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• Weighing alone will not prevent hypernatraemic dehydration.
  David Harding
  Published on: 9 January 2022
• Hypernatraemic dehydration - excess sodium is not the cause
  Sam Richmond
  Published on: 9 January 2022
• Hypernatremic dehydration
  Jack Newman
  Published on: 9 January 2022
• Hypernatraemia in the first few days: is the incidence rising?
  Graham C Smith
  Published on: 9 January 2022
• Hypernatraemia in breastfed infants
  Sam J Oddie
  Published on: 9 January 2022
• Hypernatraemia in the first few days: a tragic case.
  Peter D Macdonald
  Published on: 9 January 2022
• Weighing of breast fed babies is important
  Egware Benjamin Odeka
  Published on: 9 January 2022

• Published on: 9 January 2022

  Weighing alone will not prevent hypernatraemic dehydration.

  • David Harding, Lecturer, neonatal Medicine
  • Other Contributors:
    • Jacky Moxham, Clinical Risk Manager and Pamela Cairns, Consultant Neonatologist

  Dear Editor

  Having recently reviewed the case notes of babies readmitted to hospital in the first 10 days of life (over a 1 year period), we firmly agree with the views expressed by Laing and Wong.[1] The incidence of documented hypernatraemic dehydration secondary to the failure of lactation in Bristol is 1.7 per 1000 live births much higher than that described by Oddie et al. [2] in the Northern Region (2.5...

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  Dear Editor

  Having recently reviewed the case notes of babies readmitted to hospital in the first 10 days of life (over a 1 year period), we firmly agree with the views expressed by Laing and Wong.[1] The incidence of documented hypernatraemic dehydration secondary to the failure of lactation in Bristol is 1.7 per 1000 live births much higher than that described by Oddie et al. [2] in the Northern Region (2.5 per 10,000 live births). In addition only 50% of infants readmitted with weight loss of <10% had a plasma sodium concentration measured. The true incidence of hypernatraemic dehydration secondary to lactation problems in Bristol could thus be as high 3.4 per 1000 live births. Our estimate could be an underestimate as our study looked only at infants readmitted within 10 days(Oddie et al looked at infants readmitted up to one month of age) and due to failure of recognition of this condition.

  Laing and Wong [1] have proposed weighing all infants when the Guthrie blood samples are taken to identify those infants at risk of dehydration. We believe that this is too late as in many areas this occurs on days 7 or on day 10 with hand-over of care to the health visitor. We have already described a series of babies with hypernatraemic dehydration where all presented to hospital before day 7.[3]

  The case has been made correctly [1, Newman] that newborn hypernatraemia is due to failure of successful feeding. While we agree that careful examination, observation of the infant while feeding etc may identify these babies we would dispute that this is currently universally possible. Due to midwifery shortages, postnatal wards are short staffed, community midwives are fully stretched and many women are discharged within a few hours of delivering. If a midwifery home visit does not coincide with a feed the mother’s assessment of feeding is assumed to be correct (as indeed it usually is). Weighing will reassure most mothers that their baby is following the normal pattern of loss followed by gain. Identification of excessive weight loss should prompt the health professional to examine the baby for evidence of illness and carefully observe breast-feeding technique. These mother-baby dyads could then be given additional support and advice in the community and thus successfully establish feeding. In our experience once the baby has become ill and required readmission to hospital the mother is reluctant to continue to attempt to breast-feed.

  There continues to be confusion regarding the best way to manage this problem [1, Smith]. It should be remembered that these babies have normal guts and are suffering from starvation. If the infant is not shocked the rehydration can safely occur using enteral fluids – expressed breast milk or a breast milk substitute. Serum sodium should initially be measured six hourly and the volume of milk altered to ensure a slow return to normality.

  We believe we need to foster a greater awareness of this problem and weigh the babies at risk around day 5 if we are to prevent tragedies from a common condition affecting otherwise well babies.

  References

  (1) Hypernatraemia in the first few days: is the incidence rising? Laing IA, Wong M. Arch Dis Child 2002;87:F158-161.

  (2) Hypernatraemic dehydration and breast feeding: a population study. Oddie S, Richmond S, Coulthard M. Arch Dis Child 2001;85:318-20.

  (3) Hypernatraemia: why bother weighing breast fed babies? Harding D, Cairns P, Gupta S, Cowan F. Arch Dis Child Fetal Neonatal Ed 2001; 85: F145.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Hypernatraemic dehydration - excess sodium is not the cause

  • Sam Richmond, Neonatologist

  Dear Editor

  I am grateful to Laing and Wong for raising once again the issue of hypernatraemic dehydration in the first few days of life.[1] However, I think it is important to remember that hypernatraemic dehydration, like anaemia, is a sign of disease not a diagnosis in itself. A low haemoglobin concentration in blood can be caused by a large number of different pathological and physiological processes. Hypern...

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  Dear Editor

  I am grateful to Laing and Wong for raising once again the issue of hypernatraemic dehydration in the first few days of life.[1] However, I think it is important to remember that hypernatraemic dehydration, like anaemia, is a sign of disease not a diagnosis in itself. A low haemoglobin concentration in blood can be caused by a large number of different pathological and physiological processes. Hypernatraemic dehydration should be seen in the same light.

  Laing and Wong’s article describes two situations in which a child can be found to exhibit the typical biochemical and clinical features of hypernatraemic dehydration, i.e. weight loss and hypernatraemia. The first mentioned is associated with gastroenteritis in a bottle fed infant, commonly a few weeks old and the second is seen in ‘breastfed’ infants in the first few days of life. The hypernatraemia associated with these situations is caused by different problems with water balance – in neither is the problem an increased intake of sodium. In the infant with diarrhoea there is an excess loss of water and in the ‘breastfed’ baby an insufficient intake of water.

  In discussing hypernatraemic dehydration in association with diarrhoea in young infants Laing and Wong refer to a paper by Chambers and and Steel [2] where attention is drawn to the slightly increased concentration of sodium in artificial milk mixed incorrectly by parents. This is a red herring. The excess sodium concentration of the artificial milk mixed incorrectly by the mothers reached a maximum of 59 mmol/L with a mean of 37.2 mol/L. Those who believe that this concentration of sodium could be responsible for hypernatraemic dehydration should remember that the concentration of sodium in the standard oral rehydration solutions in use in this country is 60 mmol/L (Dioralyte®, Dioralyte Relief®, Rehidrat®), or in one case 50 mmol/L (Electrolade®) and that the WHO formulation for oral rehydration solution contains 90 mmol/L of sodium.

  In fact the cause of this association of hypernatraemic dehydration with diarrhoea is the continued feeding with artificial milk after the onset of diarrhoea. The intestinal hurry associated with gastroenteritis results in the delivery of a solution rich in protein and complex carbohydrates to the colon which, after digestion by colonic bacteria, produces a considerable osmotic load in the colon which in turn results in the production of voluminous stool low in sodium.[3] The result is hypernatraemic dehydration due to excessive water loss. Those who require further discussion of this hypothesis are advised to read the excellent paper by Hirschhorn.[3]

  The second situation relates to the title of the piece namely, hypernatraemic dehydration in the first few days of life in association with ‘breastfeeding’. Though the breast milk produced, in very small quantities, by the mothers of these children is often found to contain a high concentration of sodium, this has nothing to do with their hypernatraemic state. As Jack Newman so eloquently puts it in his electronic response to Laing and Wong, these babies are not dehydrated because they are breastfed but because they are only pretending to breastfeed. They are, in fact, starving. This is amply illustrated by the case described in Oddie et al of a ‘bottle fed’ baby admitted at six days of age with hypernatraemic dehydration whose dehydration had nothing to do with the bottle milk being ‘fed’ to her but was caused by the fact that she had oesophageal atresia. Hypernatraemic dehydration is frequently seen in the elderly and the mentally handicapped when their need for basic care, and presumably a regular intake of water, is neglected. [5,6,7]

  Hypernatraemic dehydration is a sign of illness not a diagnosis. It is commonly caused by excess water loss or by insufficient water intake either alone or in combination. It is almost never the result of excess sodium intake which would result in retention of water and an increase in body weight, though this would obviously require intact thirst mechanisms and access to sufficient water.

  Sam Richmond

  References

  (1) Laing IA, Wong CM, Hypernatraemia in the first few days: is the incidence rising? Arch Dis Child Fetal Neonatal Ed 2002; 87: F158-F162.

  (2) Chambers TL, Steel AE. Concentrated milk feeds and their relation to hypernatraemic dehydration in infants. Arch Dis Child 1975; 50: 610-5.

  (3) Hirschhorn N. The treatment of acute diarrhea in children. An historical and physiological perspective. Amer J Clin Nutrition 1980; 33: 637-63.

  (4) Oddie S, Richmond S, Coulthard M. Hypernatraemic dehydration and breastfeeding: a population study. Arch Dis Child 2001; 85: 318-20.

  (5) Aaronson L, Seaman LP. Managing hypernatremia in fluid deficient elderly. J Gerontol Nurs 1989; 15: 29-34

  (6) Miller PD, Krebs RA, Neal BJ. McIntyre DO. Hypodipsia in geriatric patients. Am J Med 1982; 73: 354-6.

  (7) Himmelstein DU, Jones AA, Woolhandler S. Hypernatremic dehydration in nursing home patients: an indicator of neglect. J Am Geriatr Soc 1983;31: 466-71.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Hypernatremic dehydration

  • Jack Newman, Paediatrician

  Dear Editor

  I have read the recent lead article in the Archives, Laing and Wong.[1] I wish to point out that dehydration in the first few days does not occur in breastfed babies. If the babies were breastfeeding, they wouldn't get dehydrated. It occurs in babies who are only pretending to breastfeed. But unfortunately, this is altogether too common, babies leaving hospital only pretending to breastfeed.

  The...

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  Dear Editor

  I have read the recent lead article in the Archives, Laing and Wong.[1] I wish to point out that dehydration in the first few days does not occur in breastfed babies. If the babies were breastfeeding, they wouldn't get dehydrated. It occurs in babies who are only pretending to breastfeed. But unfortunately, this is altogether too common, babies leaving hospital only pretending to breastfeed.

  The problem is not that babies are not being weighed frequently enough in the first few days after birth, but rather that hospital staff, in general, have not the training or the skills or the time, perhaps, to help mothers with breastfeeding and to know when a baby is not breastfeeding well. So mothers go home thinking the baby is breastfeeding when he is not. And the mothers are also not given the information about how to know the baby is getting milk, what to expect from urine output, bowel movements and so on. Instead, mothers are told to wake the baby up every three hours in order to feed the baby. But a baby who feeds well, will wake up when he is hungry. And if the baby feeds so poorly he is going to get dehydrated, there is no point in waking a baby up every 3 hours so he gets nothing 8 times a day instead of nothing 5 times a day, say.

  We are so fixated on numbers and weighing that we do not really look at babies on the breast and make sure they are latched on and feeding well. Because, in fact, observation of the baby at the breast can tell you if the baby is getting milk or not. It's simple, yet paediatricians and family physicians rarely watch the baby at the breast, at least partly because they haven't a clue what to look for. A baby can be seen to be getting milk at the breast even on day one of life, if the observer knows what to look for. Babies are being readmitted to the hospital with severe dehydration because we don't know how to help mothers with breastfeeding. Sometimes these babies die. Sometimes they end up with severe neurological sequelae. Yet, very little effort is being made, it seems, to help doctors and nurses understand how breastfeeding works. Even the latest training too often emphasizes frequency of going to the breast, length of time on the breast, percentage weight loss as something worthwhile, when, in fact, this information is useless. Hospital staff nurses need to help mothers get a good latch (but they need to know how to achieve this), they need to observe the feeding and teach the mother how to know the baby is getting milk (but they need to know this first themselves, don't they?). If the mothers knew how to know the baby was getting milk, they would come back for help before it was too late. Ask the paediatricians.
  What is the normal stool pattern of the baby doing well on the breast?
  Most don't know.
  What are the worrisome signs?
  Most don't know.
  Is a baby who is passing only meconium on day 4 okay?
  Most don't know.

  If one depends on a scale in the physician's office and compares it to the hospital weight, one can go dangerously wrong. Either urging supplementation for a baby who doesn't need it, or reassuring oneself and the mother that all is well, when it isn't. The ignorance of how breastfeeding works, and the lack of support in North America and Western Europe (with few exceptions), boggles the mind. Undoubtedly, this article will be picked up by the press, and yet another series of television programmes, radio talk shows will start discussing hypernatremic dehydration and thousands more women will be frightened out of breastfeeding their babies. A real shame.

  Jack Newman, MD, FRCPC
  Breastfeeding Clinic
  St. Michael's Hospital
  Toronto, Ontario

  Reference

  (1) Laing IA, Wong CM, Hypernatremic dehydration the first few days: is the incidence rising? Arch Dis Child Fetal Neonatol Ed 2002;87:F158-F162.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Hypernatraemia in the first few days: is the incidence rising?

  • Graham C Smith, Consultant Paediatric Nephrologist

  Dear Editor

  As Laing and Wong [1] correctly state, there is increasing recognition of the occurrence of hypernatraemic dehydration in breast fed babies. However there continues to be confusion regarding the best way to manage this life-threatening problem. The disagreement centres on whether the deficit of free water should be replaced with an isotonic solution (0.9% saline) or a hypotonic one.

  Hype...

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  Dear Editor

  As Laing and Wong [1] correctly state, there is increasing recognition of the occurrence of hypernatraemic dehydration in breast fed babies. However there continues to be confusion regarding the best way to manage this life-threatening problem. The disagreement centres on whether the deficit of free water should be replaced with an isotonic solution (0.9% saline) or a hypotonic one.

  Hypernatraemia results from the ingestion of sodium in excess of water or the loss of water in excess of sodium. The latter is seen in diabetes insipidus. However in breast fed babies presenting with this problem, the evidence suggests that they may have received an excess of sodium while at the same time being deficient in water. Sodium concentrations of up to 104 mmol/l have been recorded in the breast milk of mothers of babies presenting with hypernatraemic dehydration [2] and this is thought to be the result of an arrest in the normal maturational decline in the sodium content of breast milk from the 65 + 4 mmol/l of early colostrum, to 7 + 2 mmol/l in mature milk [3,4]. As a result, these babies do not need more sodium but require replacement of free water.

  Laing and Wong correctly state that initial resuscitation of the child, to re-establish an adequate circulatory volume, should be with an isotonic solution, either colloid or 0.9% saline. Some authors [5] would advise that if the serum sodium concentration is known to be >175 mmol/l, extra sodium should be added to the fluids to bring the sodium concentration to within 0-10 mmol/l of the serum sodium. The aim is to fill the intravascular compartment without reducing the osmolality, thereby avoiding cell oedema, particularly within the brain.

  However the authors then advocate the continued use of 0.9% saline to rehydrate the child.[1] The continued administration of large amounts of sodium will contribute to the problem of excess total body sodium, which will already have been increased by the sodium content of the initial resuscitation fluids. The need is for slow replacement of free water and this is best accomplished by rehydration with hypotonic solutions such as 0.18% NaCl + 4.5% dextrose. The aim is to reduce the serum sodium by 0.5 – 1 mmol/l/hr and this is guided through regular monitoring of serum electrolytes. Two papers have described such management protocols.[5,6] The idea that rehydration fluids must contain high sodium concentrations needs to be finally laid to rest.

  References

  (1) Laing IA, Wong CM. Hypernatraemia in the first few days: is the incidence rising? Arch Dis Child 2002;87: F158-F162.

  (2) van Amerongen RH, Moretta AC, Gaeta TJ. Severe hypernatremic dehydration and death in a breast-fed infant. Ped Emerg Care 2001;17: 175 -180.

  (3) Koo WWK, Gupta JM. Breast milk sodium. Arch Dis Child 1982;57: 500-502.

  (4) Aperia A, Broberger D, Herm P, Zetterstrom R. Salt content in human breast milk during the first three weeks after delivery. Acta Paediatr Scand 1979; 68: 441-442.

  (5) Molteni KH. Initial management of hypernatraemic dehydration in the breastfed infant. Clin Pediatr 1994; December: 731-740.

  (6) Jacobsen J, Bohn D. Severe hypernatraemic dehydration and hyperkalaemia in an infant with gastroenteritis secondary to rotavirus. Ann Emerg Med 1993; 22: 1630-1632.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Hypernatraemia in breastfed infants

  • Sam J Oddie, Higher Specialist Trainee in Neonatology

  Dear Editor

  I congratulate Laing and Wong for a thorough review of the literature on hypernatraemic dehydration in breastfed infant.[1] Their appreciation of the importance of supporting breastfeeding as a way of avoiding this very uncommon problem is most welcome. I entirely agree that simply to promote breastfeeding is not enough, practical support must be made available to women to ensure that problems with in...

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  Dear Editor

  I congratulate Laing and Wong for a thorough review of the literature on hypernatraemic dehydration in breastfed infant.[1] Their appreciation of the importance of supporting breastfeeding as a way of avoiding this very uncommon problem is most welcome. I entirely agree that simply to promote breastfeeding is not enough, practical support must be made available to women to ensure that problems with initiating and maintaining lactation are dealt with.

  However I am concerned that the title of this piece, the use of the word "epidemic" and the way it was introduced in the Fantoms piece lend weight to the idea that the incidence of this problem is increasing. I know of no reliable data supporting this idea, and for this reason alone would be cautious about an "intensive education programme" directed at parents. Clearly as the profile of this form of hypernatraemic dehydration is raised, it will be more frequently diagnosed .[2]

  The article appears to suggest that shortening postpartum hospital stays may be responsible for this problem. The most frequently quoted United Kingdom work to support this idea was published in 1967,[3] and there is little evidence to shown that there is a causal association in the United Kingdom where organised postpartum visiting has so long been routine.

  I am not at all convinced that weighing does actually cause parental anxiety, and I have been struck by how little evidence exists to support this idea.[4] Indeed I strongly support the authors assertion that all infants should be weighed in the early postpartum period.[5]

  However remarkably little evidence exists to suggest how such weights should be interpreted. Most readers of Archives will be aware that standard UK growth charts are not helpful in interpreting normal neonatal weight changes, but some may not know quite how few published data support the idea that normal weight loss is less than 10%.[4] For example the paper quoted by Laing and Wong suggests that 2.5% of breastfed infants babies will lose more than 12% of their birthweight.[6] However this study was based on only 100 infants and importantly gives little information as to the timing of the weight nadir.

  Larger good quality studies defining the normal range of neonatal weight change and particularly the timing of the weight nadir may be in progress. However until such work is published it may not be prudent to measure the serum sodium on up to 5% of breastfed infants with weight loss that may actually be "normal" and no other clinical findings, outside ethically approved research studies. Rather it may be important to concentrate on providing experienced breastfeeding support (usually not medical) to mother infant dyads where there is unusual weight loss. Clearly review and repeated weighing may be wise.

  Particularly as six of their cases occurred in hospital, Laing and Wong may be interested to look at the convincing evidence that where breastfeeding is well supported in hospital, weight loss is less marked and of shorter duration.[7,8] This literature has clear implications for those planning a protocol for management of extreme newborn weight loss.

  References

  (1) Laing IA, Wong CA. Hypernatraemia in the first few days: is the incidence increasing. Arch Dis Child 2002;87:F158-F162.

  (2) Manganaro R, Mami C, Marrone T, et al. Incidence of dehydration and hypernatremia in exclusively breast-fed infants. J Pediatr 2001;139:673–5.

  (3) Arthurton MW, Bamford FN. Paediatric aspects of early discharge of maternity patients. BMJ 1967;3:517-520.

  (4) Sachs M, Oddie S. MIDIRS Midwifery digest 2002;12:296-300.

  (5) Oddie S, Richmond S, Coulthard M. Hypernatraemic dehydration and breast feeding: a population study. Arch Dis Child 2001;85:318–20.

  (6) Maisels MJ, Gifford K. Breast feeding, weight loss, and jaundice. J Pediatr 1983;102:117–18.

  (7) Mikiel-Kostyra K, Mazur J. Hospital policies and their influence on newborn body weight. Acta Paediatr 1999;88(1):72-5.

  (8)Avoa A, Fischer PR. The influence of perinatal instruction about breast- feeding on neonatal weight loss. Pediatrics1990;86(2):313-5

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Hypernatraemia in the first few days: a tragic case.

  • Peter D Macdonald, Consultant Neonatal Paediatrician
  • Other Contributors:
    • Louise Grant, Peter D Macdonald, Samantha RM Ross

  Dear Editor

  Laing and Wong [1] highlight the fact that hypernatraemic dehydration can be difficult to recognise and may have serious consequences. We describe an extreme case.

  An 8-day-old infant was admitted to hospital with a small haematemesis. She had lost 19% of her birth weight and her plasma sodium was 173 mmol/l. She had renal and hepatic impairment and was found to have a thrombosis of th...

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  Dear Editor

  Laing and Wong [1] highlight the fact that hypernatraemic dehydration can be difficult to recognise and may have serious consequences. We describe an extreme case.

  An 8-day-old infant was admitted to hospital with a small haematemesis. She had lost 19% of her birth weight and her plasma sodium was 173 mmol/l. She had renal and hepatic impairment and was found to have a thrombosis of the descending aorta. In spite of rehydration, thrombolysis and full intensive care support, she died the following day from progressive sub-diaphragmatic ischaemia and multi-organ failure. A post mortem revealed no underlying abnormalities. Parental thrombophilia screens were normal.

  The maternity notes revealed that she was born at term weighing 3.18kg after an uneventful pregnancy. She was breastfed from birth. On day 3 she had 5 wet nappies and appeared to be feeding well. She was allowed home, with a discharge weight of 2.77kg, and visited several times by the community midwives. On each occasion she seemed contented and was thought to be feeding well.

  We agree with Laing and Wong that health professionals may fail to realise how dehydrated some infants have become until they are dangerously unwell. Our infant had lost 12.8% of her birth weight at initial discharge. The severity of this weight loss was not recognised and no further attention was paid to the weight as the baby was considered to be feeding well. To target at risk infants, we consider that clinical skills need to be supplemented with a clear policy of regular weight monitoring with defined thresholds for intervention.

  Reference

  (1) Laing IA, Wong CM. Hypernatraemia in the first few days: is the incidence rising? Arch Dis Child 2002; 87(3): F158-F162.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Weighing of breast fed babies is important

  • Egware Benjamin Odeka, Doctor
  • Other Contributors:
    • Anjali Date

  Dear Editor, We read with interest the article by Laing and Wong [1] which highlights the risk of Hyernatraemic dehydration in breast fed babies.

  Undoubtedly, hypernatraemic dehydration is a potentially devastating condition associated with risk of cerebral edema, gangrene, hydrocephalus, intracranial haemorrhage and death.[2] Recently, there has been an increase in the number of cases that are reported [3] and b...

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  Dear Editor, We read with interest the article by Laing and Wong [1] which highlights the risk of Hyernatraemic dehydration in breast fed babies.

  Undoubtedly, hypernatraemic dehydration is a potentially devastating condition associated with risk of cerebral edema, gangrene, hydrocephalus, intracranial haemorrhage and death.[2] Recently, there has been an increase in the number of cases that are reported [3] and breast-feeding ‘malnutrition’ has been identified as a key factor in its pathophysiology.[4] At our hospital, we admitted and treated 5 cases of hypernatraemic dehydration in 18 months. All babies were born at term, and breast fed. Four [4] of them had been discharged from hospital and later referred by midwives to hospital because of weight loss, poor feeding and lethargy at 6-7 days of age. One baby on postnatal ward was diagnosed early on day-4 because of poor feeding. All babies were dehydrated and jaundiced on admission. Clinical details are summarized in Table1. Two babies were managed with top up feeds of expressed breast milk and four babies needed intravenous fluids. All babies made uneventful recovery after slow rehydration.

  In breast fed babies dehydration and poor weight gain are frequent problems.[5] These can be identified early by regular weighing of breast fed babies after discharge. This will aid in early detection of inadequate intake and help in the prevention of hypernatraemic dehydration. There is no doubt that breast milk is best for babies and while promoting its advantages, the potential dangers of hypernatremia should not be overlooked. Mothers should be taught how to spot the signs of successful breast-feeding and the warning signs of dehydration [Table 2a and 2b]. The importance of monitoring baby’s weight should be addressed at mothers and health care professionals.

  In our hospital breast feeding advisors are now actively involved from antenatal clinic through to discharge with improved liaison with community nurses. A breast-feeding checklist card is given to mothers at the time of hospital discharge to assist them. All breast-fed babies are weighed after discharge on day 7. If weight loss is between 10-15%, baby is referred to the General practitioner or the Infant feeding advisor who establishes an individualised plan of care including re-weighing. If weight loss is more than 15%, baby is referred to hospital for review by a paediatrician.

  The place of breastfeeding advisors is essential and funding for this position should be sort as part of quality provision to children’s services. The problem of inadequate staffing will make universal provision for all hospitals a challenge that needs to be upheld.

  Table 1Clinical details of babies presenting with hypernatraemic dehydration

  Case	Gestational age [weeks]	Birth Weight [kg]	Age of Presentation [days]	Weight loss[%]	Plasma sodium on admission	Plasma urea on admission
  1	42	3.75	6	12	150	15
  2	40	4.25	7	13	158	13.2
  3	38	4.08	7	29	154	11
  4	40	3.25	6	25	161	15.9
  5	40	3.34	4	12	156	16.3

   

  Table 2a Indicators of successful breast feeding [first 2 –3 weeks]

  Wet nappies at least 4-5 times a day

  2-3 bowel movements/24 hours [stools-brownish seedy or mustard yellow]

  Baby content after most feeds

  Baby drinks only breast milk

  Baby breast feeds at least 7-8 times in 24 hours

  Mums get the feeling of emptied breasts after feeds

   

  Table 2b Warning signs of dehydration

  Reduced wet nappies than usual

  Infrequent passage of stool

  Symptoms-Jaundice, Lethargy, fever, irritability

  Weight loss >10% of birth weight in first 2 weeks of life

  References

  (1) Laing IA, Wong CM. Hypernatraemia in the first few days:is the incidence rising? Arch Disc Child Fetal Neonatal Ed 2002;87:158-161.

  (2) Kaplan JA,Siegler RW,Schmunk GA.Fatal hypernatraemic dehydration in exclusively breast-fed infants due to maternal lactation failure. Am J Forensic Med and Patholology 1998;19-22.

  (3) Cooper WO, Atherton HD,Kahana M,Kotagal UR.Increased incidence of severe breastfeeding malnutrition and hypernatraemia in a metropolitan area. Pediatrics 1995;96:957-60.

  (4) Livingstone VH, Willis CE, Abdel-Wareth LO, et al. Neonatal hypernatraemic dehydration associated with breast-feeding malnutrition;a retrospective survey. Can Med Assoc J 2000;162:647-52.

  (5) Manganaro R,Mami C,Maarrone T et al.Incidence of dehydration and hypernatremia in exclusively breast-fed infants. J Pediatr 2001;139:673-5.

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  Conflict of Interest:
  None declared.

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