What is the appropriate management for a 6‑month‑old infant with viral hepatitis who presents with hyponatremia, hypokalemia, and hyperglycemia?

Management of a 6-Month-Old with Viral Hepatitis Presenting with Electrolyte Disturbances and Hyperglycemia

This infant requires immediate assessment for acute liver failure and aggressive supportive care with careful fluid and electrolyte management, as the combination of hyponatremia, hypokalemia, and hyperglycemia in the setting of viral hepatitis suggests significant hepatic dysfunction with potential for rapid deterioration.

Immediate Risk Stratification and Assessment

The presence of electrolyte abnormalities and hyperglycemia in a 6-month-old with viral hepatitis mandates urgent evaluation for acute liver failure. You must immediately assess for coagulopathy (check PT/INR), encephalopathy (mental status changes, altered consciousness), and hypoglycemia risk, as any of these indicate potential acute liver failure requiring immediate specialist consultation or emergency evaluation 1, 2.

Key parameters to check immediately include:

• Prothrombin time/INR, albumin, and comprehensive metabolic panel 1
• Mental status and neurological examination for encephalopathy 1, 2
• Signs of ascites or portal hypertension 1, 2
• Viral hepatitis serologies if not already done (HBsAg, anti-HAV IgM, anti-HCV) 2

Critical Supportive Care for Fluid and Electrolyte Management

The cornerstone of management is aggressive supportive care with meticulous attention to fluid restriction and electrolyte correction 3:

Fluid Management Strategy

• Restrict fluid therapy to 50-60% of maintenance volume calculated by the Holliday-Segar formula to prevent fluid overload and worsening edema, which can exacerbate hyponatremia 1, 2
• Use only isotonic maintenance fluids (normal saline or balanced crystalloids) to reduce hyponatremia risk 1, 2
• Avoid lactate-buffered solutions (like Ringer's lactate) in severe liver dysfunction to prevent lactic acidosis, as the liver cannot metabolize lactate effectively 1, 2

Electrolyte Correction Approach

For hyponatremia in the setting of liver disease:

• The hyponatremia is likely hypervolemic (dilutional) due to impaired free water excretion from hepatic dysfunction 4, 5
• Correct slowly to avoid osmotic demyelination syndrome—do not increase serum sodium by more than 8-10 mEq/L in 24 hours 4, 5
• Fluid restriction is the primary intervention for asymptomatic or mildly symptomatic hyponatremia 4, 5
• Hypertonic saline is reserved only for severe, symptomatic hyponatremia with neurological manifestations 4, 5

For hypokalemia:

• Correct cautiously with potassium supplementation while monitoring cardiac rhythm
• Check magnesium levels as hypomagnesemia often coexists and prevents potassium repletion

Glucose Management

• Monitor glucose levels closely (every 4-6 hours initially) as infants with acute liver failure are at high risk for hypoglycemia despite presenting with hyperglycemia 1, 2
• The hyperglycemia may reflect stress response or impaired hepatic glucose regulation 6
• Provide glucose-containing maintenance fluids (D5 or D10 in isotonic saline) once hyperglycemia resolves to prevent hypoglycemia 6

Daily Monitoring Protocol

Implement intensive monitoring until the patient stabilizes 1, 2:

• Fluid balance (strict input/output) every shift
• Electrolytes (sodium, potassium, chloride, bicarbonate) daily or twice daily if unstable
• Glucose monitoring every 4-6 hours initially, then every 8 hours when stable
• Liver function tests (ALT, AST, bilirubin, albumin) and coagulation studies (PT/INR) daily 1, 6
• Mental status examination every 4-6 hours to detect early encephalopathy 1, 6

Etiology-Specific Considerations

While supportive care is paramount, identifying the specific viral etiology guides additional management 2:

If Hepatitis A

• This is typically self-limiting in children, though infants under 6 years can develop acute liver failure 7, 8
• Management is entirely supportive 7
• The child is highly infectious; implement contact precautions 7

If Hepatitis B

• At 6 months of age, this likely represents perinatal transmission 9
• If the infant shows signs of acute decompensation or has evidence of cirrhosis, consider immediate antiviral therapy regardless of ALT or HBV DNA levels 1
• Lamivudine is the only nucleoside analog with data in very young children, though it has high resistance rates 9

If Hepatitis C

• Acute liver failure from HCV is rare in infants 8
• Treatment is not indicated in acute phase; focus on supportive care 9, 8

Warning Signs Requiring Immediate Escalation

Do not delay specialist consultation or transfer to a tertiary center with pediatric hepatology and transplant capabilities 2. Immediate escalation is required for:

• Worsening coagulopathy (rising INR) 1, 2
• Mental status changes or encephalopathy 1, 2
• Worsening jaundice or rising bilirubin 2
• Abdominal distension suggesting ascites 1, 2
• Unusual bleeding or petechiae 2
• Persistent vomiting or inability to maintain hydration 2
• Fever suggesting secondary infection 2

Common Pitfalls to Avoid

• Do not use hypotonic fluids, which will worsen hyponatremia 2
• Do not correct hyponatremia rapidly, as this can cause irreversible osmotic demyelination syndrome 4, 5
• Do not assume hyperglycemia will persist—infants with liver failure can rapidly develop life-threatening hypoglycemia 6
• Do not delay referral—the threshold for specialist consultation should be lower in children than adults, especially infants 1, 2
• Do not overlook fluid overload, which can exacerbate ascites and worsen outcomes 1, 2

Disposition and Follow-Up

This infant requires hospitalization, likely in a pediatric intensive care unit setting given the age and metabolic derangements 6. Transfer to a center with pediatric liver transplant capability should be considered early if there is any evidence of acute liver failure (coagulopathy, encephalopathy, or rapidly rising bilirubin) 6, 8. Mortality in pediatric acute liver failure is predominantly due to raised intracranial pressure, infections, and multi-organ failure 6.