What is the treatment for water intoxication seizures in a child?

Treatment of Water Intoxication Seizures in Children

Immediate management of water intoxication seizures in children requires fluid restriction, hypertonic saline administration with careful sodium correction (no more than 8-10 mmol/L increase in 24 hours), seizure control with benzodiazepines if needed, and close monitoring to prevent central pontine myelinolysis from overly rapid correction. 1, 2, 3

Immediate Stabilization and Safety

Seizure Management

• Place the child on their side in the recovery position to reduce aspiration risk, clear the area of objects, and stay with the child throughout the seizure 4, 5
• Never restrain the child, put anything in their mouth, or give oral medications during the seizure 4, 5
• Activate emergency medical services immediately for any first-time seizure, seizures lasting >5 minutes, or failure to return to baseline within 5-10 minutes 4, 5
• If seizures are ongoing or recurrent, administer intravenous lorazepam 0.05 mg/kg (up to 4 mg maximum) slowly, with airway equipment immediately available 6

Initial Assessment

• Obtain immediate serum sodium, glucose, and other electrolytes—hyponatremia (typically <120 mmol/L) is the hallmark finding in water intoxication 1, 2, 7
• Check for associated hypothermia and hyperglycemia, which are common features of the syndrome 1, 2
• Look for premonitory symptoms including marked diaphoresis, lethargy, and vomiting that often precede seizures 2
• Assess for respiratory distress, as severe cases may require intubation and ventilatory support 2

Definitive Treatment: Sodium Correction

Hypertonic Saline Administration

• Initiate hypertonic saline infusion (3% NaCl) with the critical goal of correcting serum sodium by no more than 8-10 mmol/L in the first 24 hours to prevent central pontine myelinolysis 3
• This rate can be cautiously exceeded only if life-threatening symptoms (ongoing seizures, severe altered mental status) do not resolve with initial correction 3
• Use formulae to calculate the exact sodium deficit and required hypertonic fluid volume for safer correction 3
• Monitor serum sodium levels frequently (every 2-4 hours initially) during correction 3

Fluid Restriction

• Institute strict fluid restriction as the cornerstone of management alongside sodium replacement 1
• Avoid any additional free water intake until sodium normalizes 1, 2

Common Clinical Pitfalls

Recognize the Underlying Cause

• Water intoxication in infants typically results from overdiluted formula, aggressive supplementation with water or clear juices, or excessive water feeding during gastroenteritis 1, 2, 7
• Document the feeding history carefully—infants averaging 5 months of age are most commonly affected 2
• Consider that hyponatremia accounts for the majority (58%) of afebrile seizures in children under 2 years 7

Avoid Overcorrection

• The most critical error is correcting sodium too rapidly, which causes irreversible central pontine myelinolysis with permanent neurological damage 3
• Even in life-threatening presentations, maintain vigilance about correction rates 3
• Do not assume this is epilepsy requiring chronic anticonvulsants—these are provoked metabolic seizures that resolve with sodium correction alone 5, 8

Monitoring and Disposition

Intensive Monitoring Required

• Admit to intensive care for continuous cardiorespiratory monitoring and frequent sodium checks 2, 3
• Maintain patent airway with equipment readily available, as respiratory compromise can occur 6, 2
• Monitor for resolution of seizures, return to baseline mental status, and normalization of temperature 1, 2

Expected Recovery

• With appropriate management, full recovery without long-term neurological complications is expected 3
• Seizures typically resolve once sodium is adequately corrected and do not require ongoing anticonvulsant therapy 5, 8

Parent Education

• Counsel parents on proper formula preparation and appropriate fluid intake for age 1, 2, 7
• Emphasize avoiding excessive water supplementation, especially during illnesses with vomiting or diarrhea 1, 7