Transcript TNO Presentation - Kennispoort Verloskunde

Borstvoeding:
Hypertone dehydratie
Kennispoort Verloskunde 2009
K van Wouwe en R Pelleboer, kinderartsen
Ko van Wouwe, kinderarts
Partner: Catharine Ziekenhuis Eindhoven
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Risico is groter
WHO: “breast is best”
• more mothers start in comparison with 1996
• weighing a baby is much less practice
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Risico is kleiner
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Hoe vaak?
• To establish the incidence of serious hypernatremic dehydration
in exclusively breastfed infants needing hospital admission in the
Netherlands
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Kenmerken van de kinderen
• Weight gain through extra feeding
• Fast weight loss
• Quiet baby’s
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Onderscheid
• during the first 2 weeks: not enough fluid (dehydration)
• > 2 weeks: not enough calories (failure to thrive)
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Studie duur
• From May 1st 2003 till July 1st 2005 a study through the Dutch
Pediatric Surveillance Unit amongst all pediatricians
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Meldingen
Reported cases
Other diagnosis
Too old
Insufficient data
Cases analysed
Boys/Girls
First born
Ko van Wouwe, kinderarts
250 (n)
81
9
2
158 (n)
77 / 78
58
50 / 50
37
TNO Kwaliteit van Leven, 26 November 2009
Anamnese
%
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
Ko van Wouwe, kinderarts
58
66
37
42
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
<1 / 8/ 11
34 / 16 / 4
22
TNO Kwaliteit van Leven, 26 November 2009
Incidentie
per year per 100,000 breastfed infants
Incidence rate in infants up to 3 months old
Clinical scored dehydration / in first born infants
58 / 46
Presumed hypernatraemic dehydration
20
Laboratory documented hypernatraemic dehydration
2
Incidence rate in infants up to 1 month old
Clinical scored dehydration
55
Incidence rate in infants up to ≤ 11 days old
Clinical scored dehydration
40
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Zorg
Lactation interventions
158 (n) (%)
Use of a breast pump at home
49
31
Use of a breast pump at the hospital
129
82
Lactation consultant available at the hospital 116
73
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Symptomen
Symptoms at admission
n
Age at admission, modus / median
3 / 7 days
Inadequate growth
96
61
Insufficient volume intake
65
41
Classical dehydration signs
39
25
Lethargy
35
22
Jaundice
18
11
Clinical response to fluid
10
6
Signs of shock or seizures
5
3
Inadequate body temperature
9
6
Ko van Wouwe, kinderarts
%
TNO Kwaliteit van Leven, 26 November 2009
Lab uitslagen
Laboratory tests
n
%
Serum bilirubin
50
32
Serum sodium measured / value ≥149 mmol/L
19 / 6
12 / 4
Various other tests
29
18
No laboratory entry
81
63
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Behandeling
Treatment
n
%
Nasogastric tube
48
30
Intravenous drip
34
21
Both
11
7
Duration of admission, median days
3
In hospital 1 day / 2 days / 3 days
13 / 33 / 35
8 / 21 / 22
≥ 4 – 10 days, ≥ 10 days
66 / 7
41 / 4
Exclusively breastfed at hospital
39
25
Breastfed and formula fed
84
53
Formula fed only
19
12
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Bij ontslag
At dismissal
n
%
Exclusively breastfed
52
33
Breastfed and formula fed
59
37
Formula fed only
30
19
Follow up by lactation consultant
20
13
Referred to breastfeeding organization
4
3
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Conclusie: problematisch klinisch beeld
• neonates have better preserved extracellular volume
• less pronounced clinical signs of dehydration
• low volume intake of human milk causes a disproportionate
deficit of water, relative to body sodium, in otherwise, healthy full
term infants
• (Laing, Archives 2002)
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Symptomen volgens tekstboeken
•
•
•
•
•
•
•
Skin turgor
Anterior fontanelle
Urine output
No underlying cause for hypernatraemia
Renal failure or thrombotic events
Underlying problem: water deficiency
Alert and hungry or lethargic, irritable and moribund
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Vergelijking
• Moritz:
(USA ’05, 470/y/100.000)
• Oddie:
(UK ‘01, 71/y/100.000 up to 1mo
• Pelleboer:
(NL, ’09, 55/ 71/y/100.000 up to 1mo
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Theorie
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Literatuur
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Onderzoek
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009
Beleid
Ko van Wouwe, kinderarts
TNO Kwaliteit van Leven, 26 November 2009