|Home | About | Journals | Submit | Contact Us | Français|
A female infant presented with severe hypernatremic dehydration and failure to thrive two weeks after birth. The diagnosis and management of the infant are described, highlighting the need for follow-up and support after early discharge of newborns.
Une fillette de deux semaines se présente à l’hôpital atteinte de déshydratation hypernatrémique et de retard staturopondéral. Cet article décrit le diagnostic et le traitement du nourrisson et souligne le besoin d’un suivi et d’un soutien après le congé précoce des nouveau-nés.
This report describes an infant with severe hypernatremic dehydration, failure to thrive and Escherichia coli sepsis, who presented to a community hospital in Chatham, Ontario, at two weeks of age.
A female baby was born at 38 weeks’ gestation, birth weight 2.625 kg to a gravida 2 para 2 married 34-year-old mother. The pregnancy was described as ‘uneventful’, and the mother was group B streptococcus negative. The birth was by spontaneous vaginal delivery and was “uncomplicated”. Apparently nursing was initiated “with some difficulty” and required “considerable assistance” from the lactation nurse consultant. Despite problems with nursing, the baby and mother were discharged after two days in hospital. The discharge weight was 2.355 kg – a weight loss of 0.270 kg from birth. The mother was given strict instructions to nurse at least every 3 h, and an early post discharge follow-up appointment was made for seven days after discharge. However, no homecare nurse follow-up was arranged.
Approximately two to three days after discharge, the baby developed a purulent eye discharge and was taken into the family physician on about day seven. Antibiotic eye drops were prescribed, and the mother was told to make an appointment if the situation worsened or did not improve. The baby began sneezing and coughing, had an increasing reluctance to nurse and became quite irritable.
The mother had reported that the baby was “not urinating well from the beginning”, but despite this, weight was actually 2.55 kg on day seven, a gain of 0.195 kg post-discharge.
On day 14 of life, the baby was brought in for a routine follow-up at the request of the family physician. The baby weighed 1.845 kg at that time and appeared “moribund” according to the family physician. The baby was immediately transferred to the local community hospital paediatric ward where the author was asked to see the baby in consultation.
The baby appeared markedly wasted (Figure 1) with clinical evidence of severe dehydration. She was lethargic, with moaning respirations that were shallow; breath rate was 48 breaths/min. Heart rate was 180 to 200 beats/min, and she responded to stimulation with a weak moan. Blood pressure was attempted but could not be obtained. Oxygen saturation monitoring was attempted but, with poor perfusion (capillary refill approximately 4 s), was difficult to achieve. Supplementary oxygen was, therefore, prophylactically administered, and the baby placed under a radiant warmer. The baby’s colour was sallow, the anterior fontanelle was small but sunken, and there was marked tenting of the skin with a wrinkled appearance and paucity of subcutaneous fat.
The abdomen was scaphoid. The baby’s eyelids were stuck together with exudate (a culture was done), but there was no apparent nasal discharge. Neurologically, she was extremely lethargic, with a weak cry and marked hypotonia. Rectal temperature at that time was 36°C.
An intravenous line was started shortly thereafter, and, at the same time, blood was drawn for culture, electrolytes, urea (blood urea nitrogen), creatinine, bilirubin, liver function tests, random glucose, complete blood count and calcium. The results of the tests were returned within 10 to 15 mins (tests were confirmed in the laboratory where they were repeated) (Table 1).
Before obtaining the blood results, an intravenous dosage of cefotaxime 115 mg was administered along with ampicillin 115 mg. A minibolus of 10 mL/kg of normal saline was administered over about 10 to 15 mins simultaneously with the initiation of 5% dextrose solution with 0.45% saline at just above maintenance. Potassium chloride 20 MEq/L was added after the first void. A second minibolus of normal saline was administered once the initial blood results were obtained, and the miniboluses were repeated until hemodynamic stability was achieved.
Measurement of electrolytes was repeated along with measurement of arterial blood gas at approximately 3 h after the first result. It should be noted that measurement of arterial blood gas had been unsuccessfully attempted with the initial bloodwork. The results of the repeat bloodwork are shown in Table 1.
Once hemodynamically stable, the baby was transferred to a tertiary institution for further management, given concerns about the potential complications and management challenges that were anticipated with this infant.
At approximately 18 h after transfer the blood culture came back positive for E coli. Urine was latex agglutination negative and culture negative. A spinal tap was perfomed at the tertiary institution and was negative (clear). An eye swab grew large quantities of Haemophilus influenzae biotype III, beta-lactamase positive.
At the tertiary hospital, the baby was rehydrated over appropriately 48 to 72 h, and the hypernatremia slowly corrected over several days. At discharge sodium was 144 mmol/L, chloride 110 mmol/L, potassium 4.5 mmol/L, urea 1.5 mmol/L and creatinine 25 mmol/L. She received a 10-day course of ampicillin and cefotaxime for the Gram-negative sepsis. She was discharged home from the tertiary hospital on formula.
Follow-up: The baby was followed very closely by the author and a developmental team at the local rehabilitation centre over the subsequent two-and-a-half years. There were no concerns whatsoever with regards to her development because she seemed to be age appropriate in many developmental areas and actually advanced in some of her developmental domains.
This case was reported for several reasons. First, it demonstrates the need to keep an open mind in paediatrics when dealing with a sick neonate and cover all bases. For example, in this particular case, the symptoms may have easily been attributed entirely to the hypernatremic dehydration, and one may have omitted looking for other causes. This would have resulted in missing a very serious underlying cause of the hypernatremic dehydration and failure to thrive in this infant, which may have been fatal.
This baby was probably also at risk of breastfeeding failure from the beginning because of the following factors: low birth weight, early breastfeeding difficulties (1–4), an apparently not fully informed mother at time of discharge, no homecare or lactation consultant follow-up arranged (5), and early hospital discharge (5,6).
Clearly, one should learn from this particular experience that for early discharge to be without significant risk, all potential risk factors must be identified and appropriate mechanisms should be in place to deal with them should they arise. This case had a ‘happy ending’ but had the routine follow-up appointment not been scheduled when it was, the outcome may have been entirely different.