We would like to thank Karthikeyan and Modi for their concerns regarding issues related to breast-feeding arising out of our report(1). While we share their concern towards promotion of breast-feeding, adverse events related to inadequate breast-feeding do occur rarely and cannot be ignored. Various case reports have reported catastrophic outcomes related to inadequate lactation resulting in failure to thrive, dehydration and death(2).

1. In our report, all the three neonates were exclusively breast fed and had evidence of under-feeding at admission. This was probably related to inadequate lactation and dehydration in these neonates. In two of the three cases, we were successful in establishing breast-feeding. This was noted in the form of weight gain in the neonates and a drop in breast milk sodium. This is consistent with the comment made by Karthikeyan and Modi in which it was stated that 55% mothers with elevated breast milk sodium were successful in breastfeeding(3). We have emphasized the need of breastfeeding counseling and evaluation for adequacy of lactation at the end of the report.

2. The main concern of Karthikeyan and Modi seems to be regarding the diagnosis and management of the first neonate with hypernatremia. We would like to share our thoughts on this issue. The classical response to hypernatremic dehydration in children is sodium conservation(4). In these children, sodium re-absorption in the renal tubules is increased and hence urinary sodium is usually low. In contrast, hypernatremia related to increased sodium intake results in excretion of sodium with resultant high urinary sodium(5). High urinary sodium has been used for the diagnosis of sodium overload related hypernatremia. Since, this neonate had high urinary sodium in the presence of hypernatremia, we suspected sodium overload as one of the possiblities.

3. The neonate was on exclusive breast-feeding and no other supplements were being given. Hence breast milk was considered to be the source of sodium overload. Significant and persistent elevation of breast milk sodium in Case 1 pointed towards a possible contributory role of high breast milk sodium in hypernatremia in this case.

4. While emphasizing on the findings in experimental mammals, Karthikeyan and Modi have not considered the classical response of sodium conservation in humans in response to dehydration induced renal hypoperfusion. The renal physiology in other mammals is different and it is possible that their sodium handling capacity is better than humans(6).

5. Contrary to the statement of Karthikeyan and Modi, we have mentioned that fluid therapy in these neonates was based on free water deficit and level of dehydration in standard fashion. Seizures are a known complication of hypernatremic infants and the seizures noted in case I occurred inspite of and not because of the fluid therapy used.

6. We would like to state that at no point have we advocated cessation of breast-feeding in breast-milk related hypernatremia. Breast-feeding should definitely be encouraged in mothers and breast milk sodium usually normalizes with improving lactation. Oral feeds had been stopped at admission in the 1st case due to lethargy in the neonate. However in view of the persistently high breast milk sodium and inadequate lactation, formula feeds were started in this infant. In the other two cases, breast-feeding was encouraged and these infants were discharged on exclusive breast feeds. Adverse events related to breast-feeding cannot be ignored for the fear that it will hamper the promotion of breast-feeding. Rather, our message was to create an awareness of this condition and to highlight the importance of breast-feeding counseling in the successful management of these cases.

Anurag Bajpai,
Rajiv Aggarwal,
Ashok K. Deorari,
Vinod K. Paul,
Department of Pediatrics,
All India Institute of Medical Sciences,
Ansari Nagar New Delhi, India.

1. Bajpai A, Aggarwal R, Deorari AK, Paul VK. Neonatal hypernatremia due to high breast mill sodium. Indian Pediatrics 2002; 39: 193-196.

2. Neifert MR. Prevention of breast-feeding tragedies. Pediatr Clin North Am 2001; 48: 273-297.

3. Neville MC, Keller R, Seacat J, Lutes V, Neifert M, Casey C et al. Studies in human lactation: milk volume in lactating women during the onset of lactation and full lactation. Am J Clin Nutr 1988; 48: 1375-1386.

4. Haycock GB. Sodium and body fluids. In: Barratt TM, Avner ED, Harmon WE, editors. Lippincot: Pediatric Nephrology 4th Edn. Williams and Wilkins, 1999 pp 133-153.

5. Meadow R. Non-accidental salt poisoning. Arch Dis Child 1993; 68: 448- 452.

6. Finberg L. Hypernatremic dehydration. In: Finberg L, Kravath RE, Hellerstein S, editors. Water and Electrolytes in Pediatrics: Physiology, Pathology and Treatment, 2nd edition. Philadelphia: W.B. Saunders company, 1993. pp 124-134.