This document discusses fluid and electrolyte management in neonates. It outlines the physiological changes in neonates that impact fluid needs, including higher total body water and immature kidney function. It provides guidelines for calculating daily fluid requirements based on gestational age and weight. It describes the use of IV fluids for initial resuscitation and maintenance, adjusting for enteral feedings and weight changes. Conditions requiring IV fluids and formulas for replacing various fluid losses are also summarized.

2. 13/2/14Geetanjli NINE, PGIMER

3. 13/2/14Geetanjli NINE, PGIMER

4.  Scientific understanding of physiological
changes and management in order to
calculate correct amount of fluid and
electrolytes
 Individual rhythms of suck, swallow, and
respiration

5.  Explain the physiological changes and need
of fluid management in neonate
 Identify the babies who need IV fluids
 Calculate daily fluid requirement of baby
 Monitor babies receiving IV fluids
 Adjusting IV fluids with enteral feeding

8.  Body composition and surface area:
 More total body water (TBW)
 preterm have larger surface area,
 thin skin, and fast breathing
More loss of TBW + insensible water
loss

9. After birth efflux of ICF ECF
This flood neonates kidney with salt and water
Loss of ECF water leads to physiological wt loss in 1st
week of life
The preterms has more water i.e 75-80% and by end
of 1st
week lose more wt than term baby i.e
approximately 15% and 10% in term
So risk is more

10.  Immature kidney (25% functional) and hormonal effect
(Concentrate urine 600 -700 mOsm/L≃ )
 Activated Renin-angiotensin, aldosterone
 Arginine vasopressin (AVP, ADH) in response to stress, such as
birth, asphyxia, RDS, positive pressure ventilation,
pneumothorax and intracranial haemorrhage.
 Glomerular filtration rate and distal tubular reabsorption of
sodium and initially kidneys are unable to excrete sodium.
Limited capacity :
Patent ductus arteriosus
Necrotizing enterocolitis
Chronic lung disease.

11.  Neonatal kidney
 Has a limited capacity both to excrete and to conserve
sodium.
 Diurise water and sodium in the first 48-72 hours of life
Fluid of choice for
1st
48-72 hours of
life is 10% D

12.  Also remember
 Preterm neonates (<34 week) have a limited tubular
capacity to reabsorb as well as excrete sodium
 Failure to supplement sodium will result in low body
stores of sodium.
 Failure to give adequate sodium is associated with poor
weight gain
 Very low birth weight infants on exclusive breast-
feeding may need sodium
So it is important to
give Sodium (Na) after
diuresis

13.  Ensure initial diuresis by
 Decrease in serum sodium
 At least by 5-6% weight loss then only give fluids
with Na.
 Sodium requirement ranges from 3-5
mEq/kg/day in preterm neonates after the first
week of life.
 Calcium: <1500g (day 1: 36-37mg/kg/day=
4ml/kg/day 10% calcium gluconate)
 Supplementation in addition to breast milk
until 32-34 weeks corrected age.

14.  After 48-72 hours, administer Isolyte P
 If not available, and baby requires higher
infusion rate prepare solution as follow:
Add NS 20ml/kg body weight which is
equal to 3mEq of Na/kg to the required
volume of 10% dextrose and add 1 ml
KCL/100 ml prepared fluid.

15.  Extremely/very preterm and LBW
 Hemodynamically unstable
 In Shock and severe asphyxia
 Lethargic and have refusal to feed
 In moderate to severe breathing difficulty
 Having abdominal distension with bilious or blood
stained vomiting
 Having metabolic abnormalities (hypoglycemia,
electrolyte derangements),
 Dehydrated
 In Post surgical condition necessitating
contraindication to oral feed.

16.  Skin :70%
 Respiration: 30%
 Causes of increased loss
 increased respiration & activity, crying lead to
50-70% in IWL
 Skin injury
 Surgical malformation e.g gastrochisis,
omphalocele
 Increased body & environmental temp
 Use of radiant warmer & Photherapy

18.  transparent plastic barriers (cling wrap) reduce
the IWL by 50-70%/ incubator use
 Increase humidity
 Limit air movement
 Better thermal control
 coconut oil application
 caps and socks
 Adequate fluid/ feeding
when under radiant warmer/phototherapy
 Give humidified oxygen
 Prevent and treat for high temp

19.  Use micro drip set or infusion pump
 Check
 Date
 Clarity
 Seal of the bottle
 Calculate, set and ensure that it is going well
 Change IV set and bag/syringe every 24
hourly even if it still contains IV fluid
 If 2 hours fluid goes within 1 hour, do not stop
the fluid for next 1 hour, infuse the remaining
fluid equally in the remaining hours

20. Birth
weight
Day
1
Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
< 1.5 kg 80 95 110 125 140 150 150
≥1.5 kg 60 80 100 120 140 150 150
Continue this till 32-34 weeks of gestation than Holliday & Segar method

21.  Allow breastfeeding as soon as possible
 If BF not possible, give EBM by NG or paladai
 If tolerates feed, keep increasing enteral feed
 Increase feed @ of 10 ml/kg/day up to 20-30
ml/kg/day
 Feed baby 2-3 hourly

22.  Keep decreasing the total amount of enteral
feed from the total fluid requirement of day
 Discontinue IV fluid when the baby has
started taking > 2/3 of the total fluid
requirement enterally

23. 1. Inspect infusion site hourly
2. Look for redness or swelling, if present, stop and
start a new IV line
3. Amount of fluid going to the baby via all source
e.g with antibiotics, blood products etc should be
deducted form total fluid of the day.
4. Follow strict aseptic precaution while preparing
fluid
5. Prepare under laminar flow
6. Weigh the baby daily and report the changes in
weight.

24.  Chart as follows
S.
No
Time Prepared IV
fluid/L
In Remaining
fluid
1 9am 30 ml 0 30 ml
2 10am 30 ml 10 ml 20 ml
3 11am 30 ml 10 ml 10 ml
4 12 noon 30 ml + 30 ml 10 ml 30 ml
5 1 pm 60 ml 10 ml 20 ml
60= Total prepared 40= Infused 20=
Remaining

25. 5. Measure blood glucose 6-8 hourly till the
baby is on IV fluids
6. If blood sugar is < 45mg/dl, treat for low
blood sugar
7. If BS > 150 mg/dl, change IV fluid to 5%
dextrose (can lead to brain damage)

26.  Fluid loss if 10% of body wt signs and
symptom like
Sunken eye and fontanel,
cold and clammy skin
poor skin turgor and oliguria (U/O <1ml/kg/hr)
 Fluid loss if ≥15%
 hypotension, tachycardia and weak pulses
 Urine output normal 1-3ml/kg/hr
 Monitor the weight and alter the fluid amount
accordingly as per the following

27. Weight Action Amount
• If normal weight
loss is not there i.e.
• Term: 1-3% of birth
weight
• Preterm: 2-3% of
birth weight
Do not give daily
increment.
Keep the
amount same
as it was on
previous day
> 5% Increase fluid volume @ 10 ml/kg/
body weight
Weight loss with
decreased urine
output
Increase fluid volume @10-20 ml/kg

28. Weight Action Amount
• Weight gain
> 3-5%
Decrease fluid 15-20 ml/kg/day
• Weight gain &
decreased urine
output
Decrease fluid
Evaluate for renal
failure
10 ml/kg
• over hydration Check serum Na,
Urine S. Gravity
Decrease fluid by
half for 24 hours
after noticing

29. Mild dehydration (<5%) Moderate dehydration (5–
10%)
Severe dehydration (>10%)
• normal or increased heart rate
• urine output < 1 ml/kg/hr
• normal physical findings
• tachycardia
• urine output < 0.5 ml/kg/hr
• irritable/lethargic
• sunken eyes and fontanel
• decreased tears
• dry mucous membranes
• mild delay in elasticity (skin
turgor)
• delayed capillary refill (>3
sec)
• cool and pale
• rapid and weak or absent
peripheral pulses
• depressed consciousness
• decreased blood pressure
• no urine output
• very sunken eyes and
fontanel
• no tears
• parched mucous membranes
• delayed elasticity (poor skin
turgor)
• delayed capillary refill (>3
sec)
• cold and mottled
• limp

30. STEP I : Correct shock- normal saline 20 mL/kg over 30 min. Repeat if
needed
STEP II (Rapid volume repletion): 20 mL/kg normal saline over 2 hrs.
STEP III: Calculate 24-hr fluid needs i.e maintenance + deficit volume .
Subtract isotonic fluid already administered from 24 hr fluid needs
Administer remaining volume over 24 hr using D5 ½ normal saline + 20
mEq/L KCl
Replace ongoing losses as they occur.

31.  Volume by volume replacement is needed (in addition to
maintenance requirements) for
 diarrhea with dehydration
 chest tube drainage
 excess GI aspirates
 surgical wound drainage
 excessive urine losses from osmotic diuresis.
 Estimate losses over past 6-12 hrs. Replace
losses (only if total loss ≥ 5 ml/kg in 12 hrs period)
volume by volume over next 6-12 hrs.

32.  Vomiting, Nasogastric aspirations and excess
urine output in polyuria (>4 ml/kg/hour)
 with N/2 saline with + 10 mEq/L KCl (1 ml KCl added
per every 100 ml of fluid)
 Ileostomy losses
Normal saline +10 mEq/L KCl (1 ml KCl added
per every 100 ml of fluid)
 Chest tube drainage and third space losses
normal saline
 Diarrheal losses (10-20 ml per stool)
 0.2 NS in D5 + 20 mEq/L KCl (2 ml KCl added
per every 100 ml of fluid)

33.  Serum sodium values should be between
135-145 meq/L.
 Hyponatremia + weight loss= sodium
depletion : replace sodium
 Hyponatremia + weight gain= suggests water
excess: restrict fluid

34. .
 Hypernatremia + weight loss= dehydration-
correct fluid over 48 hours.
 Hypernatremia + weight gain= salt and water
load- restrict fluid and sodium
Look for hyper-excitability and hyper-reflexia

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