Intracranial haemorrhage due to vitamin K deficiency associated with alpha-1-antitrypsin deficiency type PiZ.

Sir, Sandhu et al.1 showed convincingly that oral rehydration with a glucose-polymer solution (12.5 g/100 ml, giving 730 mmol/l glucose) and 90 mmol/l sodium predisposes to hypernatraemia. In so doing they reproduced the circumstances that contributed to the epidemic of hyper-natraemia in the 1950s.2 At that time commercial oral rehydration solutions were changed to high concentrations of glucose polymers, and probably caused hypernatraemia despite an unexceptional concentration of sodium, 50 mmol/l. The imbalanced ratio of glucose to sodium, and the high concentration of the former, cause osmotic loss of water from the intestines,2 and increase stool loss (well demonstrated in the study by Rodriguez et al.3 cited also by Sandhu et al.). The authors mis-stated my analysis2 of the nutritional benefit of oral rehydration. It is not the glucose content that benefits, as they imply, but the improved appetite for normal foods brought about by rapid rehydration and electrolyte repletion. Trying to increase caloric density with an expensive poly-glucose is the wrong approach to nutrition as well as to rehydration. Rapid oral rehydration with the WHO formula, using the monomer glucose, or sucrose, and early refeeding is a well-proved treatment which does not lead to hyper-natraemia even in rotavirus infection.2 Oral rehydration in acute infantile diarrhoea with a glucose-polymer electrolyte solution. Arch Dis Child 1982; 57: 152-4. 2 Hirschhorn N. The treatment of acute diarrhea in children. An historical and physiological perspective. Treatment of acute diarrhoea with oral electrolyte solutions (abstract). Dr Sandhu and co-workers comment: It is true that palatability of a glucose-polymer electrolyte solution may prove a problem in older children, but the child referred to by Dr Hughes-Davies as refusing received sufficient to allow rehydration. We agree that glucose-polymer may be incompletely absorbed as may be the case with many 'normal' often starch-containing foods, which are reintroduced immediately after rehydra-tion. Despite evidence of malabsorption of glucose-polymer Rodriguez et al.3 found recovery without hypernatraemia the rule in their subjects. However, we should like to emphasise that, contrary to suggestions in the above letters, we did not recommend the formulation used in our study for widespread use but suggested that further studies using a much lower sodium and glucose-polymer content were required. The statement by Dr Hirschhorn that a sodium content of 50 mmol/l is 'unexceptional' ignores the possible contribution of such levels to the development of hypernatraemia. Intracranial haemorrhage due to vitamin K deficiency associated with alpha-1-antitrypsin deficiency …