|Year : 2014 | Volume
| Issue : 3 | Page : 153-157
Complications due to breastfeeding associated hypernatremic dehydration
Asif Ahmed, Javeed Iqbal, Ikhlas Ahmad, Bashir A Charoo, Qazi Iqbal Ahmad, Sheikh Mushtaq Ahmad
Department of Pediatrics and Neonatology, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||8-Sep-2014|
Dr. Asif Ahmed
Department of Pediatrics and Neonatology, SKIMS, Soura, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Objective: The aim was to assess the incidence, presenting features, and complications of breastfeeding associated hypernatremic dehydration among hospitalized neonates. Materials and Methods: A retrospective study over a period of 18 months to identify term and near term (≥35 weeks of gestation) breastfed neonates, who were admitted with serum sodium concentration of ≥150 mEq/l and no apparent explanation for their hypernatremia other than inadequate breastmilk intake. Results: The incidence of breastfeeding associated hypernatremic dehydration among 2100 term and near term neonates was 1.38%. The median serum sodium at presentation was 164 mEq/l (range: 151-191 mEq/l). The mean weight loss in these patients was 10.16% ±6.6%. The reasons for seeking medical attention were refusal of feeds (72.41%), lethargy (68.96%), decreased urine output (44.82%), jaundice (27.58%) and fever (24.13%). Five patients (17.24%) had seizures and three (10.34%) had coagulopathy. Other complications included hypoglycemia, hypocalcemia, acute kidney injury (AKI) (37.93%) and intraventricular hemorrhage. The mean serum creatinine was 1.82 ± 2.5 mg/dl (range: 0.19-9.6). A statistically significant association was seen between serum sodium concentration at presentation and AKI. It was also found that those patients who had AKI had a higher weight loss and had presented later to the hospital than those without AKI. One patient died within 12 h of admission. This child had disseminated intravascular coagulopathy, AKI, and hypoglycemia. Conclusions: Breastfeeding associated hypernatremic dehydration is a serious condition with many serious complications and even results in death if detected late. Health care providers have increasing responsibilities of promoting proper breastfeeding techniques and taking measures for early diagnosis and treatment of this problem.
Keywords: Breastfeeding, hypernatremia, neonates
|How to cite this article:|
Ahmed A, Iqbal J, Ahmad I, Charoo BA, Ahmad QI, Ahmad SM. Complications due to breastfeeding associated hypernatremic dehydration. J Clin Neonatol 2014;3:153-7
|How to cite this URL:|
Ahmed A, Iqbal J, Ahmad I, Charoo BA, Ahmad QI, Ahmad SM. Complications due to breastfeeding associated hypernatremic dehydration. J Clin Neonatol [serial online] 2014 [cited 2021 Aug 2];3:153-7. Available from: https://www.jcnonweb.com/text.asp?2014/3/3/153/140402
| Introduction|| |
Sodium is the dominant cation of extracellular fluid. It is the principal determinant of extracellular osmolality. Sodium is unique among electrolytes because water balance, not sodium balance, usually determines its concentration. 
Hypernatremia is a serum sodium concentration of >145 mEq/l, although it is sometimes defined as >150 mEq/l.  Mild hypernatremia is fairly common in children, especially among infants with gastroenteritis.
Hypernatremic dehydration in neonates is infrequent. Neonatal hypernatremic dehydration results from inadequate transfer of breast milk from mother to the neonate. It is the most dangerous form of dehydration due to the complications of dehydration as well as of its treatment. Breastfed infants with hypernatremia are often profoundly dehydrated, with failure to thrive. Probably because of intracellular water loss, the pinched abdominal skin of a dehydrated, hypernatremic infant has a "doughy" feel.
Hypernatremia can cause serious neurologic damage, including seizures, intracranial hemorrhages,  vascular thrombosis,  and death.  Hypernatremic dehydration in neonates occurs due to inadequate breastfeeding in an exclusively breast fed infant.  Normally the sodium concentration of breastmilk falls over first 15 days of lactation.  It has been seen that sodium concentration of colostrum in first 5 days is 22 ± 12 mmol/l, and of transitional milk from day 5 to 10 is 13 ± 3 mmol/l, and of mature milk after 15 days is 7 ± 2 mmol/l.  Failure to establish proper breastfeeding results in failure of this physiological fall in sodium concentration in breastmilk.  This further aggravates the problem of hypernatremia in inadequately breastfed newborns. Hypernatremic dehydration is a rare complication of breastfeeding,  but if it is not recognized in time, the consequences can be deadly for the patient, ranging from seizures to intracranial thrombosis to death.
| Materials and Methods|| |
This study was conducted in the neonatology unit of a tertiary care hospital. This study was conducted retrospectively, to identify otherwise healthy term and near term (gestational age ≥35 weeks) neonates admitted during previous 1 year period with a discharge diagnosis of hypernatremic dehydration and a serum sodium concentration ≥150 mEq/l. A total of 2100 term and near term infants <29 days of age were admitted in the neonatology unit from February 2012 to July 2013. The in-patient records of neonates with hypernatremia were reviewed. Patients, in whom a cause other than inadequate breastfeeding, such as an acute or chronic illness affecting feeding led to hypernatremic dehydration, were excluded from the study.
A total of 29 infants fulfilled the study criteria. All these neonates were exclusively breast fed. All these neonates were from singleton pregnancies. No formula fed neonates fulfilled the study criteria. Four neonates (13.79%) were near term (35-37 weeks gestation) and 25 were term babies. Data about various parameters such as age at presentation, birth weight, mode of delivery, birth order, weight at the time of presentation to hospital, maternal age, reason for seeking medical attention, was arranged in Microsoft Office Excel 2010 version (Microsoft Corporation USA). Values of various analytes like serum sodium, serum potassium, serum bicarbonate, pH, serum creatinine, serum glucose, serum calcium, serum bilirubin at admission was recorded. Acute kidney injury (AKI), usually defined as an acute deterioration in the ability of the kidneys to maintain the homeostasis of body fluids was identified by a progressive increase in the infant's serum creatinine above normal values for age and gestation. 
Results of sepsis screening in all cases were recorded, as were the complications occurring in various patients and their outcome.
Statistical analysis was performed using GraphPad Instat 3.1 statistical software (GraphPad Software, Inc. CA USA). Student's t-test, Fisher's test, and multiple regression analysis were performed for statistical analysis.
| Results|| |
From February 2012 to July 2013, a total of 2100 term and near term neonates were admitted in the neonatology unit. Of these, 29 (1.38%) had hypernatremic dehydration associated with breastfeeding [Table 1]. These patients had a serum sodium concentration more than 150 mEq/l and met the inclusion criteria for our study. Thirteen patients were males and 16 were females. The mean maternal age in these patients was 25.9 ± 4.5 years (n = 22), with a range of 20-36 years. Seventeen patients (58.62%) were born through cesarian section and 12 (41.37%) were born through a normal vaginal delivery. The mean gestational age of the cases was 37.9 ± 1.08 weeks (n = 29), with a range of 35-40 weeks and a median of 38 weeks. The mean age at presentation was 8.96 ± 6.4 days, with a range of 2-24 days and median age of 8 days. The mean weight at admission for these patients was 2.52 ± 0.41 kg, with range of 1.91-3.5 kg and median weight of 2.5 kg. The mean weight loss in these patients was 10.16 ± 6.6% with a range of 0-25% and a median of 10%. The median serum sodium in these patients was 164 mEq/l, with a range of 151-191 mEq/l.
The main reason for seeking medical attention in these neonates was refusal of feeds, which was seen in 72.41% of patients [Table 2]. Fifteen patients (51.72%) were visibly dehydrated at admission. All the cases were evaluated completely for sepsis. None of these patients was subsequently found to have a blood culture proven sepsis or meningitis. Other reasons for seeking medical attention were lethargy (68.96%), decreased urine output (44.82%), jaundice (27.58%) and fever (24.13%). One patient (3.44%) came to hospital convulsing. In all, five patients (17.24%) had seizures. Neuroimaging was done in three patients. One of these had brain edema and another had intraventricular hemorrhage (IVH), where as imaging was normal in the third patient.
|Table 2: Presenting signs of breastfeeding associated hypernatremic dehydration|
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This patient with brain edema was a male child, born to a 36-year-old mother with no significant antenatal history, at a gestational age of 38.3 weeks. He was admitted on day 11 of life with the complaints of lethargy and refusal of feeds. He was visibly dehydrated at admission. He had serum sodium of 188 mEq/l and a serum creatinine of 6 mg/dl at admission. He had a birth weight 2.65 kg and admission weight of 2.2 kg and had lost 17% of body weight.
The baby with IVH was a female child admitted on day 15 of life with the complaints of refusal of feeds, lethargy, and decreased urine output. She had serum sodium of 167 mEq/l and serum creatinine of 8.2 mg/dl. She also had hyperkalemia at admission (8.2 mEq/l) and convulsed during hospitalization.
One patient (3.44%) was received with disseminated intravascular coagulopathy (DIC) and expired within 12 h. A total of three patients (10.34%) had coagulopathy.
Out of eight patients presenting with jaundice, only three had clinically significant jaundice  (bilirubin >15 mg/dl). None of the patients with jaundice had hemolytic jaundice.
The values of various serum analytes were recorded [Table 3].
Many complications occurred in these patients and included hypoglycemia, coagulopathy, seizures, hyperkalemia, and AKI [Table 4].
Hypoglycemia (blood glucose < 50 mg/dl) occurred in seven patients (24.13%). Eleven patients (37.93%) had AKI and one patient (3.44%) had hypocalcemia (calcium <7 mg/dl).
When we compared serum sodium at presentation in the patients with AKI and in those without AKI, we found that the former group had a mean serum sodium of 176.3 ± 10.04 mEq/l, with a range of 164-191 mEq/l and a median sodium of 175 mEq/l; whereas the patients in the latter group had a mean serum sodium of 161.2 ± 8.3 mEq/l, with a range of 151-184 mEq/l and a median sodium of 159 mEq/l. The presence of a higher serum sodium at admission in patients with AKI was statistically significant (P = 0.0002).
When we compared weight loss in the patients with and without AKI, we found that the mean weight loss in the former group was 14.75 ± 4.6%, with a range of 8.1-25% and a median weight loss of 14.3%; while as in the latter group, the mean weight loss was 7.35 ± 6.2%, with a range of 0-20% and a median weight loss of 5.97%. The occurrence of a higher weight loss in patients having AKI was statistically significant (P = 0.002).
When we compared the age at presentation in the patients with and without AKI, we found that the mean age at admission in the former group was 14 ± 5.8 days, with a range of 5-24 and a median age of 14 days. In comparison, the patients in the latter group presented earlier, with a mean age of 5.9 ± 4.7 days, range of 2-20 and a median age of 3.5 days. The later age at presentation in patients with AKI was statistically significant (P = 0.0003).
When analyzing the effect of serum sodium concentration at admission, percentage dehydration and age at presentation of patients on serum creatinine by multiple regression analysis, it was found that percentage of dehydration had a significant independent correlation with AKI (P = 0.008).
None of the patients had complications like cerebral edema resulting from treatment.
| Discussion|| |
In this study, we saw 29 neonates, who developed hypernatremia attributable to inadequate breastfeeding. Affected infants were term babies, mostly born to primiparous mothers. Refusal to feed was the most common presenting complaint in these children. All the infants were evaluated for sepsis and none was found to have sepsis subsequently. Nonfatal complications were frequent in these children and included hypoglycemia, hypocalcemia, seizures, hyperkalemia, IVH, AKI, and hyperbilirubinemia. One patient (3.44%) came with bleeding from DIC and expired within 12 h.
Over a period of 1 year, we found incidence of hypernatremia in term and near term hospitalized babies to be 1.38%. This number seems to be smaller than the actual magnitude of the problem. A retrospective study by Moritz et al.  showed that the incidence of breastfeeding-associated hypernatremic dehydration among 3718 consecutive term and near-term hospitalized neonates was 1.9%, occurring for 70 infants. In their study, the most common presenting symptom was jaundice (81%). Sixty-three percent of infants underwent sepsis evaluations with lumbar puncture. No infants had bacteremia or meningitis. These infants had a mean weight loss of 13.7%. There were no deaths.
A prospective study by Manganaro et al.  the authors found that 7.7% of term, healthy neonates being exclusively breastfed had a weight loss >10% in the 1 st week of life. Thirty-six percent of those with weight loss exceeding 10% were hypernatremic, with a maximum sodium concentration of 160 mmol/L, which returned to normal with adequate hydration.
The incidence of breastfeeding associated hypernatremic dehydration has been on a rise as suggested by recent reports. ,,,
Breastfeeding undoubtedly improves the health of babies and has numerous advantages for the infant as well as the mother. There has been a constant effort worldwide by governments, pediatricians, obstetricians and bodies like WHO to promote breastfeeding practice. This has resulted in increasing breastfeeding practices and could very well explain the increasing incidence of hypernatremia in breast fed neonates.
Breastfeeding associated hypernatremia is a potentially dangerous condition which requires early diagnosis and prompt management. The presentation may be varied, as we saw in our study that these patients presented with lethargy, refusal to feed, decreased urine output, jaundice, seizures and DIC. The infant may not have features of dehydration on presentation due to having a better preserved extracellular volume and therefore less signs of dehydration.  Only 15 patients (51.72%) in our study were visibly dehydrated at admission.
One patient (3.44%) in our study expired within 12 h of admission. This was a female baby born at term gestation to a 26-year-old primigravida via caesarian section. She was brought to hospital on day 22 of life with complaints of lethargy, refusal to feed and decreased urinary output. She was visibly dehydrated at admission and was found to have hypernatremic dehydration (serum sodium 178 mg/dl), hypoglycemia (blood sugar 34 mg/dl), metabolic acidosis (Ph 7.21, Bicarbonate 11.6 mEq/l) and AKI (serum creatinine 1.94 mg/dl). She also had DIC at admission. The child was in shock and needed mechanical ventilation, but could not be saved. Had the problem been identified at an early age, the outcome could have been better. A total of three patients (10.34%) had DIC. van Amerongen et al.  saw DIC as the second most common complication in their study.
In our study, we saw that 44.82% of patients came with a history of decreased urine output and 37.93% patients had AKI. Decreased urine output can thus be an important clue in the history, which can lead to early identification of hypernatremic dehydration. Acute renal failure was the most common complication seen in 37.93% patients. Unal et al.  also saw AKI to be the most common complication in their study on breastfeedimg associated hypernatremic dehydration in neonates. The hypovolemic states of these neonates lead to acute renal failure.
In our study, seizures occurred in 17.24% of the patients. Unal et al.  saw seizures in 5.9% of patients. van Amerongen et al.  in their study have reported seizures among the most common complication in their study. Boskabadi et al.  saw results similar to our study, with seizures occurring in 22.6% of patients.
We found a statistically significant association between serum sodium concentration at presentation and AKI. As the dehydration progresses, serum sodium rises and patients have a higher chance of getting prerenal AKI.
We also found that those patients, who had AKI, had a statistically significant higher weight loss than those without AKI. This is again a direct consequence of more dehydration and resulting prerenal AKI in the group with more weight loss.
We found that the patients with AKI presented to hospital later than those without AKI. The only patient who died was also brought to hospital quite late on day 22 of life. It all the more emphasizes the need to recognize this condition early and intervene promptly.
| Conclusions|| |
Breastfeeding is such a fruitful and important intervention for both the mother and the baby. The occurrence of breastfeeding associated hypernatremic dehydration should not be allowed to bring disrepute to the practice of breastfeeding. Breastfeeding associated hypernatremic dehydration is a serious condition with many serious complications and even results in death if detected late. We lost one patient to complications of hypernatremic dehydration. The neonates with hypernatremic dehydration may not be visibly dehydrated. AKI is a common and serious complication which occurred in 11 patients in our study and so are seizures and DIC, which occurred in five and three patients respectively in our study. Two patients in our study had brain injury, which can have a lasting impact on their neurodevelopment.
This problem occurs due to lactational failure due to incorrect technique or some other problems like an inverted nipple. Breastfeeding is by itself a boon for the baby. Thus, this scenario increases our responsibility as health care providers to encourage not only breastfeeding, but proper method of breastfeeding and address any problems which may lead to lactational failure. Lactational counseling should be an essential part of antenatal care being provided to pregnant women, to prepare them to undertake this highly beneficial activity with proper technique and with pride and confidence. Efforts should be made for early diagnosis of this condition by measures like frequent weighting of the baby during first 2 weeks of life to look for excessive weight loss.
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[Table 1], [Table 2], [Table 3], [Table 4]