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HS 8116 Neonatal Case Presentation

In Course Assessment

1. Hyperbilirubinemia
Hyperbilirubinemia is an elevation of serum bilirubin levels in a baby.
The common abnormal physical finding in newborn is yellow
discoloration of the skin and sclera. This is known as jaundice. It
develops from the deposits of the yellow pigment bilirubin in lipid
It is common in babies to have jaundice due to the newborn’s
shortened cell life span, slower uptake by the liver, lack of intestinal
bacteria and poorly established hydration.
Normal range: Preterm 15mg/dL (257umol/L) (Merenstein & Gardner,

2. Fluid Requirement for Baby John

Baby John will receive 46.8mls/kg/day based on 60mls/kg fluid.

Type of Fluid

Dextrose 10%
Dextrose 10% provides approximately 40cal/100ml. Minimum of
60cal/100mls is required to prevent tissue catabolism and produce
growth. The reason for dextrose 10% is because after birth, blood
glucose level will fall from about 4mmol/L to between 2 or 3mmol/L.
therefore IV Dextrose 10% fluid regime is required to ensure that blood
glucose is maintained. This is also so to prevent hypoglycemia or
hyperglycemia in premature neonate.

Normal Saline 0.45%

IA Normal Saline 0.45% is being administered is actually to ensure
patency of the IA line in cases of emergency.
Importance of fluid balance in preterm infants
Intracellular fluid is essential to maintain the health of the cell and to
move constituents of body fluid from one part of the cell to another.
It is also needed to move the constituents of body fluid from one cell to
another, and between the blood vessels and the cells.
Intravascular fluid (serum or plasma) is required to move blood cells
and the constituents of body fluid from one area of the body to

3. Insensible Water Loss

“Insensible water requirement are based on evaporative loss via the
skin and respiratory tract. One third of insensible water loss occurs
through the respiratory tract and the remaining two third occurs
through the skin.” (Fanaroff & Martin, 2002, p. 621)
Factors that affect insensible water loss by the flowing:

(a) Phototherapy – 25-50%

“It is a therapy that has been used for the reduction of elevated STB
levels and for the ‘prophylactic’ prevention of hyperbilirubinemia in
premature infants” (Taeusch & Ballard, 2005, p.1249)
The decrease in STB levels resulting from phototherapy is mainly result
of excretion of photoproducts in the bile and subsequent removal in
stools and urine. Therefore, fluid is loss through stools and urine and
monitoring of fluid must be closely monitored.

(b) Radiant Warmer – 40% - 50%

“Radiant warmers provide infrared heat energy to heat the baby’s skin
while he or she lies naked on an open bed.” (Merenstein & Gardner,
2002, p.109)
With very premature infants, severe dehydration may occur if water
intake is not increased to replace the inordinate insensible water loss.
Temperature must be monitored carefully in order to prevent excessive
raise in temperature. With every 1°C rise in body temperature,
metabolism and fluid needs increases approximately 10%.

(c)Respiratory Tract
“Respiratory losses is estimated to be 0-10mls/kg/day; related to
temperature and humidity of inspired gases and minute ventilation.”
(Sun Xia)
Transepithelial water loss is the major component of insensible water
loss in neonate.
Premature neonates have less developed stratum corneum than full-
term infants and therefore experience a greater diffusion of water
through the epidermal surface and a greater insensible water loss
through the skin.
With phototherapy and radiant warmer requirement for Baby John, the
insensible water loss by skin can be from 50%-100%.

(e) Stool & Urine

There is an estimation of 5ml/kg/day if the infant is eliminating.
However, this appears to be individualized from one preterm to
another. (Sun Xia). Loose stools and increased urine output may also
result from increased bilirubin excretion.

(f) Sweat
With result of being under radiant warmers and phototherapy, the
preterm infant would have a rise in temperature. The infant lying on
the plastic incubator would give rise to sweat development which
would increase more insensible water loss by the mode of evaporation.
This incorporates with loss of fluid from the skin.