2. Page 2
WHY FLUID MANAGEMENT ??....
• Neonatal body fluid physiology is very different from
older children & adults.
• Fluid and electrolyte requirement in a newborn varies as
per weight and gestation age as well as the Postnatal age
of the same child.
• Term and Preterm babies vary in their fluid and electrolyte
quantity requirement & compositions.
• Improper fluid and electrolyte management in newborn,
by itself, can result in serious morbidity and mortality in
the baby.
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Intrauterine Physiology
Early gestation : High Total body water content & large
extracellular compartment
Advancing gestation : Rapid cellular growth, Increased body
solids, fat deposition.
Reductions in Total body water, reduction in ECF volume and
Increase in ICF volume
Therefore, Premature infants have excess Total body fluids
& ECF volume expansion.
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Postnatal physiology - Late
Early days – Interstitial fluid absorbtion
in the intravascular compartment
Rise in circulating blood volume
Atrial Natriuretic Peptide released from
heart which enhances Sodium and
water excretion.
Abrupt decrease in Total Body water
and resultant weight loss in baby.
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Goals of Fluid therapy in newborns:
• 1. Maintain appropriate ECF volume.
• 2. Maintain ECF and ICF osmolality.
• 3.Maintain Ionic concentrations and
pH.
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Steps :
• 1. Estimating existing deficits or
excess.
• 2. Ongoing maintainance needs
calculations.
• 3. Supplying additional needs &
Ongoing losses.
Sensible fluid loss Insensible fluid loss
supply
FLUID
IV
ORAL
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Insensible water loss
• Known as "insensible water loss" as it is a process over
which organisms have little physiological control.
• Includes transepidermal water loss and fluid loss through
respiratory tract.
• IWL PRETERM>TERM
Reasons : Immaturity of Skin Barrier
Respiratory Distress
Larger body water content
More surface area for fluid loss.
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Insensible water loss (cont…..)
• Gestational age, postnatal age and environmental factors
determine amount of IWL.
• Ambient humidity is one of the greatest determinants of
IWL.
• Other environmental factors include activity, airflow,
elevated body, and environmental temperature, skin
breakdowns & mucosal defects like seen in
gastrochisis,etc.
• Respiratory IWL is mainly dependant on the temperature
and humidity of the inspired gas, respiratory rate and tidal
volume and dead space ventillation.
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Insensible water loss (cont…..)
* IWL values increased approximately upto 30% with
Phototherapy exposure.
* Radiant warmers increase IWL by approx 50%.
Age
(d)
Birth weight Range (kg)
0.50-0.75 0.75-1 1-1.25 1.25-1.50 1.5-1.75 1.75-2
0-7 100 65 55 40 20 15
7-14 80 60 50 40 30 20
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Factors affecting Insensible water loss
Factors Effects on IWL
Maturity Inversely proportional to
birth wt. and gestational
age.
Radiant warmer Increased – 50%
Phototherapy Increased – 30%
High humidity Decreased – 30%
Plastic heat shield Decreased – 30%
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Ways to Minimise IWL
• Incubator use (min 50 % humidity).
• Humidification of inspired gases in head box and
ventilators.
• Thermoneutral temperature.
• Increased ambient humidity
• Thin transparent plastic barrier.
• Local oil application to minimise evaporative losses.
• Minimal use of stickings on baby skin and proper newborn
skin care.
• Humidified ventillator gases.
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Assessment
• HISTORY.........
• Body weight daily recording and charting.
• Tachycardia – may indicate hypo/hypervolemia.
• Perfusion – capillary refill time.
• Edema
• Hepatomegaly
• Blood pressure
• Skin turgor, mucus membrane dryness, AF – non reliable.
• Decreased urine output.
• Systemic examination to look for RDS, CHD, BPD
changes fluid calculations
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Laboratory Parameters
• Serum electrolytes :
Serum Na+ and K+ on admission and day3.
Every alternate day estimation for ventillated /
unstable baby.
Twice a week for other babies on IV Fluids.
• BUN and Creat twice a week.
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Laboratory Parameters
.
• Glucose estimation twice a day for ventillated
or unstable babies. Rest – once daily.
• Plasma osmolarity . Normal : 280-300mosm/l
• Urine specific gravity : 1.008 – 1.012 and correlate
with plasma osmolarity for ventillated/ sick babies.
• Blood gas analysis, septic workup for dehydrated
baby.
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Maintainance fluids
Birth
weight
(kg)
Dextrose
(conc)
Fluid Rate (ml/kg/day)
< 24 hrs 24 – 48 hrs > 48 hrs
< 1.0 5 – 10 100 120 140
1.0 – 1.5 10 80 100 120
> 1.5 10 60 80 100
Add maintainance calcium from day1
Electrolytes to be added after 48 hours of life. During 1st wk,
requirement of Na+,K+, Cl is 1-2 mEq/kg/d and beyond first wk,
2-3mEq/kg/d.
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Appropriate fluid & electrolyte balance
.Normal urine output : 1- 3 ml/kg/hr
Urine specific gravity : 1008 – 1012
Weight loss of 5% in term and 15% in preterm babies.
A weight loss of 2 – 3% per day is expected in the first week
of life.
Normal serum electrolytes.
Normal weight graph on charts.
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Respiratory distress syndrome
Consists of 3 phases – prediuretic phase (stabilization phase), Diuretic
phase (Restriction maintainance phase), Post diuretic (liberalization
phase.)
WHAT TO DO ???
1. Fluid restriction to 2/3rd of maintainanceduring the initial phase. After
diuresis occurs, fluid rate can be cautiously increased.
2. Prevent hypoglycemia. Shock can be treated with normal saline ±
ionotropes.
3. Full maintainance fluids can be achieved at the end of first week once
initial diuresis is completed.
4. Special care to be taken for calculating the insensible fluid losses and
supplying it.
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Birth asphyxia
Oliguria or anuria may be seen in these babies secondary to
SIADH or renal injury.
WHAT TO DO ???
1. Fluid restriction to 2/3rd of maintainance during period of
anuria.
2. Restore fluid intake to normal when urine production is
normal.
3. Fluid push (20cc/kg Normal saline) can be given if pre
renal cause suspected.
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PDA (only if symptomatic)
Patent ductus arteriosus need fluid restriction only if signs of
failure are present – tachycardia, hepatomegaly, edema,
sudden weight gain.
WHAT TO DO ???
1. Supply 2/3rd of total maintainance fluid.
2. Iv frusemide may be given SOS.
