Fluids, Electrolyte, and Nutrition

Management in Neonates

N. Ambalavanan MD
Neonatologist
October 1998

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FEN Management in Neonates

Essentials of life:
Food (Nutrition)
water (Fluid/electrolyte)
shelter (control of environment - temperature etc)

Essentials of neonatal care:

Fluid, electrolyte, nutrition management (All babies)
Control of environment (All babies)
Respiratory /CVS/CNS management (some babies)
Infection management (some babies)
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Why is FEN management

important?
Many babies in NICU need IV fluids
They all dont need the same IV fluids
(either in quantity or composition)
If wrong fluids are given, neonatal
kidneys are not well equipped to handle
them
Serious morbidity can result from fluid
and electrolyte imbalance
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Fluids and Electrolytes

Main priniciples:
Total body water (TBW) = Intracellular fluid
(ICF) + Extracellular fluid (ECF)
Extracellular fluid (ECF) = Intravascular fluid (in
vessels : plasma, lymph) + Interstitial fluid
(between cells)

Main goals:
Maintain appropriate ECF volume,
Maintain appropriate ECF and ICF osmolality and
ionic concentrations
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Things to consider:

Normal changes in TBW, ECF

All babies are born with an excess of TBW,
mainly ECF, which needs to be removed
Adults are 60% water (20% ECF, 40% ICF)
Term neonates are 75% water (40% ECF,
35% ICF) : lose 5-10 % of weight in first week
Preterm neonates have more water (23 wks:
90%, 60% ECF, 30% ICF): lose 5-15% of
weight in first week
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Things to consider:

Normal changes in Renal Function

Adults can concentrate or dilute urine
very well, depending on fluid status
Neonates are not able to concentrate or
dilute urine as well as adults - at risk for
dehydration or fluid overload
Renal function matures with increasing:
gestational age
postnatal age
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Things to consider:

Insensible water loss (IWL)

Insensible water loss is water loss that
is not obvious (makes sense?): through
skin (2/3) or respiratory tract (1/3)
depends on gestational age (more preterm:
more IWL)
depends on postnatal age (skin thickens with
age: older is better --> less IWL)
also consider losses of other fluids: Stool
(diarrhea/ostomy), NG/OG drainage, CSF
(ventricular drainage), etc
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Assessment of fluid and

electrolyte status
History: babys F&E status partially reflects
moms F&E status (Excessive use of oxytocin,
hypotonic IVF can cause hyponatremia)
Physical Examination:
Weight: reflects TBW. Not very useful for
intravascular volume (eg. Long term paralysis and
peritonitis can lead to increased body weight and
increased interstitial fluid but decreased intravascular
volume. Moral : a puffy baby may or may not have
adequate fluid where it counts: in his blood vessels)
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Assessment of fluid and

electrolyte status (contd.)
Physical Examination (contd.)
Skin/Mucosa: Altered skin turgor, sunken AF,
dry mucosa, edema etc are not sensitive
indicators in babies
Cardiovascular:
Tachycardia can result from too much (ECF
excess in CHF) or too little ECF (hypovolemia)
Delayed capillary refill can result from low cardiac
output
Hepatomegaly can occur with ECF excess
Blood pressure changes
very late
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Assessment of fluid and

electrolyte status (contd.)
Lab evaluation:
Serum electrolytes and plasma osmolarity
Urine output
Urine electrolytes, specific gravity (not very
useful if the baby is on diuretics - lasix etc),
FENa
Blood urea, serum creatinine (values in the
first few days reflect moms values, not babys)
ABG (low pH and bicarbonate may indicate
poor perfusion) www.similima.com
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Management of F&E
Goal: Allow initial loss of ECT over first
week (as reflected by wt loss), while
maintaining normal intravascular volume
and tonicity (as reflected by HR, UOP,
lytes, pH). Subsequently, maintain water
and electrolyte balance, including
requirements for body growth.
Individualize approach (no cook book is
good enough!)
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Management of F&E (contd.)

Total fluids required:
TFI = Maintenance requirements
(IWL+Urine+Stool water) + growth
In the first few days, IWL is the largest component
Later, solute load increases (80-120 Cal/kg/day = 15-20
mOsm/kg/day => 60-80 ml/kg/day to excrete wastes)
Stool: 5-10 cc/kg/day
Growth: 20-25 cc/kg/day (since wt gain is 70% water)
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Management of F&E (contd.)

Guidelines for fluid therapy
Birth Wt
(kg)

Dextrose Fluid rate (ml/kg/d)

(%)
<24 hr

<1.0

5-10

24-48 hr >48 hr

100-150 120-150

140-190

1.0-1.5 10

100-120 100-120

120-160

>1.5

60-80

120-160

10

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80-120

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Management of F&E (contd.)

Factors modifying fluid requirement:
Maturity--> Mature skin --> reduces IWL
Elevated temperature (body/environment)--> increases
IWL
Humidity: Higher humidity--> decreases IWL up to
30% (over skin and over respiratory mucosa)
Skin breakdown, skin defects (e.g. omphalocele)-->
increases IWL (proportional to area)
Radiant warmer --> increases IWL by 50%
Phototherapy --> increases IWL by 50%
Plastic Heat Shield --> reduces IWL by 10-30%
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Let there be lytes!

Electrolyte requirements:
For the first 1-3 days, sodium, potassium, or
chloride are not generally required
Later in the first week, needs are 1-2
mEq/kg/day (1 L of NS = 150+ mEq; 150
cc/kg/day of 1/4 NS = 5.9 mEq/kg/day which is too
much)

After the first week, during growth, needs

are 2-3 or even 4 mEq/kg/day
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F&E in common neonatal

conditions
RDS:

Adequate but not too much fluid. Excess leads to

hyponatremia, risk of BPD. Too little leads to
hypernatremia, dehydration

BPD:

Need more calories but fluids are usually

restricted: hence the need for rocket fuel. If diuretics
are used, w/f lyte problems. May need extra calcium.

PDA:

Avoid fluid overload. If indocin is used, monitor

urine output.

Asphyxia:

May have renal injury or SIADH. Restrict

fluids initially, avoid potassium. May need fluid challenge
if cause of oliguria is not
clear.
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Common lyte problems

Sodium:
Hyponatremia (<130 mEq/L; worry if <125)
Hypernatremia (>150 mEq/L; worry if >150)
Potassium:
Hypokalemia (<3.5 mEq/L; worry if <3.0)
Hyperkalemia > 6 mEq/L (non-hemolyzed)
(worry if >6.5 or if ECG changes )
Calcium:
Hypocalcemia (total<7 mg/dL; i<4)
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Hypercalcemia (total>11;

Sodium stuff :
Hyponatremia
Sodium levels often reflect fluid status
rather than sodium intake
ECF Excess

Excess IVF, CHF,

Sepsis, Paralysis

Restrict fluids

ECF Normal

Excess IVF, SIADH,

Pain, Opiates

Restrict fluids

ECF Deficit

Diuretics, CAH, NEC

(third spacing)

Increase
sodium intake

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Sodium stuff :
Hypernatremia
Hypernatremia is usually due to excessive
IWL in first few days in VLBW infants
(micropremies). Increase fluid intake and
decrease IWL.
Rarely due to excessive hypertonic fluids
(sod bicarb in babies with PPHN).
Decrease sodium intake.

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Potassium stuff
Potassium is mostly intracellular: blood levels
do not usually indicate total-body potassium

pH affects K+: 0.1 pH change=>0.3-0.6 K+

change (More acid, more K; less acid, less K)

ECG affected by both HypoK and HyperK:
Hypok:flat T, prolonged QT, U waves
HyperK: peaked T waves, widened QRS, bradycardia,
tachycardia, SVT, V tach, V fib

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Hypo- and Hyper-K

Hypokalemia:
Leads to arrhythmias, ileus, lethargy
Due to chronic diuretic use, NG drainage
Treat by giving more potassium slowly

Hyperkalemia:
Increased K release from cells following IVH,
asphyxia, trauma, IV hemolysis
Decreased K excretion with renal failure, CAH
Medication error very common
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Management of Hyperkalemia
Stop all fluids with potassium
Calcium gluconate 1-2 cc/kg (10%) IV
Sodium bicarbonate 1-2 mEq/kg IV
Glucose-insulin combination
Lasix (increases excretion over hours)
Kayexelate 1 g/kg PR (not with sorbitol!
Not to give PO for premies!)
Dialysis/ Exchange transfusion
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Calcium stuff
At birth, levels are 10-11 mg/dL. Drop normally
over 1-2 days to 7.5-8.5 in term babies.
Hypocalcemia:
Early onset (first 3 days):Premies, IDM,
Asphyxia If asymptomatic, >6.5: Wait it out.
Supplement calcium if <6.5
Late onset (usually end of first week)High
Phosphate type: Hypoparathyroidism, maternal
anticonvulsants, vit. D deficiency etc. Reduce
renal phosphate load
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Things we arent going to

discuss (i.e.) homework:
Acid-base disorders: Acidosis or Alkalosis,
Metabolic or Respiratory or Mixed
Hypercalcemia
Magnesium disorders
Metabolic disorders
Methods of feeding: Continuous vs.
Intermittent; TP vs OG vs NG vs NJ;
Trophic feeds; Complications of TPN
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(We can discuss these,
if time permits)

Common fluid problems

Oliguria : UOP< 1cc/kg/hr. Prerenal, Renal, or
Postrenal causes. Most normal term babies pee
by 24-48 hrs. Dont wait that long in sick lil
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

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Nutrition
Goals: Normal growth and development
(as compared to intrauterine growth for preterm
neonates, or as compared to growth charts for
term neonates)

Nutrient requirements:
Energy (Cals)
Water
Protein
Fat

Carbohydrate
Minerals
Vitamins
Trace elements
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Energy { E = mc

E=energy required
m =mass of baby
2
c = cry loudness

Energy needs: depend upon age, weight,

maturation, caloric intake, growth rate, activity,

thermal environment, and nature of feeds.

Growing premies: (Cal/kg/day)

Resting expenditure:
Minimal activity:
Occasional cold stress:
Fecal loss (10-15%):
Growth (4.5 Cal/g +):

50
4-5
10
15
45
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Energy
Stressed and sick infants need more energy
(e.g. sepsis, surgery)
Babies on parenteral nutrition need less energy
(less fecal loss of nutrients, no loss for
absorption): 70-90 Cal/kg/day+ 2.4-2.8
g/kg/day Protein adequate for growth
Count non-protein calories only! Protein to be
preferred used for growth, not energy
65% from carbohydrates, 35% from lipids ideal
>165-180 Cal/kg/day not useful
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Calculations
To calculate a neonates F,E,& N:
First calculate the amount of fluid (Water)
Then calculate how you plan to give it:
Parenteral (IV) or Enteral (OG/PO)
Then calculate the amount of energy
required
Decide how to provide the energy: amount
and nature of carbohydrates and lipids
Provide proteins, vitamins, trace elements
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Calculations: practical hints

for TPN
Do not starve babies! The ones who dont complain are
the ones who need it the most.
Use birthweight to calculate intake till birthweight
regained, then use daily wt
Start TPN on 2nd or 3rd day if the baby will not be on
full feeds by a week
Start with proteins (1 g/kg/d) and increase slowly.
After a few days (3rd or 4th day), add lipids (0.5
kg/kg/d)
Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d Protein
(NPC/N of 150-200)
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Carbohydrate
IV:
Dextrose 3.4 Cal/g = 34 Cal/100 cc of D10W.
Tiny babies are less able to tolerate dextrose. If
< 1 kg, start at 6 mg/kg/min. If 1-1.5 kg, start
at 8 mg/kg/min.
If blood levels >150-180 mg/dL, glucosuria=>
osmotic diuresis, dehydration
Insulin can control hyperglycemia
Hyper- or hypo-glycemia => early sign of sepsis
Avoid Dextrose>12.5% through peripheral IV
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Carbohydrate
Enteral:
Human milk/ 20 Cal/oz formula = 67 Cal/100 cc
Lactose is carbohydrate in human milk and term
formula. Soy and lactose free formula have
sucrose, maltodextrins and glucose polymers
Preterm formula has 50% lactose and 50%
glucose polymers (lactase level lower in premies,
but glycosidases active)
Lactose provides 40-45% of calories in human
milk and term formula
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Fat
Parenteral:
20% Intralipid (made from Soybean) better than
10%
High caloric density (2 Cal/cc vs 0.34 for D10W)
Start low, go slow (0.5-3 g/kg/day)
Avoid higher amounts in sepsis, jaundice, severe
lung disease
Maintain triglyceride levels of < 150 mg/dL.
Decrease infusion if >200-300 mg/dL.
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Fat
Enteral:
Approximately 50% of the calories are
derived from fat. >60% may lead to ketosis.
Medium-chain triglycerides (MCT) are
absorbed directly. Preterm formula have more
MCT for this reason.
At least 3% of the total energy should be
supplied as EFA
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Protein
Term infants need 1.8-2.2 g/kg/day
Preterm (VLBW) infants need 3-3.5 g/kg/day (IV or
enteral)
Restrict stressed infants or infants with cholestasis
to 1.5 g/kg/day
Start early - VLBW neonates may need 1.5-2
g/kg/day by 72 hours
Very high protein intakes (>5-6 g/kg/day) may be
dangerous
Maintain NP Calorie/Protein ratio (at least 25-30:1)
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Minerals (other than Na,K, Cl)

Calcium & Phosphorus:
Third trimester Ca accretion (120-150mg/kg/day)
and PO4 (75-85 mg/kg/day) is more than
available in human milk. Hence, HMF is essential.
Premie formula has sufficient Ca/PO4. Ratio
should be 1:7:1 by wt.
Magnesium: sufficient in human milk & formula
Iron: Feed Fe-fortified formula. Start Fe in breast
fed term infants at 4 months of age, and in premies
once full feeds are reached. (Does not prevent
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Anemia of Prematurity
)

Vitamins
Fat soluble vitamins: A, D, E, K
Water soluble vitamins: Vitamins B1,B2, B6, B12,
Biotin, Niacin, Pantothenate, Folic acid, Vitamin C
All neonates should get vit K at birth
Term neonates: No vitamin supplement required,
except perhaps vit D
Preterm: Start vitamin supplements once full
feeds established if on human milk without HMF.
No need if on human milk with HMF, or preterm
infant formula (except: add vit D if on SSC24).
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Trace elements
Zinc, Copper, Selenium, Chromium,
manganese, Molybdenum, Iodine
Most preterm formulas contain sufficient
amounts
Fluoride supplementation not required in
neonatal period

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Special formula
Soy formula:
Not recommended for premies: impaired mineral and
protein absorption; low vitamin content
Used if galactosemia, CMPI, secondary lactose intolerance
following gastroenteritis

Pregestimil: (Alimentum is similar, but with sucrose)

Hydrolyzed casein; 50% MCT; glucose polymers
Used if malabsorption or short bowel syndrome

Portagen:
Casein; 75% glucose polymers+25% sucrose; 85% MCT
Useful for persistent chylothorax. Can cause EFA def.
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Special formula (contd.)

Similac PM 60/40:
Low sodium and phosphate; high Ca/PO4 ratio
Used in renal failure, hypoparathyroidism
Similac 27:
High energy with more Protein, Ca/Po4, Lytes
Used for fluid restricted infants: CHF, BPD
Nutramigen:
Hypoallergenic, lactose and sucrose free
Used for protein allergies, lactose intolerance
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