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HYPERNATRÆMIA AND GASTROENTERITIS
252
agulants at all. 36% used them in selected high-risk patients, usually meant patients with previous history of thromboembolism, significant heart-disease, and so on. One of the interesting findings of our survey was that 23% used one of the other antithrombotic pharmacological regimens (i.e., dextran, aspirin, low-dose heparin). This enthusiasm for drugs other than warfarin, which would have decreased bleeding complications, was even greater among academic orthopxdic surgeons and suggested that if the efficacy of such a regimen could be demonstrated it would be more readily adopted than warfarin prophylaxis. The significant difference of opinion among surgeons concerning the role that thromboembolic episodes play in the morbidity and mortality of hip-fracture patients was also evident in our survey. The findings for hip
which
reconstruction surgery were similar. It is interesting that in both the United States and the United Kingdom there has been considerable resistance to the acceptance of recommendations for routine anticoagulant prophylaxis of hip-fracture patients. This shows that more convincing data need to be obtained, and the follow-up article by Morris and Mitchell on the results of a trial with warfarin is an important step in that direction. Puget Sound Blood Center, Seattle, Washington 98104, U.S.A.
TOBY L. SIMON
HYPERNATRÆMIA AND GASTROENTERITIS
SIR,-It has been suggested that high-solute feeds from overconcentrated dried milks’and very early introduction of mixed feeding3 contributed to the high incidence of hypernatraemia complicating infantile gastroenteritis in Britain in recent years.4 In 1974 a working-party of the Department of Health urged that these practices should be discouraged and recommended that modified (low solute) milks should be given in preference to unmodified (high solute) milks.5 Against this background, it was therefore interesting to read the report by Dr Whaley and Dr Walker-Smith (Jan. 1, p. 51) of a drop in the frequency of hypernatrsemia in children admitted to hospital with gastroenteritis which, they suggest, might be a result of an increase in feeding low-solute milks. Our data confirm a decline in the incidence of hypernatrsemia which we believe is due, at least in part, to safer feeding practices. 75 infants under one year old were studied. These were consecutive admissions to gastroenteritis units at the East Glamorgan Hospital, South Wales, and Monsall Hospital, Manchester. The South Wales infants were admitted between November, 1974, and 1975 and those in Manchester between April and November, 1975. The mothers were asked about the milk usually given before the onset of illness, whether mixed foods were introduced before three months of age; and about the oral feeds given between the onset of illness and hospital admission. They were also asked to bring a sample of milk as usually made up so that -its osmolality could be measured as an index of concentration. Only 1 infant was hypernatra:mic (serum-sodium 152 mmol/1). This was a seven-week-old boy who had been fed on an unmodified milk formula with a concentration 95% of recommended; mixed feeding had not been introduced and only boiled water was given before hospital admission. None of the infants was being breast fed. 16 (21%) were fed modified milks, compared with 7% in a random sample of about 1000 South Wales infants between 1972 and 1973 (unpublished). However, the plasma-sodium levels of the infants fed unmodified and modified milks were the same at 137 mmol/1. Of 47 infants under three months old 1. 2. 3. 4. 5.
only
10
(21%)
were
Taitz, L. S., Byers, H. D. Archs Dis. Childh 1972, 47, 257. Stern, G. M., Jones, R. B., Fraser, A. C. L. ibid p. 468. Davies, D. P. Br. med. J 1973, ii, 340. Ironside, A. G., Tuxford, A. F., Heyworth, B. ibid. 1970, iii, 20. D.H.S.S. Working Party. Present tionery Office, 1974
Day Practice in Infant Feeding. H.M. Sta-
already introduced to mixed foods. This is a much lower figure than the 85-93% reported in Britain in the early 1970s/ 65 samples of milk were collected. 10 (15%) had a concentration 25% greater than recommended by the manufacturers but 22 (34%) were 75% less than recommended. Compared with earlier studies 1 2much greater care was clearly shown by the mothers in making up the milk feeds. From the onset of illness until hospital admission, 3 (4%) were given home-made sugar or salt solutions; the remainder were given boiled water or milk. These findings imply that attempts to discourage high-solute feeds are being successful, and it is tempting to suggest that this improvement contributed to the very low frequency of hypernatraemia in our infants admitted with gastroenteritis. However, this is unlikely to be the only explanation. Only 2 of the 75 infants required intravenous fluids which suggests that the gastroenteritis was mild. The amount of water needed to be conserved by the infant is likely, therefore, to have been well within the kidney’s limitations, particularly since function was not compromised before illness by too high a solute intake. We are undecided on the part played by modified milks, Most bottle-fed infants less than than six months old are now fed these milks since a 1976 D.H.S.S. recommendation’ that
when breast feeding is not possible modified milks should always be used. However, only 21% of our infants were fed modified milks which, though an improvement on earlier data, still constituted only a small proportion. We suggest that since the sodium levels in the two infant groups were similar, those who were fed the unmodified milks and who developed gastroenteritis were able to maintain plasma-sodium in the normal range because greater care was taken in making up the feeds, Attention to this detail might therefore have been more important than the tvpe of milk. Department of Child Health, Leicester Royal Infirmary, Leicester LE1 5WW
D. P. DAVIES
Department of Child Health, East Glamorgan General Hospital, Church Village, Mid Glamorgan, South Wales Department of Infectious Diseases, Monsall Hospital, Manchester
B. M. ANSARI
B. K. MANDAL
DRUGS FOR DIARRHŒA IN SMALL CHILDREN to see your editorial discouraging the of antidiarrhoeal agents for diarrhoea in young children.’e I fear that Mr Gough and Dr Ryder (Jan. 8, p. 91) have missed the most important point in your message. The mistaken but prevalent practice of prescribing opiates or binding agents for young children, especially in the first year, stems from a lack of appreciation of the difference in priorities when treating acute diarrhoea in adults and infants. In the adult, these drugs will mitigate the inconvenience and discomfort of frequent visits to the lavatory, and are therefore good treatment. In infancy, the overriding danger is of fluid and electrolyte loss from the body into the bowel, which these drugs’will not prevent, only mask. There are few more dangerous situations than pooling of fluid in the bowel, which is not manifest as diarrhoea. If a baby has diarrhoea, I want to know about it. Particularly to be deprecated is the use of compound preparations containing kaolin and an antibiotic. I can think of no indication for these expensive mixtures in early childhood, and I have seen a very severe reaction, with protein-losing enteropathy, in a small infant who had been given a sulphonamidecontaining mixture. The dangers of opiate poisoning from potent drugs such as ’Lomotil’ have been well documented.9
SiR,—Iwas very glad
use
6. Smith, B. A. M. Br. med. J. 1974, iv, 741 7. D.H.S.S. Baby Milk and Infant Feeding (CNO 76, 1). H.M. Office, 1976. 8. Lancet, 1976, ii, 1126. 9. Wheeldon, R., Heggarty, H. J. Archs Dis. Childh. 1971, 46, 562.
Stationery
agulants at all. 36% used them in selected high-risk patients, usually meant patients with previous history of thromboembolism, significant heart-disease, and so on. One of the interesting findings of our survey was that 23% used one of the other antithrombotic pharmacological regimens (i.e., dextran, aspirin, low-dose heparin). This enthusiasm for drugs other than warfarin, which would have decreased bleeding complications, was even greater among academic orthopxdic surgeons and suggested that if the efficacy of such a regimen could be demonstrated it would be more readily adopted than warfarin prophylaxis. The significant difference of opinion among surgeons concerning the role that thromboembolic episodes play in the morbidity and mortality of hip-fracture patients was also evident in our survey. The findings for hip
which
reconstruction surgery were similar. It is interesting that in both the United States and the United Kingdom there has been considerable resistance to the acceptance of recommendations for routine anticoagulant prophylaxis of hip-fracture patients. This shows that more convincing data need to be obtained, and the follow-up article by Morris and Mitchell on the results of a trial with warfarin is an important step in that direction. Puget Sound Blood Center, Seattle, Washington 98104, U.S.A.
TOBY L. SIMON
HYPERNATRÆMIA AND GASTROENTERITIS
SIR,-It has been suggested that high-solute feeds from overconcentrated dried milks’and very early introduction of mixed feeding3 contributed to the high incidence of hypernatraemia complicating infantile gastroenteritis in Britain in recent years.4 In 1974 a working-party of the Department of Health urged that these practices should be discouraged and recommended that modified (low solute) milks should be given in preference to unmodified (high solute) milks.5 Against this background, it was therefore interesting to read the report by Dr Whaley and Dr Walker-Smith (Jan. 1, p. 51) of a drop in the frequency of hypernatrsemia in children admitted to hospital with gastroenteritis which, they suggest, might be a result of an increase in feeding low-solute milks. Our data confirm a decline in the incidence of hypernatrsemia which we believe is due, at least in part, to safer feeding practices. 75 infants under one year old were studied. These were consecutive admissions to gastroenteritis units at the East Glamorgan Hospital, South Wales, and Monsall Hospital, Manchester. The South Wales infants were admitted between November, 1974, and 1975 and those in Manchester between April and November, 1975. The mothers were asked about the milk usually given before the onset of illness, whether mixed foods were introduced before three months of age; and about the oral feeds given between the onset of illness and hospital admission. They were also asked to bring a sample of milk as usually made up so that -its osmolality could be measured as an index of concentration. Only 1 infant was hypernatra:mic (serum-sodium 152 mmol/1). This was a seven-week-old boy who had been fed on an unmodified milk formula with a concentration 95% of recommended; mixed feeding had not been introduced and only boiled water was given before hospital admission. None of the infants was being breast fed. 16 (21%) were fed modified milks, compared with 7% in a random sample of about 1000 South Wales infants between 1972 and 1973 (unpublished). However, the plasma-sodium levels of the infants fed unmodified and modified milks were the same at 137 mmol/1. Of 47 infants under three months old 1. 2. 3. 4. 5.
only
10
(21%)
were
Taitz, L. S., Byers, H. D. Archs Dis. Childh 1972, 47, 257. Stern, G. M., Jones, R. B., Fraser, A. C. L. ibid p. 468. Davies, D. P. Br. med. J 1973, ii, 340. Ironside, A. G., Tuxford, A. F., Heyworth, B. ibid. 1970, iii, 20. D.H.S.S. Working Party. Present tionery Office, 1974
Day Practice in Infant Feeding. H.M. Sta-
already introduced to mixed foods. This is a much lower figure than the 85-93% reported in Britain in the early 1970s/ 65 samples of milk were collected. 10 (15%) had a concentration 25% greater than recommended by the manufacturers but 22 (34%) were 75% less than recommended. Compared with earlier studies 1 2much greater care was clearly shown by the mothers in making up the milk feeds. From the onset of illness until hospital admission, 3 (4%) were given home-made sugar or salt solutions; the remainder were given boiled water or milk. These findings imply that attempts to discourage high-solute feeds are being successful, and it is tempting to suggest that this improvement contributed to the very low frequency of hypernatraemia in our infants admitted with gastroenteritis. However, this is unlikely to be the only explanation. Only 2 of the 75 infants required intravenous fluids which suggests that the gastroenteritis was mild. The amount of water needed to be conserved by the infant is likely, therefore, to have been well within the kidney’s limitations, particularly since function was not compromised before illness by too high a solute intake. We are undecided on the part played by modified milks, Most bottle-fed infants less than than six months old are now fed these milks since a 1976 D.H.S.S. recommendation’ that
when breast feeding is not possible modified milks should always be used. However, only 21% of our infants were fed modified milks which, though an improvement on earlier data, still constituted only a small proportion. We suggest that since the sodium levels in the two infant groups were similar, those who were fed the unmodified milks and who developed gastroenteritis were able to maintain plasma-sodium in the normal range because greater care was taken in making up the feeds, Attention to this detail might therefore have been more important than the tvpe of milk. Department of Child Health, Leicester Royal Infirmary, Leicester LE1 5WW
D. P. DAVIES
Department of Child Health, East Glamorgan General Hospital, Church Village, Mid Glamorgan, South Wales Department of Infectious Diseases, Monsall Hospital, Manchester
B. M. ANSARI
B. K. MANDAL
DRUGS FOR DIARRHŒA IN SMALL CHILDREN to see your editorial discouraging the of antidiarrhoeal agents for diarrhoea in young children.’e I fear that Mr Gough and Dr Ryder (Jan. 8, p. 91) have missed the most important point in your message. The mistaken but prevalent practice of prescribing opiates or binding agents for young children, especially in the first year, stems from a lack of appreciation of the difference in priorities when treating acute diarrhoea in adults and infants. In the adult, these drugs will mitigate the inconvenience and discomfort of frequent visits to the lavatory, and are therefore good treatment. In infancy, the overriding danger is of fluid and electrolyte loss from the body into the bowel, which these drugs’will not prevent, only mask. There are few more dangerous situations than pooling of fluid in the bowel, which is not manifest as diarrhoea. If a baby has diarrhoea, I want to know about it. Particularly to be deprecated is the use of compound preparations containing kaolin and an antibiotic. I can think of no indication for these expensive mixtures in early childhood, and I have seen a very severe reaction, with protein-losing enteropathy, in a small infant who had been given a sulphonamidecontaining mixture. The dangers of opiate poisoning from potent drugs such as ’Lomotil’ have been well documented.9
SiR,—Iwas very glad
use
6. Smith, B. A. M. Br. med. J. 1974, iv, 741 7. D.H.S.S. Baby Milk and Infant Feeding (CNO 76, 1). H.M. Office, 1976. 8. Lancet, 1976, ii, 1126. 9. Wheeldon, R., Heggarty, H. J. Archs Dis. Childh. 1971, 46, 562.
Stationery