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Laing and Wong1 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 subdiaphragmatic ischaemia and multiorgan failure. A postmortem revealed no underlying abnormalities. Parental thrombophilia screens were normal.
The maternity notes revealed that she was born at term weighing 3.18 kg after an uneventful pregnancy. She was breastfed from birth. On day 3 she had five wet nappies and appeared to be feeding well. She was allowed home, with a discharge weight of 2.77 kg, 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.
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