Stille ondervoeding aan de borst: hoe bestaat het? - Borstvoeding.com

Stille ondervoeding aan
de borst: hoe bestaat het?
Rolf Pelleboer
Kindergastro-enteroloog enteroloog
Catharina-ziekenhuis Eindhoven

(Hypernatraemic) dehydration and
malnutrition in fully breastfed
infants in the Netherlands
Rolf Pelleboer, pediatric gastro-enterologist and Sander Bontemps,
registrar Pediatrics, Catharina-hospital hospital Eindhoven (at present:
Maastricht)
Rob Pereira and Ko van Wouwe, pediatricians, and Paula van
Dommelen, Paul Verkerk, TNO Qualityof Life, Leiden, the
Netherlands

Overzicht
• 1. Casus
• 2. Studie stille ondervoeding aan de borst via de
NSCK
• 3. Conclusies

Prevalence of breastfeeding in the Netherlands
Years
Day1
3 Months 6 Months
1996 70% 17% 6%
2001 80% 35% 17%
2005 79% 35% 25%

Birth rates in the Netherlands
• 2003: 200.000 births
• 2004: 194.000 births
• 2005: 187.000 births
• (2006: 185.000)

DB, meisje, geb. 270304
• Moeder G 1 P 0, russische, hoog opgeleid
• Vanaf 33e week zwsch in NL
• Zwsch ongecompliceerd
• Poliklinische partus in ons ziekenhuis
• Via verloskundige, geb.gew. 3325 gram
• AS 9-10
• < 1 uur pp aangelegd

• Op 4-5-04 gezien op SEH ivm. ernstige
ondervoeding
• Gew. 2650 gr., - 675 gr. ( 20% gew. verlies)
• Moeder gaf dag en nacht BV
• Moeder had er veel over gelezen

• Eerste week pp: geen problemen
• Later navraag: gew. op dag 10: 3100 gr.
• Babywas vrij rustig, huilde niet abnormaal veel
• Consult ha. 3 wk. pp ivm slecht groeien: ha. was
tevreden
• Bij 5 wk. eerste contact CB: 2650 gr.

Lichamelijk onderzoek:
• Zeer ernstig ondervoed kind
• Zeer bleek
• Ingevallen fontanel
• Vitale parameters stabiel
• Lever en milt niet palpabel
• Gespannen neonaat met hoge tonus

Aanvullend onderzoek:
• Hb 9,3 mmol/l; leuco’s 6,6/nl; thr. N
• CRP < 6 mg/l; gluc. 4.8 mmol/l
• ASAT 454, ALAT 326, LD 917, AF 269 u/l
• pH 7,40; Na 138; K 4,9; Cl 105 mmol/l

Aanvullend onderzoek:
• Veel lab naar oorzaak verhoogde transaminasen:
alles neg.
• Echo abdomen: geen afw.
• Zweettest 2 x mislukt
• X Thorax geen afw.

Conclusie:
• Ernstige SOB met fors afwijkende
transaminasen ( geduid als passend bij
ondervoeding) bij Russische primipara

Behandeling:
• Voor en na BV wegen: er kwam heel weinig BV
• Bijvoeding bij BV: gew. vloog omhoog
• ( 330 gr. in eerste week)
• Transaminasen daalden fraai
• Video interactie begeleiding
• Ontslag 20 mei: gew. 3290 gr
• Eerste weken na ontslag: BV en FV bijvoeding
• Op 2 aug: ( 4 ½ maand) 6 kg., 62,5 cm .
• Goede tonus en prima ontwikkeling

Objective:
• To establish the incidence of malnutrition/
(hypernatremic) dehydration in fullybreastfed
infants in admitted children in the Netherlands

Inclusion criteria(1)
• Everybabywith insufficient amount of breast
feeding but who doesn’t cry(is quiet)
• Veryfast weight gain through extra feeding with
weighing before and after breastfeeding or
measuring the amount of milk through
expressed breast milk
• Clear (and often impressive) undernutrition;
weight after f.i. 1 month still under birth weight
(failure to thrive)

Inclusion criteria (2) : 2 types
• In the first 2 weeks: not enough fluid (with
the risk of f.i. hypernatraemia)
• > 2 weeks: not enough calories (failure to
thrive)

Case definition
• Everybabyadmitted in the hospital within
the first 3 months of life exclusively
breastfed with (hypernatraemic)
dehydration or malnutrition (FTT) who
seemed satisfied
• Exclusion: UTI, bronchiolitis, much crying,
diarrhoea, etc.

Methods
• From mid 2003 till mid 2005 we did a
surveillance studyin the Netherlands through
the Dutch Pediatric Surveillance Unit amongst
all Dutch pediatricians
• This is the first prospective orientating study
worldwide as far as we know

Characteristics of Dutch infants up to 3 months old
admitted for dehydration or undernutrition over a 2-year
period
Reported cases
250 (n)
Other diagnosis/outpatient
81
Age > 3 months
9
Insufficient data
2
Cases analysed
Boys/Girls
First born
158 (n) 100
(%)
77 / 78
58
50 / 50
37

History
Home delivery
Hospital delivery: natural birth
Hospital delivery: 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
158 (n) %
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

Incidence rates of Dutch infants admitted
for dehydration while breastfed
Incidence rate in infants up to 3 months old
per year
per 100,000 breastfed
infants
Clinical scored dehydration / in first born
infants
Presumed hypernatraemic dehydration
Laboratory documented hypernatraemic
dehydration
Incidence rate in infants up to 1 month old
Clinical scored dehydration
Incidence rate in infants up to ≤ 11 days old
Clinical scored dehydration
58 / 46
20
2
55
40

Clinical characteristics of Dutch infants up to 3 months old
admitted for dehydration over a 2-year period
Lactation interventions
158 (n) 100 (%)
Use of a breast pump at home
49
31
Use of a breast pump at the
hospital
Lactation consultant available at
the hospital
129
116
82
73

Symptoms at admission
158 (n) %
Age at admission, modus / median
Inadequate growth
Insufficient volume intake
Classical dehydration signs
Lethargy
Jaundice
Clinical response to fluid
Signs of shock or seizures
Inadequate body temperature
3 / 7 days
96
65
39
35
18
10
5
9
61
41
25
22
11
6
3
6

Laboratory tests
158 (n) %
Serum bilirubin
Serum sodium measured /
value ≥149 mmol/L
Various other tests
No laboratory entry
50
19 / 6
29
81
32
12 / 4
18
63

Clinical picture of hypernatraemic
dehydration
• Notoriouslydifficult
• Neonates have better preserved extracellular
volume and therefore less pronounced clinical
signs of dehydration
• Lowvolume intake of human milk causes a
disproportionate deficit of water, relative to
bodysodium, in otherwise, healthyfull term
infants (Laing, Archives 2002)

Clinical picture
• Spectrum from alert and hungryto lethargic,
irritable and moribund
• Skin turgor is preserved
• Anterior fontanelle can retain its normal fullness
• Urine output, although reduced, can be
maintained
• No underlying cause for hypernatraemia
• Renal failure or thrombotic events
• Underlying problem: water deficiency

Incidence of hypernatraemic
dehydration
• Oddie: (UK ‘01, 71/y/100.000 up to 1mo)
• Moritz: (USA ’05, 470/y/100.000)

Ned Tijdschr Geneeskd. 2006;150:904-8
(Weight loss, serum sodium concentration and
residual symptoms in patients with hypernatremic
dehydration caused by insufficient breastfeeding;
Dutch Journal of Medicine)

Five-Year Neurodevelopmental
Outcome of Neonatal Dehydration
(Escobar, J.Pediatrics, 8/ 07)
• Results are reassuring

Hypernatraemic dehydration
• Found: 2/year/100.000
• Estimated: 22/year/100.000
• We found 6 cases (Na 152-186 186 mmol/L), 5 of
them 2-4 days of age, 1 was 14 days of age, none
hyperbilirubinemia, none hypoglycemia

Hypoglycemia
• 3 children: bls 0,1-1,9 1,9 mmol/L, 1 with
convulsions Nicu

Importance of weighing babies

Conclusions:
• Weighing babies earlycoupled with
appropriate lactation support resulted
in earlyrecognition of hypernatraemic
dehydration, with less dehydration, less
severe hypernatraemia and higher
breast feeding rates in the short and
medium term

Conclusions
• Diagnosis is difficult to make (Dutch
pediatrician is not familiar with this
diagnosis); probablysome cases are missed;
also there is a wide varietyin severityof the
diagnosis
• (Hypernatraemic) dehydration and
malnutrition in apparentlysatisfied fully
breastfed infants are not veryrare entities

Conclusions (2)
• Hypernatremic dehydration, a severe
complication, was 6 x noted (Na measured
only24 x); Na 152-186 186 mmol/l !
• Severe hypoglycaemia was encountered in
3 patients and 1 of them had severe
convulsions
• Hyperbilirubinaemia and dehydration: what
is first and what is second?

Recommendations
• Weighing the babymore frequentlyduring
the first month after birth will probably
prevent manyof these cases (as mentioned
bythe newNutrition Bulletin (2007) of the
Netherlands Nutrition Centre)
• Sodium should be measured more often
• Breast pump at home should be used more
often

Funds
• Scientific Foundation Catharina-
hospital Eindhoven

Acknowledgements
• Regien Carbo, pediatric nurse in Cath
who put all the data in Excel
• All the Dutch pediatricians, who
contributed and filled in the
questionnaires

Thank you!
Rolf Pelleboer
Pediatric gastro-enterologist
Catharina-ziekenhuis Eindhoven