Hypernatraemia: why bother weighing breast fed babies?

Editor—Hypernatraemic dehydration is associated with cerebral oedema, intracranial haemorrhage, hydrocephalus, gangrene, and death,1 but is notoriously difficult to detect clinically. It is accepted in paediatric practice that weighing is an essential part of the assessment of an infant's hydration.

In Bristol, one neonate a month is admitted with hypernatraemic dehydration secondary to delayed recognition of inadequate lactation. We believe that this is a result of the reluctance of midwives to weigh breast fed infants.

Five neonates admitted after they became unwell from dehydration secondary to lactation failure are described (table 1). Assessment of lactation and hydration had raised no concern. Four of five of these mothers were primigravidas and four of five gave up breast feeding despite encouragement to continue.

The weighing practices of midwifery teams and the opinion of neonatologists throughout the South West Region were compared by telephone survey. Four of 13 community midwifery units always or often weighed babies on day 3, 4, or 5, and the other nine routinely weighed for the first time since birth on day 7 or 10. Twelve of 14 consultant neonatologists thought that the optimum care would be provided by routinely weighing on day 3, 4, or 5 after birth (midwifery practicev consultant opinion, p = 0.006; χ² test).

Hypernatraemic dehydration as the result of failure to establish lactation is well described, although not recently in this country. Associated factors include first time motherhood, poor support of lactation, and failure to monitor early weight loss.2Identification of excessive weight loss can swiftly identify breast feeding problems, enabling appropriate lactation support to be given and prevention of hospital admission.

In common with the American Academy of Pediatrics and others, we recommend that breast fed infants should be weighed between 72 and 96 hours after birth when normal weight loss is at its maximum.3