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Non-Accidental Salt Poisoning

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Non-Accidental Salt Poisoning 448 ArchivesofDiseasein Childhood 1993; 68: 448-452 Non-accidental salt poisoning Roy Meadow Arch Dis Child: first published as 10.1136/adc.68.4.448 on 1 April 1993. Downloaded from Abstract Table I Presentation of12 childrenfrom 10families The clinical features of 12 children who Sex (M/F) 6/6 incurred non-accidental salt poisoning are Age (months) of first confirmed hypernatraemia reported. The children usually presented to 11 children I 5-9 (median 2 - 5) 1 child 41 hospital in the first six months of life with Duration (months) of recurrent unexplained hypernatraemia and associated hypernatraemia 1-45 (median 3) illness. Most ofthe children suffered repetitive poisoning before detection. The perpetrator was believed to be the mother for 10 children, the mother confessed to the poisoning and the father for one, and either parent for one. explained how she had done it.) Four children had serum sodium concentra- tions above 200 mmol/l. Seven children had incurred other fabricated illness, drug inges- PRESENTATION tion, physical abuse, or failure to thrive/ The main features are outlined in table 1. neglect. Two children died; the other 10 Usually the child was presented to hospital remained healthy in alternative care. Features within the first three months of life because of are described that should lead to earlier repetitive illness. Vomiting was the predominant detection of salt poisoning; the importance of feature, often associated with diarrhoea and checking urine sodium excretion, whenever failure to thrive. At times there was drowsiness hypernatraemia occurs, is stressed. which, on occasion, could amount to coma. Four (Arch Dis Child 1993; 68: 448-452) children had markedly abnormal neurological signs including rigidity, hyper-reflexia, and seizures at the time of hypernatraemia. Six had Non-accidental poisoning is a serious form of at least one episode in which he/she became child abuse which is becoming recognised more comatose. Unless the child was vomiting excess- frequently.' 2 The usual perpetrator is the ively, or was comatose, thirst was a usual feature. mother who commonly uses therapeutic and (One doctor recorded 'every time he came into prescribed drugs such as laxatives, hypnotics, or hospital he drank like a fish'.) anticonvulsants to make her young child ill.3 Table 1 shows the age at which hyper- Sometimes household products, including cook- natraemia was verified. In several cases there are ing ingredients, pest killers and horticultural strong reasons for believing that salt was being http://adc.bmj.com/ agents, are given. One of the more common given to the child before the hypernatraemia was products used is common salt/table salt/sodium first identified. In all except two cases the chloride." children suffered repetitive poisoning. Poison- For many of the children the non-accidental ing usually recurred for about three months poisoning is part of Munchausen syndrome by before it was detected, but in one case it con- proxy child abuse.78 During the past 15 years, tinued over a period of45 months. These periods nearly 300 such cases have been referred to, and are minimum times as several ofthe children had on October 1, 2021 by guest. Protected copyright. studied by, the author. Altogether 20-25% ofthe recurrent alleged illnesses before the serum children have incurred non-accidental poisoning sodium concentration was measured. as part of the factitious illness abuse. The details All the children were referred initially to of 12 children who incurred salt poisoning are hospital paediatricians and were admitted to presented together with an analysis of the children's wards. In five cases the degree of features and the investigations that may lead to illness seemed mild to moderate. Seven children earlier identification of salt poisoning. had severe illness, three of whom required ventilation in intensive care units. The poisoned children CRITERIA FOR DIAGNOSIS ASSOCIATED PROBLEMS Each child had: Table 2 shows that five of the children appeared (1) Illness associated with high serum sodium to suffer only from salt poisoning. However the concentrations and even higher urine sodium other seven suffered a combination of problems concentrations. including other factitious illness and other forms (2) Normal renal, endocrinological, and other of abuse. One child suffered salt poisoning investigations during the course of extensive during admission for genuine pertussis. The Department of investigation for natural disease. other children had no major genuine health Paediatrics and Child (3) Cessation of hypernatraemia and good Health, St James's problem. University Hospital, health when separated from probable perpe- Leeds LS9 7TF trator. Correspondence to: (4) Circumstantial evidence indicating that SODIUM CONCENTRATIONS IN BLOOD AND URINE Professor Meadow. either the child's mother or the father was The children had repeated estimations of serum Accepted 18 November 1992 poisoning the child with salt. (For seven children sodium concentrations, partly because the Non-accidental saltpoisoning 449 Table 2 Otherproblemsfor clinicians tended to be incredulous at the high children there was either definite, or highly 12 poisoned children concentrations that were reported, and partly probable, evidence that the parent poisoned the Failure to thrive/neglect 4 because of the detailed testing that the children child while the child was resident in hospital as Recurrent apnoea/seizures 3 underwent to find a cause for the recurrent well as at home. In addition to the other facti- Other fabricated ilness 3 Arch Dis Child: first published as 10.1136/adc.68.4.448 on 1 April 1993. Downloaded from Other drug ingestion 2 hypernatraemia. The highest serum sodium con- tious illnesses and abuse that seven of the Physical abuse 2 centration recorded for each child lay in the children incurred, a number of unusual happen- No other abuse/problems 5 range 150-228 mmol/l (table 3). Five children ings are worthy of note. Two children yielded had very high concentrations (190, 210, 213, extraordinarily high concentrations of sodium 216, and 228 mmol/l); the other seven children and chloride (above 1000 mmol/l) when sub- had highest values in the range 150-175 mmol/l. jected to sweat tests while in the care of their The three children who required ventilation all mothers. Two of the mothers, similarly tested, had concentrations above 200 mmolll and one yielded extraordinarily high concentrations died. But of the five with very high values four, themselves; one of the mothers subsequently including the one with the serum sodium of 228 admitted to tampering with the test. One mother mmol/l, survived without apparent brain provided two samples of her breast milk which damage or other long term injury; another child yielded sodium concentrations of 68 and 165 died during follow up, with a serum sodium of mmol/l. Subsequent samples collected under 200 mmol/l. The urine sodium concentration at nursing supervision all had a sodium content in the time ofthe hypernatraemia ranged from 150- the range 1-93-5 mmol/l. For another child, 360 mmol/l. Usually it was in the range 200-230 a reliable and well maintained infusion set sud- mmol/l. Otherwise the serum electrolytes were denly ran in an extra 100 ml offluid inexplicably unexceptional. The serum chloride, when while the mother was alone with the baby in a measured, was raised but the bicarbonate and hospital cubicle. urea concentrations were usually normal or low. The high urine sodium concentration was accompanied by high urine chloride concentra- Outcome for index child tion when that was measured. The high serum All the children were investigated and assessed sodium concentration usually returned to through standard child abuse procedures. One normal within 24 hours, except in those cases of child died in hospital at the time of acute extreme hypernatraemia where the clinicians hypernatraemia. Ten children were taken into deliberately tried to lower the serum sodium care away from the perpetrator. That served the concentration more slowly. dual purpose of ensuring the safety of the child and verifying the diagnosis (in that the children immediately became well when separated from The poisoning the perpetrator, and thereafter had no further In 10 cases there was circumstantial evidence episodes of hypernatraemia or unusual illness). implicating the mother. (In seven of which the One child remaining with the perpetrator died mother confessed to her actions and explained suddenly a few months later (and had a serum how she had done it - usually adding table salt to sodium of 200 mmol/l shortly before death). http://adc.bmj.com/ the child's drink or putting salt in the child's mouth.) In one case there was circumstantial evidence implicating the father and, for one Siblings child, circumstantial evidence implicating the In six of the 10 families there were siblings in parents without it being clear whch one was addition to the index child. Of the 12 siblings, responsible. five appeared healthy and there was nothing to Both the histories and the laboratory findings suggest that they were being abused. However on October 1, 2021 by guest. Protected copyright. suggested repetitive poisoning for 10 children. seven siblings were incurring, or had incurred, Further information about the mode of poison- problems; these are listed in table 4. ing was available for seven ofthe children: excess salt was identified in the milk that the mother was about to give the child in four cases and in Psychopathology ofperpetrators fruit drink for one child. Two further children Several of these mothers form part of a were found to have exceedingly high salt concen- more detailed psychosocial study of mothers trations in their stomachs and, for one of these, who fabricate illness and cause their child the mother admitted to placing it there via a Munchausen syndrome by proxy abuse. Details nasogastric tube. For at least nine of the 12 of that study will be published.
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