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# Pediatric Hypernatremia Treatment & Management

• Author: Ewa Elenberg, MD, MEd; Chief Editor: Timothy E Corden, MD  more...

Updated: Feb 13, 2014
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## Medical Care

Medical care involves the correction of hypernatremia. However, avoid rapid correction of sodium levels in patients with chronic hypernatremia, because a rapid decline in the serum sodium concentration can cause cerebral edema.

The recommended rate of sodium correction is 0.5 mEq/h or as much as 10-12 mEq/L in 24 hours. Dehydration should be corrected over 48-72 hours. Guidelines for hydration management have been established.[4] If the serum sodium concentration is more than 200 mEq/L, peritoneal dialysis should be performed using a high-glucose, low-sodium dialysate.

### Body water deficit

Body water deficit may be calculated. The equations used are based on a goal of plasma sodium concentration of 145 mEq/L. In children, total body water (TBW) is 60% of their lean body weight. Therefore, TBW = 0.6 X weight. Babies are an exception to these equations and may have a TBW as much as 80% of their body weight.

One of the following equations may be used to calculate body water deficit:

• Water deficit (in L) = [(current Na level in mEq/L ÷ 145 mEq/L) - 1] X 0.6 X weight (in kg)
• Water deficit (in L) = [(current Na level in mEq/L - 145 mEq/L)/145 mEq/L)] X 0.6 X weight (in kg)
• Water deficit (in L) = [1- (145 mEq/L ÷ current Na level in mEq/L)] X 0.6 X weight (in kg)

An example calculation is: A child weighs 10 kg and has a plasma sodium concentration of 160 mEq/L. By using the first equation, water deficit (in L) = [(160 mEq/L ÷ 145 mEq/L) - 1] X 0.6 X 10 = 0.62 L.

### Replacement fluid

The volume of replacement fluid needed to correct the water deficit is determined by using the concentration of sodium in the replacement fluid. The replacement volume can be determined as follows:

• Replacement volume (in L) = TBW deficit X [1 ÷ 1 - (Na concentration in replacement fluid in mEq/L ÷ 154 mEq/L)]

An example calculation is: If the patient from the example calculation above has a TBW of 0.62, and if the replacement fluid contains 0.2% NaCl (Na concentration of 34 mEq/L), the replacement volume (in L) = 0.62 L X [1 ÷ 1 - (34 mEq/L ÷ 154 mEq/L)] = 0.79 L. This volume has to be replaced slowly over 48-72 hours.

### Intravenous fluid

The election of intravenous fluid is based on the following:

• If the patient is hypotensive, normal saline (lactated Ringer solution, or 5% albumin solution) should be used regardless of a high serum sodium concentration.
• In hypernatremic dehydration, 0.45% or 0.2% NaCl should be used as a replacement fluid to prevent excessive delivery of free water and a too-rapid decrease in the serum sodium concentration.
• In cases of hypernatremia caused by sodium overload, sodium-free intravenous fluid (eg, 5% dextrose in water) may be used, and a loop diuretic may be added.
• The serum sodium concentration should be monitored frequently to avoid too-rapid correction of hypernatremia.
• In cases of associated hyperglycemia, 2.5% dextrose solution may be given. Insulin treatment is not recommended because the acute decrease in glucose, which lowers plasma osmolality, may precipitate cerebral edema.
• Once the child is urinating, add 40 mEq/L KCl to fluids to aid water absorption into cells.
• Calcium may be added if the patient has an associated low serum calcium level.

### Serum sodium levels

Serum sodium levels should be monitored every 4 hours.

### Further inpatient care

Inpatient management also includes the following:

• Record daily body weights in patients with hypernatremia.
• Frequently monitor electrolyte concentrations.
• Restrict sodium and protein intake.
• Treat the underlying disease.

### Transfer

Patients with symptomatic hypernatremia should be transferred to a pediatric intensive care unit for appropriate treatment and close monitoring.

Patients should be transferred to a facility that has dialysis in case of renal failure or in case the serum sodium concentration is more than 180 mEq/L.

### Diet

In diabetes insipidus, a sodium-restricted and protein-restricted diet should be prescribed

Next

## Consultations

Consultation is also recommended for patients with renal dysplasia, medullary cystic disease, reflux nephropathy, or polycystic disease. Consider obtaining consultations with the following specialists:

• Critical care specialist: Patients with symptomatic hypernatremia may need to be transferred to a pediatric ICU for appropriate treatment and monitoring.
• Endocrinologist: Consult an endocrinologist for patients with primary hyperaldosteronism.
• Nephrologist: Consult a nephrologist in cases of renal failure, obstructive uropathy, and serum sodium levels of more than 180 mEq/L for possible peritoneal dialysis.
Previous

Contributor Information and Disclosures
Author

Ewa Elenberg, MD, MEd Associate Professor of Pediatrics, Renal Section, Texas Children's Hospital, Baylor College of Medicine

Ewa Elenberg, MD, MEd is a member of the following medical societies: American Society of Nephrology, American Society of Pediatric Nephrology

Disclosure: Nothing to disclose.

Coauthor(s)

Muthukumar Vellaichamy, MD, FAAP Clinical Assistant Professor, Department of Pediatrics, Wesley Medical Center, University of Kansas School of Medicine-Wichita

Muthukumar Vellaichamy, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

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Figure A: Normal cell. Figure B: Cell initially responds to extracellular hypertonicity through passive osmosis of water extracellularly, resulting in cell shrinkage. Figure C: Cell actively responds to extracellular hypertonicity and cell shrinkage in order to limit water loss through transport of organic osmolytes across the cell membrane, as well as through intracellular production of these osmolytes. Figure D: Rapid correction of extracellular hypertonicity results in passive movement of water molecules into the relatively hypertonic intracellular space, causing cellular swelling, damage, and ultimately death.

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