This is the story of parents who wanted to do the rightthing for their infant, but unknowingly were influ-enced by advertising, and wound up with a sick baby.

The World Health Organization recommends exclusivebreastfeeding for the first 6 months of life, a recommenda-tion generally supported by other health advisory groups(Venter & Dean, 2008). Breast milk is composed of over300 components, while commercially prepared formulacontains approximately 75 components (Venter & Dean,2008). Human milk is specific to the infant, and is unlikeany marketed feeding preparation (Gartner & Eidelman,2005). Breast milk evolves as the infant grows, changing toprovide the most appropriate nutrition for the child at theirstage of development (Wagner, Graham, & Hope, 2006).Breast milk also conveys significant benefits to the infant,including a decrease in the incidence or severity of a widerange of infectious diseases such as respiratory tract infec-tion, necrotizing enterocolitis, and otitis media, a decreasedrisk for sudden infant death syndrome, type 1 and type 2diabetes, and some forms of cancer (Gartner & Eidelman,2005). Additionally, research suggests that breastfeeding isassociated with enhanced cognitive development (Gartner& Eidelman, 2005).

Using Enhanced Water to

290 VOLUME 34 | NUMBER 5 September/October 2009

CASE REPORT:

Abstract

In this case study report of an infant with

metabolic alkalosis, the healthcare team

worked to discover the cause of the illness.

They found that well-meaning parents had

diluted their newborn’s powdered formula

with electrolyte-enhanced water. Electrolyte

balance in the newborn is reviewed in this

article, along with information about en-

hanced waters. It is essential that nurses

working with new families be aware that

heavily advertised enhanced waters could be

used unknowingly by parents for their new-

borns, and that the consequences could be

dire.

Key Words: Bottle feeding; Infant formula;

Infant nutrition disorders; Parent education.

Dilute Powdered Formula

Metabolic Alkalosis After

Spatz (2006) identifies several important steps in encour-aging the new mother to breastfeed, including a focus onprovision of milk, rather than breastfeeding, as some mothersmay choose to bottle-feed breast milk. Nurses must also fo-cus on providing information to the mother and family onthe benefits of human milk, and establishing and maintain-ing an adequate milk supply. We know as nurses, however,that some mothers may not desire to breastfeed, or may beunable to breastfeed, and may instead use formula. This casestudy concerns a woman who chose to feed her infant withprepared formula, had the baby’s best interests at heart, butunknowingly chose an unconventional, and eventually adetrimental way to dilute the formula. The components offormula are meant to closely mimic breast milk. In bothbreast milk and infant formula, over half of the caloriescome from fat. Carbohydrates may be in the form of lactose(as in cow’s milk formulas) or sucrose or cornstarch in soy-based formulas. Vitamins and minerals, usually in amountsspecified by the FDA, are also added to infant formula.

Case PresentationA twenty-day-old female “Mary” was brought to the pedi-atrician’s office for a worsening cough and respiratory dis-

tress. After being evaluated by the physician, she was ad-mitted to the pediatric unit of the local hospital for hypox-emia, poor oral intake, respiratory distress, and respiratorysyncytial virus bronchiolitis. Prior to this episode, Maryhad an uncomplicated prenatal and neonatal course.

During the course of her hospitalization the parentsmentioned that they had been diluting Mary’s brand namepowdered formula with an electrolyte-enhanced water.Electrolyte waters are being marketed aggressively in theUnited States, and the manufacturer of this particular prod-uct advertises it as “vapor distilled” and as (water in) “itspurest original state.” The packaging does state that thewater contains calcium chloride, magnesium chloride, andpotassium bicarbonate, but it became clear to us in thecourse of working with this family that merely labeling the

September/October 2009 MCN 291

Recently, electrolyte-enhanced watershave been aggressively marketed in theUnited States.

Anne Kathryn Eby, BSN, RN

water meant nothing to the new parents. They had no un-derstanding at all that it could be dangerous to their childto use this enhanced water to dilute formula. For manynew parents, the idea of water in “its purest original state”may be appealing, and may lead them to believe that this isa “healthier” alternative to tap or bottled water for theirinfant. In this case, the parents told us that they thoughtthis was merely another form of distilled water, which wasappropriate to use to dilute the child’s formula.

Mary’s electrolytes upon admission showed a hyperkalemicmetabolic alkalosis with an elevated calcium. Her sodium was138, potassium was 5.8, chloride was 100, and carbon diox-ide (CO2) was 33. Her blood urea nitrogen was 6, creatininewas 0.3, glucose was 83, her calcium was elevated to 10.4,and her magnesium was 2.2. Table 1 shows arterial blood gasvalues and variances in newborns.

Acid-base balanceBody fluids contain acids made of positively charged hy-drogen ions (H+) and anions, or negatively charged ions(Clancy & McVicar, 2007). The measure of a solution’sacidity or alkalinity is the pH. Clancy and McVicar statethat “the neutral point (pH of pure water) relates to a situ-ation in which acid ions (hydrogen [H+]) and alkali ions(hydroxyl [OH-]) are equal” (p. 1017). A solution with a pHof less than 7 is considered acid, while a solution with a pHof greater than 7 is considered alkaline, often called “base”(Clancy & McVicar). The arterial blood pH shows thebalance between CO2, an acid, and bicarbonate (HCO3), abase. The buffer system of the body acts to regulate theacid-base balance; if there are excess hydrogen ions in thebody fluid, the body will release acid buffers, while if thebody fluid is deficient in hydrogen ions, the buffer systemwill cause the release of alkaline buffers, chemicals whichrelease hydrogen ions (Clancy & McVicar). Further com-pensation may be either metabolic or respiratory. In a case

of respiratory acidosis, for example, the kidneys will at-tempt to compensate by reabsorbing HCO3

- and excretinghydrogen ions, while with respiratory alkalosis, the kidneyswill secrete HCO3

- and reabsorb hydrogen ions (Roman,Thimothee, & Vidal, 2008).

The body’s acid-base balance is controlled by the renal andrespiratory systems. The kidneys maintain the composition ofthe extracellular and intracellular fluid and regulate acid-basebalance by secreting hydrogen ions, reabsorbing sodium andbicarbonate ions, acidifying phosphate salts, and producingammonia (Pathophysiology Made Incredibly Easy, 1998).The respiratory system helps to modify the acid-base balanceof the body by increasing respiration in acidosis (to excreteexcess CO2) or decreasing respirations in alkalosis.

To evaluate an arterial blood gas reading, it is necessary todiscover whether the pH is normal (7.35-7.45), elevated, ordecreased. If the pH is >7.45, the patient is alkalotic, and if itis <7.35, the patient is acidotic. The second step is to evaluatethe PaCO2 to determine if the imbalance is respiratory ormetabolic. If the pH and the PaCO2 move in opposite direc-tions (i.e., the pH is decreased and the PaCO2 is elevated),then the problem is respiratory (Roman et al., 2008). Thethird step is to assess the HCO3; if the problem is metabol-ic the pH and HCO3 will move in the same direction (i.e.,both will be elevated or decreased) (Roman et al.). The bodystrives to maintain homeostasis by normalizing the pH. Incases of compensated acid-base abnormalities, the patientwill have a normal pH but an increased or decreased CO2 orHCO3 (Roman et al.). In Mary’s case, her arterial bloodgas demonstrated a metabolic alkalosis (evidenced by anelevated bicarbonate) with respiratory compensation (evi-denced by her elevated PCO2).

Metabolic Alkalosis

This acid-base disturbance is caused by an elevation in plas-ma bicarbonate concentration (Huang & Priestley, 2008). It

292 VOLUME 34 | NUMBER 5 September/October 2009

TABLE 1. Arterial Blood Gas Values and Variances in the Term Newborn

DisorderpH

(7.35-7.45)HCO3

(22-26)PCO2

(35-45)

Metabolic alkalosis i i If i with normal pH, indicates respiratory compensation

Respiratory alkalosis i If m, indicates renal compensation

m

Metabolic acidosis m m If m with normal pH, indicates respiratory compensation

Respiratory acidosis m If i, indicates renal compensation

iNote: Adapted from Brouillette & Waxman, 1997.

is often classified as chloride-responsive (indicated by aurine chloride level of less than 10 mEq/L) or chloride-resistant (indicated by a urine chloride level of more than20 mEq/L) (Huang & Priestley). Metabolic alkalosis ismost often caused by a loss of hydrochloric acid throughthe GI tract, as from vomiting (Huang & Priestley). Poten-tial sequelae associated with metabolic alkalosis in the in-fant include hypoxemia, respiratory arrest, life-threateningcardiac arrhythmias, and seizures (Huang & Priestley).

Respiratory Alkalosis

This is an acid-base disturbance typically caused by anunderlying hypoxia, metabolic acidosis, or stimulation ofrespiration by the central nervous system (Mancini &Deshpande, 2006). Sequelae from respiratory alkalosis mayinclude altered mentation, seizures, and very rarely, dys-rhythmias in patients with underlying cardiac disease(Mancini & Deshpande).

Metabolic Acidosis

This acid-base disturbance is characterized by a decreasedserum pH resulting from a decrease in plasma bicarbonateconcentration or an increase in hydrogen ion concentration(Priestley, 2006). Causes may include undiagnosed diabetesmellitus and diabetic ketoacidosis, toxin ingestion (includ-ing salicylates or ethanol), or sepsis. Clinical findings mayinclude lethargy, coma, seizures, hyperventilation or Kuss-maul’s respirations, and signs of dehydration or low cardiacoutput (Priestley).

Respiratory Acidosis

This acid-base disturbance is characterized by an increasedPCO2 resulting from an imbalance between carbon dioxideproduction by the body and excretion from the lungs(Priestley & Litman, 2009). Clinical manifestations mayinclude depressed consciousness and a hyperdynamiccardiovascular state characterized by tachycardia, high car-diac output, and decreased systemic vascular resistance(Priestley & Litman).

Mary’s Hospital CourseIn order to better understand what was going on with Mary,we contacted the company which manufactured the particu-lar electrolyte water the parents had used to dilute the pow-dered formula, and they told us that there are 10mg per literof calcium chloride, 10mg per liter of magnesium, and15mg per liter of potassium bicarbonate. Mary’s electrolytesrevealed an underlying metabolic alkalosis with respiratorycompensation, as her pH was 7.43, PCO2 49.6, and her bi-carbonate was 32.2 with a base excess of 6.5. Bicarbonatelevels were monitored throughout the course of her admis-sion, and this value actually increased to 34.8 approximately24 hours into her hospitalization, although her potassiumdecreased to 5.4 and her calcium decreased to 10.1.

During her hospitalization, Mary’s cardiopulmonary statusand oxygen saturations were closely monitored. She receivedoxygen initially to maintain a saturation of 92%, althoughlater in the course of the hospitalization this goal was changedto 88%. She was fed breast milk and Pedialyte ad lib, and herintake, output, and daily weights were closely monitored.Saline wash and suctioning were ordered as needed, and acet-aminophen was given every 4 hours as needed for fever or ir-ritability. A chest X-ray was obtained which demonstrated amild degree of atelectasis or infiltrate. A pediatric cardiologyconsult was obtained for a grade 2/6 heart murmur and anisolated elevated blood pressure. The murmur was identifiedas a pulmonary outflow murmur with no treatment required,and the elevated blood pressure was most likely an erroneousreading. An echocardiogram revealed a structurally normalheart with normal function. She did not receive intravenousfluids or medications, and her acid-base imbalance was moni-tored closely and resolved on its own.

Mary was hospitalized for 4 days. At the time of dis-charge, Mary’s electrolytes had normalized and her elevatedbicarbonate had resolved. The last electrolyte panel showeda sodium of 137, a potassium of 6.9 (but with a hemolyzedspecimen), a chloride of 99, a CO2 of 27.7, a BUN of 8, acreatinine of 0.2, a glucose of 91, and a normal AST andALT. Her albumin was 3.8, protein was 6.5, calcium was10.6, bilirubin was 0.3, and alkaline phosphatase was nor-mal at 234. The oxygen was weaned to one-thirty-secondliter per minute via nasal cannula; however, she did at timesrequire O2 of up to one-quarter of a liter and so was dis-charged home with home O2 and pulse oximetry.

September/October 2009 MCN 293

Parents unaware of the dangers maymistakenly believe that they are helping their child’s nutritional statusby diluting formula with vitamin/electrolyte-enhanced water.

Mary’s case was interesting and frightening for us, forshe had demonstrated a marked metabolic alkalosis, and itwas important that everyone understand why this had hap-pened. With the diagnosis of respiratory syncytial virusbronchiolitis one would expect the child to be acidotic,which may suggest that without the concurrent infectionthis child would have demonstrated a more severe alkalosis.While it is possible that this child’s tachypnea would lead toan alkalotic state, it was clear to us that Mary had a meta-bolic, not a respiratory, alkalosis.

An extensive literature review revealed no publications ad-dressing the issue of giving formula mixed with electrolyte-

enhanced waters to infants. One Web site “Ask Dr. Sears”had a few sentences advising parents not to dilute formulawith these waters (www.askdrsears.com/faq/fo3.asp).

Implications for NursingThis case makes it abundantly clear that parent educationneeds to include appropriate education about feeding withpowdered formula:1. Enhanced vitamin waters should not be used to dilute

infant formula.2. If using a ready to feed formula, do not dilute further

with water or any other liquid.3. If using a concentrated infant formula, mix exactly

according to directions on the package.4. Tap water used to reconstitute infant formula should

be boiled for 1 to 2 minutes to eliminate bacterial con-tamination. It must then be allowed to cool fully beforediluting formula.

5. Unused, diluted formula should be refrigerated imme-diately.

The importance of parent education before and afterbirth cannot be overstated. It is imperative that nurses con-tinuously assess parental knowledge and educational needs,especially as it relates to proper feeding methods and signsand symptoms of feeding problems. Additionally, familiarity

with normal infant blood gas values and potential sequelaeassociated with acid-base disturbances allows the nurse toremain vigilant for potential complications.

This case study highlights the need for continuing andincreased pre- and postnatal education about the nutrition-al needs of infants and the proper procedures for dilutingformula. As the product involved in this case and otherenhanced waters become ever more popular among Ameri-cans, the need for parental education will grow. Discussionof the potential hazards of the use of electrolyte-enhancedwater to dilute formula may prevent infant morbidity suchas the marked metabolic alkalosis experienced by the infantin this case study. ✜

Acknowledgment

The author thanks Dr. Michael Garver for his assistance withthis project.

Anne Kathryn Eby is a Staff Nurse, Orthopedics andNeurosurgery, Benefis Health System, Great Falls, Mont.Ms. Eby encountered this case while doing a clinical rota-tion as a family nurse practitioner student at MontanaState University. She can be reached via e-mail atkneby@hotmail.com

The author has disclosed that she has no financial rela-tionships related to this article.

References

Ask Dr. Sears. (2009). Electrolyte Water. Retrieved April 3, 2009, fromwww.askdrsears.com/faq/fo3.asp

Brouillette, R. T., & Waxman, D. H. (1997). Evaluation of the newborns’blood gas status. Clinical Chemistry, 43, 215-227.

Clancy, J., & McVicar, A. (2007). Short-term regulation of acid-base home-ostasis of body fluids. British Journal of Nursing, 16(16), 1016-1022.

Gartner, L. M., & Eidelman, A. I. (2005). Breastfeeding and the use of hu-man milk. Pediatrics, 115(2), 496-506.

Huang, L. H., & Priestley, M. A. (2008). Alkalosis, metabolic. In Emedicine.Retrieved March 9, 2009, from http://emedicine.medscape.com/article/906819-overview

Mancini, M. C., & Deshpande, G. G. (2006). Alkalosis, respiratory. InEmedicine. Retrieved March 11, 2009, from http://emedicine.medscape.com/article/906929-overview

Pathophysiology made incredibly easy! (1998). Springhouse, Pennsylva-nia: Springhouse Corporation.

Priestley, M. A. (2006). Acidosis, metabolic. In Emedicine. Retrieved March9, 2009, from http://emedicine.medscape.com/article/906440-overview.

Priestley, M. A., & Litman, R. (2009). Acidosis, respiratory. In Emedicine.Retrieved March 12, 2009, from http://emedicine.medscape.com/article/906545-overview

Roman, M.A., Thimothee, S., & Vidal, J.E. (2008). Arterial blood gases.MEDSURG Nursing, 17(4), 268-269.

Spatz, D. L. (2006). State of the science: Use of human milk and breast-feeding for vulnerable infants. Journal of Perinatal and NeonatalNursing, 20(1), 51-55.

Venter, C., & Dean, T. (2008). Caring for the newborn: Infant nutrition part1. British Journal of Midwifery, 16(11), 726-733.

Wagner, C. L., Graham, E. M., & Hope, W. W. (2006). Human milk and lac-tation. In Emedicine. Retrieved March 9, 2009, from WebMDhttp://emedicine.medscape.com/article/976504-overview.

294 VOLUME 34 | NUMBER 5 September/October 2009

For more than 28 additional continuing nursing education articles on neonatal topics, go to nursingcenter.com/ce

In this case study, the child demon-strated a marked metabolic alkalosis,possibly due to dilution of her formulawith electrolyte-enhanced water.