Long term neurodevelopmental outcome after neonatal dehydration


Insufficient breastmilk is a relatively common condition affecting up to 15% of first time mothers attempting to initiate and maintain breastfeeding.

Lactation professionals are notoriously poorly informed about this risk of exclusive breastfeeding, many insisting that it is only the “rare” mother who has insufficient supply. Furthermore, breastfeeding professionals insist or imply that the benefits of breastfeeding outweigh the risks of infant weight loss and its complications. They are dead wrong.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is more important to preserve a baby’s brain function than a breastfeeding relationship.[/pullquote]

A new paper, Long-Term Neurodevelopmental Outcome of Neonates with Hypernatremic Dehydration, published in the journal Breastfeeding Medicine reveals the potentially devastating consequences of newborn dehydration.

The authors explain the nature and magnitude of the problem. Physiologic weight loss often occurs in the first few days but should be resolved by the end of the first week.

  • If weight loss continues beyond the first week or if weight loss is rapid (more than 2% of neonates weight in each day), insufficient breastmilk should be suspected.
  • Neonatal dehydration is almost entirely a phenomena of insufficient lactation and does not occur in the bottle fed child.
  • The incidence of NHD has been reported to be 1-3%.
  • Initially there are few symptoms, so it is often overlooked.
  • The hypernatremia [elevated salt level] and weight loss due to inadequate milk intake in breastfed infants may ultimately cause severe complications such as stroke and intracranial hemorrhage.
  • The incidence of NHD has increased in recent years.

The authors looked at 65 infants who had been admitted for neonatal hypernatremic dehydration and compared them to a control group of 65 breastfed infants. What did they find?

The most prevalent sign in infants of case group in our study was weight loss…

We found a significant positive relationship between the severity of weight loss and severity of hypernatremia. In studies by Moritz there was also a positive association be- tween severity of weight loss and severity of hypernatremia. So it seems that early detection of weight loss in neonates can prevent severe weight loss and severe hypernatremia. Uras et al. found that a weight loss of greater than 7% of birth weight was also associated with an increased risk of hypernatremia…

The importance of frequent neonatal weighing during their first week of life to prevent excessive weight loss and its complications is clearly evident.

Neonatal hypernatremic dehydration can be deadly:

In our study 7 out of 65 patients died as a result of complications of hypernatremia. There was a significant correlation between severity of hypernatremia and mortality (p = 0.001). All who died had serum sodium concentration >160 mmol/L.

But even when there were no obvious short term consequences to neonatal dehydration, the longterm consequences could be severe.

All infants in the control group were developmentally normal at ages 6 and 12 months, but in the case group 25% and 21% had developmental delay at 6 and 12 months, respectively. At 18 months the incidence of developmental delay was 3% for the control group and 19% for case group, and at 24 months 12% of case infants had developmental delay versus none for the case group. At the age of 6 months, the severity of developmental delay was directly related to the severity of hypernatremia ( p = 0.001)…

Long-term neurologic delay means that the child at the age of 2 years had developmental retardation of at least two from four Denver (gross motor, fine motor, speech, and Social). For example, baby at 2 years has a delay in speech, impaired walking, and seizures.

Looking back at initial brain CT scans, the authors found:

CT scan was performed in 39 of the cases. The results showed 5 cases with bleeding (12.8%), 29 healthy (74%), and 5 cases with cerebral edema. CT scans were performed in the second to fourth day of treatment.

They comment:

The higher prevalence of intracranial complications in our study may be due to the more severe hypernatremia and also late presentation of our patients. It has been reported previ- ously that a serum sodium concentration concentration ≥158mmol/L is associated with a high mortality rate. Acute brain injury is reported in 8% of patients with hypernatremia. Increased serum osmolality due to hypernatremia can cause brain in- jury with widespread hemorrhage, thrombosis, and subdural effusion, which lead to death or permanent neurologic sequelae…

The take home messages from this study:

  • neonatal hypernatremic dehydration is common
  • weight loss is a critical prognostic sign
  • frequent weights are crucial to diagnosing the problem early before severe complications can occur
  • Neonatal weight loss after the first few days is NOT normal and is a cause for significant concern and aggressive monitoring

Early supplementation is the key to reducing the risk of neonatal hypernatremic dehydration. Lactation professionals insist that supplementation can ruin the breastfeeding relationship; that’s not true but even if it were, dehydration can ruin the baby’s brain.

When it comes to the relative importance of the two, there is no contest.