Stille ondervoeding aan de borst: hoe bestaat het? Rolf Pelleboer Kindergastro--enteroloog Kindergastro Catharina--ziekenhuis Eindhoven Catharina
(Hypernatraemic) dehydration and malnutrition in fully breastfed infants in the Netherlands Rolf Pelleboer, pediatric gastrogastro-enterologist and Sander Bontemps, registrar Pediatrics, CatharinaCatharina-hospital Eindhoven (at present: Maastricht) Rob Pereira and Ko van Wouwe, pediatricians, and Paula van Dommelen, Paul Verkerk, TNO Quality of Life, Leiden, the Netherlands
Overzicht n n
n
1. Casus 2. Studie stille ondervoeding aan de borst via de NSCK 3. Conclusies
Prevalence of breastfeeding in the Netherlands Years
Day 1
3 Months
6 Months
1996
70%
17%
6%
2001
80%
35%
17%
2005
79%
35%
25%
Birth rates in the Netherlands 2003: 200.000 births n 2004: 194.000 births n 2005: 187.000 births n (2006: 185.000) n
DB, meisje, geb. 270304 n n n n n n n
Moeder G 1 P 0, russische, hoog opgeleid Vanaf 33e week zwsch in NL Zwsch ongecompliceerd Poliklinische partus in ons ziekenhuis Via verloskundige, geb.gew. 3325 gram AS 99-10 < 1 uur pp aangelegd
n
n n n
Op 44-5-04 gezien op SEH ivm. ernstige ondervoeding Gew. 2650 gr., - 675 gr. ( 20% gew. verlies) Moeder gaf dag en nacht BV Moeder had er veel over gelezen
n n n n
n
Eerste week pp: geen problemen Later navraag: gew. op dag 10: 3100 gr. Baby was vrij rustig, huilde niet abnormaal veel Consult ha. 3 wk. pp ivm slecht groeien: ha. was tevreden Bij 5 wk. eerste contact CB: 2650 gr.
Lichamelijk onderzoek: n n n n n n
Zeer ernstig ondervoed kind Zeer bleek Ingevallen fontanel Vitale parameters stabiel Lever en milt niet palpabel Gespannen neonaat met hoge tonus
Aanvullend onderzoek: n n n n
Hb 9,3 mmol/l; leuco’s 6,6/nl; thr. N CRP < 6 mg/l; gluc. 4.8 mmol/l ASAT 454, ALAT 326, LD 917, AF 269 u/l pH 7,40; Na 138; K 4,9; Cl 105 mmol/l
Aanvullend onderzoek: n
n n n
Veel lab naar oorzaak verhoogde transaminasen: alles neg. Echo abdomen: geen afw. Zweettest 2 x mislukt X Thorax geen afw.
Conclusie: n
Ernstige SOB met fors afwijkende transaminasen ( geduid als passend bij ondervoeding) bij Russische primipara
Behandeling: n n n n n n n n n
Voor en na BV wegen: er kwam heel weinig BV Bijvoeding bij BV: gew. vloog omhoog ( 330 gr. in eerste week) Transaminasen daalden fraai Video interactie begeleiding Ontslag 20 mei: gew. 3290 gr Eerste weken na ontslag: BV en FV bijvoeding Op 2 aug: ( 4 ½ maand) 6 kg., 62,5 cm . Goede tonus en prima ontwikkeling
Objective: n
To establish the incidence of malnutrition/ (hypernatremic) dehydration in fully breastfed infants in admitted children in the Netherlands
Inclusion criteria(1) n n
n
Every baby with insufficient amount of breast feeding but who doesn’t cry (is quiet) Very fast weight gain through extra feeding with weighing before and after breastfeeding or measuring the amount of milk through expressed breast milk Clear (and often impressive) undernutrition; weight after f.i. 1 month still under birth weight (failure to thrive)
Inclusion criteria (2) : 2 types In the first 2 weeks: not enough fluid (with the risk of f.i. hypernatraemia) n > 2 weeks: not enough calories (failure to thrive) n
Case definition Every baby admitted in the hospital within the first 3 months of life exclusively breastfed with (hypernatraemic) dehydration or malnutrition (FTT) who seemed satisfied n Exclusion: UTI, bronchiolitis, much crying, diarrhoea, etc. n
Methods n
n
From mid 2003 till mid 2005 we did a surveillance study in the Netherlands through the Dutch Pediatric Surveillance Unit amongst all Dutch pediatricians This is the first prospective orientating study worldwide as far as we know
Characteristics of Dutch infants up to 3 months old admitted for dehydration or undernutrition over a 2-year period
Reported cases
250 (n)
Other diagnosis/outpatient Age > 3 months Insufficient data Cases analysed
81 9 2 158 (n)
Boys/Girls First born
77 / 78 58
100 (%) 50 / 50 37
History Home delivery Hospital delivery: natural birth Hospital delivery: forcipal /vacuum /caesarean Age of mother, mean ± sd Pregnancy duration, mean ± sd APGAR score after 5 min, mean ± sd Birth weight, mean ± sd Weight loss at admission, median Weight loss >10.0% / >12.0% / 15.0% Previous pediatric consultation
158 (n)
%
58 66 1 / 13 / 17
37 42 <1 / 8/ 11
30.9 ± 4.6 year 39.1 ± 1.6 wk 9.3 ± 0.9 3.433 ± 578 g 6.8 % 54 / 25 / 7 35
34 / 16 / 4 22
Incidence rates of Dutch infants admitted for dehydration while breastfed per year per 100,000 breastfed infants Incidence rate in infants up to 3 months old Clinical scored dehydration / in first born infants Presumed hypernatraemic dehydration Laboratory documented hypernatraemic dehydration
58 / 46
Incidence rate in infants up to 1 month old Clinical scored dehydration
55
Incidence rate in infants up to ≤ 11 days old Clinical scored dehydration
40
20 2
Clinical characteristics of Dutch infants up to 3 months old admitted for dehydration over a 22-year period Lactation interventions
158 (n)
Use of a breast pump at home 49 Use of a breast pump at the 129 hospital Lactation consultant available at 116 the hospital
100 (%)
31 82 73
Symptoms at admission Age at admission, modus / median Inadequate growth Insufficient volume intake Classical dehydration signs Lethargy Jaundice Clinical response to fluid Signs of shock or seizures Inadequate body temperature
158 (n) 3 / 7 days 96 65 39 35 18 10 5 9
%
61 41 25 22 11 6 3 6
Laboratory tests
Serum bilirubin Serum sodium measured / value ≥149 mmol/L Various other tests No laboratory entry
158 (n)
%
50 19 / 6
32 12 / 4
29 81
18 63
Clinical picture of hypernatraemic dehydration n n
n
Notoriously difficult Neonates have better preserved extracellular volume and therefore less pronounced clinical signs of dehydration Lowvolume intake of human milk causes a disproportionate deficit of water, relative to body sodium, in otherwise, healthy full term infants (Laing, Archives 2002)
Clinical picture n n n n n n n
Spectrum from alert and hungry to lethargic, irritable and moribund Skin turgor is preserved Anterior fontanelle can retain its normal fullness Urine output, although reduced, can be maintained No underlying cause for hypernatraemia Renal failure or thrombotic events Underlying problem: water deficiency
Incidence of hypernatraemic dehydration Oddie: (UK ‘01, 71/y/100.000 up to 1mo) n Moritz: (USA ’05, 470/y/100.000) n
Ned Tijdschr Geneeskd. 2006;150:904-8
(Weight loss, serum sodium concentration and residual symptoms in patients with hypernatremic dehydration caused by insufficient breastfeeding; Dutch Journal of Medicine)
Five-Year Neurodevelopmental FiveOutcome of Neonatal Dehydration (Escobar, J.Pediatrics, 8/ 07) n
Results are reassuring
Hypernatraemic dehydration n n n
Found: 2/year/100.000 Estimated: 22/year/100.000 We found 6 cases (Na 152152-186 mmol/L), 5 of them 22-4 days of age, 1 was 14 days of age, none hyperbilirubinemia, none hypoglycemia
Hypoglycemia n
3 children: bls 0,10,1-1,9 mmol/L, 1 with convulsions à Nicu
Importance of weighing babies
Conclusions: n Weighing babies early coupled with
appropriate lactation support resulted in early recognition of hypernatraemic dehydration, with less dehydration, less severe hypernatraemia and higher breast feeding rates in the short and medium term
Conclusions Diagnosis is difficult to make (Dutch pediatrician is not familiar with this diagnosis); probably some cases are missed; also there is a wide variety in severity of the diagnosis n (Hypernatraemic) dehydration and malnutrition in apparently satisfied fully breastfed infants are not very rare entities n
Conclusions (2) Hypernatremic dehydration, a severe complication, was 6 x noted (Na measured only 24 x); Na 152152-186 mmol/l ! n Severe hypoglycaemia was encountered in 3 patients and 1 of them had severe convulsions n Hyperbilirubinaemia and dehydration: what is first and what is second? n
Recommendations Weighing the baby more frequently during the first month after birth will probably prevent many of these cases (as mentioned by the newNutrition Bulletin (2007) of the Netherlands Nutrition Centre) n Sodium should be measured more often n Breast pump at home should be used more often n
Funds n
Scientific Foundation CatharinaCatharinahospital Eindhoven
Acknowledgements n Regien Carbo,
pediatric nurse in Cath who put all the data in Excel n All the Dutch pediatricians, who contributed and filled in the questionnaires
Thank you!
Rolf Pelleboer Pediatric gastrogastro-enterologist Catharina--ziekenhuis Eindhoven Catharina
