K van Wouwe en R Pelleboer, kinderartsen Borstvoeding: Hypertone dehydratie Kennispoort Verloskunde 2009 K van Wouwe en R Pelleboer, kinderartsen Ko van Wouwe, kinderarts

Partner: Catharine Ziekenhuis Eindhoven Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Risico is groter WHO: “breast is best” more mothers start in comparison with 1996 weighing a baby is much less practice Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Risico is kleiner Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Hoe vaak? To establish the incidence of serious hypernatremic dehydration in exclusively breastfed infants needing hospital admission in the Netherlands Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Kenmerken van de kinderen Weight gain through extra feeding Fast weight loss Quiet baby’s Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Onderscheid during the first 2 weeks: not enough fluid (dehydration) > 2 weeks: not enough calories (failure to thrive) Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Studie duur From May 1st 2003 till July 1st 2005 a study through the Dutch Pediatric Surveillance Unit amongst all pediatricians Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Meldingen Reported cases 250 (n) Other diagnosis Too old Insufficient data 81 9 2 Cases analysed 158 (n) Boys/Girls First born 77 / 78 58 50 / 50 37 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Anamnese % Home delivery Hospital delivery: natural birth 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 58 66 1 / 13 / 17 30.9 ± 4.6 year 39.1 ± 1.6 wk 9.3 ± 0.9 3.433 ± 578 g 6.8 % 54 / 25 / 7 35 37 42 <1 / 8/ 11 34 / 16 / 4 22 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Incidentie per year per 100,000 breastfed infants Incidence rate in infants up to 3 months old Clinical scored dehydration / in first born infants 58 / 46 Presumed hypernatraemic dehydration 20 Laboratory documented hypernatraemic dehydration 2 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 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Zorg Lactation interventions 158 (n) (%) Use of a breast pump at home 49 31 Use of a breast pump at the hospital 129 82 Lactation consultant available at the hospital 116 73 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Symptomen Symptoms at admission n % Age at admission, modus / median 3 / 7 days Inadequate growth 96 61 Insufficient volume intake 65 41 Classical dehydration signs 39 25 Lethargy 35 22 Jaundice 18 11 Clinical response to fluid 10 6 Signs of shock or seizures 5 3 Inadequate body temperature 9 6 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Lab uitslagen Laboratory tests n % Serum bilirubin 50 32 Serum sodium measured / value ≥149 mmol/L 19 / 6 12 / 4 Various other tests 29 18 No laboratory entry 81 63 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Behandeling Treatment n % Nasogastric tube 48 30 Intravenous drip 34 21 Both 11 7 Duration of admission, median days 3 In hospital 1 day / 2 days / 3 days 13 / 33 / 35 8 / 21 / 22 ≥ 4 – 10 days, ≥ 10 days 66 / 7 41 / 4 Exclusively breastfed at hospital 39 25 Breastfed and formula fed 84 53 Formula fed only 19 12 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Bij ontslag At dismissal n % Exclusively breastfed 52 33 Breastfed and formula fed 59 37 Formula fed only 30 19 Follow up by lactation consultant 20 13 Referred to breastfeeding organization 4 3 Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Conclusie: problematisch klinisch beeld neonates have better preserved extracellular volume less pronounced clinical signs of dehydration low volume intake of human milk causes a disproportionate deficit of water, relative to body sodium, in otherwise, healthy full term infants (Laing, Archives 2002) Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Symptomen volgens tekstboeken Skin turgor Anterior fontanelle Urine output No underlying cause for hypernatraemia Renal failure or thrombotic events Underlying problem: water deficiency Alert and hungry or lethargic, irritable and moribund Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Vergelijking Moritz: (USA ’05, 470/y/100.000) Oddie: (UK ‘01, 71/y/100.000 up to 1mo Pelleboer: (NL, ’09, 55/ 71/y/100.000 up to 1mo Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Theorie Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Literatuur Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Onderzoek Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

Beleid Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009