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Fluids, Electrolyte, and Nutrition
Management in Neonates
Mohamed Khashaba,MD
Professor of Pediatrics
Director of NICU,MUCH
Mansoura Faculty of Medicine
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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, neonatalkidneys 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% ofweight in first week
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Things to consider:Normal changes in Renal Function
Adults can concentrate or dilute urine verywell, depending on fluid status
Neonates are not able to concentrate ordilute urine as well as adults - at risk fordehydration 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 thatis 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 reflectsmoms F&E status (Excessive use of oxytocin,
hypotonic IVF can cause hyponatremia) Physical Examination:
Weight: reflects TBW. Not very useful forintravascular volume (eg. Long term paralysis andperitonitis can lead to increased body weight andincreased interstitial fluid but decreased intravascularvolume. 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 sensitiveindicators in babies
Cardiovascular:
Tachycardia can result from too much (ECF excess
in CHF) or too little ECF (hypovolemia) Delayed capillaryrefill can result from low cardiac
output
Hepatomegalycan 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, serumcreatinine (values in the firstfew days reflectmoms values, not babys)
ABG (low pH and bicarb may indicate poor
perfusion)
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Management of F&E
Goal: Allow initial loss of ECT over firstweek (as reflected by wt loss), while
maintaining normal intravascular volumeand tonicity (as reflected by HR, UOP,lytes, pH). Subsequently, maintain water
and electrolyte balance, includingrequirements for body growth.
Individualize approach (no cook book isgood 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 largestcomponent
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 therapyBir th t(k )
e x tro se( )
lu id ra te ( l/ k /d )
< h r 2 4 - 4 8 h r > 4 8 h r
< . - 1 0 1 0 0 - 1 5 0 1 2 0 - 1 5 0 1 4 0 -1 9 0
1 .0 - 1 .5 1 0 1 0 0 - 1 2 0 1 0 0 - 1 2 0 1 2 0 -1 6 0
> 1 .5 1 0 6 0 - 8 0 8 0 - 1 2 0 1 2 0 - 1 6 0
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Management of F&E (contd.)
Factors modifying fluid requirement: Maturity-- Mature skin -- reduces IWL
Elevated temperature (body/environment)-- increasesIWL
Humidity: Higher humidity-- decreases IWLup to30% (over skin and overrespiratorymucosa)
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 generallyrequired Later in the first week, needs are 1-
mEq/kg/day (1 L of NS = 150+ mEq; 150cc/kg/day of 1/4 NS = 5.9 mEq/kg/day which is too
much)
After the first week, during growth, needs are2-3 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 tohyponatremia, risk of BPD. Too little leads tohypernatremia, dehydration
BPD: Need more calories but fluids are usuallyrestricted: hence the need forrocket fuel. If diureticsare used, w/f lyte problems. May need extra calcium.
PDA: Avoid fluid overload. If indocin is used, monitorurine output.
Asphyxia: May have renal injury or SIADH. Restrictfluids initially, avoid potassium. May need fluid challenge
ifcause of oliguria is notclear.
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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)
Hypercalcemia (total>11; i>5)
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Sodium stuff :
Hyponatremia
Sodium levels often reflect fluid statusrather than sodium intake
cess cess I , ,Se sis, aral sis
estrict fluids
ormal cess I , SI ,ain, iates estrict fluids
eficit iuretics, ,
(third s acin )
Increase
sodium intake
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Sodium stuff :
Hypernatremia
Hypernatremia is usually due to excessiveIWL in first few days in VLBW infants
(micropremies). Increase fluid intake anddecrease 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 levelsdo notusually indicate total-bodypotassium
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 diureticuse, NG drainage Treat by giving more potassium slowly
Hyperkalemia:
Increased Krelease fromcells following IVH,asphyxia, trauma, IV hemolysis
Decreased K excretion with renal failure, CAH
Medication error verycommon
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Management of Hyperkalemia
Stop all fluids with potassium
Calcium gluconate 1- cc/kg (10%) IV
Sodium bicarbonate 1- mEq/kg IV
Glucose-insulin combination
Lasix (increases excretion over hours)
Kayexelate 1 g/kg PR (not with sorbitol!Not to give PO forpremies!)
Dialysis/ Exchange transfusion
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Calcium stuff
At birth, levels are 10-11 mg/dL. Drop normallyover 1- 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. Supplementcalcium if 6.5
Late onset (usually end of first week)HighPhosphate type: Hypoparathyroidism, maternalanticonvulsants, vit. D deficiency etc. Reducerenal phosphate load
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Things we arent going to
discuss (i.e.) homework:
Acid-base disorders: Acidosis or Alkalosis,Metabolic or Respiratory orMixed
Hypercalcemia
Magnesium disorders
Metabolic disorders
Methods of feeding: Continuous vs.Intermittent; TP vs OG vs NG vs NJ;Trophic feeds; Complications of TPN
(We can discuss these, if time permits)
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Common fluid problems
Oliguria : UOP 1cc/kg/hr. Prerenal, Renal, orPostrenal causes. Most normal term babies peeby 24-48 hrs. Dont wait that long in sick lilbabies! Check Baby, urine, FBP. Try fluidchallenge, then lasix. Get USG if no response
Dehydration: Wt loss, oliguria+, urine sp.
gravity >1.012. Correct deficits, thenmaintenance + ongoing losses
Fluid overload: Wt gain, often hyponatremia.Fluid+ sodiumrestriction
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Nutrition
Goals: Normal growth and development(as compared to intrauterine growth forpreterm
neonates, or as compared to growth charts forterm neonates)
Nutrientrequirements:
Energy (Cals) Carbohydrate
Water Minerals
Protein Vitamins
Fat Trace elements
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Energy { E = mc2 }
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: 50
Minimal activity: 4-5
Occasional cold stress: 10
Fecal loss (10-15%): 15
Growth (4.5 Cal/g +): 45
125
E=energy required
m =mass of baby
c = cry loudness
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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 forabsorption): 70-90 Cal/kg/day+ 2.4- .8g/kg/day Protein adequate for growth
Count non-protein calories only! Protein to bepreferred used for growth, not energy
65% fromcarbohydrates, 35% from lipids ideal
>165-180 Cal/kg/day notuseful
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Calculations
To calculate a neonates F,E,& N:
Firstcalculate the amount of fluid (Water)
Then calculate how youplan to give it:Parenteral (IV) or Enteral (OG/PO)
Then calculate the amount of energyrequired
Decide how to provide the energy: amountand nature ofcarbohydrates and lipids
Provide proteins, vitamins, trace elements
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Calculations: practical hints
forTPN
Do not starve babies! The ones who dontcomplain arethe 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 (0.5kg/kg/d)
Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d Protein(NPC/N of 150- 00)
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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. If1 kg, start at 6 mg/kg/min. If 1-1.5 kg, startat 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 termformula. Soy and lactose free formula havesucrose, 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% ofcalories in humanmilk and term formula
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Fat
Parenteral:
20% Intralipid (made from Soybean) better than
10% High caloric density (2 Cal/ccvs 0.34 for D10W)
Start low, go slow (0.5-3 g/kg/day)
Avoid higher amounts in sepsis, jaundice, severelung 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 moreMCT for this reason.
At least 3% of the total energy should besupplied as EFA
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Protein
Term infants need 1.8- .2 g/kg/day
Preterm (VLBW) infants need 3-3.5 g/kg/day (IV orenteral)
Restrict stressed infants or infants with cholestasisto 1.5 g/kg/day
Start early-VLBW neonates may need 1.5-
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 thanavailable in human milk. Hence, HMF is essential.Premie formula has sufficient Ca/PO4. Ratioshould 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 premiesonce full feeds are reached. (Does notprevent
Anemia of Prematurity )
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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 getvit K at birth
Term neonates: No vitamin supplementrequired,exceptperhaps vit D
Preterm: Startvitamin supplements once fullfeeds established if on human milk without HMF.No need if on human milk with HMF, orpreterminfant formula (except: add vit D if on SSC24).
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Trace elements
Zinc, Copper, Selenium, Chromium,manganese, Molybdenum, Iodine
Mostpreterm formulas contain sufficientamounts
Fluoride supplementation notrequired in
neonatal period
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Special formula
Soy formula:
Notrecommended forpremies: impaired mineral andprotein absorption; low vitamin content
Used if galactosemia, CMPI, secondary lactose intolerancefollowing gastroenteritis
Pregestimil: (Alimentum is similar, but with sucrose)
Hydrolyzed casein; 50% MCT; glucose polymers
Used ifmalabsorption or short bowel syndrome
Portagen:
Casein; 75% glucose polymers+25% sucrose; 85% MCT
Useful forpersistentchylothorax. 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 forprotein allergies, lactose intolerance