FLUID ELECTROLYTE IN NEONATES

In foetus
Primarily water much of it in ECF Increase in gestation age decrease the TBW and ECF and increase the ICF The high water content due to the prolactin and increased water binding capacity in fetal cells

Urine production / GFR begins by9-10 weeks LOH by functions by 14 weeks TR by 9-12wks RBF GFR are low throughout the fetal period due to high RVR and low systemic pressure They increase between 20-35 wks and level off to birth. This is due to increases in no and growth of nephrons

 40-50% of the combined ventricular output goes to placenta and only 2-3% to kidney Still uo is good as they are the main constituent of the AF. Fetal bladder fill and emptyevery 20-30 min F&E balance is maintained by placenta and maternal balance.

Fetal urine
Concentration is limited 20-30% of adult Hypotonic 200mosm/kg due incr TR Become less hypotonic with inc gestation Not dependent on kidney for Na conservation as it is readily transported across placenta AVP is only by 12wk immaturity of receptors 3 rd trimester urine become isotonic

RAS
Active in fetus AT II2 is needed for normal renal development AT II1 neurovascular development. AGT by 9wks in yolk sac Renin by 4-6 wks high in fetus>term>adult

Neonatal physiology
Differs in GFR and TR than adult No of adult nephrons reached at birth but shorter and less functionally mature Altered RF and FE balance is more in PT Post renal maturation is function of post birth than gestational age

Renal function in NB
alteration GFR implication Water intoxication and overload Narrow margin of safety for fluid management Inc half-life of drugs Risk of hyperglycemia

 Altered tubular function

Na
Glcose

bicarbonate

Increased NA loss in urine Risk of acidosis,hyperkalemia,hypo cal,glucose Unable to handle exogenous glucose Risk of glycosuria Risk of hyponatremia and dehydration Risk of acidosis

Transition events
Function of placenta taken over AVP and RAS increase due to effect of catecholamine at birth BP increases and redistribution of fluids to vital organs RBF increase 24hrs and RVR falls RAS increases Transient increase of GFR occurs

Body composition
Changes with gest age TBW ECF decreases and ICF increases 32 week 83 % water 78% at term ECF 59% at 24 wks-53% at 32 wks 44% at term ICF24-34% ECF has NA CL IC ions are K,Mg,Po4 Protein fat carbohydrate increase with age SGA has more water and less fat LGA has more fat and less water.

 At birth due to ANF and increase catecholamine and increased capillary permeability lead to inc interstial fluid and reduced IVF

With increased oxygenation and improved capillary permeability the ECF and IVF is restored Diuresis after birth ensues due better GFR and ANP due reduced pulmonary vascular resistance

Postnatal changes of water and NA homeostasis

PHASE I Birth -36 hrs GFR low Water and na excretion minimal regardless of intake Water and Na balance zero water and NA balance on restricted intake

Phase II Age 12-96 hrs GFR increases rapidly Water NA excretion diuresis and natreuresis happens irrespective of intake Water NA balance negative irrespective of intake

 Phase III Age 2-4 days GFR decrease slightly and then slow incre with maturation Water NA excretion appro with intake Water NA balance stabilize and becomes positive with growth

 Loss of body weight in preterm may be as high as 15% as their ECF is high and they produce dilute urine GFR and RBF increases after birth 20ml/min/1.73m2 at 30wks to 45 at 35 wks and 83 at term Tubular function altered in neonates smaller absorptive surface hence loose more solute.

CLINICAL implications
Regulation is a narrow range in NB Transitional events transient negative balance Allow this or may end up in risk for fluid over load. Calculation needs maintainence+replacement +allowance for growth

Maintenance
Endogenous water production by oxidative metabolism +ISWL+loss in urine and stools Individual variation in these unless major are not crucial and kidney will adjust In VLBW and ill RF is insufficient Stool alter is 5-10ml/kg/day not considered in first few days after birth. 5-10ml/kg of endogenous water are produced by oxidation ignored in calculation Water for growth varies with composition infants with 70% 0.7ml/gm/bwt Because it is not static estimate 10-20ml/kg/day with higher values for immature After 1st wk(after physiological wt loss)maintainence is only IWL and urine loss

IWL
70% from skin and 30% form RS Consist of 32 % total water requirement It is altered by some modalities Usually 20ml/kg/day 0.7-1.6ml/kg/day

Urine water loss

56% of TBW abt 50-100ml/kg/day Urine volume(ml/kg)=solute load(mosm/kg)/urine osmolarity(mosmol/l)*1000 Solute load is less for infants on DBF Risk of over hydration and dehydration is there due to renal immaturity