To:
ADC Fetal and Neonatal Edition Letters and ADC Education and Practice Letters
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Electronic letters published:
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Hypernatraemic dehydration a rare but preventable occurrence with breast feeding
- Anne Marie Oudesluys-Murphy (24 October 2001)
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An ounce of prevention is worth a pound of cure
- Magda Sachs (26 October 2001)
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Re: An ounce of prevention is worth a pound of cure AND Hypernatraemic dehydration eLetter
- Sam Oddie (31 October 2001)
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How can we know that extra weighings will help?
- Heather Neil (31 October 2001)
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High sodium concentrations in breast milk in hypernatremic dehydration
- Fusun Kitapcy Uysal (5 November 2001)
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Hypernatraemic dehydration is not a negligible problem
- David Harding, Pamela Cairns (8 November 2001)
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Re: hypernatremic dehydration not hard to prevent
- Laurie Wheeler, MN IBCLC (8 November 2001)
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Anne Marie Oudesluys-Murphy, Paediatrician Medical Centre Rijnmond Zuid, Rotterdam, The Netherlands
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oudesluys{at}tip.nl Anne Marie Oudesluys-Murphy
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Dear Editor I read the paper “Hypernatraemic dehydration and breast feeding: a population study” by Oddie et al. [1] with great interest. Even though this paper may appear sombre in drawing attention to hypernatraemic dehydration as one of the few negative effects of breast feeding, I feel that the extremely low prevalence reported is an encouragement to those who attempt to promote breast feeding. This prevalence of 2.5 per 10,000 live births or 0.025% is practically negligible when we consider that the World Health Organisation estimates that over one million children die each year from diarrhoea, respiratory and other infections because they are not breastfed. This unnecessary mortality and morbidity occurs not only in developing countries but also in Western countries [2]. These cases of hypernatraemic dehydration are rare, but tragic in that they could probably be prevented if the mothers were adequately educated about breast feeding, especially as it is noted that these mothers were of higher than average educational attainment. The fact that so few as 35% of mothers breast fed at discharge from hospital suggests that there is probably very little encouragement, education and practical guidance given on breast feeding in the region of the study. Even though these mothers were probably highly motivated to breastfeed only 1 of the 8 continued at second discharge. This was also the only mother with a home delivery. It is clear that these figures represent only the top of the iceberg of insufficient education and guidance on breast feeding. The authors’ closing statement that “ensuring practical support for breastfeeding mothers both in hospital and at home should prevent this problem” may go some way, but a lot more work will need to be done before the number of breastfeeding mothers approaches the figures of countries such Norway where 98% of mothers begin breast feeding. It will only be when breastfeeding is seen as the normal way to feed a baby that mothers and carers will also be able to see when all is not as well as it should be with the breastfed baby. References |
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Magda Sachs, MPhil/PhD Student, Dept of MIdwifery Studies, University of Central Lancashire Breastfeeding Supporter, The Breastfeeding Network
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magda{at}sachsdavis.clara.net Magda Sachs
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Dear Editor Oddie et al [1] present cases of hypernatraemic dehydration in babies due to ‘unsuccessful breastfeeding’. They fail to highlight that these cases are likely to be "essentially an iatrogenic problem" [2], due to inadequate understanding of the normal physiological process of breastfeeding by health professionals and the mothers who relied on their care. These babies are described as being exclusively breastfed: it is likely that, although put to the breast, they never actually breastfed effectively, and this was not recognised by their mothers or by the staff. From the first breastfeed, women and babies deserve the skilled attendance of professionals who are trained to observe breastfeeding and can suggest any improvements or fine-tuning in technique [3], and who can give information about the normal physiological patterns of feed frequency, and patterns of ‘output’ (stools and urine) [4, 5]. A recent review of the evidence on how professional practice can support breastfeeding in the UK [6] emphasises the need for knowledge of the physiological processes of breastfeeding and skills for practical support of good breastfeeding technique. Midwives [7,8] and pediatricians all too often “have significant educational needs in the area of breastfeeding”[9]. Slight adjustments to how a baby is held, how the mother brings her to the breast and how the baby herself takes the breast can make an enormous difference to the effective transfer of milk [3,5,7]. To prevent cases of hypernatraemic dehydration, the authors suggest routine weighing. In the UK practice varies widely, but babies may weighed several times within the first 2 weeks. These weights, measured on different sets of scales, by different professionals from different professions, using differing protocols, may not provide clinically useful information. Additionally, weight charts in current use may not accurately reflect the weight gain pattern of exclusively breastfed babies [11,12]. Indeed Oddie et al point out that it is unclear how much weight loss can be considered physiologically normal. Relying on weighing is likely to lead to late diagnosis of difficulty, whereas skilled breastfeeding assessment should begin with the first feeds to allow early preventative interventions. Newman [2] presents a similar case, along with a ‘decision-making tree’ for identification and interventions. This describes early attention to breastfeeding technique and further measures such as supplementation at the breast. Newman reports that these measures can preserve, or re-establish, breastfeeding as well as reverse dehydration, to the ultimate health benefit of the baby. Only one of the eight babies Oddie et al identify was breastfeeding after treatment.[1] Further safeguards could be provided by creating facilities for specialist outpatient evaluation of breastfeeding [6]. Until such measures are in place, the cases identified in this paper and in the 20+ years of literature cited, will continue. Isn’t it time to invest in breastfeeding support skills so that the serious consequences of late identification of breastfeeding difficulties, hospital readmission, and early cessation of breastfeeding can be avoided? References |
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Sam Oddie, Specialist Registrar Neonatology Neonatal Unit, James Cook University Hospital, Middlesbrough
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s.j.oddie{at}ncl.ac.uk Sam Oddie
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Dear Editor, We thank Oudesluys-Murphy and Sachs, for their interest in our paper. We are grateful for their recognition that professionals' understanding of the normal physiology of breastfeeding is inadequate (although we would not agree that the causation of this problem is in keeping with the usual meaning of the word iatrogenesis). The poor professional knowledge and practice that allowed these cases to happen was one of the reasons for writing the paper. We agree that these cases indeed represent the tip of the iceberg and by extension feel that many other women and their babies may experience significant distress and perhaps harm due to the same knowledge deficit. It is for this reason that we do not feel that the incidence of 2.5 per 10 000 livebirths or perhaps 22.3 per 10 000 primiparous women breastfeeding at hospital discharge is "negligible" and can safely be ignored. Sachs appears to share the views of those we have met who feel that weighing may be intrinsically harmful. However it is our clinical experience that families welcome information about the progress of their infants, and we do not believe that a normal degree of weight loss in a well baby should be difficult to communicate nor difficult for families to comprehend. Weighing is variably practiced, but these infants had marked weight loss which was not noted. Sachs points out some of the problems associated with weighing, but fails to acknowledge that had the substantial (and by any standards abnormal) weight loss of these babies been noted earlier, safer treatment or even prevention of the problem with preservation of breastfeeding, might have been possible. While we agree that growth charts may be unsuitable for this purpose, we did not note any evidence of harm caused by the practice of weighing in her letter. We certainly agree that a full history and observation of breastfeeding by a skilled breastfeeding counsellor is the ideal assessment where there may be problems, but feel that weighing as part of an initial feeding appraisal may be useful as a means of ascertaining those needing a more detailed assessment. Such skilled assessments of feeding are likely to make such breastfeeding failures less frequent. Sam Oddie
Sam Richmond |
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Heather Neil, Volunteer Breastfeeding Counsellor; Writer and Health Journalist National Childbirth Trust, UK
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heathwel{at}blueyonder.co.uk Heather Neil
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Dear Editor, Oddie et al. [1] highlight the issue of dehydration in exclusively breastfed babies. However, they give no practical guidance for preventing it apart from more frequent weighing of infants in the first week of life, as suggested (they point out) by the American Academy of Pediatrics. While it is of course essential that dehydration is
avoided, together with the resulting distress from
hospital admission and treatment, and the loss of
breastfeeding, the paper does not provide evidence
that a strategy of extra weighings would contribute to
this. * is there evidence from the US that when AAP guidelines on weighing are followed, it results in a lower incidence of hypernatraemic dehydration in breastfed babies? * are there other babies in the cohort who lost 15 per cent or more of their weight, and yet did not become dehydrated? If so, then weight alone cannot be a useful diagnostic tool. * how much weight loss is normal, and up to what age? Oddie et al. say themselves that this is 'uncertain'. What are midwives looking for, if they weigh more frequently? If they don’t know, what will be gained by weighing? * how will the known difficulties [2] in getting an accurate weight be overcome? Data referenced in the paper recording weight loss in the first week of life was collected in the 1960s and early 1980s. This was a time before routine 'rooming in' and when breastfeeds were likely to be scheduled, timed and possibly supplemented with formula, glucose or water. It may be that the more physiological breastfeeding promoted today [3] - untimed, unscheduled, and ad lib - would return different data. In an otherwise healthy, term breastfed baby, dehydration is very likely to be the result of ineffective breastfeeding. There are many signs of this - soreness in the mother, miserable baby, very frequent, unsatisfying feeds, or (conversely) infrequent feeds, crying and fighting at the breast or (again conversely), sleeping at the breast with no suckling [4]. Oddie et al. mention stools and urine which deviate from the expected pattern. From my own experience as a volunteer counsellor, I can confirm that parents and professionals can sometimes overlook what seems to my eyes and ears to be a clear case of unhappy, ineffective breastfeeding, often improved dramatically by attention to breastfeeding technique. Educating health professionals and mothers in how to recognise ineffective and effective breastfeeding, from the very first hours and days of life, would seem to be worthwhile, rather than the unknown consequences of extra weighings - which recommendation, as Oddie et al. point out, meets with 'considerable resistance' among midwives.
Heather Neil
References (2) Alsop-Shields L and Alexander H. (1997) A study of errors that can occur when weighing infants. J Advan Nurs 25:587-594. (3) World Health Organisation (1998) Evidence for the ten steps to successful breastfeeding. WHO/CHD/98.9. (4) Renfrew M, Woolridge M and Ross-McGill H. (2000) Enabling women to breastfeed. London: The Stationery Office. |
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Fusun Kitapcy Uysal, Assistant Professor of Pediatrics, Neonatologist Fatih University Medical School
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Fusunuysal{at}hotmail.com Fusun Kitapcy Uysal
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Dear Editor, We read with interest the article by Oddie et al. titled ‘Hypernatraemic Dehydration and Breast Feeding: a population Study’ in your journal (Arch Dis Child 2001;85:318-320). We followed 16 breast-fed newborns with hypernatraemic dehydration in our NICU between 1994-1999. The mean age of the babies was 5.3 (3-16) days on admission and all but one were term. Gestational age of one baby was 34.5 weeks. Main complaints were fever in 7 cases, poor feeding in 5 cases and jaundice in 4 cases. Mean weight loss compared to birth weight was 13% (6.3- 30%) in the babies, above 15% in 6 of them. Serum sodium levels were 150-210 mEq/L and elevated BUN levels existed in 6 babies. One baby with sodium concentration of 187 mEq/L had convulsion and one died from sepsis with sodium level of 154 mEq/L. Although poor interaction between baby and breast was main problem in these babies, elevated breast milk sodium concentration was noted in two cases (12.5%). Our findings suggest that high sodium concentrations in the breast milk may be an important cause for hypernatremia in newborn infants and must be taken account in evaluation of these patients. Füsun Kitapçý UYSAL, MD |
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David Harding, Lecturer in Neonatology St Michaels Hospital, Bristol, Pamela Cairns
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David.Harding{at}bristol.ac.uk David Harding, et al.
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Dear Editor Oddie et al [1]suggest that neonatal hypernatraemic dehydration is uncommon, occuring with an incidence of "at least 2.5 per 10,000 live births". We recently described 5 infants re-admitted with hypernatraemic dehydration secondary to failure of lactation and its support [2]. During the six months of our study a pair of 36 week gestation twins were also readmitted with hypernatraemic dehydration secondary to failure of breast feeding, but were excluded because of prematurity. We estimate the incidence of documented hypernatraemic dehydration secondary to the failure of lactation is much higher in Bristol (1.7 per 1,000 live births) than that described by Oddie et al [1] in the Northern Region (2.5 per 10,000 live births). Although our estimate could also be an underestimate as our study looked only at infants readmitted within 10 days (Oddie et al looked at infants readmitted up to one month of age). In addition only 50% of infants readmitted with weight loss of >10% in Bristol during this time had a plasma sodium concentration measured. The true incidence of hypernatraemic dehydration secondary to lactation problems in Bristol could thus be as high 3.4 per 1000 live births! Furthermore, during 2000, of a total of 15 infants readmitted to Southmead Hospital Neonatal Intensive Care Unit from home, 5 babies (33%) were readmitted with hypernatraemic dehydration. We continue to see one infant a month with hypernatramic dehydration; these have included one infant who had seizures, one case which unmasked a metabolic disorder but presented with apnoea followed by respiratory arrest resulting in hypoxic brain damage and one infant with pre-renal failure which resolved. We agree with Oddie et al that hypernatraemic dehydration secondary to lacation failure is not a negligible problem and leads to preventable morbidity. Excessive neonatal weight loss may allow early identification and enable appropriate breast feeding support to be instituted. Due to midwifery shortages, postnatal wards are short staffed and many women are discharged within a few hours of delivering. The vast majority of mother/baby dyads establish breast feeding successfully. However it appears difficult to recognise when this is failing. None of the cases that we have seen have been recognised to have a feeding problem and therefore had no increased support or advice. We remain unconvinced that weighing neonates within the first week of life is harmful and may be beneficial. David Harding Pamela Cairns Department of Child Health References
(1) Hypernatraemic dehydration and breast feeding: a population study.
Oddie S, Richmond S, Coulthard M. Arch Dis Child. 2001;85:318-20.
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Laurie Wheeler, Lactation consultant / registered nurse Methodist Hospital New Orleans USA, MN IBCLC
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wheeler57{at}hotmail.com Laurie Wheeler, et al.
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Dear Editor This paper leads one to believe that breastfeeding somehow can cause hypernatremic dehydration and so requiring breastfed babies to be watched. This seems to miss the point that babies who become dehydrated and hypernatremic are really not breastfeeding, so breastfeeding needs to be watched. More to the point, these babies are not breastfeeding EFFECTIVELY. It is possible too that a mother may have insufficient milk for any number of reasons. So the problem does not lie with breastfeeding, but with lack of effective feeding. This could mean not breastfeeding often enough or not extracting milk well with each breastfeeding, however frequent. This needs to be assessed very early by a skilled breastfeeding observer/helper. And of course taught and shown to the parents who continue to assess breastfeeding's course over the next few days. Many healthcare providers are not skilled in assessing breastfeeding. Believe me, I have had many mothers of new babies tell me that they reported no stooling to their pediatrician, only to be told to give the baby a suppository. This will not nourish the baby! I would be willing to guess that on the day of birth or certainly by 3 or 4 days after birth with the babies studied, this ineffective breastfeeding was quite evident. In my opinion, the cardinal signs are low volume of urine and stool, no "milk stools" by 4th day, and jaundice. Lack of breast fullness in the mother after a few days is also a "red flag." It is imperative that corrective measures to optimize the breastfeeding, the milk supply, and the infant's intake be undertaken at this early stage. |
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