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Breastfeeding associated hypernatraemic dehydration Brest Feeding

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									    Original article

               Breastfeeding-associated hypernatraemic dehydration
                                     Desidratação hipernatrêmica associada ao aleitamento materno
             Sónia Melo Gomes1, Claudia Almeida Fernandes2, Helena Ramos3, Eduardo Fernandes4, Manuela Santos5,
                                        Odília Nascimento6, António Marques Valido7

aBStract                                                                                                       reSUMO
Objective: In the last few years there has been an increase in case                                            Objetivo: Nos últimos anos verificou-se um aumento do número de
reports of hypernatraemic dehydration in breastfed newborns.                                                   casos descritos de desidratação hipernatrêmica em recém-nascidos
Insufficient intake has an important role in the pathophysiology of                                            em aleitamento materno exclusivo, sendo o déficit de aporte o
this condition. The aim of this study was to evaluate exclusively                                              desencadeante habitual. O objetivo deste estudo foi caracterizar a
breastfed neonates admitted for hypernatraemic dehydration.                                                    população de recém-nascidos com desidratação hipernatrêmica,
Methods: Retrospective study of breastfed neonates diagnosed                                                   associada ao aleitamento materno exclusivo numa maternidade de nível
with hypernatraemic dehydration, between March 2002 and                                                        1. Métodos: Estudo retrospectivo, entre Março de 2002 e Março de
March 2008, in a level 1 maternity. results: Nineteen cases were                                               2008, dos recém-nascidos internados por desidratação hipernatrêmica
identified (0.44% of neonatal intermediate care hospitalizations),                                             em aleitamento materno exclusivo. resultados: Foram 19 casos
53% of them were male. The annual distribution revealed a higher                                               (0,44% das internações), sendo que 53% eram do sexo masculino. A
number of cases in 2008: 26.3% in only three months. Median                                                    distribuição anual revelou um maior número de casos em 2008 (26,3%,
birth weight was 3,000 g and the median gestational age was 38                                                 em apenas três meses). O parto eutócico foi o mais frequente (42%).
weeks. Vaginal delivery was the most frequent form of birth (42%),                                             A mediana de peso ao nascer foi de 3.000 g e a da idade gestacional,
and 79% of mothers were primiparas. Admissions were made                                                       38 semanas; 79% das mães eram primíparas, e 68,4% dos recém-
through the emergency department in 68.4%. The main reasons                                                    nascidos foram admitidos pelo serviço de urgência, sendo os principais
for seeking medical attention were: poor oral intake (32%), weight                                             motivos de consulta: recusa alimentar (32%), perda ponderal (26%) e
loss (26%), and jaundice (26%). The median age at admission was                                                icterícia (26%). A mediana de idade à internação foi de quatro dias. A
four days. Percentage of weight loss: 6.7 to 40%, median was 11%.                                              percentagem de peso perdido foi de 6,7 a 40% (mediana de 11 %) e
Dehydration signs were absent in 42% of the patients. Median Na+                                               42% não apresentavam sinais de desidratação. A mediana dos valores
values were 152 mEq/l. Jaundice was the most frequent comorbidity                                              de Na+ à admissão foi de 152 mEq/l. A comorbidade mais frequente
found (74%). Intravenous fluids were administered in 89% and                                                   (74%) foi icterícia. O tratamento foi prioritariamente intravenoso (89%).
acute neurological complications were found in 21%, there were                                                 Complicações neurológicas agudas foram observadas em 21% e não
no deaths. conclusions: Breastfeeding-associated hypernatraemic                                                houve óbitos. conclusões: A desidratação hipernatrêmica associada ao
dehydration seems to be a consequence of breastfeeding difficulties                                            aleitamento materno exclusivo surge como consequência de dificuldades
in inexperienced mothers. Since many cases are paucisymptomatic,                                               na amamentação em mães inexperientes. Dado que muitos casos são
there should be a high level of suspicion, especially in those patients                                        oligossintomáticos, é necessário ter um elevado índice de suspeita desta
with jaundice.                                                                                                 alteração, especialmente nos que se apresentam com icterícia.

Keywords: Dehydration; Hypernatremia; Infant, newborn; Breast                                                  Descritores: Desidratação; Hipernatremia; Recém-nascido; Aleitamento
feeding                                                                                                        materno

Study carried out at the Pediatrics Department of the Neonatal Stepdown Unit at Maternidade Dr. Alfredo da Costa – Lisboa, Portugal.
    Medical student of the Complementary Internship in Pediatrics at Centro Hospitalar das Caldas da Rainha – Lisboa, Portugal.
    Medical student of the Complementary Internship in Pediatric at Centro Hospitalar de Setúbal, EPE – Lisboa, Portugal.
    Pediatrician; Hospital assistant of Hospital do Espírito Santo de Évora, EPE – Lisboa, Portugal.
    Pediatrician; Hospital assistant of Maternidade Dr. Alfredo da Costa – Lisboa, Portugal.
    Pediatritian; Hospital assistant of Maternidade Dr. Alfredo da Costa – Lisboa, Portugal.
    Head of the Pediatrics Department at Maternidade Dr. Alfredo da Costa – Lisboa, Portugal.
    Director of the Pediatrics Department at Maternidade Dr. Alfredo da Costa – Lisboa, Portugal.
    Corresponding author: Sónia Melo Gomes – Rua Dr. Bastos Gonçalves, n 3-3ºB – CEP 1600-898 – Lisboa, Portugal – e-mail:
    Received on Apr 6, 2009 – Accepted on May 25, 2009
    The authors received no financial support to conduct this work. All authors declared they participated in preparing the article, are responsible for it and there is no conflict of interest regarding what is
    stated in the text.

einstein. 2009;7(2 Pt 1):206-10
                                                                                             Breastfeeding-associated hypernatraemic dehydration    207

intrODUctiOn                                                 and urea) at admission, comorbidities, treatment, acute
Hypernatraemic dehydration is a potentially severe           neurological complications, and deaths. The software
pathology, especially in newborns. Complications can         Microsoft Office Excel 2003 was used for descriptive
occur due to hypernatraemia or its treatment, and            analysis of the data.
include cerebral oedema, seizures, intraventricular
haemorrhage, haemorrhagic infarct and permanent
brain damage, disseminated intravascular coagulation,
vascular thrombosis, renal failure, and eventually,          From 110 patient medical charts reviewed, a total of 19
death(1-5).                                                  cases that satisfied the inclusion criteria were identified,
     In the last ten years, there has been an increase       which accounted for 0.44% of hospitalizations in the
in case reports of exclusively breastfed neonates with       Neonatal Intermediate Care Unit during that period.
                                                                 The annual distribution revealed a higher number
hypernatraemic dehydration, which can be either a
                                                             of cases in 2008, with five cases in only three months
reflection of greater awareness of the medical community
                                                             (Figure 1). The monthly distribution showed that the
of this problem or a true rise in incidence.
                                                             majority of cases occurred during the cold months, from
     Several studies have implied that insufficient
                                                             October to March.
intake associated with exclusive breastfeeding has an
important role in the pathophysiology of this condition(6-
   . Although this matter has been amply discussed in           6
international literature, there are no data acknowledging                                                                                   5
the magnitude and relevance of this entity in Portugal.         5

                                                                                  3                                  3           3
The aim of this study was to evaluate breastfed neonates        3
admitted to a level 1 maternity with hypernatraemic                     2                      2
dehydration.                                                    2
A retrospective study was conducted through the review          0
                                                                      Mar-      2003         2004       2005       2006        2007       Jan-
of clinical charts of breastfed neonates hospitalized                Dec 02                                                              Mar 08
for hypernatraemic dehydration at the Neonatal
Intermediate Care Unit of a level 1 maternity in             Figure 1. Annual distribution
Portugal. The time period was six years, between March
2002 and March 2008.                                             Birth weight ranged from 2,370 to 4,145 g, with a
    Besides clinical charts with the final diagnosis of      mean of 3,163 g (± 4,30.2 g), median of 3,000 g and
dehydration and/or hypernatraemia, all readmissions          gestational age from 35 weeks plus three days to 40
for jaundice, hypoglycaemia, weight loss, poor oral          weeks plus six days, mean of 38 weeks plus four days (±
intake, and fever were also reviewed.                        9.6 days); median of 38 weeks plus five days. Fifty-three
    Patients were enrolled in the study based on the         percent of the patients were male. Vaginal delivery was
following criteria: exclusively breastfed newborns under     the most frequent method of birth (42%), and 16%
28 days of life, with a gestational age greater than 35      were caesarean sections.
weeks, significant weight loss (defined as > 5% in 24            Maternal age varied between 16 and 38 years (mean
hours or > 7%, during the first week of life and > 10%       of 28 years ± 5.4 years; median of 30 years); 79% of
after the first week), and hypernatraemia (Na+ >145          mothers were primiparas; for 5% it was the second
mEq/l). Neonates with suckling disorders and infection       child, and for 16%, the third.
or organic pathology were excluded.                              In most of the cases, admission was made through the
    Data collected included month and year of                emergency department (68%, n = 13). Four neonates
occurrence, gender, gestational age and birth weight,        were transferred from the maternity ward at a very low
delivery method, maternal age and number of prior            age, one was admitted through the outpatient clinic and
gestations, provenience and reasons for seeking medical      another was transferred from another hospital.
assistance, age at admission, percentage of weight loss,         The most frequent reasons for seeking medical
dehydration signs, laboratory values (sodium, glucose,       attention were poor oral intake (32%, n = 6), weight

                                                                                                                         einstein. 2009;7(2 Pt 1):206-10
208      Gomes SM, Fernandes CA, Ramos H, Fernandes E, Santos M, Nascimento O, Valido AM

loss (26%, n = 5), and jaundice (26%, n = 5). Another                                          Regarding laboratory values at admission: natraemia
important reason was newborn irritability with constant                                    values ranged from 146 to 196 mEq/l, with mean of
crying, referred in four cases (21%), as seen in Figure 2.                                 154.6 mEq/l (± 11.2 mEq/l) and median of 152 mEq/l).
                                                                                           While 47.4% of neonates presented with only slight
                                                                                           hypernatraemia (Na+ ≤ 150 mEq/l), three of them had
            Poor oral                                                                      natraemia values > 160 mEq/l (15.8%). Glucose and
             intake                                                                        urea values were also analysed (Table 1).

       Weight loss                                            5
                                                                                           table 1. Laboratory values upon admission
                                                                                                                   n      Min. Max.          Mean        Median % patient/Value
            Jaundice                                          5
                                                                                            Na+ (mEq/l)           19      146       196   154.6 ± 11.2    152     47.4% < 150
                                                                                                                                                                  15.8% > 160
         Irritability                                    4                                  Glucose (mg/dl)       15       30       107   65.6 ± 18.6      64      20% < 50
                                                                                            Urea (mg/dl)          15       18       291       63.9         37      80% < 40
                                                                                                                                                                   34% > 70
            Seizures               1                                                       Na+: sodium; Min.: minimum; Max.: maximum.

                                   1                                                           Comorbidities were identified in 74% (n = 14),
       nº of stools
                                                                                           and all of the patients had jaundice due to indirect
      Reevaluation                 1                                                       hyperbilirubinemia, the most frequent comorbidity.
                                                                                           Other comorbidities found were hypoglycaemia (n = 3,
                         0                 2         4             6             8
                                                                                           21%) and acute kidney injury (n = 1, 7%). Treatment
                                                                                           was intravenous except for two cases, the ones with the
Figure 2. Reasons for seeking medical care
                                                                                           mildest dehydration.
                                                                                               Acute neurological complications were found in
    Concerning age at admission, the minimum was 2                                         21% (n = 4): two cases of seizures (10.5%), one cerebral
and maximum 21 days. Over half of newborns (52.7%)                                         infarct (5.2%), and one grade III intraventricular
were admitted before five days of life (mean of five                                       haemorrhage (5.2%). Brain ultrasound was performed
days, ± 4.25 days); median of four days; Mo = 3 days                                       in about half of the neonates (n = 10, 53%), showing no
(n = 6).                                                                                   abnormality in 80%.
    Variation of weight loss changed from 6.7% in a
two-day-old neonate (criterion: weight loss > 5% in 24
hours) to 40%. Mean weight loss was 13.9% (± 7.95%),                                       DiScUSSiOn
and the median was 11%. In 42% of the cases (n = 8),                                       Due to its important role in optimizing growth and
the weight loss was between 10 and 15% (Figure 3). The                                     development, exclusive breastfeeding is the best source
dehydration signs were absent in 42% (n = 8) of the                                        of nourishment during the first months of life(1). Benefits
patients.                                                                                  for both mother and infant are multiple, so breastfeeding
                                                                                           must be stimulated and promoted.
                                                                                               Nevertheless, breastfeeding failure, whether due
        9                                                                                  to hypogalactia, insufficient feedings, or inadequate
                                       8          Minimum = 6.7%
        8                                         Maximum = 40%
                                                                                           breastfeeding techniques, can have severe consequences
                                                  Mean = 13.9% ± 7.45                      such as hypernatraemic dehydration in neonates(2).
                                                                                               In this study, the percentage of primiparous mothers
        6                                                                                  was very high (80%), as is described in medical literature,
        5                                                                                  which supports the idea that inexperience is a key factor
                   4                                                                       in breastfeeding failure(1).
                                                                                               The low percentage of caesarean sections verified,
                                                                                           opposed to the usual 30% in this maternity, may reflect
        2                                                                                  the influence of premature patient discharges in limiting
        1                                                                                  opportunities for contact with healthcare professionals,
                                                                                           and therefore, fewer possibilities for teaching and
                                                                                           supervision of breastfeeding techniques.
                <10%              10-15%        16-20%            >20%
                                                                                               Most cases occurred during the cold months of the
Figure 3. Percentage of weight loss in relation to birth weight                            year. Given the retrospective nature of this study, it was

einstein. 2009;7(2 Pt 1):206-10
                                                                                     Breastfeeding-associated hypernatraemic dehydration    209

not possible to assess why, but other published series          clinical situation, but also on how the treatment is
with similar results have identified overheating and the        conducted(3).
consequent increase of unperceived water loss as a risk               Rehydration should be performed slowly, with
factor(3).                                                      frequent monitoring of sodium levels, adjusting rhythm
    In this series, the median age at admission was much        and/or IV serum composition so that the decrease
lower than the classically described of ten days of life.       of sodium levels does not surpass 0.6 mEq/l/hour. If
These data, together with the significant percentage            correction is made too quickly, osmotic changes can
of hospitalizations from the maternity ward (21%),              heighten the risk for cerebral oedema and contribute
underline the urgent need for better support, with closer       towards permanent brain damage(9).
supervision and better instruction as to breastfeeding                In light of the data presented, the following question
techniques.                                                     emerges: Is the incidence actually rising?(11-14). To fully
    Considering weight loss, it is important to remember        understand this question, the next points should be
that according to recent recommendations of the                 taken into consideration. First, the true incidence seems
American Academy of Paediatrics, a weight loss greater          to be highly underestimated. Breastfeeding-associated
than 7% during the first week of life should constitute         hypernatraemic dehydration is underdiagnosed, since
an alert signal to the possibility that breastfeeding           many patients are paucisymptomatic and in many cases,
is insufficient. In these cases, clinical status and,           such as those presenting with hyperbilirubinemia,
more specifically, breastfeeding techniques, must be            a high level of suspicion is warranted. Besides, the
evaluated(4).                                                   true incidence in this maternity cannot be calculated
    Other alert signals to watch for are a continuing           for we cannot exclude the possibility of recurrences
weight loss beyond the first week of life and inability to      (referred) to other medical institutions. It should be
achieve birth weight by the tenth day of life(4).               pointed out that a selection bias could have occurred,
    In order to prevent this situation, as recommended          because this pathology is not always contemplated in
by the American Academy of Paediatrics, all breastfed           the final diagnosis. On the other hand, the increasing
newborns should be daily weighed and clinically                 lack of knowledge of mothers on breastfeeding and the
assessed until three to five days of life(5), with assessment   growing lack of availability of healthcare professionals,
and direct observation of breastfeeding techniques by           with reduced doctor/patient and nurse/patient ratios,
specialized healthcare professionals(6).                        together with premature maternity patient discharges,
    Over 40% of newborns presented no signs of                  are factors that can contribute to an actual rise in
dehydration, which is a contributing factor in masking          incidence.
this situation and making diagnosis more difficult. In                As breastfeeding-associated hypernatraemic dehy-
hypernatraemic dehydration, as opposed hypo- and                dration should be completely preventable(7), it is essen-
isonatraemia, extracellular volume is much better               tial that a group of measures should be established to
preserved than the intracellular one, and as such,              counteract this tendency(11).
dehydration signs are much less pronounced.                           Breastfeeding-associated hypernatraemic dehydration
    On the other hand, weight loss and decreased                seems to be a consequence of breastfeeding difficulties
frequency of urination and bowel movements are                  in inexperienced mothers. This highlights the need
sensitive indicators of dehydration in breastfed                for greater support from healthcare professionals in
neonates that should always be sought when assessing a          education and follow-up monitoring of breastfeeding
newborn with signs of fever, weight loss, jaundice and/         techniques. Some intervention strategies should be
or lethargy(7).                                                 implemented, such as: improvement in the education
    Another point to consider is the fact that indirect         of pregnant women and new mothers on breastfeeding.
hyperbilirubinemia is such a common comorbidity                 This fact can be achieved either during prenatal
that some authors advise that weight and natremia               appointments or during courses of preparation for
assessment should be part of the practice guidelines for        delivery or puericulture. There should be a nursing
the management of hyperbilirubinemia(7).                        staff specialized in lactation, similar to what happens
    These factors are of extreme importance, as even            in other countries, and there could also be brochures
those cases of hypernatraemia that resolve without              given to new mothers when leaving the maternity,
being identified and adequately treated may result in           with advice on breastfeeding and the warning signs
some degree of neurological damage, which can become            of inadequacy of breastfeeding and dehydration(15).
apparent years later(8).                                        Weight assessment before discharge, which could lead
    Acute neurological complications were found in              to identification of newborns potentially at risk(16-
21%. Values described in literature vary from series            19)
                                                                    ; continuous training of healthcare professionals
to series, as they depend not only on the underlying            in order to undermine certain fundamentalist

                                                                                                                 einstein. 2009;7(2 Pt 1):206-10
210     Gomes SM, Fernandes CA, Ramos H, Fernandes E, Santos M, Nascimento O, Valido AM

concepts, regarding breastfeeding and to increase                                         6. Yaseen H, Salem M, Darwich M. Clinical presentation of hypernatremic
the level of suspicion as to this pathology, especially                                      dehydration in exclusively breast-fed neonates. Indian J Pediatr.
in those patients presenting with hyperbilirubinemia;
                                                                                          7. Moritz ML, Manole MD, Bogen DL, Ayus JC. Breastfeeding-
development of better communication with Primary                                             associated hypernatremia: are we missing the diagnosis? Pediatrics.
Healthcare Centres, to alert family doctors to this                                          2005;116(3):e343-7.
pathology and to promote early weight and clinical                                        8. Ergenekon E, Unal S, Gücüyener K, Soysal SE, Koç E, Okumus N, et al.
status assessment, as is proposed in the National Child                                      Hypernatremic dehydration in the newborn period and long-term follow up.
Healthcare Surveillance Program.                                                             Pediatr Int. 2007;49(1):19-23.
                                                                                          9. Laing IA. Hypernatraemic dehydration in newborn infants. Acta Pharmacol Sin.
cOnclUSiOn                                                                                10. Bhat SR, Lewis P, David A, Liza SM. Dehydration and hypernatremia in breast-
                                                                                              fed term healthy neonates. Indian J Pediatr. 2006;73(1):39-41.
The adoption of intervention strategies would allow
                                                                                          11. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.
not only the prevention, but also the identification
                                                                                              Management of hyperbilirubinemia in the newborn infant 35 or more weeks of
of situations that point to hypernatraemic dehydration as                                     gestation. Pediatrics. 2004;114(1):297-316.
early as possible, so that breastfeeding will always be in                                12. Oddie S, Richmond S, Coulthard M. Hypernatraemic dehydration and breast
the baby’s best interest.                                                                     feeding: a population study. Arch Dis Child. 2001;85(4):318-20.
                                                                                          13. Manganaro R, Mamì C, Marrone T, Marseglia L, Gemelli M. Incidence of
                                                                                              dehydration and hypernatremia in exclusively breast-fed infants. J Pediatr.
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   rising? Arch Dis Child Fetal Neonatal Ed. 2002;87(3):F158-62.                              severe breastfeeding malnutrition and hypernatremia in a metropolitan area.
                                                                                              Pediatrics. 1995;96(5 Pt 1):957-60.
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einstein. 2009;7(2 Pt 1):206-10

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