Dehydration and hypernatremia in breast-fed term healthy neonates
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《美国医学杂志》
Department of Pediatrics, St John's Medical College, Bangalore, India
Abstract
Objective : The aim of the study was to determine the incidence of significant weight loss, dehydration, hypernatremia and hyperbilirubinemia in exclusively breast-fed term healthy neonates and compare the incidence of these problems in the warm and cool months. Methods : During the study period 496 neonates were recruited. Results : 157 neonates (31.6%) had significant weight loss (> 10 % cumulative weight loss or per day weight loss > 5%). Clinical dehydration was present in 2.2% of neonates. Of these 157 neonates, 31.8% had hypernatremia and 28 % had hyperbilirubinemia. Conclusion : The incidence of the above mentioned problems were higher in the warm months but the difference was not statistically significant.
Keywords: Hypernatremia; Dehydration; Neonates
Exclusive breast feeding is the accepted method of feeding for all neonates. The institution where the authors are affiliated to has been declared as a baby-friendly hospital in 1994, and since then the institution has been adhering to the baby friendly hospital initiative (BFHI) policies. Recently, the authors have been noticing that some normal healthy newborns on exclusive breast feeds were found to be dehydrated especially in summer. The present study was undertaken to determine the incidence of dehydration and hypernatremia in exclusively breast fed babies. One of the causes of hypernatremia dehydration in neonates is due to inadequate breast feeding[1].
Materials and Methods
This was a prospective study conducted for a period of 6 months from April to September 2003. April, May and June were considered warm months for the study purpose. All term healthy neonates on exclusive breast feeds, who were with the mother were included in the present study. The mother neonate dyad were in the postnatal or private wards of the hospital while the study was being done. All study babies were followed up from birth to time of discharge (range 3-8 days).
Ethical approval was obtained from the institutional ethical committee and informed consent was taken from the mothers.
Measures taken to promote breast feeding in our center include the following practices: Counseling mothers regarding breast feeding during the antenatal visits by a trained lactation consultant; early initiation of feeding practised in the delivery room; daily rounds by pediatric residents, obstetric nurses and by lactation nurse in the postnatal wards to ensure and encourage mothers to practise exclusive breast feeding. These practices were carried out during the study period.
All the neonates who fulfilled the criteria were included in the present study. Daily weights were recorded using an electronic weighing machine with a sensitivity of 10gm. All the neonates were evaluated daily for adequacy of feeding, urine output, neonatal jaundice and clinical evidence of dehydration. Adequacy of feeding was checked by observing the method of feeding and questioning the mother regarding feeding. Urine output was not measured but the frequency of micturition was noted over each 24 hour period. Depresssed anterior fontanelle, dry mucous membrane and loss of skin turgor were used to diagnose presence of dehydration. Jaundice was assessed using Kramer's criteria. If the clinician felt that the jaundice was significant and the baby may require phototherapy (icterus level upto lower abdomen), the baby was labeled to have significant hyperbilirubinemia and bilirubin estimation was done. Any neonate with a weight loss > 10% and or a weight loss of > 5% in a 24 hour period was considered to have significant weight loss and electrolytes and serum osmolality were done in these neonates.
All neonates who had hypernatremia (Na > 150 meq), clinical dehydration and were not active or feeding well were shifted to the NICU and oral feeds or IV fluids were started and clinical and electrolyte monitoring was done till values returned to normal. In the neonates who were not sick but had abnormal values repeat investigations were done till values returned to normal. Data was entered into the computer and analysis was done using the EPI 6 statistical package. Chi square was used for statistical analysis.
Results
The total number of livebirths during the 6 month period was 832. Of these, 496 fulfilled the criteria. The remaining 336 were either preterm, sick, on IV fluids or did not have adequate data. 157 (31.6%) neonates had significant weight loss, of these 123 (24.7% ) had > 5 % weight loss and 34 (6.8%) had > 10% weight loss. Clinical evidence of dehydration was present in 11 (2.2%) neonates. Eight neonates with dehydration or hypernatremia needed intervention in the form of NICU care or IV fluids. All these neonates did well and parameters returned to normal Figure1. All the 157 neonates with significant weight loss underwent serum electrolyte estimation. Among these 157 neonates with significant weight loss 31.8% had hypernatremia, 15.5% had high serum osmolality and 28% had hyperbilirubinemia (bilirubin >. 0.15 mg%). The warm months were taken to be April-June with a mean max. room temperature of 33.0 + 2.2oC and the cool months were taken to be July-September with a mean maximum ambient temperature of 29.0 + 1.28 C. The incidence of significant weight loss, clinical dehydration, hypernatremia and hyperbilirubinemia were higher in the warm months but the difference was not significant table1. The incidence of hyperbilirubinemia in the group with significant weight loss was marginally higher, 28% against 25% in the neonates with no significant weight loss, but this difference was not statistically significant (P=0.48).
Discussion
Exclusive breast feeding is the accepted method of feeding all neonates. However, despite adequate measures to ensure proper lactation , problems can occur. Many centers have reported malnutrition, failure to thrive and hypernatremic dehydration in exclusively breast fed neonates.[2],[3],[4],[5],[6],[7] This has been attributed either to inadequate feeding or high sodium content in breast milk.
Hypernatremic dehydration has been reported in an exclusive breast fed neonate[2] and also authors have been observing dehydration and failure to gain weight in exclusively breast fed neonates. Not many studies have been done to determine the electrolyte imbalance, if any, in exclusively breast fed neonates. The present study shows that exclusively breast fed neonates can have problems in the initial few days of life. These problems include significant weight loss, dehydration, hypernatremia and hyperbilirubinemia. Weight loss of more than 10% has occurred in 6.8% of neonates and weight loss of less than 5% per day has occurred in 24.7% of neonates. This weight loss could be because of seasonal variation and also because of inadequate feeding which has occurred despite adequate measures to promote breast feeding. It was also noted that these problems were marginally higher in the warm months as compared to the cool months. Hypernatremia has occurred in 31.8% of the neonates who had significant weight loss. This again could be because of inadequate feeding in the first few days of life. The present study highlights the need to be vigilant about dehydration, hypernatremia and hyperbilirubinemia in exclusively breast fed neonates while emphasizing the need to promote exclusive breast feeding.
References
1. Adelman RD, Solhang M J Pathophysiology of Body Fluid and Fluid therapy - sodium. In Behrman RE, Kliegman RM, Jenson HB, eds. NELSON Text Book of Pediatrics, 16th edn. WB Saunders Company, 2000; 193-196.
2. Bhat SR, Lewis P, Dinakar C. Hypernatrenic dehydration in a neonate. Indian Pediatr 2001; 38: 1174-1177.
3. Bajpai A, Aggarwal R, Deorari AK, Paul, VK. Neonatal hypernatremia due to high breast milk sodium. Indian Pediatr 2002; 39: 193-196.
4. Cooper WO, Atherton HD, Kahana M, Kotagal UR. Increased incidence of severe breast feeding malnutrition and hypernatremia in a metropolitan area. Pediatr 1995; 96 : 957-960.
5. Chilton, LA. Prevention and management of hypernatremic dehydration in breast fed infants. WJM 1995;163: 74-76.
6. Davies DP. Is inadequate breast feeding an important cause of failure to thrive. Lancet 1979: 541-542.
7. Roddey OF, Martin ES, Swetenburg RZ. Critical weight loss and malnutrition in breastfed infants. Am J dis Child 1981;135 : 597-599.(Bhat Swarna Rekha, Lewis )
Abstract
Objective : The aim of the study was to determine the incidence of significant weight loss, dehydration, hypernatremia and hyperbilirubinemia in exclusively breast-fed term healthy neonates and compare the incidence of these problems in the warm and cool months. Methods : During the study period 496 neonates were recruited. Results : 157 neonates (31.6%) had significant weight loss (> 10 % cumulative weight loss or per day weight loss > 5%). Clinical dehydration was present in 2.2% of neonates. Of these 157 neonates, 31.8% had hypernatremia and 28 % had hyperbilirubinemia. Conclusion : The incidence of the above mentioned problems were higher in the warm months but the difference was not statistically significant.
Keywords: Hypernatremia; Dehydration; Neonates
Exclusive breast feeding is the accepted method of feeding for all neonates. The institution where the authors are affiliated to has been declared as a baby-friendly hospital in 1994, and since then the institution has been adhering to the baby friendly hospital initiative (BFHI) policies. Recently, the authors have been noticing that some normal healthy newborns on exclusive breast feeds were found to be dehydrated especially in summer. The present study was undertaken to determine the incidence of dehydration and hypernatremia in exclusively breast fed babies. One of the causes of hypernatremia dehydration in neonates is due to inadequate breast feeding[1].
Materials and Methods
This was a prospective study conducted for a period of 6 months from April to September 2003. April, May and June were considered warm months for the study purpose. All term healthy neonates on exclusive breast feeds, who were with the mother were included in the present study. The mother neonate dyad were in the postnatal or private wards of the hospital while the study was being done. All study babies were followed up from birth to time of discharge (range 3-8 days).
Ethical approval was obtained from the institutional ethical committee and informed consent was taken from the mothers.
Measures taken to promote breast feeding in our center include the following practices: Counseling mothers regarding breast feeding during the antenatal visits by a trained lactation consultant; early initiation of feeding practised in the delivery room; daily rounds by pediatric residents, obstetric nurses and by lactation nurse in the postnatal wards to ensure and encourage mothers to practise exclusive breast feeding. These practices were carried out during the study period.
All the neonates who fulfilled the criteria were included in the present study. Daily weights were recorded using an electronic weighing machine with a sensitivity of 10gm. All the neonates were evaluated daily for adequacy of feeding, urine output, neonatal jaundice and clinical evidence of dehydration. Adequacy of feeding was checked by observing the method of feeding and questioning the mother regarding feeding. Urine output was not measured but the frequency of micturition was noted over each 24 hour period. Depresssed anterior fontanelle, dry mucous membrane and loss of skin turgor were used to diagnose presence of dehydration. Jaundice was assessed using Kramer's criteria. If the clinician felt that the jaundice was significant and the baby may require phototherapy (icterus level upto lower abdomen), the baby was labeled to have significant hyperbilirubinemia and bilirubin estimation was done. Any neonate with a weight loss > 10% and or a weight loss of > 5% in a 24 hour period was considered to have significant weight loss and electrolytes and serum osmolality were done in these neonates.
All neonates who had hypernatremia (Na > 150 meq), clinical dehydration and were not active or feeding well were shifted to the NICU and oral feeds or IV fluids were started and clinical and electrolyte monitoring was done till values returned to normal. In the neonates who were not sick but had abnormal values repeat investigations were done till values returned to normal. Data was entered into the computer and analysis was done using the EPI 6 statistical package. Chi square was used for statistical analysis.
Results
The total number of livebirths during the 6 month period was 832. Of these, 496 fulfilled the criteria. The remaining 336 were either preterm, sick, on IV fluids or did not have adequate data. 157 (31.6%) neonates had significant weight loss, of these 123 (24.7% ) had > 5 % weight loss and 34 (6.8%) had > 10% weight loss. Clinical evidence of dehydration was present in 11 (2.2%) neonates. Eight neonates with dehydration or hypernatremia needed intervention in the form of NICU care or IV fluids. All these neonates did well and parameters returned to normal Figure1. All the 157 neonates with significant weight loss underwent serum electrolyte estimation. Among these 157 neonates with significant weight loss 31.8% had hypernatremia, 15.5% had high serum osmolality and 28% had hyperbilirubinemia (bilirubin >. 0.15 mg%). The warm months were taken to be April-June with a mean max. room temperature of 33.0 + 2.2oC and the cool months were taken to be July-September with a mean maximum ambient temperature of 29.0 + 1.28 C. The incidence of significant weight loss, clinical dehydration, hypernatremia and hyperbilirubinemia were higher in the warm months but the difference was not significant table1. The incidence of hyperbilirubinemia in the group with significant weight loss was marginally higher, 28% against 25% in the neonates with no significant weight loss, but this difference was not statistically significant (P=0.48).
Discussion
Exclusive breast feeding is the accepted method of feeding all neonates. However, despite adequate measures to ensure proper lactation , problems can occur. Many centers have reported malnutrition, failure to thrive and hypernatremic dehydration in exclusively breast fed neonates.[2],[3],[4],[5],[6],[7] This has been attributed either to inadequate feeding or high sodium content in breast milk.
Hypernatremic dehydration has been reported in an exclusive breast fed neonate[2] and also authors have been observing dehydration and failure to gain weight in exclusively breast fed neonates. Not many studies have been done to determine the electrolyte imbalance, if any, in exclusively breast fed neonates. The present study shows that exclusively breast fed neonates can have problems in the initial few days of life. These problems include significant weight loss, dehydration, hypernatremia and hyperbilirubinemia. Weight loss of more than 10% has occurred in 6.8% of neonates and weight loss of less than 5% per day has occurred in 24.7% of neonates. This weight loss could be because of seasonal variation and also because of inadequate feeding which has occurred despite adequate measures to promote breast feeding. It was also noted that these problems were marginally higher in the warm months as compared to the cool months. Hypernatremia has occurred in 31.8% of the neonates who had significant weight loss. This again could be because of inadequate feeding in the first few days of life. The present study highlights the need to be vigilant about dehydration, hypernatremia and hyperbilirubinemia in exclusively breast fed neonates while emphasizing the need to promote exclusive breast feeding.
References
1. Adelman RD, Solhang M J Pathophysiology of Body Fluid and Fluid therapy - sodium. In Behrman RE, Kliegman RM, Jenson HB, eds. NELSON Text Book of Pediatrics, 16th edn. WB Saunders Company, 2000; 193-196.
2. Bhat SR, Lewis P, Dinakar C. Hypernatrenic dehydration in a neonate. Indian Pediatr 2001; 38: 1174-1177.
3. Bajpai A, Aggarwal R, Deorari AK, Paul, VK. Neonatal hypernatremia due to high breast milk sodium. Indian Pediatr 2002; 39: 193-196.
4. Cooper WO, Atherton HD, Kahana M, Kotagal UR. Increased incidence of severe breast feeding malnutrition and hypernatremia in a metropolitan area. Pediatr 1995; 96 : 957-960.
5. Chilton, LA. Prevention and management of hypernatremic dehydration in breast fed infants. WJM 1995;163: 74-76.
6. Davies DP. Is inadequate breast feeding an important cause of failure to thrive. Lancet 1979: 541-542.
7. Roddey OF, Martin ES, Swetenburg RZ. Critical weight loss and malnutrition in breastfed infants. Am J dis Child 1981;135 : 597-599.(Bhat Swarna Rekha, Lewis )