K van Wouwe en R Pelleboer, kinderartsen

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

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

3 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

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

5 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

6 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

7 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

8 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

9 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

10 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

11 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

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

13 Symptomen Symptoms at admission n %
Age at admission, modus / median 3 / 7 days Inadequate growth Insufficient volume intake Classical dehydration signs Lethargy Jaundice Clinical response to fluid Signs of shock or seizures Inadequate body temperature Ko van Wouwe, kinderarts TNO Kwaliteit van Leven, 26 November 2009

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

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

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

17 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

18 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

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

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

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

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

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