
18
20
Urea
(mmol/L)
76.8
Creatinine
(mmol/L)
366
Ca
(mmol/L)
2.94
AST
(u/L)
LDH
(u/L)
ALT
(u/L)
AlkPhas
(u/L)
GGT
(u/L)
Alb
(g/L)*
40
49
Bilirubin
(mmol/L)
222
66
1361
57
pH
7.38
PCO2
32
BE
–5.0
189
P02
74
Oxygen saturation
95%
Hg
95
Hct
0.28
Lkcs
19.1
MCV
105
MCH
35.6
MCHC
338
Myel
0.01
Matamyel
0.01
Bands
0.12
Neuts
0.37
Lymphs
0.37
Monos
0.12
Glucose
(mmol/L)
7.0
Plts
324
*Total protein 76 g/L. Alb Albumin; AlkPhas Alkaline phosphatase; ALT Alanine aminotransferase; AST Asparate aminotransferase; BE Base excess; Ca Calcium; Cl Chloride;
GGT Gamma-glutamyl transferase; Hct Hemocrit; Hg Hemoglobin; K Potassium; Lkcs Leukocytes; LDH Lactate dehydrogenase; Lymphs Lymphocytes; MCV Mean cell volume; MCH Mean cell hemoglobin; MCHC Mean cell hemoglobin concentration; Metamyel Meta myelocytes; Monos Monocytes; Myel Myelocytes; Na Sodium; Neuts Neutrophils; Plts Platelets; PCO2 Partial pressure of carbon dioxide; PO2 Partial pressure of oxygen; TCO2 Bicarbonate
414
Paediatr Child Health Vol 3 No 6 November/December 1998
2
G:\PAEDS\1998\Vol3No6\smith.vp
Mon Dec 14 12:26:57 1998
Color profile: Disabled
Composite Default screen
Severe hypernatremic dehydration
tion centre over the subsequent two-and-a-half years.
There were no concerns whatsoever with regards to her
development because she seemed to be age appropriate in
many developmental areas and actually advanced in some
of her developmental domains.
DISCUSSION
This case was reported for several reasons. First, it demonstrates the need to keep an open mind in paediatrics
when dealing with a sick neonate and cover all bases. For
example, in this particular case, the symptoms may have
easily been attributed entirely to the hypernatremic dehydration, and one may have omitted looking for other
causes. This would have resulted in missing a very serious
underlying cause of the hypernatremic dehydration and
failure to thrive in this infant, which may have been fatal.
This baby was probably also at risk of breastfeeding
failure from the beginning because of the following factors:
low birth weight, early breastfeeding difficulties (1-4), an
apparently not fully informed mother at time of discharge, no homecare or lactation consultant follow-up arranged (5), and early hospital discharge (5,6).
Clearly, one should learn from this particular experience that for early discharge to be without significant risk,
all potential risk factors must be identified and appropriate mechanisms should be in place to deal with them
should they arise. This case had a ‘happy ending’ but had
the routine follow-up appointment not been scheduled
when it was, the outcome may have been entirely different.
REFERENCES
1. Chilton LA. Prevention and management of hypernatremic
dehydration in breast-fed infants. West J Med 1995;163:74-6.
2. Kaplan JA, Siegler RW, Schmunk GA, et al. Fatal hypernatremic
dehydration in exclusively breast-fed newborn infants due to
maternal lactation failure. Am J Forensic Med Pathol
1998;19:19-22.
3. Molteni KH. Initial management of hypernatremic dehydration in the
breastfed infant. Clin Pediatr (Phila) 1994;33:731-40.
4. Newman J. Decision tree and postpartum management for
Paediatr Child Health Vol 3 No 6 November/December 1998
preventing dehydration in the “breastfed” baby. J Hum Lact
1996;12:129-35.
5. Joint Statement of Fetus and Newborn Committee, Canadian
Paediatric Society and Maternal Fetal Medicine Committee, Society of
Obstetricians and Gynaecologists of Canada. Facilitating discharge
home following a normal term birth. Paediatr Child Health
1996;1:165-8.
6. Britton JR, Britton HL, Beebe SA. Early discharge of the term infant:
A continued dilemma. Pediatrics 1994;94:291-5.
415