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J Matern Fetal Neonatal Med, 2014; 27(5): 491–494

! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2013.819334

ORIGINAL ARTICLE

Comparison of oral and intravenous fluid therapy in newborns with

hypernatremic dehydration
Aydin Erdemir, Zelal Kahramaner, Hese Cosar, Ebru Turkoglu, Ali Kanik, Sumer Sutcuoglu, and Esra Arun Ozer

The Ministry of Health Tepecik Teaching and Research Hospital, Neonatology Clinic, Yenisehir, Izmir, Turkey

Abstract Keywords
Objective: To evaluate the efficacy and complications of oral and intravenous fluid therapy in Breast-fed infant, hypernatremic dehydration,
newborns with hypernatremic dehydration. newborn, oral formula, therapy
Methods: A total of 75 term and near-term (435 weeks) neonates with hypernatremic
dehydration (Na  150 mmol/L) were included in this retrospective study. The patients were History
divided into two groups according to therapy approach for rehydration (breast milk-oral
formula and intravenous fluid). The decline in sodium concentration (50.5 mmol/L/h was Received 24 March 2013
regarded as safe drop) and complications were analyzed. Revised 20 June 2013
Results: The mean gestational age, birth weight and age at admission were 38.9  1.4(36–42) Accepted 21 June 2013
weeks, 3341  504 (2500–4500) gram and 4.3  2.6 (1–17) day, respectively. Fever (61.8%) and Published online 30 July 2013
jaundice (39.4%) were the most common presenting signs. Forty-four (58.6%) of the infants
were treated with breast milk and/or oral formula (group 1) and 31 (41.4%) of the infants were
treated with IV fluid (group 2). In group 1 and group 2, respectively, mean % weight loss, 5 and
7.5; median serum sodium at admission, 153 and 152 mmol/L; median change in sodium
at 12 hours, 7 and 11 mmol/L; and median change in sodium at 24 hours, 10 and 15 mmol/L.
The decline in sodium concentration was more safely in group 1 than group 2 at both 12 and
24 hours of rehydration. One patient had convulsion associated with cerebral edema in group
2. Otherwise no complication was observed in both groups.
Conclusion: Enteral route for fluid replacement may be safe and effective and may be an
alternative to intravenous fluid therapy in newborns with hypernatremic dehydration when
clinical situation is stable.

Introduction Also, its improper treatment can lead to brain edema and
eventually death [3,6,7].
Breast-feeding is advocated as the preferred feeding for all
Infants admitted to hospital for hypernatremic dehydration
infants and is recommended up to at least 6 months of age [1].
usually undergo rehydration with intravenous fluids, whereas
Although the advantages of breast-feeding are well docu-
the treatment of hypernatremia requires meticulous attention,
mented, neonatal hypernatremic dehydration may occur
because most of the complications due to hypernatremia
because of insufficient breast-feeding in the first days of
life. Neonatal hypernatremic dehydration is a serious com-
occur during rapid correction of serum sodium. The slower 14
rate of correction for the higher sodium level should be done
20
plication and increased incidence has been reported in recent
to avoid brain edema [8,9]. There are concerns about how best
studies [2,3]. Insufficient breast-feeding is a major factor in
to direct this condition. Although there are different sugges-
its pathophysiology and may be due to insufficient milk
tions for the treatment of hypernatremic dehydration in
production or failure of established breast-feeding [4,5].
newborns, no precise protocol is determined.
The signs of neonatal hypernatremic dehydration include
The aim of this study was to assess the efficacy and
decreased number of stools or the presence of urate crystals,
complications of treatment approaches in newborns with
weight loss, fever and elevated serum sodium levels. Neonatal
hypernatremic dehydration.
hypernatremic dehydration can cause severe complications
including acute renal failure, disseminated intravascular
Methods
coagulation, convulsion, venous sinus thrombosis and intra-
cranial hemorrhage if it is not recognized and treated early. We retrospectively evaluated all term and near-term
(435 gestational age) neonates admitted to The Ministry of
Health Tepecik Teaching and Research Hospital’s
Neonatology Clinic (level III neonatal intensive care unit, in
Address for correspondence: Esra Arun Ozer, The Ministry of Health
Tepecik Teaching and Research Hospital, Neonatology Clinic, Yenisehir, Izmir, Turkey) for hypernatremic dehydration (with a serum
Izmir, Turkey. Fax: + 90 232 4330756. E-mail: eozer@deu.edu.tr sodium 150 mEq/L) between 1 January 2009 and
492 A. Erdemir et al.
31 December 2010. We excluded 11 infants with cerebral
injury, perinatal asphyxia, intrauterine infection and congeni-
tal heart disease for causing feeding problems and 3 infants
treated with a bolus intravenous (IV) fluid to standardize
the treatment. Seventy-five infants fulfilled the study criteria.
The study was approved by ethics committee of Izmir Tepecik
Teaching and Research Hospital.
Detailed maternal and infant history and examination
including gender, gestational age, birth weight, mode deliv-
ery, maternal parity, postnatal age on admission, the degree of
dehydration, presenting complaints and complications were
recorded from the patients’ charts.
Therapy for hypernatremia involved correcting water
deficit and sodium excess through careful rehydration. The
deficit fluid (mL) was administered within 48 hours with
maintenance fluid (postnatal 1. day: 60 mL/kg/d; postnatal 2.
day: 90 mL/kg/d; postnatal 3. day: 120 mL/kg/d; postnatal 4.
day and subsequent days 150 mL/kg/d), and the deficit fluid
was calculated by percent dehydration [(weight loss/birth
weight) – (daily physiological loss)] X birth weight in all
patients according to the clinical protocol of our institution.
The patients were divided into two groups according to
therapy approach for rehydration; group 1 consisted of
patients treated with breast milk and/or oral formula and
group 2 consisted of patients treated with IV fluid
(all including 4/5% 10 dextrose þ 1/5 normal saline).
The serum sodium, urea and creatinine levels on admission,
12 and 24 hours after admission and the markers of infection
were also recorded. The decline in sodium concentration
50.5 mmol/L/h was regarded as safe drop while sodium
concentration 40.5 mmol/L/h was regarded as non-safe drop.
Statistical analysis
Statistical analysis was performed using the Statistical
Package of Social Science (SPSS), Version 15.0 (SPSS,
Inc., Chicago, IL). Data were expressed as mean  standard
deviation. Mann–Whitney U test was used for comparing
group averages. A p value less than 0.05 was considered as
statistically significant.
Results
Seventy-five infants (435 gestational age) with hypernatremic
dehydration were identified in this study. The mean gesta-
tional age, birth weight and age at admission were 38.9  1.4
(36–42) weeks, 3341  504 (2500–4500) gram and 4.3  2.6
(1–17) day, respectively. Thirty-two of infants were born
vaginally (42.7%) while 43 were born by cesarean section
(57.3%). Sixty infants (80%) were the first child of the mother.
Seventy infants (93.3%) were exclusively breast-fed and the
others were supplemented with formula.
The most common presenting symptom was fever (61.8%).
The other presenting signs were jaundice in 30 of the patients
(39.4%), poor oral intake in 27 (35.5%) and restlessness in
2 (5%) of the patients (Table 1). Laboratory evidence of
infection was present in 12 of the patients (15.8%) while
absent in 64 of the patients (84.2%).
Forty-four (58.6%) of the infants treated with breast milk
and/or oral formula (group 1) and 31 (41.4%) of the infants
treated with IV fluid (group 2). Mean gestational age
J Matern Fetal Neonatal Med, 2014; 27(5): 491–494
Table 1. Presenting signs of hypernatremic dehydration.
Signs %
Fever 61.8
Jaundice 39.4
Poor oral intake 35.5
Restlessness 2.6
and birth weight of the infants were similar in both groups.
There were no significant differences in terms of gender,
mode delivery, maternal parity and postnatal age at admission
between the groups. The mean % weight loss; the median
sodium, urea and creatinine levels at admission; the median
change in sodium (delta) at 12 and 24 hours were significantly
higher in group 2, while the median sodium levels at
12 and 24 hours were significantly lower in group 1
(p50.05) (Table 2).
The decline in sodium concentration was a safe drop
(50.5 mmol/L/h) in 2 infants (6.45%) and non-safe drop
(40.5 mmol/L/h) in 29 infants (93.5%) who were treated with
intravenous fluid, while the decline was a safe drop in
19 infants (43.2%) and non-safe drop in 25 infants (56.8%)
who were treated with breast milk and/or oral formula at
12 hours of rehydration (p50.05) (Table 3).
The decline in sodium concentration was a safe drop in
11 infants (35.5%) and non-safe drop in 20 infants (64.5%)
who were treated with intravenous fluid, while the decline
was a safe drop in 35 infants (79.5%) and non-safe drop
in 9 infants (20.5%) who were treated with breast milk
and/or oral formula at 24 hours of rehydration (p50.05)
(Table 3).
A total of 24 infants had a serum sodium concentration of
4155 mmol/L (11 treated with intravenous fluid and 13 treated
with breast milk and/or oral formula). The decline in sodium
concentration was non-safe drop in all of the infants treated
with intravenous fluid at both 12 hours and 24 hours of
rehydration, while it was safe drop in five infants and
nine infants treated with breast milk and/or oral formula at
12 hours and 24 hours of rehydration, respectively (p50.05)
(Table 4).
One patient had convulsion associated with cerebral edema
in group treated with IV fluid. Otherwise no complication was
observed in both groups. This patient was born at 38 weeks
gestation and weighing 3550 grams. At seven days of age
(on admission), the infant weighed 10% below birth weight
and laboratory results included sodium 157 mmol/L, creatin-
ine 1.2 mg/dl. The serum sodium level fell to 145 mmol/L
12 hours after admission and the infant had a seizure at this
time. Computed tomography scan of the head revealed signs
of cerebral edema. After restricted fluid therapy, the patient
was discharged on the sixth hospital day with normal results
on an examination and feeding well.
Discussion
Hypernatremic dehydration in the newborn can cause severe
complications both during the condition itself and during
treatment. It is observed more frequently in breast-fed infants.
The cause of hypernatremic dehydration in breast-fed infants
is currently attributed to poor fluid intake rather than to high
DOI: 10.3109/14767058.2013.819334 Treatment of hypernatremic dehydration in newborns 493
Table 2. Characteristics of the groups.

Characteristics Parenteral (n ¼ 31) Enteral (n ¼ 44) p

Birth weight, g, mean  SD (range) 3390  62 (2700–4500) 3265  607 (2500–4400) 0.27
Gestational age, w, mean  SD (range) 39.0  1.4 (36–41) 38.9  1.5 (36–42) 0.57
Age at admission, d, mean  SD (range) 4.8  3.0 (2–15) 3.8  2.2 (1–17) 0.10
Weight loss, %, mean  SD (range) 7.5  6.6 (1–30) 5.0  3.3 (1–18) 0.03*
Male gender, % 61.3 70.5 0.41
First-born, % 77.4 79.5 0.75
Caesarean delivery, % 58.1 56.8 0.91
Sodium concentration at admission, mmol/L, median (range) 153 (150–168) 152 (150–158) 0.02*
Sodium concentration at 12 hours, mmol/L, median (range) 143 (133–159) 146 (140–152) 0.006**
Sodium concentration at 24 hours, mmol/L, median (range) 140 (130–150) 142.5 (136–149) 0.007**
Change in sodium (delta) at 12 hours, mmol/L, median (range) 11 (4–20) 7 (0–14) 0.000***
Change in sodium (delta) at 24 hours, mmol/L, median (range) 15 (5–28) 10 (4–16) 0.000***
Urea concentration at admission, mg/dl, median (range) 57 (27–175) 41 (17–107) 0.001**
Creatinine concentration at admission, mg/dl, median (range) 1.2 (0.3–2.4) 1.1 (0.7–2.0) 0.02*

*p50.05; **p50.01; ***p50.001.

Table 3. Comparison of the decline in sodium concentration between the

Hypernatremic dehydration has reported mostly in prim-
groups.
iparous mothers of infants due to lack of education on
Parenteral Enteral breast-feeding. Manganaro et al. [12] have reported that lower
(n ¼ 31) (n ¼ 44) p maternal education was a risk factor for hypernatremic
Safe drop at 12th hour 2 19 50.05 dehydration in neonates. Moritz et al. [13] found that
Non-safe drop at 12th hour 29 25 hypernatremic infants were significantly more likely to be
Safe drop at 24th hour 11 35 50.05 born to primiparous mothers. Livingstone et al. [5] noted that
Non-safe drop at 24th hour 20 9 the proportion of primiparous mothers whose infants had
hypernatremic dehydration was 17%. Similarly, 60 infants
Table 4. Comparison of the decline in sodium concentration between the (80%) were the first child of the mother in our study.
groups (if infants had a serum sodium concentration 4155 mmol/L). Hypernatremic dehydration has reported higher in cesar-
ean deliveries because of delay to start feeding. Manganaro
Parenteral Enteral et al. [12] and Erdeve et al. [14] have reported that cesarean
(n ¼ 11) (n ¼ 13) p
delivery was a risk factor for hypernatremic dehydration in
Safe drop at 12th hour 0 5 50.05 neonates. In this study, the proportion of neonates delivered
Non-safe drop at 12th hour 11 8 by cesarean section was 57.3%.
Safe drop at 24th hour 0 9 50.05
Non-safe drop at 24th hour 11 4 Age on presentation to the hospital ranged from 4 days to
21 days with an average of 11.7 days in case reports with
hypernatremic dehydration in the literature. The percentage
sodium concentration in the milk [3,9]. The last policy weight loss from birth weight ranged from 10% to 37% with
statement of the American Academy of Pediatrics about an average loss of 26% in these cases [11]. In this study, the
breast-feeding and the use of human milk have reported that mean admission day and weight loss of the neonates were
weight loss in the infant of greater than 7% from birth weight 4,3  2,6 days (range from 1 to 17) and 6,01  5,08 (range
should indicate possible feeding problems and should require from 1 to 30), respectively.
more intensive evaluation of breast-feeding [1]. In the studies of Moritz et al. [13] and Unal et al. [15], the
The degree and correction rate of hypernatremia are very most common complaint of the parents was neonatal jaundice
important during treatment and for prognosis [9]. with proportion of 87% and 47.3%, respectively. In our study,
Neurological complications of severe hypernatremic dehy- the most common presenting symptom was fever (61.8%).
dration may be cerebral venous thrombosis, pontine myeli- Despite the frequency of cases with fever, evidence of sepsis
nosis and if hypotonic fluid therapy is administered, brain was absent in 84.2% of the infants. Neonatal jaundice was
edema, seizures and death [6,10,11]. Despite these serious the presenting symptom in 30 (39.4%) of the neonates in our
complications, there is no sufficient data about the treatment study.
of hypernatremic dehydration in newborns. The major complications reported in neonates with
In recent studies, the reports of hypernatremic dehydration hypernatremic dehydration are convulsions, disseminated
in breast-fed infants have increased. Oddie et al. [2] have intravascular coagulation, vascular complications, renal fail-
reported the incidence of hypernatremic dehydration 2.5 per ure, dural thrombosis, massive intraventricular hemorrhage,
10 000 live births. Manganaro et al. [12] found that the brain damage and death [3,13,16]. The central nervous system
incidence of hypernatremia and weight loss of 410% was is affected most commonly due to both hyperosmolar state
7.7% in breast-fed infants. Moritz et al. [13] have reported that and rehydration therapy in these patients but complications
the incidence of breastfeeding-associated hypernatremia was characteristically occur during treatment rather than at
1.9% in hospitalized term and near-term neonates. Similarly, presentation [8,17].
these reports, seventy infants (93.3%) were exclusively breast- There is no clear consensus about the treatment of
fed in our study. hypernatremic dehydration in neonates but it requires careful
494 A. Erdemir et al.
rehydration to prevent cerebral edema and neurologic
sequelae. Central nervous system cells can maintain intracel-
lular volume despite slowly increasing plasma osmolality by
manufacturing intracellular osmotically active substances.
Rapid correction of plasma osmolality without allowing
sufficient time for the brain cells to dismantle these
substances causes cerebral edema and brain damage. These
osmoprotective molecules are broken down slowly while
serum osmolality diminishes rapidly [8,10,11,18].
Optimal correction rate of serum sodium in hypernatremia
is uncertain but fluid therapy for hypernatremic dehydration
correcting hypernatremia at a maximum safe decline (0.5–
1.0 mmol/L/h) is recommended [10,11]. The difficulty of
therapy is that in these patients with high levels of serum
sodium, even normal saline (154 mEq/L) is hypotonic and can
lead to too rapid decline in serum sodium levels.
Primarily, enteral route for rehydration fluid is recom-
mended in neonates with hypernatremic dehydration [19].
Fluid replacement was made by breast milk and/or oral
formula in infants with no feeding difficulties and by
intravenous fluid (4/5%10 dextrose þ 1/5 normal saline) in
infants with poor sucking or vomiting in our study. The deficit
fluid was administered with maintenance fluid within
48 hours.
In this study, the effectiveness of management approach
was evaluated according to the rate of decline in serum
sodium concentration (a decline of 50.5 mmol/L/h was
regarded as safe drop and of 40.5 mmol/L/h was regarded
as non-safe drop) and rehydration with oral feeding was found
more safely than intravenous fluid in infants with hyperna-
tremic dehydration.
The most common complication reported in neonates with
hypernatremic dehydration is seizure and always occur during
rapid rehydration therapy. Six of 16 (38%) breast-fed patients
with hypernatremic dehydration had seizures during rehydra-
tion therapy in a review [10,11,17,20]. In our study, only a
patient had convulsion associated with cerebral edema in
group treated with IV fluid. Other than this, no complication
was observed in this study.
The drawback of this study includes a low percent weight
loss and peak median serum sodium in comparison to other
studies which can alter the outcomes.
In conclusion, hypernatremic dehydration is a serious, life-
threatening disorder in neonates and recent studies indicate an
increase in the frequency. Early recognition and appropriate
management are essential to prevent complications. The main
goal of treatment is to restore circulating volume rapidly and to
avoid lowering the serum sodium level quickly. Although there
are various recommendations for the therapy, no certain
protocol is defined. In this study, we speculate that enteral
route for fluid replacement may be safe and effective and may
be an alternative to intravenous fluid therapy in newborns with
hypernatremic dehydration when clinical situation is stable.
J Matern Fetal Neonatal Med, 2014; 27(5): 491–494
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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