Fluid and Electrolyte Management

Edward F. Bell
William Oh
Infants who are born prematurely or who are critically ill cannot regulate their own intake of
fluids and nutrients. Moreover, enteral feeding is often limited by feeding intolerance or
medical problems that preclude or limit use of the gastrointestinal tract for feeding. In other
cases, the infant presents with disordered fluid and electrolyte balance as a primary result of
an underlying illness. In all of these situations, water and electrolytes must be provided by
prescription of the health provider. Prescribing the correct amounts of water and electrolytes
helps to assure the infant's healthy recovery.
The goal of fluid and electrolyte management is to replace losses of water and electrolytes so
as to maintain normal balance of these essential substances during growth and recovery from
disease. A subsidiary aim in the first days of life is to allow successful transition from the
aquatic environment of the uterus into the arid extrauterine milieu. The principles of fluid and
electrolyte management in the neonatal period are similar to those established for older
children, except for some variations and specific features of body composition, insensible
water loss (IWL), renal function, and neuroendocrine control of fluid and electrolyte balance.
To manage fluid therapy of newborns appropriately, the clinician should understand the
normal physiologic mechanisms that govern water and electrolyte balance and the variations
in these mechanisms that can occur in sick or premature infants. The clinician should develop
a systematic approach to the estimation of fluid and electrolyte requirements for correction of
deficits and replacement of ongoing losses, both normal and abnormal. Finally, the results of
fluid and electrolyte management must be carefully monitored so that the intakes of water
and electrolytes can be adjusted as needed.
BODY COMPOSITION OF THE FETUS AND NEWBORN INFANT
Changes in Body Water During Growth
The total body water (TBW) is divided into two major compartments, intracellular (ICW) and
extracellular (ECW). The ECW is further divided into the interstitial water and the plasma
volume, which is the intravascular component of the ECW (Fig. 21-1).
In the early stages of fetal development, a large part of the body consists of water (1). It has
been estimated that TBW is 94% of the body weight during the third month of fetal life. As
gestation progresses, the TBW per kilogram declines. By 24 weeks the TBW is
approximately 86%, and by term it is about 78% of body weight (Fig. 21-2). There also are
characteristic changes in the partition of body water between ECW and ICW during
development. ECW decreases from 59% of body weight at 24 weeks of gestation to about
44% at term, and ICW increases from 27% to 34% of body weight during the same period
(Table 21-1) (1,2,3,4,5,6). Infants born prematurely thus have higher TBW and ECW per
kilogram than their term counterparts (7,8,9), and small-for-gestational-age infants have
higher TBW per kilogram than do appropriate-for-gestational-age infants (9).
After birth, TBW per kilogram of body weight continues to fall, due primarily to contraction
of the ECW (2,7,8,10,11,12,13). This mobilization of extracellular fluid occurs in conjunction
with the improvement in renal function that takes place following birth (14,15), which is
thought to occur as a result of increasing glomerular filtration rate and perhaps, too, as a
result of increasing levels of the epithelial transport proteins involved in renal tubular
function (16). It has also been suggested that atrial natriuretic peptide
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plays a role in the postnatal contraction of the ECW (13). Various studies have shown an
increase, decrease, or no change in the ICW after birth. ICW probably increases roughly in
proportion to body weight in the first weeks of postnatal life (2,7,8,17). Thereafter, ICW
increases faster than body weight and exceeds ECW by 3 months of age (Fig. 21-2) (1,2).
These postnatal changes in body water and its partition between ECW and ICW are
influenced by the intake of water and electrolytes (11,18). Failure to allow the normal
postnatal contraction of ECW in premature infants may increase the risk of significant patent
ductus arteriosus (PDA) (19), necrotizing enterocolitis (NEC) (20,21,22), and
bronchopulmonary dysplasia (BPD) (23,24).

Figure 21-1 Distribution of body water in a term newborn infant.

Solute Distribution in Body Fluids
The major cation in the blood plasma is sodium (Fig. 21-3). Potassium, calcium, and
magnesium constitute the balance of the cation fraction. The primary anion is chloride, with
protein, bicarbonate, and some undetermined anions constituting the balance of the anions.
The interstitial fluid (i.e., nonplasma ECW) has a solute composition that is similar to plasma
except that its protein content is lower. The ICW contains potassium and magnesium as its
primary cations, and phosphate, both organic and inorganic, is the major anion, with
bicarbonate contributing a smaller fraction.
TABLE 21-1 CHANGES IN BODY WATER AND ELECTROLYTE COMPOSITION
DURING INTRAUTERINE AND EARLY POSTNATAL LIFE
Gestational Age (Weeks)
Component 24 28 32 36 40 1 to 4 Weeks After Term Birth
Total body water (%) 86 84 82 80 78 74
Extracellular water (%) 59 56 52 48 44 41
Intracellular water (%) 27 28 30 32 34 33
Sodium (mEq/kg) 99 91 85 80 77 73
Potassium (mEq/kg) 40 41 40 41 41 42
Chloride (mEq/kg) 70 67 62 56 51 48
Data from Friis-Hansen B. Changes in body water compartments during growth. Acta
Paediatr 1957;6
(Suppl 110):1–68; Friis-Hansen B. Body water compartments in children: changes during
growth and related changes in body composition. Pediatrics 1961;28:169–181; Ziegler EE,
O'Donnell AM, Nelson SE, et al. Body composition of the reference fetus. Growth
1976;40:329–341; Forbes JB, Perley A. Estimation of total body sodium by isotopic
dilution. II. Studies on infants and children: an example of a constant differential growth
ratio. J Clin Invest 1951;30:566–574; Cheek DB. Observations on total body chloride in
children.
Pediatrics 1954;14:5–10; Romahn A, Burmeister W. [Body composition during the first
two years of life: analysis with the potassium 40 method]. Klin Pädiatr
1977;189:321–327.

Figure 21-2 Changes in body water during gestation and infancy. (Adapted from Friis-
Hansen B. Changes in body water compartments during growth. Acta Paediatr 1957;46(Suppl
110):1-68., with permission.)
The electrolyte composition of the body fluids of the newborn infant is largely determined by
gestational age. Premature infants contain more sodium and chloride per kilogram of body
weight than term infants (3,4,5) because of their larger ECW (Table 21-1). Total body
potassium content largely reflects ICW and is similar or slightly lower
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per kilogram of body weight in premature infants than at term (3,6). These concepts are
important in the management of fluid and electrolyte therapy for newborn infants.

Figure 21-3 Ion distribution in the blood plasma, which represents extracellular fluid, and in
the intracellular fluid compartment.
In the fetus, fluid and electrolyte balance depends on maternal homeostasis and placental
exchange. Thus, fluid and electrolyte status at birth is influenced by the maternal fluid and
electrolyte management in labor (25,26,27,28).
INSENSIBLE WATER LOSS
The loss of water by evaporation from the skin and respiratory tract is known as insensible
water loss (IWL). About 30% of IWL normally occurs through the respiratory tract as
moisture in expired gas (29,30,31), with the remaining 70% lost through the skin. IWL can be
expressed in reference to body surface area (m2) or weight (kg). IWL depends more on
surface area than weight, but it is commonly expressed per kilogram because weight is more
easily determined than area.
TABLE 21-2 FACTORS AFFECTING INSENSIBLE WATER LOSS IN NEWBORN
INFANTS
Factor Effect on Insensible Water Loss (IWL)
Level of maturity (32,33,35, 36 and 37) Inversely proportional to birth weight and
gestational age (Fig. 21-4)
Respiratory distress (hyperpnea) (38) Respiratory IWL increases with rising minute
ventilation when dry air is being breathed
Environmental temperature above neutral Increased in proportion to increment in
thermal zone (29,39,40) temperature
Elevated body temperature (29,39) Increased by up to 300%
Skin breakdown or injury Increased by uncertain magnitude
Congenital skin defect (e.g., gastroschisis, Increased by uncertain magnitude until
omphalocele, neural tube defect) surgically corrected
Radiant warmer (33,41,42,43,44 and 45) Increased by about 50%
Phototherapy (43,46,47) Increased by about 50%
Motor activity and crying (29,49,50) Increased by up to 70%
High ambient or inspired humidity (29,31) Reduced by 30% when ambient vapor pressure
isincreased by 200%
Plastic heat shield (32,44,52) Reduced by 30% to 70%
Plastic blanket (52, 53,54) or chamber Reduced by 30% to 70%
(54,55)
Semipermeable membrane (56, 57 and 58) Reduced by 50%
Topical agents (59,60) Reduced by 50%
Figure 21-4 Relation between insensible water loss (IWL) and birth weight of 5-day-old
(mean) infants in incubators. (Data from Wu PY, Hodgman JE. Insensible water loss in
preterm infants: changes with postnatal development and non-ionizing radiant energy.
Pediatrics 1974;54:704-712, as redrawn in Shaffer SG, Weismann DN. Fluid requirements in
the preterm infant. Clin Perinatol 1992;19: 233-250, with permission.)
A number of factors are known to influence IWL in a predictable manner (Table 21-2)
(29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58
,59,60). When expressed per kilogram of body weight, IWL is inversely proportional to birth
weight and gestational age (Figs. 21-4 and 21-5) (32,33,35). In other words, smaller, more
immature infants have larger IWL per kilogram (Table 21-3). The
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same is true if IWL is expressed per square meter of body surface (36,37). Therefore,
although the greater IWL of smaller premature infants is partly due to the increased ratio of
surface area (skin and respiratory tract) to body weight, it also is thought to be related to their
thinner skin, greater skin blood flow, larger body water per kilogram of body weight, and
higher respiratory rate. Because skin permeability to water varies inversely with gestational
age, the degree of immaturity is an important determinant of cutaneous IWL independent of
birth weight.
Figure 21-5 Insensible water loss (IWL) as a function of birth weight in premature infants
nursed under radiant warmers. (Adapted from Costarino AT, Baumgart. Controversies in
fluid and electrolyte therapy for the premature infant. Clin Perinatol 1988; 15:863-878, with
permission.)
Factors That Increase Insensible Water Loss
An increase in minute ventilation increases the respiratory IWL (38) as long as the water
vapor pressure is less in the inspired than in the expired gas. Increased minute ventilation
may occur in infants with cardiac disease, pulmonary dysfunction, or metabolic acidosis.
TABLE 21-3 AVERAGE INSENSIBLE WATER LOSSa OF PREMATURE INFANTS
IN INCUBATORS
Birth Weight Range (kg)
Age (d) 0.50-0.75 0.75-1.00 1.00-1.25 1.25-1.50 1.50-1.75 1.75-2.00
0–7 100 a
65 55 40 20 15
7–14 80 60 50 40 30 20
a
Insensible water loss (mL/kg/day).
Data from Wu PY, Hodgman JE. Insensible water loss in preterm infants: changes with
postnatal development and non-ionizing radiant energy. Pediatrics 1974;54:704–712;
Okken A, Jonxis JH, Rispens P, et al.
Insensible water loss and metabolic rate in low birthweight newborn infants. Pediatr Res
1979;13:1072–1075; Hammarlund K, Sedin G. Transepidermal water loss in newborn
infants. III. Relation to gestational age. Acta Paediatr Scand 1979;68:795–801.
Environmental temperature above the neutral thermal zone increases IWL in proportion to the
increment in temperature (29,39,40). This effect can occur even without a rise in body
temperature. In contrast, a subneutral environmental temperature is not associated with
reduced IWL, although metabolic heat production is increased (40). Increased body
temperature, whether caused by fever or environmental overheating, elevates IWL (29,39).
Skin breakdown or injury disrupts the barrier against cutaneous evaporation and raises IWL.
Skin trauma from thermal, chemical, or mechanical injury is common among critically ill,
small, premature infants. Such injury may result from removal of tape and adherent
monitoring devices or from prolonged skin exposure to disinfectant solutions. IWL also is
increased in conjunction with the skin manifestations of essential fatty acid deficiency, a
potential problem in infants receiving fat-free parenteral nutrition. Congenital skin defects,
such as those seen in gastroschisis, omphalocele, and neural tube defects, are associated with
increased IWL until surgically corrected.
Use of nonionizing radiant energy, in the form of either a radiant warmer or phototherapy,
has been shown to increase IWL by about 50% (33,41,42,43,44,45,46,47,48). For infants in
incubators with controlled air temperature, the increase in IWL with overhead phototherapy
is most likely a result of increased body temperature because of the warmer incubator walls
(46). For infants in incubators operated to control skin temperature, the rise in IWL with
phototherapy can be explained by the lower absolute humidity resulting from the reduced air
temperature that accompanies the warming of the incubator walls by the phototherapy. The
impact on IWL of phototherapy delivered by fiberoptic blankets or pads is not known but is
probably negligible unless the blanket produces a warmer or moister microenvironment
around the infant. Investigators using direct measurements of transepidermal and respiratory
water loss have obtained
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conflicting results regarding the effect of overhead phototherapy on IWL. One group (47)
found an increase in transepidermal water loss with phototherapy, but another did not (61,62).
TABLE 21-4 RELATIVE AND ABSOLUTE HUMIDITY AS RELATED TO
INSENSIBLE WATER LOSS IN INCUBATORS AND UNDER RADIANT
WARMERS
Measurement Incubator Radiant Warmer
Air temperature (°C) 35.0 27.6
Saturation pressure (mm Hg) 42.1 27.7
Relative humidity (%) 31.4 39.0
Absolute humidity (mm Hg) 13.2 10.8
Insensible water loss (mL/kg/hour) 2.37 3.40
Data from Bell EF, Weinstein MR, Oh W. Heat balance in premature infants: comparative
effects of convectively heated incubator and radiant warmer, with and without plastic heat
shield. J Pediatr 1980;96: 460–465.
If an infant's IWL is measured at the same skin temperature under a radiant warmer and in an
incubator, the IWL is higher (by about 50%) under the radiant warmer. IWL is higher
because absolute humidity (water vapor pressure) is lower under the radiant warmer than in
the incubator (44). This may be true even if relative humidity is higher under the radiant
warmer (43,44) because the lower air temperature with the radiant warmer means that the
saturation pressure of water vapor is considerably lower than in the incubator (Table 21-4).
This finding has been confirmed using direct measurements of transepidermal water loss
(45). It is now understood that the higher IWL with radiant warmers arises from the lower
ambient water vapor pressure and not from higher air velocity or a direct effect of
nonionizing radiation on the skin. The same phenomenon explains the effect of phototherapy
on IWL of infants in incubators operated by skin temperature servocontrol. The effects on
IWL of radiant warmers and phototherapy are additive; the IWL with the combination is
approximately twice as large as in an incubator without phototherapy (43,48).
Increased motor activity and crying increase IWL by up to 70% (29,49,50). This effect may
be partly due to elevated minute ventilation.