PRINCIPLES OF FLUID &

ELECTROLYTE THERAPY IN
NEONATES

Presented by: Dr. Manaswinee Sahoo

Guided by: Dr. Tapas Bandopadhyay
OVERVIEW:
 Introduction
 Developmental changes
 Determinants of fluid balance
 Postnatal adaptation
 Goals of therapy
 Fluid restriction
 Electrolyte abnormalities
 Conclusion
Introduction:

 Transition from Aquatic-in-utero to gaseous environment

 Neonatal kidney is immature
 Fluid overload is deleterious(Inc. PDA, NEC)
 Fluid & electrolyte balance is required for normal cell & organ
function
Definitions:

 Total Body Water(TBW)=

Intracellular fluid(ICF) + Extracellular fluid(ECF)

 ECF = Intravascular + Interstitial + Third space fluid

 Insensible water loss(IWL) =

Fluid intake – Urine output + wt Loss
Fluid intake – Urine output – wt gain

Avery’s disease of the newborn: 10 th edn;2017

Developmental changes:
 Intra-uterine life:
- High proportion of TBW
- Large Extracellular compartment

TBW-94%
ECF- 2/3RD
16wk

TBW-75%
Term ECF-1/2

Infants born Pre-term: TBW excess & ECF expansion.

Avery’s disease of the newborn: 10 th edn;2017
Developmental changes..

Avery’s disease of the newborn: 10 th edn;2017

Determinants of fluid balance:
 Transepidermal water loss:
- Reflects skin immaturity &
Increased surface area to weight ratio
- Stratum corneum is barrier to TEWL
- Stratum corneum is not well developed until 34weeks GA
- Skin maturation is accelerated by Birth not by ANS
- By 32wks TEWL in preterm equates that of term

• 1ml of TEWL accompanies 560 calories of heat

( difficult to keep warm)
Arch Dis Child Fetal Neonatal Ed 2004;89:F108–F111. doi: 10.1136/adc.2001.004275, N.Modi
Transepidermal water loss in full-term and pre-term infants; , ACTA Pediatr
G Sedin, K Hammarlund, B Strömberg
IWL:
Birth weight(g) IWL (mL/kg/d)

<750 100+

750-1000 60-70

1001-1500 30-65

>1500 15-30

Textbook of Neonatal-Perinatal medicine; Fanaroff & Martin’s; Eleven Edition;2019

 Determinants of fluid
balance:
• Radiant warmers increase TEWL by 0.5-2x
• Phototherapy increase TEWL by 30%
Methods to reduce TEWL:
• Inc. Ambient humidity
• Use of plastic bags for preterms
• Incubators(Double wall reduce IWL BY 30% at humidity of 90%)
• Barriers: Emollients, paraffin (Reduce IWL by 50% in open care)
• plastic barriers (e.g cling wrap)/ shields- Rduce IWL by 30-60%

Arch Dis Child Fetal Neonatal Ed 2004;89:F108–F111. doi: 10.1136/adc.2001.004275,N.Modi

Topical Oil Application and Trans-Epidermal Water Loss in Preterm
Very Low Birth Weight Infants—A Randomized Trial 
Sushma Nangia, Vinod Kumar Paul, Ashok Kumar Deorari, V. Sreenivas, Ramesh Agarwal, Deepak Chawla
Journal of Tropical Pediatrics, Volume 61, Issue 6, December 2015

• Conclusion: Coconut oil application reduced TEWL without increasing

skin colonization in VLBW neonates.
Emollient therapy for preterm newborn infants – evidence from the
developing world
Rehana A Salam, Jai K Das, Gary L Darmstadt & Zulfiqar A Bhutta 
BMC Public Health volume 13, Article number: S31 (2013)

• Conclusion :Emollient therapy is associated with improved weight

gain, reduced risk of infection and associated newborn mortality in
preterm neonates and is a potentially promising intervention for use
in low resource settings
Cling wrap, an innovative intervention for temperature maintenance and reduction
of insensible water loss in very low-birthweight babies nursed under radiant
warmers: A randomized, controlled trial
Article in Annals of Tropical Paediatrics International Child Health, 2005

By M Kaushal, R Agarwal

• Aim: The value of polythene film (‘cling wrap’) to improve thermal

control and reduce postnatal weight loss in preterm, very low-
birthweight babies was investigated

• Result: Maximum cumulative weight loss during the 1st 7 days was
lower in the CW group
Effectiveness of cling wrap in terms of maintenance of body
temperature and weight of neonates
Article in International Journal of Nursing Education 10(3):106 · January 2018

• CONCLUSION :Use of cling wrap might be a simple method of

maintaining body temperature of low birth weight neonates in
developing countries
 Determinants of fluid
balance..
 Renal function:
-Neonatal Kidney has limited capacity to concentrate urine

Immaturity of distal nephron & short loop of Henle

- Urine osmolality varies 50-600 (Pre-Term) to 800 mmol/L (Term)

- Limited capacity to conserve/ excrete Sodium
- Salt & water diuresis normally occurs in 1st 24-48 hrs

Na+ supplement should be started after diuresis

(Decrease in serum Na+ / wt loss of 5-6%)
 Renal function cont.

 Pre-term neonates have increased urinary losses of Na+

(Limited tubular Reabsorption)

Na+ supplementation after 1st wk needed @ 3-5mEq/kg/day

Failure to provide leads to poor weight gain

Effect of antenatal glucocorticoid:
Results in maturation of kidney & skin

 Lower IWL, Less hypernatremia, Earlier diuresis & natriuresis than

unexposed neonates

Arch Dis Child Fetal Neonatal Ed 2005;90:F509–F513. doi: 10.1136/adc.2005.071688

Post-natal Adaptation:

 Phase I: Transition phase

1. Relative oliguria- Initial phase
- Considerable IWL through immature skin
- Lasts hrs-days
2. Diuretic phase - progressive decrease in IWL
- Lasting days
- contraction of ECF compartment
3. Continued natriuresis (as in fetal life)
 Transition phase ends at maximum weight loss

Jochum F, et al., ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Fluid and electrolytes,
Clinical Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.06.948
Post-natal Adaptation:
Phase II: Intermediate phase
- Period between minimum wt & regain of birth wt
- Duration is variable
- ELBW/VLBW : Diuresis & natriuresis might continue
- Breastfed term babies: 7-10 days
 Phase III: Stable Growth
- Continuous weight gain
- Positive water & electrolyte balance

Jochum F, et al., ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Fluid and electrolytes,
Clinical Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.06.948
Goal of therapy:
Phase I:
- Allow contraction of ECF without compromising CVS function
- Maintain normal serum electrolyte
- Secure urine output without oliguria for >12hr
- Ensure regulation of body temp by providing fluid for TEWL
- Prevent excess Insensible water loss
- Restricted Na+ intake for 1st 2-3 days
- ELBW/VLBW Na+/k+ may b recommended from Day1
(Provided adequate urine output present)

Jochum F, et al., ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Fluid and

electrolytes,Clinical Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.06.948
Goal of therapy:

Phase II:
- Replete body electrolyte losses
- Maintain proper fluid electrolyte homeostasis
- Na+ @ 3-5 mEq/kg/day supplement
- PT <35 wk Na+ supplement with 4-5mEq/kg/d have better
neurodevelopment than lower Na+ supplement

Jochum F, et al., ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Fluid and

electrolytes,Clinical Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.06.948
Goal of therapy:
Phase III:
-Replace losses of water & electrolyte
-Provide extra water & electrolyte for growth and homeostasis
-Preterm VLBW need Na+ supplement @1.5-2.6mq/kg
Because of higher growth rate

Inability to provide may lead to wt loss

-Recommended K+ = 2-3mEq/kg/day

Jochum F, et al., ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Fluid and

electrolytes,Clinical Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.06.948
Jochum F, et al., ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Fluid and
electrolytes,Clinical Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.06.948
Jochum F, et al., ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Fluid and electrolytes,Clinical
Nutrition (2018), https://doi.org/10.1016/j.clnu.2018.06.948
2017
Objectives:

1. Higher (commencing 2 mmol/kg/day) versus lower (commencing <

2 mmol/kg/day) sodium supplementation in preterm infants less
than 7 days of age.

2. Higher ( 5 mmol/kg/day) versus lower (< 3mmol/kg/day) or

intermediate ( 3mmol/kg/day to < 5 mmol/kg/day) sodium
supplementation in preterm infants 7 days of age.

3. Early and late higher versus lower sodium intake.(<7d/>=7d)

Primary outcomes
1. Mortality (latest time reported up to hospital discharge)

2. Neurodevelopmental disability at least 18 months of

postnatal age (defined as neurological abnormality including
cerebral palsy on clinical examination, developmental delay more
than two standard deviations below population mean on a
standardised test of development, blindness (visual acuity less
than 6/60), or deafness (any hearing impairment requiring
amplification) at any time after term corrected)
 Early Na+ supplementation <7 days will lead to delay in physiological loss of
body water that is normal post-natal adaptation

Implication in RDS / PDA

•.Arch Dis child fetal neonatal ed 2000 Jan;82(1):F24-8.

 doi: 10.1136/fn.82.1.f24.
Randomised controlled trial of postnatal sodium supplementation on
body composition in 25 to 30 week gestational age infants
Goals of therapy:

Monitor
Administer

Calculate

Assess
Assess:
 History:
- Maternal excessive use of oxytocin, diuretics, IV fluids
(risk of fetal hyponatremia)
- Use of ANS
- Oligohydramnios(risk of renal dysfunction)
- Perinatal asphyxia (ATN)
 Examination:
- Change in weight
- Skin & mucosal manifestation: Not sensitive
- Cardiovascular : Tachycardia, CFT delay, BP changes late
- Environment in which baby is cared
- Input & output measurements
Assess:
Lab studies:
- Serum electrolyte & plasma osmolarity
( Reflects composition & tonicity of ECF)
- BUN & Sr Creatinine ( ECF volume & GFR)
- Urine electrolyte & specific gravity
Renal capacity to
Aborb/Excrete Na+ Concentrate/dilute urine

- FENa(glomerular filtration & tubular reabsorption balance)

<1%- Pre-renal factors
2.5%- Renal failure
>2.5%- <32wk GA common
- Arterial PH: Poor tissue perfusion- Met Acidosis
Calculate:

1. Replace the deficit:

10% dehydration= 100ml/kg ECF loss(moderate dehydration)
15% dehydration= 150ml/kg ECF loss(severe dehydration)

Correct gradually over 24hrs

(1/2 correction over 8hrs & 1/2 over 16hrs)
IVF = N/2 saline

2. Calculate maintenance & add

3. Replace ongoing losses

Replace the ongoing loss:

THE HARRIET LANE HANDBOOK; TWENTY-FIRST EDITION, 2018

Monitor:
1. Weight:
Term: 1-3% per day / 5-10% in 1st wk
Pre-term: 2-3% per day / 10-15% in 1st wk
Increased loss: fluid correction
Decreased loss: fluid restriction(10-20% reduction in daily fluid)
2. Clinical examination: Unreliable
10% dehydration: signs of dehydration
15% dehydration: signs of shock
3. Serum biochemistry:
Serum Na+ & plasma osmolarity
Avery’s disease of the newborn: 10 th edn;2017
Monitor:
4. Urine parameters:
- urine output ( N= 1-3ml/hr)
- specific gravity (1.005 – 1.012): Dipstick/Refractometer
- Osmolarity (100-400mosm/L): Freezing point osmometer
- FENa
- BUN/Creatinine (serial samples are better indicator)
Fluid restriction:

2014
Conclusion:
• the most prudent prescription for water intake of premature infants
would seem to be careful restriction of water intake so that
physiological needs are met without allowing significant dehydration.
This practice could be expected to decrease the risks of patent ductus
arteriosus and necrotizing enterocolitis without a significant increase
in adverse consequences.
Electrolyte abnormalities:

Normal Sr Na+ = 135-145mEq/L

Normal Sr K+ = 3.5 – 5mEq/L

Na+ K+
Hypo<130 Hypo<3.5

Hyper>145 Hyper>6
Na+ abnormalities:

Hyponatremia Hypernatremia +Wt. Gain= salt & water

+Wt. Gain=water excess
overload

+Wt. Loss=Na+ depletion +Wt. Loss= Dehydration

z
Management of hyponatremia:

 Na+ Deficit / Excess (mEq) = 0.7 x Kg x {(Na+)desired – (Na+)actual}

(Assuming 70% body water as distributing place for Na+)
Serum Na+ <120mEq/L

Urgent Correction 3% Saline(513mEq/L Na+) over 4-6hrs till

Sr Na=120mEq/L

 Acute symptomatic (Seizures/Coma)- IV bolus @4-6ml/kg of 3% NS

 Rapid correction may be associated with pontine/ extrapontine

myelinolysis Avery’s disease of the newborn: 10 th
edn;2017
Management of hyponatremia:

 Once Serum Na >120mEq/L : No 3% NS

 Once neurological condition stabilises/Sr Na >120mEq/L

 Complete correction over next 48hrs

(2/3rd replacement in 1st 24hrs & 1/3rd replacement in next 24hrs)

 IVF=N/2 D5 or DNS

Avery’s disease of the newborn: 10th edn;2017

Management of hyponatremia:
Hyponatremia

ASymptomatic Symptomatic
(Seizure/coma)

Sr Na<120 Sr Na>120 Bolus 4-6ml/kg of

3% NS

Correct with 3% NS
Over 4-6hrs till Na=120
Correct over 48hrs
(2/3 over 24hrs & 1/3 over
next24hrs)

Avery’s disease of the newborn: 10th edn;2017

Hypernatremia:

Avery’s disease of the newborn: 10 th edn;2017

Management of hypernatremia:
 Euvolemic/ Hypovolemic :
Increase free water administration to reduce sr Na+
 Hypervolemic : Restrict Na+ administration

 Acute Na+ overload cases : Correct Na+ @ 1mEq/L/hr(24mEq/L/Day)

 Chronic/ time unknown: Correct Na+ @0.5mEq/L/hr(12mEq/L/day)
Abrupt correction
Cerebral Edema

Avery’s disease of the newborn: 10 th edn;2017

Management of hypernatremia:
 Free water deficit(ml)=
4 x Preillness wt(kg) x {(Na)current-(Na)desired}
 Amount of free water required to
decrease Sr Na+ by 1mEq/L is 4ml/kg
(If Sr Na+ >170 then free water required is 3ml/kg)
 Solute fluid deficit(SFD) = Total fluid deficit – free water deficit
(SFD is additional fluid vol lost beyond free water loss)
 In severe hypernatremia( Sr Na >175mEq/L): Simultenous NS &
3% NS is given
Avoid fluids with conc. >15mEq/L below that of serum Na.
THE HARRIET LANE HANDBOOK; TWENTY-FIRST EDITION, 2018
Sample calculation for hypernatremic dehydration:
Q) Baby of 3kg birth weight presents on day15 with 10% dehydration &
Sr Na+ is 155mEq/L.
• Requirement: 1. Maintenance @150ml/kg = 450ml
2. Total fluid deficit@10% dehydration= 300ml

Replacement rate over 24hrs = 450+300/24hr @31ml/hr

• Calculation for fluid selection:
1. Free water deficit = 4x3(wt)x(155-145) = 120ml
2. Solute fluid deficit = 300(TFD) – 120(FWD)= 180ml
3. Maintenance Na+ requirement= 3mEq/100ml of
maintenance fluid= 13mEq in 450ml
Sample calculation for hypernatremic dehydration:

4. Sodium deficit = 8-10mEq/100ml of SFD

=10 x 180ml(SFD)/100ml = 18mEq
5. Total Na required = Maintenance Na + Deficit Na
= 13+18 = 31mEq
6. Na required per L = Total Na / Fluid deficit in L
= 31/0.3L = 103mEq
• Best fluid that approximates Na requirement/L
= RL (130mEq/L)
THE HARRIET LANE HANDBOOK; TWENTY-FIRST EDITION, 2018
Na+ content of various fluids:
FLUID TYPE Na Content(mEq/L)

D5W/D19W 0

NS 154

½ NS 77

D51/4NS 38.5

3%Nacl 513

8.4% NaHCO3(1mEq/ml) 1000

RL 130

Intralipid 2.5

THE HARRIET LANE HANDBOOK; TWENTY-FIRST EDITION, 2018

K+ Abnormalities:
• K+ is major intracellular cation

• Sr K+ does not reflect total body stores

• pH effect: Inc of 0.1pH unit results in 0.6mEq/L fall in Sr K+

(Due to intracellular shift) less acid less K+
Hyperkalemia:(>6mEq/L)
 Etiology:
1. Inc. K+ release from cells – IVH, Asphyxia, Hemolysis, Trauma,
Hypothermia
2. Decrease excretion with Renal failure, Oliguria, CAH
3. Medication error- Excess administration of K+ (Common)
4. Miscellaneous- Dehydration, Blood transfusion, Exchange
transfusion
Diagnosis:

1st Change

 ECG Changes may be 1st indication of hyperkalemia

 Finally SVT/VT, Bradycardia or Ventricular fibrillation
Management of Hyperkalemia:
• Stop all K+ containing fluids
• Calcium gluconate 1-2ml/kg (10%) IV [Stabilises conducting tissue]
• Sodium bicarbonate 1-2mEq/kg/hr IV[Intracellular shift]
• Glucose + insulin(Human regular insulin) =
(0.05U/kg insulin with 2ml/kg of 10% Dx)
F/b continuous infusion of insulin
(0.1U/kg/hr with 2-4ml/kg of 10% Dx)
Management of Hyperkalemia:
• Beta agonist e.g salbutamol 2.5mg via Nebulisation

• Lasix 1mg/kg/dose : increases excretion over hours

• Na polystyrene sulfonate(kayexalate)- Inc K+ excretion

Rectal administration @1g/kg at 0.5g/ml of NS with

retention time of 30min(Lowers K by 1mEq/L approx.)

• Dialysis/Exchange transfusion – if oliguria/anuria

Avery’s disease of the newborn: 10 th edn;2017
Hypokalemia:

Serum K+ <3.5mEq/L
 Etiology:
- Chronic diuretic use
- Renal tubular defects
- Loss from NG tube/ ileostomy
 Can lead to Arrhythmia, Ileus, Lethargy (usually @K<2.5mEq/L)

Avery’s disease of the newborn: 10 th edn;2017

Hypokalemia:

 ECG changes:
Management of Hypokalemia:

• Inc. daily K+ intake by 1-2mEq/kg

• In severe symptomatic hypokalemia(@K <2.5mEq/L)

KCL @0.3mEq/kg infused over 30-60min

with continuous ECG monitoring

• If hypokakemia is due to Alkalosis: Correct alkalosis(Not K+)

Avery’s disease of the newborn: 10 th edn;2017

Conclusion:
• Allow normal contraction of ECF :
Wt loss upto 10% in term & 15% in preterm

• Electrolytes to be added after 2-3days

- Na @ 3-5mEq/kg/day
- K @ 2-3mEq/kg/day
• Replace fluid deficit gradually over 24hrs

• Careful Fluid restriction in premature infants may be beneficial

• Electrolyte status should be regularly monitored.