acute water intoxication. The following is an example of our treatment
regimen. Report of a Case.\p=m-\A3-month-old previ-
ously healthy and neurologically normal
male child of an unmarried, borderline mentally retarded 15-year-old girl presented to the emergency department with tonic-clonic movements of all extremities followed by lethargy. The rectal temperature was 34.9\s=deg\C;heart rate, 108 beats per minute; respiratory rate, 40 breaths per minute; and blood pressure, 89/40 mm Hg. The infant did not have respiratory difficulty, was pink in room air, and had good pulses and normal peripheral per¬ fusion. The infant was given diazepam for seizure control initially, and when hyponatremia of 109 mmol/L was docu¬ mented, he was treated with 1 g of mannitol per kilogram intravenously, 20 mL of normal saline per kilogram over 30 min¬ utes, and was continued on a regimen of normal saline infusion until hyponatremia was corrected. Sodium levels were 118,126, and 133 mmol/L at 3, 9, and 17 hours, respectively, after the initiation of therapy. No seizures were observed after the mannitol was administered, and the child was discharged from the hospital with normal neurologic examination re¬ sults.
Comment.—The objective of treat¬ for water intoxication is to safely return the patient's intravascular sodium concentration into the nor¬ mal range and, more importantly, to prevent the severe neurologic toxicity associated with the cerebral edema that can result from relatively acute hyponatremia.1'2 Hypertonie saline solution given for the correction of severe hyponatremia has been linked to the development of central pontine and extrapontine myelinolysis.3"5 Moreover, as pointed out in the edi¬ torial by Finberg,6 having hypertonic saline in the same cabinet as other commonly used intravenous crystal¬ loid solutions may result in erroneous administration of hypertonic saline to the wrong patient, with potentially ment
life-threatening complications. As demonstrated by the case out¬ lined above, using a regimen of man¬
nitol and normal saline, the serum sodium level returns to the normal range at a rate comparable with that described by Keating et al. Mannitol is a hypertonic, relatively inexpen¬ sive, safe medication routinely used to treat cerebral edema of many causes.7-8 It causes rapid redistribu¬ tion of extravascular fluid into the
vascular space and is very effective at reducing the intracellular cerebral tis¬ sue volume with an intact bloodbrain barrier. It also functions as an osmotic diuretic, which results in free water loss with minimal sodium loss. The only significant morbidity asso¬ ciated with its use is dehydration or hyperosmolality-induced renal fail¬ ure with excessive doses. In the presence of severe hypona¬
hyperosmolality is unlikely with recommended doses of 0.25 to 1.0 g of mannitol per kilogram, and the diuresis induced by mannitol al¬ lows additional normal saline admin¬ istration in patients with water in¬ toxication without risking fluid overload. During the last 8 years we have used this regimen in a number of patients, with uniformly good neu¬ rologic outcomes, including several cases of patients who presented in a coma with signs of increased intracranial pressure. The literature routinely recom¬ mends the use of mannitol to treat cerebral edema, particularly in the face of a normal blood-brain barrier. Our experience supports the use of mannitol and normal saline to safely and effectively treat the cere¬ bral edema and hypo-osmolality/ hyponatremia associated with water intoxication in infants and children. JACOB NUTMAN, MD Department of Pediatrics MetroHealth Saint Luke's Medical Center 11311 Shaker Blvd Cleveland, OH 44104 JEFFREY H. HILL, MD, PHD Pediatric Critical Care St Joseph's Hospital and Medical Center 2828 N Central Ave Suite 890 Phoenix, AZ 85004 tremia,
Keating JP, Shears GJ, Dodge PR. Oral waintoxication in infants: an American epidemic.
1. ter
AJDC. 1991;145:985-990. 2. Arieff AI.
Hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women. N Engl J Med. 1986;314:1529-1535. 3. Norenberg MD, Leslie KD, Robertson AS. Association between rise in serum sodium and central pontine myelinolysis. Ann Neurol. 1982; 11:128-135. 4. Cluitmans FH, Meinders AE. Management of severe hyponatremia: rapid or slow correction. Am J Med. 1990;88:161-166. 5. Sterns RH, Riggs JE, Schochet SS. Osmotic demyelination syndrome following correction of hyponatremia. N Engl J Med. 1986;314:1535\x=req-\ 1542.
6. Finberg L. Water intoxication: a prevalent problem in the inner city. AJDC. 1991 ;145:981\x=req-\
982. 7. Prough DS, Dewitt D. 'Cerebral resuscitation.' In: Chernow B, ed. The Pharmacologic Approach to the Critically Ill Patient. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992:206-207. 8. Dean JM, Moss SD. 'Intracranial hypertension.' In: Fuhrman BP, Zimmerman JJ, eds. Pediatric Critical Care. St Louis, Mo: Mosby\p=n-\Year Book; 1992:584-585.
In Reply. \p=m-\Sincewater intoxication has been a rare entity, it is not surprising that studies providing critical comparison of hypertonic saline vs mannitol have not been published. I agree with Nutman and Hill that mannitol is a reasonable choice, but it has not been proven to be safer or more effective. Although discussion of refinements of therapy is interesting, prevention is a more attractive topic. Interventions directed to the population at risk might include education, public service announcements, or modification of the instructions given to new mothers when they leave the hospital. Incentives to promote breast-feeding in the context of the Supplemental Food Program for Women, Infants, and Children (WIC) may be the most meaningful project. Finberg1 has suggested financial incentives to eligible mothers in the WIC program who breast\x=req-\ feed. Study of that approach in an appropriately structured fashion is overdue. JAMES P. KEATING, MD Department of
Pediatrics-Gastroenterology Washington University School of Medicine
400 S Kingshighway Blvd St Louis, MO 63110 1.
Finberg
L. Oral water intoxication. AJDC.
1992;146:893-894.
Water Intoxication: A Problem of
Bottle-Feeding Sir.\p=m-\Iwas appalled, but only slightly surprised, that neither in the article by Keating et al,1 nor in the editorial comment by Finberg,2 is there the slightest suggestion that water intoxication would have been prevented by the mothers' breast-feeding. After all, water intoxication is a complication of bottle feeding. Despite the suggestion by Keating et al that" ... preventive interventions applicable to the
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/13/2015
population at risk are discussed...," all they can manage is that more formula be supplied by the Supplemental Food Program for Women, Infants, and Children (WIC) of the US Department of Agriculture. This is feeble. Surely they are not suggesting that this population is incapable of breast\x=req-\ feeding? Rather, the provision of free formula by WIC is more likely than not to encourage mothers to
use
the
formula and
discourage them from breast-feeding.3 Surely a good beginning to the resolution of the problem would be to take
even a
small
percentage of the
amount of money used by WIC to pay for formula and more prof¬ itably employ this cash to promote run, pro¬ breast-feeding. In the long moting breast-feeding is an invest¬ ment; promoting formula-feeding with free formula ends up being costly. It would be helpful, of course, if hos¬ pital routines evolved so that breast¬ feeding is encouraged rather than formula-feeding.4'5 It would not be without profit if medical students and nursing students, and, dare I say it, pe¬ diatrie residents, learned something about breast-feeding, so that they would realize, among other things, that understanding bottle-feeding and formula does not mean you under¬ stand breast-feeding, that there is a right way anda wrong way of establish¬ ing breast-feeding and that there are solutions to breast-feeding problems besides "supplement with formula." It speaks volumes that of the last 20 bro¬ chures I received for general pediatrie conferences, not one contained any session on breast-feeding. Maternity leave in the United States could also do with some rethinking. Even in Canada, by no means a model of social enlight¬ enment, new mothers have the right to 6 months' paid leave (at unemploy¬ ment insurance rates). Many European countries do much better. The population affected in this re¬ port is the very population that would benefit the most from breast-feeding, yet breast-feed the least. It really is too bad. JACK NEWMAN, MD, FRCPC enormous
Breastfeeding Support Program The Hospital for Sick
Children 555 University Ave Toronto, Ontario, Canada M5G 1X8
1.
Keating JP, Schears GJ, Dodge PR. Oral wa-
ter intoxication in
990. 2.
L. Water intoxication: a prevalent in the inner city. AJDC. 1991;145:981\x=req-\
Finberg
problem 982. 3.
infants. AJDC. 1991;145:985\x=req-\
Ryan AS, Rush D, Krieger FW, Lewandowski GE. Recent declines in breast-feeding in the United States, 1984 through 1989. Pediatrics. 1991;88:719-727. 4. Winikoff B, Laukaran VH, Myers D, Stone R. Dynamics of infant feeding: mothers, professionals, and the institutional context in a large urban hospital. Pediatrics. 1986;77:357-365. 5. Frank DA, Wirtz SJ, Sorenson JR, Heeren T. Commercial discharge packs and breastfeeding counseling: effects on infant-feeding practices in a randomized trial. Pediatrics. 1987;80:845-854. In Reply. \p=m-\Idid believe, when the article was written, that my work could be used as a reason for supporting to encourage breast-feeding but I doubt that depriving poor infants of adequate formula by weakening the WIC program will increase breast-feeding. This summer, I admitted a 3-month\x=req-\ old breast-fed infant with seizures and a serum sodium level of 114 mmol/L. The grandmother had advised the mother to stop nursing for a day and to give water instead. The infant had taken an amount of water similar to the infants in our report. Caretakers should know that interrupting feeds and offering a hungry infant water can cause water intoxication. Parents and health workers should avoid all situations in which hungry infants are given water instead of breast milk or infant formula. Increasing the availability of breast milk or formula, especially to infants living in poverty, would be an important preventive step. JAMES P. KEATING, MD Department of
Pediatrics-Gastroenterology Washington University
School of Medicine 400 S Kingshighway Blvd St Louis, MO 63110
Pubic Hair in
Infancy
Sir.\p=m-\Adamset al1 described three infant girls with premature pubarche and suggested that one infant (patient 3) may have had nonclassic 3\g=b\-hydroxysteroid deficiency based on corticotropin stimulation test results (the ratio of stimulated \g=D\5-17-hydroxypregnenolone [17-OHPreg] to 17-hydroxyprogesterone [17-OHP] of 11.6 at age 3 months). They also reported slightly elevated 17-OHPreg levels and 17\x=req-\ OHPreg-17-OHP ratios in the other
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/13/2015
infants. Normal values for prepubertal children were referenced. I wish to bring to the authors' attwo
tention
more
age-specific
normative
corticotropin stimulation data recently published.2 These newer data demonstrate significantly higher baseline and stimulated 17-OHPreg and 17\x=req-\ OHPreg-17-OHP ratios in infants (
regimen. Report of a Case.\p=m-\A3-month-old previ-
ously healthy and neurologically normal
male child of an unmarried, borderline mentally retarded 15-year-old girl presented to the emergency department with tonic-clonic movements of all extremities followed by lethargy. The rectal temperature was 34.9\s=deg\C;heart rate, 108 beats per minute; respiratory rate, 40 breaths per minute; and blood pressure, 89/40 mm Hg. The infant did not have respiratory difficulty, was pink in room air, and had good pulses and normal peripheral per¬ fusion. The infant was given diazepam for seizure control initially, and when hyponatremia of 109 mmol/L was docu¬ mented, he was treated with 1 g of mannitol per kilogram intravenously, 20 mL of normal saline per kilogram over 30 min¬ utes, and was continued on a regimen of normal saline infusion until hyponatremia was corrected. Sodium levels were 118,126, and 133 mmol/L at 3, 9, and 17 hours, respectively, after the initiation of therapy. No seizures were observed after the mannitol was administered, and the child was discharged from the hospital with normal neurologic examination re¬ sults.
Comment.—The objective of treat¬ for water intoxication is to safely return the patient's intravascular sodium concentration into the nor¬ mal range and, more importantly, to prevent the severe neurologic toxicity associated with the cerebral edema that can result from relatively acute hyponatremia.1'2 Hypertonie saline solution given for the correction of severe hyponatremia has been linked to the development of central pontine and extrapontine myelinolysis.3"5 Moreover, as pointed out in the edi¬ torial by Finberg,6 having hypertonic saline in the same cabinet as other commonly used intravenous crystal¬ loid solutions may result in erroneous administration of hypertonic saline to the wrong patient, with potentially ment
life-threatening complications. As demonstrated by the case out¬ lined above, using a regimen of man¬
nitol and normal saline, the serum sodium level returns to the normal range at a rate comparable with that described by Keating et al. Mannitol is a hypertonic, relatively inexpen¬ sive, safe medication routinely used to treat cerebral edema of many causes.7-8 It causes rapid redistribu¬ tion of extravascular fluid into the
vascular space and is very effective at reducing the intracellular cerebral tis¬ sue volume with an intact bloodbrain barrier. It also functions as an osmotic diuretic, which results in free water loss with minimal sodium loss. The only significant morbidity asso¬ ciated with its use is dehydration or hyperosmolality-induced renal fail¬ ure with excessive doses. In the presence of severe hypona¬
hyperosmolality is unlikely with recommended doses of 0.25 to 1.0 g of mannitol per kilogram, and the diuresis induced by mannitol al¬ lows additional normal saline admin¬ istration in patients with water in¬ toxication without risking fluid overload. During the last 8 years we have used this regimen in a number of patients, with uniformly good neu¬ rologic outcomes, including several cases of patients who presented in a coma with signs of increased intracranial pressure. The literature routinely recom¬ mends the use of mannitol to treat cerebral edema, particularly in the face of a normal blood-brain barrier. Our experience supports the use of mannitol and normal saline to safely and effectively treat the cere¬ bral edema and hypo-osmolality/ hyponatremia associated with water intoxication in infants and children. JACOB NUTMAN, MD Department of Pediatrics MetroHealth Saint Luke's Medical Center 11311 Shaker Blvd Cleveland, OH 44104 JEFFREY H. HILL, MD, PHD Pediatric Critical Care St Joseph's Hospital and Medical Center 2828 N Central Ave Suite 890 Phoenix, AZ 85004 tremia,
Keating JP, Shears GJ, Dodge PR. Oral waintoxication in infants: an American epidemic.
1. ter
AJDC. 1991;145:985-990. 2. Arieff AI.
Hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women. N Engl J Med. 1986;314:1529-1535. 3. Norenberg MD, Leslie KD, Robertson AS. Association between rise in serum sodium and central pontine myelinolysis. Ann Neurol. 1982; 11:128-135. 4. Cluitmans FH, Meinders AE. Management of severe hyponatremia: rapid or slow correction. Am J Med. 1990;88:161-166. 5. Sterns RH, Riggs JE, Schochet SS. Osmotic demyelination syndrome following correction of hyponatremia. N Engl J Med. 1986;314:1535\x=req-\ 1542.
6. Finberg L. Water intoxication: a prevalent problem in the inner city. AJDC. 1991 ;145:981\x=req-\
982. 7. Prough DS, Dewitt D. 'Cerebral resuscitation.' In: Chernow B, ed. The Pharmacologic Approach to the Critically Ill Patient. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992:206-207. 8. Dean JM, Moss SD. 'Intracranial hypertension.' In: Fuhrman BP, Zimmerman JJ, eds. Pediatric Critical Care. St Louis, Mo: Mosby\p=n-\Year Book; 1992:584-585.
In Reply. \p=m-\Sincewater intoxication has been a rare entity, it is not surprising that studies providing critical comparison of hypertonic saline vs mannitol have not been published. I agree with Nutman and Hill that mannitol is a reasonable choice, but it has not been proven to be safer or more effective. Although discussion of refinements of therapy is interesting, prevention is a more attractive topic. Interventions directed to the population at risk might include education, public service announcements, or modification of the instructions given to new mothers when they leave the hospital. Incentives to promote breast-feeding in the context of the Supplemental Food Program for Women, Infants, and Children (WIC) may be the most meaningful project. Finberg1 has suggested financial incentives to eligible mothers in the WIC program who breast\x=req-\ feed. Study of that approach in an appropriately structured fashion is overdue. JAMES P. KEATING, MD Department of
Pediatrics-Gastroenterology Washington University School of Medicine
400 S Kingshighway Blvd St Louis, MO 63110 1.
Finberg
L. Oral water intoxication. AJDC.
1992;146:893-894.
Water Intoxication: A Problem of
Bottle-Feeding Sir.\p=m-\Iwas appalled, but only slightly surprised, that neither in the article by Keating et al,1 nor in the editorial comment by Finberg,2 is there the slightest suggestion that water intoxication would have been prevented by the mothers' breast-feeding. After all, water intoxication is a complication of bottle feeding. Despite the suggestion by Keating et al that" ... preventive interventions applicable to the
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/13/2015
population at risk are discussed...," all they can manage is that more formula be supplied by the Supplemental Food Program for Women, Infants, and Children (WIC) of the US Department of Agriculture. This is feeble. Surely they are not suggesting that this population is incapable of breast\x=req-\ feeding? Rather, the provision of free formula by WIC is more likely than not to encourage mothers to
use
the
formula and
discourage them from breast-feeding.3 Surely a good beginning to the resolution of the problem would be to take
even a
small
percentage of the
amount of money used by WIC to pay for formula and more prof¬ itably employ this cash to promote run, pro¬ breast-feeding. In the long moting breast-feeding is an invest¬ ment; promoting formula-feeding with free formula ends up being costly. It would be helpful, of course, if hos¬ pital routines evolved so that breast¬ feeding is encouraged rather than formula-feeding.4'5 It would not be without profit if medical students and nursing students, and, dare I say it, pe¬ diatrie residents, learned something about breast-feeding, so that they would realize, among other things, that understanding bottle-feeding and formula does not mean you under¬ stand breast-feeding, that there is a right way anda wrong way of establish¬ ing breast-feeding and that there are solutions to breast-feeding problems besides "supplement with formula." It speaks volumes that of the last 20 bro¬ chures I received for general pediatrie conferences, not one contained any session on breast-feeding. Maternity leave in the United States could also do with some rethinking. Even in Canada, by no means a model of social enlight¬ enment, new mothers have the right to 6 months' paid leave (at unemploy¬ ment insurance rates). Many European countries do much better. The population affected in this re¬ port is the very population that would benefit the most from breast-feeding, yet breast-feed the least. It really is too bad. JACK NEWMAN, MD, FRCPC enormous
Breastfeeding Support Program The Hospital for Sick
Children 555 University Ave Toronto, Ontario, Canada M5G 1X8
1.
Keating JP, Schears GJ, Dodge PR. Oral wa-
ter intoxication in
990. 2.
L. Water intoxication: a prevalent in the inner city. AJDC. 1991;145:981\x=req-\
Finberg
problem 982. 3.
infants. AJDC. 1991;145:985\x=req-\
Ryan AS, Rush D, Krieger FW, Lewandowski GE. Recent declines in breast-feeding in the United States, 1984 through 1989. Pediatrics. 1991;88:719-727. 4. Winikoff B, Laukaran VH, Myers D, Stone R. Dynamics of infant feeding: mothers, professionals, and the institutional context in a large urban hospital. Pediatrics. 1986;77:357-365. 5. Frank DA, Wirtz SJ, Sorenson JR, Heeren T. Commercial discharge packs and breastfeeding counseling: effects on infant-feeding practices in a randomized trial. Pediatrics. 1987;80:845-854. In Reply. \p=m-\Idid believe, when the article was written, that my work could be used as a reason for supporting to encourage breast-feeding but I doubt that depriving poor infants of adequate formula by weakening the WIC program will increase breast-feeding. This summer, I admitted a 3-month\x=req-\ old breast-fed infant with seizures and a serum sodium level of 114 mmol/L. The grandmother had advised the mother to stop nursing for a day and to give water instead. The infant had taken an amount of water similar to the infants in our report. Caretakers should know that interrupting feeds and offering a hungry infant water can cause water intoxication. Parents and health workers should avoid all situations in which hungry infants are given water instead of breast milk or infant formula. Increasing the availability of breast milk or formula, especially to infants living in poverty, would be an important preventive step. JAMES P. KEATING, MD Department of
Pediatrics-Gastroenterology Washington University
School of Medicine 400 S Kingshighway Blvd St Louis, MO 63110
Pubic Hair in
Infancy
Sir.\p=m-\Adamset al1 described three infant girls with premature pubarche and suggested that one infant (patient 3) may have had nonclassic 3\g=b\-hydroxysteroid deficiency based on corticotropin stimulation test results (the ratio of stimulated \g=D\5-17-hydroxypregnenolone [17-OHPreg] to 17-hydroxyprogesterone [17-OHP] of 11.6 at age 3 months). They also reported slightly elevated 17-OHPreg levels and 17\x=req-\ OHPreg-17-OHP ratios in the other
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/13/2015
infants. Normal values for prepubertal children were referenced. I wish to bring to the authors' attwo
tention
more
age-specific
normative
corticotropin stimulation data recently published.2 These newer data demonstrate significantly higher baseline and stimulated 17-OHPreg and 17\x=req-\ OHPreg-17-OHP ratios in infants (
