Ann Perry asks how a two day old baby could become hypernatremic, since the
fluid reserves they are born with should cover them through the first couple
of days on colostrum.  I don't know any of the details on the baby Ann
refers to, so my post is about a hypothetical baby based on lots that I have
seen in my career.

Some babies are born juicier than others.  Some babies show signs of
dehydration almost from birth - low skin turgor on the first day of life.
These are often dysmature babies who really need a continuous supply of
colostrum if they are to establish a normal fluid balance.  Lots of times
they will be able to manage because they have access to the breast without
limits or hindrances and are able to communicate what they need, but if the
mother doesn't know how important it is to let the baby just stay at the
breast, or if the mother is unable to get baby well latched or to express
and feed colostrum, these babies go downhill fast.  Think of a scenario with
a vacuum extraction or forceps for the 'fetal distress' that is not
uncommonly seen in cases of placental insufficiency, a 6 pound (approx 2700
g), 21 inch (52 cm), term baby with a bruised head, no energy or fluid
stores to draw on, and a mother whose large fleshy primiparous nipples are
made even less protractile by the fact that she was given several liters of
IV fluid during labor including some containing pitocin and who can't sit
comfortably because of the generous episiotomy she had with the VE.  They
are at the precipice from the beginning and it takes almost nothing to push
them over the edge.  
Sending babies home without either ascertaining that they are feeding well
at the breast or having close, competent follow-up in place for the first
few days after going home, is tantamount to child neglect, IMO.  Babies have
to be sent home in an approved car seat in many places, and sometimes they
are kept in hospital if they can't maintain oxygen saturation for 20 minutes
in that car seat, but what is done to make sure they can take in
nourishment?  (Rhetorical question, I know the answer, groan groan.)
It is so damaging for the mother's confidence in her ability to feed, for
the baby to be readmitted with a serious problem 'from breastfeeding' - not
to mention how damaging it is for her confidence in herself as mother.  And
we haven't even mentioned how dangerous it can be for the baby.

Just for the record, of course I don't think we should start measuring serum
electrolytes routinely before discharge.  We should redouble our efforts to
ensure that mothers and babies are getting it together before they are cast
out into the great unknown, because in virtually all cases the mother has
what the baby needs and wants, and this problem is avoidable.  

I will also disclose that in my hospital, many of the house pediatricians
(!!!) are quick to order FORMULA for these babies during the first 48 hours
of life 'until the mother has milk', as they do not seem to know that
formula actually subjects the baby to an obligate fluid loss, thus further
endangering them and prolonging the problem.  We're working toward applying
for certification as Baby-Friendly so I expect this to change and I will be
happier when it does.

Rachel Myr
Kristiansand, Norway

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