Psychiatric disorders are associated with increased risk for developing hyponatraemia in children
-
Jakub Zieg
and
Marie Glombova
Dear Sir,
We report two cases of water intoxication in adolescents. In case 1, an 18-year-old boy with mild mental retardation 5 months after cadaveric kidney transplantation due to bilateral kidney hypoplasia presented with hyponatraemic seizures and a sodium level of 119 mmol/L. He was normotensive at the time of the convulsions. His diuretic treatment was significantly reduced the day before the occurrence of the seizure because of high urine output. The dosage of furosemide was reduced from 200 to 120 mg/day, and hydrochlorothiazide (75 mg/day) was suspended. He was instructed to lower oral intake proportionately, but he drank 2.5 L of water in 2 h, which caused dilutional hyponatraemia. The patient was treated with hypertonic saline, and his serum sodium normalized within 36 h.
In case 2, a 14-year-old boy with attention deficit hyperactivity disorder was admitted to the hospital because of a disorder of consciousness of unknown aetiology. His current medication included the serotonin-norepinephrin reuptake inhibitor (SNRI) atomoxetine hydrochloride and the antihistamine levocetirizine. He was confused, disoriented to the time and place and scored 10/15 on the Glasgow Coma Scale. His sodium level on admission was 123 mmol/L. A brain CT showed neither intracranial haemorrhage nor ischaemia, and liquor analysis was normal. He was treated with hypertonic saline, and hyponatraemia was corrected within 24 h. His clinical condition improved significantly. We found excessive water ingestion as the reason for hyponatraemia in our patient.
Excess free water is the most common aetiology of hyponatraemia in children. Whereas infants are usually affected by being fed dilute fluids (1), hyponatraemia in older children and adolescents evolves in association with voluntary drinking. Reported causes of hyponatraemia associated with an abundance of free water due to factors of surroundings include child abuse in children with excessive water ingestion (2), treatment with desmopressin, endurance sport activity and iatrogenic hyponatraemia in hospitalized children, which is usually associated with the administration of hypotonic fluids, often in a setting of an excess of nonosmotic ADH stimulation, e.g., nausea or pain after surgery (3). Both our patients were mentally ill, and it is known that children with psychiatric disorders are at higher risk of habitual polydipsia or voluntary excess drinking, which may result in dilutional hyponatraemia. The precise pathogenesis is not known, but a hypothalamic defect and medication side effects are suspected (4). Some psychiatric drugs such as SNRIs, serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors and antipsychotics are associated with the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which is accompanied by hyponatraemia and may lead to hyponatraemic encephalopathy (HE) (5). Additionally, diuretic therapy reduction in case 1 contributed to hyponatraemia through a decrease in free water excretion. Generally, diuretic administration is one of the most frequent cause of hyponatraemia.
In conclusion, we present two cases of HE in adolescents. It should be emphasized that children with mental disorders are at risk for developing symptomatic hyponatraemia. Therefore, careful evaluation of their drinking habits is needed. Diuretic treatment should be avoided in patients with psychogenic polydipsia, because it may potentiate the risk of hyponatraemia. Clinicians should be aware of the fact that certain medication such as some psychiatric drugs may be associated with free water retention and extracellular fluid expansion due to SIADH. Thus, psychiatric patients and their carers should be provided with professional advice regarding prevention of hyponatraemia.
Competing interests: None.
Funding: None.
References
1. Hansen R. Hyponatraemic seizure in a 6-month-old infant due to water intoxication. J Paediatr Child Health 2014;doi: 10.1111/jpc.12646.10.1111/jpc.12646Search in Google Scholar PubMed
2. Joo MA, Kim EY. Hyponatremia caused by excessive intake of water as a form of child abuse. Ann Pediatr Endocrinol Metab 2014;18:95–8.Search in Google Scholar
3. Moritz ML, Ayus JC. Hospital-acquired hyponatremia – why are hypotonic parenteral fluids still being used? Nat Clin Pract Nephrol 2007;3:374–82.10.1038/ncpneph0526Search in Google Scholar PubMed
4. Dundas B, Harris M, Narasimhan M. Psychogenic polydipsia review: etiology, differential and treatment. Curr Psychiatry Rep 2007;9:236–41.10.1007/s11920-007-0025-7Search in Google Scholar PubMed
5. Zieg J. Evaluation and management of hyponatraemia in children. Acta Paediatr 2014;103:1027–34.10.1111/apa.12705Search in Google Scholar PubMed
©2015 by De Gruyter
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