absence of respiratory symptoms and the normal chest radiograph made it unlikely that the water had been absorbed through the lungs, as in drowning. Water intoxication has been reported in infants with renal disease, 2 pulmonary disease, 3 endocrine disturbance, 4 central nervous system diseases: and as a consequence of improper infant formula preparation related to economic 6 or psychological factors 7'8 or parental error. 9 The patient received less than the predicted amount of sodium required for total correction of the hyponatremia. A falsely elevated serum sodium value at six hours, arising from laboratory error, would partially account for this discrepancy. The hyponatremia was corrected following salt administration and mild fluid restriction. In addition, a free water diuresis was observed. The manifestations of water intoxication include restlessness, weakness, nausea, vomiting, polyuria or oliguria, muscle twitching, convulsions, and coma; death may o c c u r . 8'9 With appropriate treatment the condition is reversible as long as hypoxia resulting from aspiration, vomiting, or respiratory arrest during seizures can be avoided. This patient had hypercarbia as a consequence of inadequate ventilation during prolonged seizures. Adequate ventilation was reestablished after the seizures ceased and before bicarbonate therapy was given. This case is reported so that physicians may be aware of this complication of infant swimming and provide appropriate anticipatory guidance to parents.