This document provides guidelines for initial electrolyte management in infants receiving intravenous fluids, with a focus on sodium, potassium, calcium, and disorders related to abnormalities in these electrolytes. It recommends: - Daily electrolyte measurements for infants receiving only IV fluids, especially very preterm infants under 750g. - Starting calcium supplementation on the first day for high-risk infants. - Not adding sodium or potassium to IV fluids for the first few days until levels begin to fall. - Maintaining sodium at 2-4 mEq/kg/day and potassium at 1-3 mEq/kg/day once supplementation begins. - Carefully managing abnormalities like hyponatremia, hypernatremia

1. DISORDER OF FLUID AND ELECTROLYTES
C.Deenalakshmi
M.sc(N) Rn, Rm

2. INITIAL ELECTROLYTE MANAGEMENT
1. General guidelines:
All infants receiving only IV fluids should have daily
measurements of electrolytes for the first few days of life.
 For infants <750 g, measure electrolytes within 12h of birth
to have a baseline, so that adjustments in fluid intake can be
made as serum sodium changes. In these extremely preterm
infants, significant hyperkalemia may develop in the first 48-
72h.
 Measure BUN and creatinine initially and at least every other
day until stable, then weekly until feedings are well
established.
 Measure magnesium in first few hours after birth if mother
had received magnesium.

3. Suggested frequency of measurements of electrolytes,
including calcium for infants receiving only IV fluids:
 <750 g q8-12 h x 3-4d, then daily
 750-1,500 g q12 h x 3-4 days, then daily
 >1,500 g daily
2.Sodium:
 Do not add Na+ to IV fluids on the first day; wait until day 3-4
days when [Na+] begins to fall.
 Na+ is usually given as NaCl, but Na-acetate may be used to
decrease metabolic acidosis from renal bicarbonate wasting
in ELBW infants.
 •Usual maintenance for Na+ is 2-4 mEq/kg/d.

4. 3. Potassium (K+):
 Do not add K+ to IV fluids for the first few days after birth,
until urine output is well established and serum K+ level
starts to decline. K+ may be given as KCl or K-acetate.
 Usual maintenance for K+ is 1-3 mEq/kg/d.
4. Calcium (Ca++):
 Ca++ should be started on the first day after birth especially
in infants who are preterm, SGA, asphyxiated, septic, and
post operative, and infants of a diabetic mother.
 Ca++ may be added to the IV solution infusing through
central catheters after the location of the catheter tip has
been verified radiographically to be in proper position.
 This includes umbilical arterial and venous catheters and
central venous catheters

5.  Ca++ should not be added to IV solutions infusing in
peripheral veins because extravasation of Ca++
containing solutions may cause severe sloughing of skin.
If peripheral IV access is being used, Ca++ should be
given as an intermittent bolus over 5 to 15 minutes while
watching the IV insertion site to ensure that fluid is not
infiltrating into the tissues.
 •Usual maintenance for Ca++ is calcium gluconate 200-
400 mg/kg/d.
 •Usual intermittent dose is calcium gluconate 50-100
mg/kg IV q6h.

7. SODIUM
NORMAL SERUM NA+ VALUE IS 135-148 MEQ/L.
 Sodium is usually excreted via the kidney, controlled by the
renin-angiotension-aldosterone system. This control
mechanism is as active in the preterm as in the term infant,
but tubular unresponsiveness leads to sodium wastage at
low gestations and in the sick new-born.
 From day 3 onwards normal sodium requirements are
1-2 mmol/kg/day for term infants and 3-5 mmol/kg/day in the
well preterm, but the very preterm needs may be higher
secondary to tubular losses and preterm infants may need as
much as 12-15 mmol/kg/day.

8. HYPONATREMIA
It is defined as serum sodium level of <130 mEq/L
Causes
Water overload
Maternal water overload before birth
Iatrogenic water overload following birth
Syndrome of inappropriate release of antidiuretic
hormone (SIADH)
► Cerebral disease (e.g., birth asphyxia and meningitis)
► Respiratory disease (e.g., pneumonia and
pneumothorax

9. Sodium depletion
 This is usually accompanied by a lesser degree of water
depletion.
Excessive GIT losses (vomiting, diarrhea, nasogastric
aspirate, or enterostomy loss).
Excessive fluid removal (repeated drainage of ascites,
pleural fluid or CSF).
Excessive renal losses:
► Primary renal tubular problems, late hyponatremia of
prematurity, or following relief of obstructive uropathy.
► Congenital adrenal hyperplasia.
Third space loss (e.g., NEC).

10. CLINICAL MANIFESTATIONS
 Decreased serum sodium (usually <120mEq/L) with
seizures or mental status changes.
 Anorexia, nausea, lethargy and apathy
 More advanced symptoms:
 disorientation,
 agitation,
 depressed reflexes,
 focal neurological deficits
 Severe: coma and seizures: sodium concentration less
than 120 mEq/L

11. MANAGEMENT
 Appropriate treatment may be either fluid restriction or
sodium supplementation:
Over hydration
► Restrict fluid intake.
► Add maintenance sodium (2-4 mEq/kg/day) to IV fluids.
► Correct serum sodium using replacement formula, if
serum level is <120 mEq/L.
Renal losses
► Increase maintenance sodium (some VLBW infants may
have sodium requirements of as much as 6-8 mEq/kg/day).
.

12. Gastrointestinal losses:
► Replace nasogastric drainage ml/ml with glucose 5% and
normal saline 0.9% (1:1 ratio). Add potassium, if needed.
SIADH
► Furosemide, at a dose of 1 mg/kg IV every 6 hrs, can be
initiated with sodium replacement using hypertonic NaCl 3%
(1-3 ml/kg) as an initial dose, if
□ Serum Na+ is <120 mEq/L. □ Neurologic signs such as
seizures develop.
 ► Once serum Na+ >120 mEq/L and neurologic signs
abort, fluid restriction alone can

13. SODIUM REPLACEMENT FORMULA
 Give 1/2 replacement (over at least 6-8 hrs) in the
maintenance IV fluid.
 Check serum Na+ level after the first replacement. If
additional sodium is needed, give the second half over
the next 16 hrs.
 Correct by hypertonic saline 3% (1 mEq in 2 ml).
Sodium concentration of various fluids
Solution -------------Na+ Concentration (mEq/L)
 3% NaCl in water --------- 513
 0.9% NaCl in water ---------154
 Ringer’s lactate ------------130
 0.45% NaCl in water --------77
 0.2% NaCl in water --------34

14. HYPERNATREMIA
It is defined as a serum sodium level of >150 mEq/L.
Causes
Water depletion
 Inadequate free water intake
 Excessive transepidermal water loss (e.g., skin
sloughing)
Excessive renal losses:
► Glycosuria
► Diabetes insipidus (congenital or acquired e.g., IVH)
Sodium overload
Excessive administration of sodium-containing solution
(sodium bicarbonate bolus infusion and sodium-containing
medications) especially in the face of reduced cardiac output.

15. CLINICAL MANIFESTATIONS
 Most infant with severe dehydration have a history of
lethargy, listlessness, and decreased responsiveness;
those with hypernatremia dehydration tend to be irritable
with stimulation with high-pitched cry. And it is associated
with breast-feeding malnutrition
 Neonates should re-gain any weight loss within a few days
of birth and regain their birth weight by the tenth day of
life.
 First signs of neonatal dehydration:
 failure to have bowel movements,
 presence of urine crystals,
 weight loss.

16. MANAGEMENT
 Treatment is difficult as persistence of hypernatremia is
associated with cerebral hemorrhage and renal vein
thrombosis in the newborn but aggressive correction may
cause cerebral edema as water enters cells down the
osmotic gradient.
1.Hypernatremia with ECF volume excess
Restrict sodium administration.

17. Hypernatermia with deficient ECF volume
 Increase free water administration.
 Use D5W/0.3-0.45% saline solution IV in volumes
equal to the calculated fluid deficit, given over 48-72 hrs to
avoid a rapid fall in serum osmolality, which can lead to
cerebral edema.
 Body weight, serum electrolytes, and urine volume and
specific gravity must be monitored regularly so that fluid
administration can be adjusted appropriately.
 Once adequate urine output is demonstrated, potassium
is added to provide maintenance requirements or replace
urinary losses. Maintenance fluids should be provided
concurrently.

18. CRITICAL THINKING
HYPO / HYPER NATREMIA
For the client experiencing
FVE & hyponatremia d/t
excessive intake of water,
which IV solution would you
expect the physician to
order?
a. D5NS
b. NS
c. D5W
d. ½ NS

20. POTASSIUM
 Normal serum K+ value is 3.5-5.5 mEq/L
 High or low values can lead to cardiac arrest.
 With adequate kidney function excess potassium is
excreted in the kidneys.
 If kidneys are not functioning, the potassium will
accumulate in the intravascular fluid
Neonatal Service –
Clinical Guidelines
 Breast milk contains about 1 mmol / kg / day
 A sick neonate with normal renal function will require 2-3
mmol / kg / day to maintain a positive balance
 If there is acute renal failure, oliguria or high potassium
levels, potassium replacement should be withheld.

21. HYPOKALEMIA
(Plasma potassium <3.5 mmol/l)
Causes
 Inadequate intake – potassium supplements may have
to be added to IV fluids after the first 48 hours unless
urine output is poor
 Gastrointestinal losses from vomiting, diarrhoea,
nasogastric or stoma
 Alkalosis (buffering of pH causes renal potassium
wastage)
 Diuretics all cause potassium wastage, particularly loop
diuretics, e.g. frusemide.
 Hyperaldosteronism.
 Hypomagnesaemia may be associated with
hypokalaemia and may need correcting

22. CLINICAL MANIFESTATIONS
 It may be asymptomatic, or may has the following
manifestations:
► Weaknessand paralysis
► Lethargy
► Ileus
► Arrhythmia
 ECG changes Flat T wave, prolonged QT interval, or the
appearance of U wave

24. MANAGEMENT
 slow potassium replacement either orally or intravenously
(1 mEq/kg KCl should raise serum potassium 1 mEq/L)
► Initial oral replacement therapy:
0.5-1 mEq/kg/day divided and administered with feedings
(small, more frequent aliquots preferred). Adjust dosage
based on monitoring of serum potassium concentration.
► Constant IV potassium infusion:
calculate the normal maintenance infusion of potassium that
should be given and increase the amount accordingly 2-3
mEq/kg/day.

25. ► Intravenous therapy:
 KCl (1 mEq/kg) may be given, over a minimum of 4 hrs.
 For emergency treatment of symptomatic hypokalemia; as
in case of cardiac arrhythmias, KCl (0.5-1 mEq/kg)IV may
be given over 1 hr,then reassess (maximum infusion rate is
1 mEq/kg/hr).
► The maximum concentration of potassium is given
 40 mEq/L for peripheral venous infusions, and
 80 mEq/L for central venous infusions.
► Rapid administration or a bolus dosing of potassium is not
recommended as life threatening cardiac arrhythmias may
occur.
► Do not give potassium to an infant who is not voiding

26. NURSING ALERT
 Before administering a potassium supplement
make sure the child is producing urine, which
demonstrates renal function.

27. TREATMENT MODALITIES
Peripheral IV with IV
house.

28. INTRAOSSEOUS THERAPY
Intraosseous needle in place for emergency vascular access.

29. CENTRAL VENOUS CATHETER

30. CENTRAL LINE BUNDLE
 Hand Hygiene
 Maximal barrier precautions upon insertion
 Chlorhexidine skin antisepsis
 Optimal catheter site selection; subclavian vein is
the preferred site for non-tunneled catheter
 Daily review of line necessity with prompt removal
of unnecessary lines

31. HYPERKALEMIA
 It is defined as a serum potassium level of >6 mEq/L,
measured in a non-hemolyzed specimen.
 Hyperkalemia is of more concern than hypokalemia,
especially when serum potassium levels exceed 6.5
mEq/L or if ECG changes have developed.

32. CAUSES
 Excessive administration of potassium (e.g., supplementation for
hypokalemia associated with diuretic therapy).
 Decreased potassium clearance due to renal failure, certain
forms of congenital adrenal hyperplasia).
 Increased potassium release secondary to :
 bleeding,
 tissue destruction,
 intraventricular hemorrhage,
 cephalhematoma,
 intravascular hemolysis,
 bowel infarction,
 trauma and
 hypothermia.
 Extracellular shift of potassium as severe acidosis.

33. CLINICAL MANIFESTATIONS
 Hyperkalemia may be asymptomatic or may result in
arrhythmias and cardiovascular instability.
ECG changes
 Peaked T waves,
 flattened P waves, increased
 PR interval, and
 widening of the QRS,
 bradycardia,
 tachycardia,
 supraventricular tachycardia (SVT),
 ventricular tachycardia, and
 ventricular fibrillation

35. MANAGEMENT
 Discontinue all exogenous sources of potassium.
 Stabilization of the conducting system:
 Calcium gluconate 10% (1-2 ml/kg) IV over 1 hr
 Antiarrhythmic agents e.g. lidocaine and bretylium
 Dilution and intracellular shifting of K+:
► Sodium bicarbonate 1-2 mEq/kg (slowly, at least over 30
minutes). Avoid rapid infusion, may lead to IVH especially in
preterm infants <34 weeks’ gestation and younger than 3
days.

36.  Human regular insulin (a bolus of 0.05 unit/kg), with
glucose 10% (2 ml/kg), followed by a continuous infusion
of insulin 10 units/100 ml, at a rate of 1 ml/kg/hr, with 2-4
ml/kg/hr glucose 10%. Monitor the infant for hypoglycemia.
 β2 agonists, such as albuterol, via nebulizer.
Enhanced K excretion
 ► Furosemide 1 mg/kg/dose in infants with adequate renal
function.
 ► Peritoneal dialysis or double volume exchange can be
considered in infants with oliguria and reversible renal
disease. Use fresh whole blood (<24 hrs).
 Peritoneal dialysis takes time to set up and it may be
technically impossible in VLBW infants and when there is
injured bowel, as in NEC.

37. CRITICAL THINKING
POTASSIUM IV ADDITIVES
Which of the following interventions will the
nurse undertake when administering
parenteral K additives?
Monitor the IV site for phlebitis
Place on cardiac monitor if > 10 mEq
Assure of adequate mixing of K in solution
Monitor for elevated K levels
Monitor for decreased Na levels
Administer potassium by slow IV push method

39. CALCIUM
 Total serum calcium levels in term infants decline from
values of 10-11 mg/dl at birth to 7.5-8.5 mg/dl over the
first 2-3 days of life.
 Calcium concentrations can be reported either in mg/dl or
mmol/L (4 mg/dl of ionized calcium equals 1 mmol/L).
 Serum calcium levels appear low in the newborn
because of low albumin level
 Normal physiology:
 3rd trimester Ca from mother

40. HYPOCALCEMIA
IT IS DEFINED AS A TOTAL SERUM CALCIUM CONCENTRATION <7 MG/DL
OR AN IONIZED CALCIUM CONCENTRATION <4 MG/DL (<1 MMOL/L)

41. CLINICAL MANIFESTATIONS
 Lethargy, Poor feeding, Vomiting, Abdominal
distension
 Cyanosis, stridor
 Seizures
 Apnea
 Tetany and signs of nerve irritability, Chvostek
sign, carpopedal spasm, Trousseau sign
 Prematurity, birth asphyxia
 ECG, prolonged QTc (>0.4 s), a prolonged ST
segment, and T wave abnormalities may be
observed

42. CHOVSTEK TROUSSEAU

43. HYPOCALCEMIA
Early-onset hypocalcemia
Occurs within the first 3 days of life, and is strongly
associated with infants of diabetic mothers, asphyxia, and
prematurity.
Often asymptomatic in preterm infants but may show
 jitteriness,
 twitches,
 apnea,
 seizures, and
 abnormalities in cardiac function.
 Early onset hypocalcemia can be prevented by the infusion
of 20-45 mg/kg/day elemental calcium in the admission IV
fluids.

44.  Maintenance requirements for the premature infant may
reach 70-80 mg/kg/day elemental calcium.
 If the infant is asymptomatic and has a total serum
calcium level of >6.5 mg/dl or an ionized calcium level of
>0.8-0.9 mmol/L, close observation alone is appropriate.
 Additional elemental calcium should be given
intravenously if biochemical abnormality persists (total
serum calcium level is <6.5 mg/dl or the ionized level is
<0.8-0.9 mmol/L) at 10-20 mg/Kg elemental calcium for 4-
6 hrs.
 Emergency calcium therapy (active seizures): 10-20
mg/Kg elemental calcium, given by IV infusion over 10-15
minutes.

45.  Care should be taken in administering the IV calcium:
 ► Monitor for bradycardia or arrhythmia. Discontinue
infusion if heart rate <100/minute.
 ► Infants who are on digoxin receive calcium only by
constant infusion.
 ► The peripheral IV site should be checked for patency
before and during administration, because of the
potential for sloughing, and necrosis caused by
infiltrated calcium

46. LATE-ONSET HYPOCALCEMIA
 It develops after the first week of life and usually has
a specific cause such as high phosphate intake,
malabsorption, hypoparathyroidism or vitamin D
deficiency.
 It should be evaluated in details.

47. HYPERCALCEMIA
 it is defined as total serum [Ca] >12 mg/dL or [ionized
calcium] >1.5 mmol/L and is rare in newborns.
Hypercalcemia may cause vomiting, hypotonia and
encephalopathy.
Cause
 Phosphate deficiency in the very preterm
 Prolonged calcium infusions without additional
phosphate
 Over-treatment with vitamin D

48. CLINICAL MANIFESTATIONS
 muscle weakness,
 renal calculi,
 fatigue,
 altered LOC,
 decreased GI motility,
 cardiac changes

49. TREATMENT OF HYPERCALCEMIA
 Correct underlying cause, if possible
 Adequate hydration
 Furosemide to increase calcium excretion
Glucocorticoids to inhibit intestinal absorption of calcium
and ↓ bone resorption
 Increase inorganic phosphate by giving oral phosphate
solution (Neutra-Phos™ 200 mg/mL) at a dose of 3-5
mg/kg.
 Avoid parenteral phosphate solution in severely
hypercalcemic infants.

51. MAGNESIUM MG2+
 1.5-2.5mEq/L
 Most located within ICF
 Needed for activating enzymes, electrical activity,
metabolism of carbs/proteins, DNA synthesis
 Regulated by intestinal absorption and kidney

52. HYPOMAGNESEMIA
 Serum < 1.5mEq/L
Causes
 decreased intake
 prolonged NPO status,
 chronic alcoholism &
 nasogastric suctioning
S/S:
 muscle weakness,
 cardiac changes,
 mental changes,
 hyperactive reflexes &
 other hypocalcemia S/S.
Treatment
 replacement IV therapy
 restore normal Ca levels ( Mg mimics Ca)
 seizure precaution

53. HYPERMAGNESEMIA
 Serum>2.5mEq/L
Causes
 renal failure,
 increased intake
S/S:
 flushing,
 lethargy,
 cardiac changes (decreased HR),
 decreased resp,
 loss of deep tendon reflexes
Treatment
 restrict intake
 diuretic rx

55. CHLORIDE CL-
 95-105mEq/L
 Most abundant anion in ECF
 Combines with Na to form salts
 Maintains water balance, acid-base balance, aids in
digestion (hydrochoric acid) & osmotic pressure (with Na
and H20)
 Regulated by kidneys
 Follows Sodium (Na)

56. HYPOCHLOREMIA
 Serum level 96mEq/L
 Results from prolonged vomiting & suctioning
S/S
 metabolic alkalosis,
 nerve excitability,
 muscle cramps,
 twitching,
 hypoventilation,
 decreased BP if severe
 Tx: diet/IV therapy

57. HYPERCHLOREMIA
 Serum level > 106mEq/L
 Results from excessive intake or retention by
kidneys – metabolic acidosis
 S/S
 Arrhythmias,
 decreased cardiac output,
 muscle weakness,
 LOC changes,
 Kussmauls’s respirations
 Tx: restore fluid & electrolyte balance

59. PHOSPHATE PO4-
 2.5-4.5mg/dl
 Needed for acid-base balance,neurological & muscle
function, energy transfer ATP & affects metabolism of
carbs/proteins/lipids, B vitamin synthesis
 Found in the bones
 Regulated by intake and kidneys
 Inversely proportional to Calcium
Therefore some regulation by PTH as well

60. HYPOPHOSPHATEMIA
 Serum level < 1.8mEq/L
 Results from decreased intestinal absorption and
increased excretion
 S/S
 bone & muscle pain,
 mental changes,
 chest pain,
 resp. failure
 Tx: Diet/ IV therapy

61. HYPERPHOSPHATEMIA
 Serum level> 2.6mEq/L
 Results from renal failure, low intake of calcium
 S/S: neuromuscular changes (tetany), EKG
changes, parathesia-fingertips/mouth
 Tx: Diet; hypocalcemic interventions
Medications: phosphate binding
 The body can tolerate hyperphosphatemia fairly
well BUT the accompanying hypocalcemia is a
larger problem!

62. COMMON FLUID PROBLEMS
 Oliguria : UOP< 1cc/kg/hr. Prerenal, Renal, or
Postrenal causes. Most normal term babies pee
by 24-48 hrs. Don’t wait that long in sick l’il
babies! Check Baby, urine, FBP. Try fluid
challenge, then lasix. Get USG if no response
 Dehydration: Wt loss, oliguria+, urine sp. gravity
>1.012. Correct deficits, then maintenance +
ongoing losses
 Fluid overload: Wt gain, often hyponatremia. Fluid+
sodium restriction

63. SURGICAL CASES ASSOCIATED WITH F,E&N
PROBLEMS
 Abdominal Wall Defects
 The exposure of bowel results in greater insensible
loss of fluid and heat
 It is crucial to place children with gastroschisis in a
warm environment and to protect the bowel (by the
help of a plastic bowel bag).
 Intravenous access should be established immediately,
and resuscitation should be initiated before any
surgical intervention
 I.V. line should be placed in the upper extremities or
the neck

65. Intestinal Obstruction
These patients usually present with choking
or vomiting
They may show signs of severe dehydration
with metabolic alkalosis (hypochloremic,
hypokalemic )
the maintenance requirements and third-
space losses ,can be replaced with 5%
dextrose in 0.25 normal saline with
supplemental potassium chloride at 3
mEq/kg/24 hr.
Consider TPN
Surgical cases associated with F,E&N problems

66. Diaphragmatic Hernia
acute respiratory distress and hemodynamic
instability
Babies will require immediate resuscitation,
correction of acidosis, and, in most cases,
endotracheal intubation.
Surgical cases associated with F,E&N problems

67. INTERVENTIONS FOR F/E BALANCE
 Assess patient carefully- note changes
 Monitor I & O (Intake & Output)
 Monitor weight changes
 Monitor urine
 Monitor vs
 Monitor lab results and dx test
 Maintain proper IV therapy

68. THANK YOU