Pediatric Hyponatremia Clinical Presentation

  • Author: Muthukumar Vellaichamy, MD, FAAP; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Jul 27, 2011
 

History

The history of patients with hyponatremia may include the following:

  • Hypotonic fluid use for maintenance hydration in hospitalized children (potential risk factor)
  • Feeding with hypotonic formula or excessive free water during infancy
  • Conditions that cause GI, Na-rich fluid loss, including the following:
    • Diarrhea
    • Vomiting
    • Fistulas
  • Renal disorders, including the following:
    • Salt-losing nephropathy
    • Acute renal failure
    • Chronic renal failure
  • Postoperative states[4]
  • Psychiatric conditions
  • Coma
  • Drug use
  • CNS and pulmonary diseases
  • Hypothyroidism
  • Adrenal insufficiency
  • Cirrhosis
  • Congestive heart failure
  • Acquired immunodeficiency syndrome (AIDS)
  • Cystic fibrosis
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Physical

  • CNS findings
    • Early signs include the following:
      • Anorexia
      • Headache
      • Nausea
      • Emesis
    • Advanced signs include the following:
      • Impaired response to verbal stimuli
      • Impaired response to painful stimuli
      • Bizarre behavior
      • Hallucinations
      • Obtundation
      • Incontinence
      • Respiratory insufficiency
      • Seizure activity
    • Far-advanced signs include the following:
      • Decorticate or decerebrate posturing
      • Bradycardia
      • Hypertension or hypotension
      • Altered temperature regulation
      • Dilated pupils
      • Seizure activity
      • Respiratory arrest
      • Coma
  • Cardiovascular findings
    • Hypotension
    • Tachycardia
  • Musculoskeletal findings
    • Weakness
    • Muscular cramps
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Causes

  • Hypervolemic hyponatremia (excess free-water retention)
    • Congestive heart failure
    • Cirrhosis
    • Nephrotic syndrome
    • Acute or chronic renal failure
  • Hypovolemic hyponatremia due to renal loss of sodium in excess of free-water
    • Diuretic excess
    • Osmotic diuresis
    • Salt-wasting diuresis
    • Adrenal insufficiency
    • Metabolic alkalosis
    • Pseudohypoaldosteronism
  • Hypovolemic hyponatremia due to extrarenal loss of sodium in excess of free-water
    • GI conditions, such as the following:
      • Vomiting
      • Diarrhea
      • Drains
      • Fistula
    • Sweat
    • Cystic fibrosis
    • Cerebral salt-wasting syndrome (CSWS)
    • Third-spacing conditions, such as the following:
  • Normovolemic hyponatremia
    • Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
      • Tumors - Adenocarcinoma of the duodenum, adenocarcinoma of the pancreas, carcinoma of the ureter, carcinoma of the prostate, Hodgkin disease, thymoma, acute leukemia, lymphosarcoma, or histiocytic lymphoma
      • Chest disorders - Infection (eg, tuberculosis or bacterial, mycoplasmal, viral, or fungal infection), positive-pressure ventilation, decreased left atrial pressure (eg, due to pneumothorax, atelectasis, asthma, cystic fibrosis, mitral valve commissurotomy, ligation of the patent ductus arteriosus ligation), or malignancy
      • CNS disorders - Infection (eg, tuberculous meningitis, bacterial meningitis, encephalitis), trauma, hypoxia-ischemia, psychosis, brain tumor, or miscellaneous CNS disorders (eg, Guillain-Barré syndrome, ventriculoatrial shunt obstruction, acute intermittent porphyria, cavernous sinus thrombosis, multiple sclerosis, anatomic abnormalities, vasculitis, stress, idiopathic causes)
      • Drugs (see image below)Drugs that impair water excretion. Drugs that impair water excretion.
    • Reset osmostat
    • Glucocorticoid deficiency
    • Hypothyroidism
    • Water intoxication due to intravenous (IV) therapy, tap-water enema, or psychogenic water drinking
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Contributor Information and Disclosures
Author

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

G Patricia Cantwell, MD, FCCM  Professor of Clinical Pediatrics, University of Miami, Leonard M Miller School of Medicine; Chief, Division of Pediatric Critical Care Medicine, Medical Manager, Urban Search & Rescue, South Florida TF-2, Medical Director, Holtz Children's Hospital Palliative Care Team, Medical Director, Tilli Kids – Pediatric Initiative of Hospice Care of SE Florida, Director, Pediatric Critical Care Transport, Holtz Children's Hospital/Jackson Memorial Hospital

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, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

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, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgments

The author would like to acknowledge his partner at work, mentor, and great physician Lindall Smith, MD, for reading the manuscript and offering valuable advice.

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