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 enhanced 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 newborns, and that the consequences could be dire.