FLUID MNAGEMENNT FOR PRETERM BABY

INTRODUCTION

The specific methods of fluid, electrolyte, and nutrition (FEN) management in newborns,
with a special focus on patients with complex fluid and electrolyte requirements. These
include premature newborns with very low birth weight (VLBW) and extremely low birth
weight (ELBW), as well as infants who have undergone abdominal surgery and those who
have sepsis. (See the image below).

An ill preterm infant, such as this patient, requires fluid, electrolyte, and nutrition
management in a neonatal intensive care unit.

Fluid, electrolyte, and nutrition management in the context of acid-base disorders (eg,
acidosis, alkalosis), hypercalcemia, magnesium disorders, metabolic disorders, and
complications of total parenteral nutrition (TPN) are not discussed in this article.
Fluid, electrolyte, and nutrition management is important because most infants in a neonatal
intensive care unit (NICU) require intravenous fluids (IVFs) and have shifts of fluids between
intracellular, extracellular, and vascular compartments. Therefore, careful attention to fluid
and electrolyte balance is essential. If inappropriate fluids are administered, serious morbidity
may result from fluid and electrolyte imbalances. Inadequate attention to nutrition in the
neonatal period leads to growth failure, osteopenia of prematurity, and other complications.
Prevalence and Loss of Body Water
Principles of fluid and electrolyte balancing include the following:
 Total body water (TBW) equals intracellular fluid (ICF) plus extracellular fluid (ECF)
 ECF equals intravascular fluid (plasma and lymph in the vessels) plus interstitial fluid
(between cells)

Body water composition

The percentage of the body composed of water is higher for a term neonate than it is for an
adult, with a newborn being 75% water (40% ECF, 35% ICF) and an adult being 60% water
(20% ECF, 40% ICF). Term newborns usually lose 5-10% of their weight in the first week of
life, almost all of which is water loss.
Preterm neonates have proportionally more water (at 23 weeks' gestation, the body is 90%
water; 60% ECF and 30% ICF), and they may lose 10-15% of their weight in the first week
of life. Small for gestational age (SGA) preterm infants may also have a particularly high
body water content (90% for SGA infants vs 84% for appropriate for gestational age [AGA]
infants at 25-30 weeks’ gestation). [1]

Insensible water loss

Insensible water loss (IWL) is water loss that is not readily measured. It consists mostly of
water lost via evaporation through the skin (two thirds) or respiratory tract (one third).
IWL varies with gestational age; the earlier the gestational age of the preterm infant, the
greater the IWL. Evidence from animal studies suggests that aquaporin channels that regulate
IWL are developmentally regulated. [2]
The magnitude of IWL also depends on the postnatal age. Because skin thickens with age, the
IWL decreases as premature neonates mature. [3] Ventilated infants receive humidified gas.
Therefore, IWL from the lungs is eliminated in these infants.

Sensible water loss

Other measurable sources of fluid loss include urine, stool (eg, diarrhea and ostomy),
nasogastric (NG) or orogastric (OG) drainage, and cerebrospinal fluid (CSF) loss (eg,
ventricular drainage).

Renal function changes

Neonates have a decreased capacity to concentrate or dilute urine in response to changes in

intravascular fluid status and are at risk for dehydration or fluid overload. The normal
maturation of renal function that occurs with increasing gestational and postnatal age also
plays a role in determining fluid requirements.
Assessing Fluid and Electrolyte Status
Numerous conditions can affect neonatal fluid and electrolyte balance, as well as renal
function. The presence of several of these can be suspected on the basis of information found
during the prenatal and neonatal history.

Maternal history

A newborn's fluid and electrolyte status partially reflects the mother's status. For example,
excessive administration of oxytocin or hypotonic IVF to the mother can cause hyponatremia
in the neonate at birth.
Placental dysfunction (eg, due to hypertension in pregnancy) can adversely affect intrauterine
growth. Infants who exhibit growth retardation at birth (< 10th percentile for gestational age)
may grow poorly unless their nutritional needs are specifically addressed after birth. The
severity and duration of the poor intrauterine malnutrition influences the degree of postnatal
catch-up growth.
Poorly controlled maternal diabetes may be associated with renal vein thrombosis. This can
adversely affect an infant's renal function.
Maternal use of angiotensin-converting enzyme (ACE) inhibitors, such as captopril, during
pregnancy can lead to acute renal failure in infants. Other medications administered to the
mother, including indomethacin, furosemide, and aminoglycoside, may also affect renal
function in the neonate.
Antenatal steroids may increase skin maturation, thereby decreasing IWL and the risk of
hyperkalemia. 

Newborn history

The presence of oligohydramnios may be associated with congenital renal dysfunction, such
as renal agenesis, polycystic kidney disease, or posterior urethral valves. Severe in utero
hypoxemia or birth asphyxia may lead to acute tubular necrosis.
In the infant, posterior urethral valves can be suspected when spontaneous urination is
lacking or when a weak urinary stream and dribbling are present. Frequently, the bladder is
full.
The environment in which an infant is cared for affects fluid loss. An environment with high
ambient humidity decreases IWL, whereas the use of a radiant warmer or phototherapy may
significantly increase an infant's IWL. In infants who are intubated, inadequate
humidification of the inspired gas may also lead to increased IWL.
For numerous reasons, an infant's weight and extracellular water volume may significantly
increase while intravascular volume decreases. For example, peritonitis or the long-term use
of paralytic agents can lead to increased interstitial fluid volume, increased fluid in the bowel
and peritoneal cavity, and increased body weight with decreased intravascular volume. This
is sometimes referred to as fluid in the third space or third spacing of fluid.

Clinical evaluation of fluid status

An inability to keep a baby sufficiency warm can signal the occurrence of excessive IWL.
Because of the latent heat of evaporation, cooling occurs with IWL, similar to cooling due to
sweating in older children and adults.
Sudden changes in an infant's weight generally reflect a change in body water. The
compartment affected depends on the gestational age and associated problems (eg, respiratory
distress syndrome, sepsis, necrotizing enterocolitis) and clinical care.
Histologic and mucosal manifestations are also noted in water loss. However, altered skin
turgor, a sunken anterior fontanelle (AF), and dry mucous membranes are not sensitive
indicators of dehydration in babies. Remembering that premature infants have poorly
keratinized skin that leads to a marked elevation in IWL is important.
Although growth charts are valuable in following growth parameters and nutritional status
over time, they play little role in the daily management of fluid and electrolyte balances.
Cardiovascular symptoms
Tachycardia may be a reflection of decreased intravascular volume, decreased stroke volume,
or ineffective cardiac output. This may be independent of the status of the ECF volume,
which is increased in congestive heart failure and decreased in dehydration.
Although delayed capillary refill occurs in low cardiac output states, it can also be seen in
infants with peripheral vasoconstriction that results from cold stress or acidosis.
As a result of an infant's compensatory mechanisms, blood pressure (BP) readings are usually
within the reference range with mild or moderate hypovolemia. With severe hypovolemia,
hypotension is almost invariably present.

Laboratory evaluation

Depending on the clinical situation and the suspected etiology of fluid and electrolyte
derangements, some or all of the tests below may be warranted.
Serum electrolyte, urea nitrogen, creatinine, and plasma osmolarity levels should be assessed.
Keep in mind that results of these tests, especially the creatinine levels, may still reflect
maternal values over the first 12-24 hours. Serum creatinine normally declines postnatally,
but very premature infants may have a delay in the decrease of serum creatinine levels. [6]
Accurate total urine output and total fluid intake may be assessed. In infants without urinary
catheters or urine bags, diapers need to be weighed soon after voiding to reduce errors due to
evaporation. [7] Infants with reduced urine output and a serum creatinine that does not decline
postnatally or increases may have acute kidney injury (AKI).
Urine electrolyte levels and specific gravity may be assessed. If the infant is being treated
with diuretics, such as furosemide, results of these tests are difficult to interpret.
Calculation of the fractional urinary excretion of sodium in relation to creatinine (FENa) and
blood gas analysis may be indicated; metabolic acidosis may be a marker of inadequate tissue
perfusion.
Fluid and Electrolyte Management

Management goals

Fluid and electrolyte management is achieved with constant assessment of fluid intake and
output, as well as monitoring of basic laboratory chemistries. Primary goals are to maintain
the appropriate ECF volume, ECF and ICF osmolality, and ionic concentrations.
The initial loss of ECF over the first week must be allowed, as reflected by weight loss, while
maintaining normal intravascular volume and tonicity, as reflected by heart rate, urine output,
and electrolyte and pH values. Subsequently, maintain water and electrolyte balance while
supplying requirements for body growth. The clinical approach must be individualized,
relying on norms for gestational age and birth weight for guidance.

Total fluid requirements

Total fluid requirements equal maintenance requirements (IWL plus urine plus stool water)
plus growth requirements. In the first few days, IWL is the largest component of lost fluids.
Later, as the renal solute load increases, the amount of water the kidneys need to excrete this
load increases (80-120cal/kg/day equal 15-20mOsm/kg/day, which means that 60-
80mL/kg/day are needed to excrete wastes). Stool requirement is usually 5-10mL/kg/d. As
infants add tissue, they also need to add water to maintain normal ECF and ICF volumes.
Because weight gain is 70% water, an infant growing 30-40g/day requires an additional 20-
25mL/day of water.

Factors that modify fluid requirements

As the skin matures postnatally, the IWL decreases. Elevated body and environmental
temperatures increase IWL. Radiant warmers increase IWL by 50%, phototherapy may
increase IWL, and the use of a plastic heat shield reduces IWL by 10-30%. Environmental
humidification decreases IWL from the skin and respiratory mucosa by as much as 30%.
Skin breakdown and skin defects (eg, omphalocele) proportionally increase IWL to the
affected area. Infants exposed to antenatal steroids have lower IWL as well as better diuresis. 
Electrolyte requirements

For the first 24 hours, supplemental sodium, potassium, and chloride are not usually required.
Starting at age 24 hours, assuming that urine production is adequate, the infant needs 1-
2mEq/kg/day of potassium and 1-3 mEq/kg/day of sodium.
Extremely premature infants who develop metabolic acidosis may benefit from sodium
acetate administration instead of sodium chloride.  Some evidence suggests that metabolic
acidosis in preterm infants is primarily due to inadequate urinary acidification by
NH4+ excretion and loss of bicarbonate. 
During the active growth period after the first week, the need for potassium may increase to
2-3mEq/kg/day, and the need for sodium and chloride may increase to 3-5mEq/kg/day. Some
of the smallest preterm infants have sodium requirements of as much as 6-8mEq/kg/day
because of the decreased capacity of the kidneys to retain sodium.
Fluids and Electrolytes in Common Neonatal Conditions
Infants with respiratory distress syndrome need appropriate fluid replacement. Administration
of excessive fluid, however, can lead to hyponatremia and volume overload, worsening the
pulmonary condition and increasing the risk that bronchopulmonary dysplasia (BPD) will
develop. Inadequate fluid administration leads to hypernatremia and dehydration.
As a result of increased work in breathing, infants with BPD have higher energy
requirements. Diuretics are often prescribed in these infants to treat pulmonary edema, which
can lead to electrolyte disturbances.
Avoiding excessive fluid administration is critical in infants with a patent ductus arteriosus
(PDA) because this often worsens their respiratory status. This is especially important when
indomethacin is prescribed to treat PDA, because indomethacin can decrease urine output
and, in fact, require restriction of fluid administration.
Infants who have experienced perinatal asphyxia may have involvement of multiple organ
systems. They are prone to acute tubular necrosis and significant oliguria, and central nervous
system (CNS) injury may produce syndrome of inappropriate antidiuretic hormone
secretion (SIADH). Restricting fluid intake to minimize the risk of volume overload is often
required. However, no evidence from randomized, controlled trials indicates that this practice
reduces morbidity or mortality.