The frightening prognosis of breastfeeding dehydration

Wilted Flower on Black

A new paper in The Journal of Maternal-Fetal and Neonatal Medicine, Predictability of prognosis of infantile hypernatremic dehydration: a prospective cohort study sheds light on the outcome of newborn dehydration due to insufficient breastmilk. It highlights the severity of the problem, the risk factors and the prognostic signs.

I find it particularly interesting because it describes almost exactly the clinical course of babies like Landon Johnson, who died of breastfeeding dehydration, and the son of Dr. Christie del Castillo-Hegyi, who suffered permanent brain injury. Lactation professionals have insinuated or even denied that those babies suffered and died as a result of insufficient breastmilk. This paper makes it clear that it is the lactation professionals who are woefully (and often willfully) ignorant of what is going on around them.

17.5% of babies suffered permanent brain injury including 7% who died.

The authors start by acknowledging what lactation professionals refuse to admit — the risk of newborn hypernatremic dehydration is increasing:

The prevalence of hypernatremic dehydration has increased in recent years most likely due to insufficient intake of breast milk as the most important factor. Other influencing factors include: early discharge of mothers from hospital after delivery, inadequate training, awareness on breast milk insufficiency and improper breastfeeding technique, breast congestion, inverted, big or flat nipple, previous breast surgery …

As breastfeeding promotion efforts have become more aggressive, more babies are suffering the serious impact of insufficient breastmilk.

In contrast to the claims of lactation professionals, breastfeeding dehydration is NOT easy to diagnose:

Infantile hypernatremic dehydration (IHD) is a life-threatening medical emergency in which the intracellular water is sucked into the extracellular space due to sodium chloride hypertonicity usually induced by free water loss or administration of excessive sodium solutions. As a result, the intracellular volume is extremely decreased while the intravascular volume and skin turgor are maintained, resulting in difficulty in early diagnosis…

Why are babies so vulnerable to dehydration?

Following low milk intake in neonates, kidneys start sodium reabsorption and fluid retention; however, kidneys in neonates have a weaker ability of urine concentration compared to adults and hence water is not reabsorbed sufficiently. Besides, insensible fluid loss through the lungs as well as immaturity of neonatal skin can amplify dehydration and hypernatremia. Due to the gradual development of the disorder, the diagnosis is very difficult and dehydration is usually undetected. Accordingly, most infants are referred to the physician when neonatal complications such as decreased urination, lethargy, weakness or brain symptoms have already been presented.

Hypernatremic means high salt concentration and it is the high salt concentration that leads to brain injuries.

Long-term follow-up has shown that neurological disorders occur in approximately one-third of infants with hypernatremic dehydration. Also, developmental delay has been shown to occurs in cases with severe hypernatremia. Monitoring birth weight, breastfeeding position and frequency, and breast changes during breastfeeding as well as defecation and urination frequency are effective measures in early diagnosis of hypernatremic dehydration and controlling its complications.

In an effort to determine prognosis, the authors looked at the impact of dehydration on 183 babies. The results are frightening:

The 36-month follow-up of infants with hypernatremic dehydration showed that 32 (17.5%) out of 183 studied cases had abnormal outcomes, out of whom 14 cases have passed away during the follow-up and 18 cases were diagnosed with developmental delay.

Remarkably, these results were BETTER than results from previous studies:

The lower incidence of developmental delay in our study can be attributed to the larger sample size, the longer duration of follow-up, and/or the difference in measurement tool for the developmental status in our study.

There were notable difference between the babies who suffered serious long term effects and those who did not:

Hypernatremic dehydrated infants with unfavorable prognosis had been referred 4 days later than those with favorable prognosis…

According to the results of this study, hypernatremic dehydrated infants with developmental delay had serum sodium levels significantly higher (176 mEq/l) than those with the normal outcome (157 mEq/l). Also of 32 hypernatremic dehydrated infants with abnormal outcomes, 26 cases (81%) had a sodium level of 167–200 mEq/l.

In addition:

Convulsion was seen almost 5 times more (34%) in infants with unfavorable prognosis compared to those with normal prognosis (7%)… Consciousness impairments were observed in 32% of infants with unfavorable prognosis, but none were observed in those with normal prognosis. Cerebral edema was observed in about one-third of infants with unfavorable prognosis… Cerebral edema can be irreversible and hence fatal in some patients.

The authors conclude:

According to the results of this study, hypernatremic dehydration is a major problem with a common occurrence in the first 2 weeks of life that leads to unfavorable outcomes such as infant mortality (7%)… [C]ombination of variables such as sodium, urea, creatinine, lethargy, state of fontanels, convulsion, loss of consciousness, state of breast during postpartum, inverted nipple and brain CT scan had a high predictive power (98.6%) for determination of unfavorable prognosis in infants with hypernatremic dehydration.

Breastfeeding dehydration leads to grievous outcomes … and the ultimate tragedy is that nearly every single one of these tragic outcomes can be avoided simply and easily by supplementing with formula at the first sign of problems.

Breastfeeding ISN’T best for every baby. For some it is brain damaging and life ending.

  • rational thinker

    OT but I wanted to share this. I was reading about GBS again and the junk science about garlic and idiots who are trying to avoid IV antibiotics for it in labor at all costs. I came across a site with this article= https://preg-u.bloomlife.com/https-medium-com-preg-u-preventing-group-b-strep-7673b312598d Ironically the website name is Preg U and their slogan is “The smart girl’s guide to pregnancy and parenting”.

    There was a comment left for the writer of the article that had me sitting at the computer screen with my jaw dropped open for about 5 min. Heres the comment=
    Hi, I’vebeen looking for research on group B strep in breastmilk and came upon your article. I’m currently pregnant with my 3rd and I’m trying
    desperately to ascertain if nursing will be a safe option for me. My
    previous pregnancy involved 26 week old preemie twins who repeatedly got
    strep b in the NICU and almost died many times. It was eventually
    discovered that I had strep B in my milk. As I was never swabbed down
    there since I didn’t make it to 35–37 weeks of pregnancy, I have no idea
    if I was positive or negative with the usual form of GBS.
    You sayin your article that you were pregnant multiple times and were positive multiple times…may I ask, were you able to safely nurse them? Was your milk ever cultured? Have you come across anything in your research that could help me gain information on this issue so that I can make the
    safest choice for my baby?

    Never heard that one before about getting strep b in the nicu or from breastmilk for that matter. Would love to hear opinions on the article and the comment.

    • mabelcruet

      GBS can be found in breast milk, but its very rare. As to its role in causing neonatal sepsis, there are very occasional reported cases, but its not entirely accepted. It could be coincidental and just there as a commensal as many pregnant women carry it naturally.

      • rational thinker

        I was not aware GBS could ever be found in breast milk. I thought this may have been making a claim similar to when home birth advocates tell people that giving birth in a hospital will put you at risk for staph/MRSA infections. I know GBS can kill a full term baby in hours so I was skeptical when she said her 26 week preemie twins got GBS multiple times in the NICU.

        • mabelcruet

          Breast milk isn’t sterile-I think there’s supposed to be some link between breast milk bacterial species and those in the gut, so it might help seed the gut with ‘good’ bugs. But the history of multiple episodes of GBS doesn’t sound right-its possible, having one bout of GBS doesn’t protect you from another, its not an infection you can develop immunity to, but multiple episodes of the same thing is not usual. It doesn’t sequester itself away and flare up again like shingles. I suppose the babies could have had recurrent bacterial infections of different types and she misunderstood that different bacteria were involved. It’s a question more suited to a neonatologist I think, but whenever I’ve had ex-premies who had a stormy time in NICU, they usually don’t have a history of multiple infections like that, just one or two.

  • The Bofa on the Sofa

    While we are giving OT stories, I saw a story on my Quora feed ths morning about a mother who nearly died after having pre-eclampsia. She was 2 1/2 weeks overdue and went in for an emergency c-section. She fell into a coma for who knows how long. Amazingly, in the end, she and the baby both survived, but it was a case of where at least one of them was expected to die.

    Of course, the whole time, all I was thinking was, “If you had just had a c-section at 41 weeks, none of this would have been an issue.” Severe pre-eclampsia at 42+3? Completely unnecessary.

    • mabelcruet

      I genuinely struggle with dating in pregnancy. Where I am (UK), mothers usually get a dating scan early on, and end up being given gestational ages like ‘5+4’ or ‘6+5’ to the exact day. But at the other end, it’s still ‘well, we can’t be sure of dates so we will let you go 2 weeks over before we bother doing anything’. I’m tired of looking at crispy, flaky-skinned, long nailed, meconium coated stillbirths. I had one last week-absolutely typical history of 41 weeks-all ok, 41+2-all ok, 41+4-reduced fetal movement, go home, there’s nothing wrong…41+5-dead baby. It is repeated over and over and nothing changes. Mothers are ignored, their concerns are glossed over-this mum went to a different hospital after being sent home at 41+4 because she was allegedly upset by the way she had been spoken to by the midwives there, but that means her stillbirth will end up in the stats of the hospital where the baby was stillborn.

      • Young CC Prof

        I don’t understand why we aren’t routinely offering induction at 39 weeks in every well-dated pregnancy. At this point, there’s so much evidence that it’s safer for mother, safer for baby and saves money.

      • The Bofa on the Sofa

        I’ve explained how this works to others before. If you think about the growth curve as a function of time, the variation increases as time goes on. Even if it isn’t quite as precise as to the specific date as implied, early estimates are only off by a couple days. So when you have a 15 mm peanut, you know pretty clearly how old that is, within a couple of days. When you have a 15 inch fetus, your range is over a few weeks, if not months.

        • mabelcruet

          But if you’re confident of your dates at the start, you should then be confident of the dates at the end of that same pregnancy, so leaving them to go well over, when we know the stillbirth rate increases, and we know early induction at 39-40 weeks is fine, seems utterly pointless to me. Why take that risk when you have known dates and known gestation?

          • The Bofa on the Sofa

            Exactly. The early dating gives you a date of ± a couple of days. You know when 40 weeks is.

          • mabelcruet

            But then why is it acceptable to leave her to go to 2 weeks over when there’s no need? And why is it been sold to mum as it’s perfectly safe, baby will come out when hes ready, and especially ‘term is flexible, we can’t be sure of your dates so it’s ok to go over a bit?’ , all of which I’ve heard from mothers of post mature stillbirths.

          • The Bofa on the Sofa

            But then why is it acceptable to leave her to go to 2 weeks over when there’s no need?

            Because those doing it think it is “acceptable”

            I agree. It used to be that they could go longer because it was hard to pinpoint the due date based on LMP, so you had to provide some leeway. Granted, even then there was no reason to go past 42 weeks, but at least there is some uncertainty. With modern US dating, though, we know the date very well. What is the purpose of waiting past 40 weeks? Nothing good happens after 40 weeks, and now we KNOW very precisely what is 40 weeks. As YCCP notes, there is no reason to wait any more.

          • AnnaPDE

            Because nature is perfect and babies aren’t library books and your body knows exactly when and how to give birth if we just leave it as alone as possible. And this is why no one ever thought childbirth was dangerous until the advent of evil, evil modern medicine.
            When a group of people with serious delusions about the kindness of nature, plus a career to lose, has staked it all on the principle of „interventions are bad“, then they won’t come around to changing their practice until they’re forced to do so by something that hurts their hip pocket even more. Think lawsuits and parents going to other providers.

          • mabelcruet

            And that’s what is now happening in the UK. One of the inquests into a baby death from East Kent has just been closed with a verdict of a wholly preventable death caused by neglect. There are criminal charges being considered, and yet still midwife ‘leaders’ and their sycophants are still touting round the country flogging the non-disturbed (previously ‘normal’, previously ‘physiological’) birth model with the emphasis on interventions are bad. They can protest all they want that they are evidence-based science based, research driven health care professionals, but their ‘natural is good, intervention is bad’ belief screams out of every pore.

            There’s just been a big maternity conference in Birmingham with the emphasis on maternal and infant safety, looking at ways of improving our horrendous stillbirth rates, and looking at how we can improve our investigation of these deaths and genuinely learn from them (not just parrot the entirely reflexive ‘lessons will be learned’ NHS management mantra). There have been some nationally known speakers-James Titcombe, Jeremy Hunt, Bill Kirkup (who chaired the enquiry into Morecombe Bay). Its been interesting stalking various twitter accounts-the whole conference has been ignored by many senior midwives and not mentioned at all, or it’s been mentioned disparagingly, in that faux-concerned way that this could make women frightened of giving birth.

          • Griffin

            Right. This is why, when I was looking for an elective CS and couldn’t get it in the Netherlands and went next door to Germany at 5 months pregnant, the German doc was initially very dubious until I said I had forced a Dutch ob-gyn to do an ultrasound at 11 weeks (I literally refused to leave his room until he did the US – which he did with very bad grace). The German ob-gyn said that without that early US dating, he would have felt very uneasy to do an elective CS at 39 weeks – he would have not been able to date my pregnancy accurately on the basis of 5-month US data…

  • mabelcruet

    OT, but there’s yet another big UK maternity scandal, this time in East Kent:

    https://www.independent.co.uk/news/health/east-kent-hospitals-baby-deaths-maternity-nhs-criminal-investigation-a9298111.html

    Some of the cases described in various news reports: missed maternal GBS resulting in neonatal sepsis and death, failure to obtain a good CTG trace in a baby whose mum complained of decreased fetal movements but the mum was sent home anyway and then came back with a baby who died in utero, missed growth restriction leading to a pregnancy that was managed as low risk instead of high risk and ending as a stillbirth, a baby born in poor condition with failed resuscitation carried out by a doctor who conceded that he was out of his depth but there was no available consultant back-up.

    The root causes are the same that we’ve seen in every other maternity scandal-poor staffing levels, poor team work, poor communication, staff not recognising potential problems, staff not acting even if they noticed the problems, failure to listen to parents about concerns, failure of senior management to tackle the problems even after they’d been highlighted by previous investigations and failure to provide necessary leadership, money and beds, staff unwilling to whistleblow or complain because they knew it would end in them being targeted and there was no point anyway because they would just be ignored by manager. It just goes on and on.

    Jeremy Hunt, our former long standing health minister presided over some of the most brutal cuts to service provision we’ve ever seen: he cut the budget by 22 BILLION pounds and got rid of 15,000 inpatient beds during his time. Funding levels were at their lowest since the 1950s under his regime (despite the country having twice the population we had in the 1950s). Over his 6 years as health minister, the stillbirth rate was static-we had been having a general slow decline in rates since the late 1970s, and it ground to a halt during his tenure. And yet he touted himself round conferences as a maternity champion, launching a maternity safety strategy to cut the number of stillbirths. Nothing he ever did as health minister went any way to improving maternal and neonatal health-the man was toxic, and this sustained lack of investment, staffing and budget is leading to some horrendous outcomes.

    • Griffin

      Yes, Hunt is appalling. I can’t look at that smug ghoul’s face.

  • disqus_SldTsP7yUC

    This is off topic.. but I lurk on a popular Orthodox Jewish mom board and unfortunately the homebirth/doula trend isn’t going away there any time soon.

    I thought my community would be more or less immune to this (at least to a much lesser degree than other online mom communities) but it really isn’t.

    Recently a 1 day old baby girl died after a home birth and her mom came to the board asking if it was the Vitamin K shot. I immediately knew it wasn’t but so many of them were convinced it was until someone brought up GBS.
    Lo and behold, it turns out the midwife did test mom for GBS and then told her to ignore the POSITIVE result and only administer antibiotics when baby starts showing symptoms. It makes me so mad!

    Not to mention when the mom tried to reach out to the midwife after, she was threatened and is now too scared to pursue charges or anything.

  • Young CC Prof

    I still vividly remember my son’s bout of hypernatremic dehydration, watching the nurses fighting to start a line in a baby with collapsed veins. He’s six now, and doing well in most ways. He has some developmental issues, but of course we can’t know what’s genetic vs IUGR vs neonatal injury.

    What I do know is that we MUST have newborn care and feeding protocols that put safety first, not ones that “balance” safety and exclusive breastfeeding as if supplementation and serious health harm are to be feared equally.

  • mabelcruet

    The effect of hypernatraemia on the infant brain has been known for a very long time-there was an accidental mass poisoning of babies in Binghampton in the 60s, and salt poisoning is known to be one of the ways in which a parent induces fictitious illness (Munchausens by proxy). The difficulty is that the symptoms are non-specific, vomiting, seizures, drowsiness, and can mimic gastrointestinal upset or infection. Unless you actively consider it and test for it quickly, it’ll be missed or not treated quickly enough. Some of the Binghampton babies survived because of renal dialysis, but others died (6 out of 14 I think).

    We’ve started routinely testing sodium levels in all infant deaths now-we can do it from vitreous humour or CSF. I haven’t had a case myself yet, but I suspect we’ve missed them in the past.

  • Sarah

    What horrible, preventable tragedies.

  • fiftyfifty1

    I have a hard time even reading this. So gruesome. Babies sacrificed for an ideology.

  • rational thinker

    This should not be happening in ANY first world country. Formula was invented to prevent this very problem. I guess for lactivists ignorance is bliss.

  • How sad, when a little formula could have prevented these deaths and developmental issues.