Aust. Paediatr. J.
(1978),14: 283-285
A Followup Study of Hyperosmolar Dehydration KEITHA FARMER,1 and B. A. MacARTHUR2 Paediatric Infectious Diseases Department, Auckland Hospital
Farmer, Keitha, and MacArthur, 5. A. (1978). Aust. Paediatr. J., 14, 283-285. A followup study of hyperosmolar dehydration. A followup study of 17 infants with gastroenteritis and hyperosmolar dehydration, four of whom showed neurological abnormality during the acute phase of their illness, revealed one case to have mild psychomotor retardation at the age of four years. This infant, the only one who convulsed during the illness, had been rehydrated rapidly because serum sodium concentration was only 149 mmol/l despite a blood urea of 27.5 mmol/l. Stanford-Binet psychometric assessment at age four years showed a positive relationship with socio-economic status of the family, and a negative relationship with blood urea concentration at the time of initial illness.
In view of the diversity of recommendations for the concentration of sodium solutions and speed of rehydration in the management of hypernatraemic and hyperosmolar dehydration (Finberg, 1973; Bannister et al., 1975), a study was undertaken to determine whether our patients suffered the acute neurological complications (Rapoport, 1947) and long term sequelae that have been reported by MacCauley and Watson (1967) and Morris Jones et a/., (1967)in 1 1 % and 9% of their cases respectively. Material and Methods Seventeen infants with gastroenteritis and hyperosrnolar dehydration, admitted to the Paediatric Infectious Diseases Department of Auckland Hospital between June 3, 1973 and August 3, 1974 were studied. In all cases serum osrnolality was greater than 320 mmol/l as calculated from concentrations of blood urea, serum sodium and potassium. Rehydration was carried out with Yz isotonic saline (0.45%) and 2.5% dextrose over a period
1. Paediatrician, Auckland Hospital and National Women's Hospital, Auckland, New Zealand. 2. Senior Lecturer, Department of Education, University of Auckland, New Zealand. Received May 10. 1970.
of 48 hours or more in order to lower the serum osmolality one mmol or less per hour. In cases where capillary blood pH was estimated to be less than 7.1, 20 mf of molar bicarbonate were given with 500 ml of 1/5 isotonic saline (0.15%) and 4.3% dextrose aiming at a half isotonic solution of sodium (75 mmol/l). During the early phase of rehydration, evidence of irritability was noted and convulsions recorded. An electroencephalogram (EEG)was performed on those showing an altered state of consciousness such as irritability, convulsions, or abnormal neurological signs. All but three of the children were observed over a period from one month to two years by one of us (KF) at an outpatient clinic and, with one exception, were thought to be progressing normally. When the children reached the age of four to five years the parents were contacted by post and the children visited at home for physical examination and psychometric assessment. Eleven children were available for this study and form the basis of this report. Results The children in the initial group of T7 infants varied from six weeks to 13 months of age at the time of admission to hospital. Eleven were mate
284
AUSTRALIAN PAEDlATRlC JOURNAL
I l l I I I I + + + +
-0 C
m m
c
d
and six female. Duration of diarrhoea was from one to five days, and all were admitted in the winter months. Feeding before admission was by a dried milk formula in seven cases, breast milk and solid foods in one, and cow's milk and solid foods in the remainder. Serum sodium concentrations varied from 149-169 rnmol/l, blood urea concentration from 5 to 30.8 mmol/l, the total osmolality from 325-375 mmol/l and the serum pH 6.87-7.26. Recognized bacterial pathogens were isolated from three cases, one E. coli, one shigelia and one salmonella. Viral studies were not available. Two children showed unusual irritability during rehydration and another had an abnormal EEG. One child aged 13 months with an initial serum sodium of 149 mmol/l but blood urea of 27.3 mrnol/l who was inadvertently rehydrated over a period of 24 hours had a convulsion at the end of this period. Table I shows the history, biochemical data and psychometric test results for the 11 children who were contacted between the age of four and five years. The six children who were not studied at age 4-5 years had been thought to have normal development when last seen. Analysis of the results obtained from an administration of the Stanford-Binet Intelligence Scale did not produce evidence of a strong relationship between age at onset, duration, serum osmolality, Serum sodium, blood pH or blood urea and cognitive development as measured by this test. Of these the highest correlation proved to be the IQ and blood urea (e = 0.38). Three cases, 6, 10 and 11 (Table I) recorded an IQ below 80. The boy who convulsed, case 11, was noted to be 'slower than his siblings' by his parents. Although the siblings were not formally tested, having observed their behaviour, we agreed with this observation. Physical examination of the subject did not reveal any neurological abnormality except he was unable to stand on the right foot as distinct to the left for 10 seconds. Cases 6 and 10 (Table I), who also obtained an IQ of less than 80, had a high blood urea and a low blood pH. Case 2, whose blood urea was the highest (30.8 mmol/l) and was asymptomatic, only had diarrhoea for one day and was two months of age. The hyperosrnolality was corrected over 72 hours. Although factors relating mainly to biochemkal data and severity gave rise to only moderate and low correlations, there was a relationship between the outcome as measured by the Stanford-Binet and the socio-economic status of the subject's 0.01). father e = 0.84, p
(1978),14: 283-285
A Followup Study of Hyperosmolar Dehydration KEITHA FARMER,1 and B. A. MacARTHUR2 Paediatric Infectious Diseases Department, Auckland Hospital
Farmer, Keitha, and MacArthur, 5. A. (1978). Aust. Paediatr. J., 14, 283-285. A followup study of hyperosmolar dehydration. A followup study of 17 infants with gastroenteritis and hyperosmolar dehydration, four of whom showed neurological abnormality during the acute phase of their illness, revealed one case to have mild psychomotor retardation at the age of four years. This infant, the only one who convulsed during the illness, had been rehydrated rapidly because serum sodium concentration was only 149 mmol/l despite a blood urea of 27.5 mmol/l. Stanford-Binet psychometric assessment at age four years showed a positive relationship with socio-economic status of the family, and a negative relationship with blood urea concentration at the time of initial illness.
In view of the diversity of recommendations for the concentration of sodium solutions and speed of rehydration in the management of hypernatraemic and hyperosmolar dehydration (Finberg, 1973; Bannister et al., 1975), a study was undertaken to determine whether our patients suffered the acute neurological complications (Rapoport, 1947) and long term sequelae that have been reported by MacCauley and Watson (1967) and Morris Jones et a/., (1967)in 1 1 % and 9% of their cases respectively. Material and Methods Seventeen infants with gastroenteritis and hyperosrnolar dehydration, admitted to the Paediatric Infectious Diseases Department of Auckland Hospital between June 3, 1973 and August 3, 1974 were studied. In all cases serum osrnolality was greater than 320 mmol/l as calculated from concentrations of blood urea, serum sodium and potassium. Rehydration was carried out with Yz isotonic saline (0.45%) and 2.5% dextrose over a period
1. Paediatrician, Auckland Hospital and National Women's Hospital, Auckland, New Zealand. 2. Senior Lecturer, Department of Education, University of Auckland, New Zealand. Received May 10. 1970.
of 48 hours or more in order to lower the serum osmolality one mmol or less per hour. In cases where capillary blood pH was estimated to be less than 7.1, 20 mf of molar bicarbonate were given with 500 ml of 1/5 isotonic saline (0.15%) and 4.3% dextrose aiming at a half isotonic solution of sodium (75 mmol/l). During the early phase of rehydration, evidence of irritability was noted and convulsions recorded. An electroencephalogram (EEG)was performed on those showing an altered state of consciousness such as irritability, convulsions, or abnormal neurological signs. All but three of the children were observed over a period from one month to two years by one of us (KF) at an outpatient clinic and, with one exception, were thought to be progressing normally. When the children reached the age of four to five years the parents were contacted by post and the children visited at home for physical examination and psychometric assessment. Eleven children were available for this study and form the basis of this report. Results The children in the initial group of T7 infants varied from six weeks to 13 months of age at the time of admission to hospital. Eleven were mate
284
AUSTRALIAN PAEDlATRlC JOURNAL
I l l I I I I + + + +
-0 C
m m
c
d
and six female. Duration of diarrhoea was from one to five days, and all were admitted in the winter months. Feeding before admission was by a dried milk formula in seven cases, breast milk and solid foods in one, and cow's milk and solid foods in the remainder. Serum sodium concentrations varied from 149-169 rnmol/l, blood urea concentration from 5 to 30.8 mmol/l, the total osmolality from 325-375 mmol/l and the serum pH 6.87-7.26. Recognized bacterial pathogens were isolated from three cases, one E. coli, one shigelia and one salmonella. Viral studies were not available. Two children showed unusual irritability during rehydration and another had an abnormal EEG. One child aged 13 months with an initial serum sodium of 149 mmol/l but blood urea of 27.3 mrnol/l who was inadvertently rehydrated over a period of 24 hours had a convulsion at the end of this period. Table I shows the history, biochemical data and psychometric test results for the 11 children who were contacted between the age of four and five years. The six children who were not studied at age 4-5 years had been thought to have normal development when last seen. Analysis of the results obtained from an administration of the Stanford-Binet Intelligence Scale did not produce evidence of a strong relationship between age at onset, duration, serum osmolality, Serum sodium, blood pH or blood urea and cognitive development as measured by this test. Of these the highest correlation proved to be the IQ and blood urea (e = 0.38). Three cases, 6, 10 and 11 (Table I) recorded an IQ below 80. The boy who convulsed, case 11, was noted to be 'slower than his siblings' by his parents. Although the siblings were not formally tested, having observed their behaviour, we agreed with this observation. Physical examination of the subject did not reveal any neurological abnormality except he was unable to stand on the right foot as distinct to the left for 10 seconds. Cases 6 and 10 (Table I), who also obtained an IQ of less than 80, had a high blood urea and a low blood pH. Case 2, whose blood urea was the highest (30.8 mmol/l) and was asymptomatic, only had diarrhoea for one day and was two months of age. The hyperosrnolality was corrected over 72 hours. Although factors relating mainly to biochemkal data and severity gave rise to only moderate and low correlations, there was a relationship between the outcome as measured by the Stanford-Binet and the socio-economic status of the subject's 0.01). father e = 0.84, p
