Fluid Administration

Fluid and Glucose Requirements

Reviewed by Carl Kuschel and David Knight

January 2007

Recommended Volumes	Insensible Water Loss	Glucose Intake	Gastrointestinal Losses
Chest and Peritoneal Drains	Renal Impairment	Glucose Solutions	References

Recommended Volumes (ml/kg/day)

	Day 0-1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7+
<37 weeks	60	75	90	105	120	150	180
37 weeks+	60	75	90	105	120	120	150

Note:	Fluid volumes administered in NICU after the first week are high to ensure good caloric intake and growth in preterm infants. Term infants have a lower requirement for fluids and calories. Infants admitted to Starship Hospital (surgical or medical services) should have fluids prescribed according to Starship Hospital guidelines (available via the intranet).
	The volume administered will depend on the clinical condition of the infant, with fluid restriction indicated with asphyxia, renal impairment or PDA. Infants receiving phototherapy, or with high insensible losses, may require higher fluid intakes. In general, fluid management in the first few days is adjusted primarily on serum sodium values and changes in weight. High serum sodium values usually indicate that the infant requires more fluid. Low serum sodium values may indicate that the infant requires less fluid, or that the infant has high sodium losses.
	There is evidence that restricting fluid volumes in preterm infants in the first few days of life reduces the incidence of patent ductus arteriosus and necrotising enterocolitis, and may decrease mortality rates.¹ Restricting sodium intake in preterm infants in the first few days may also reduce the incidence of chronic lung disease.^{2 3 4 5}

Glucose Intake

The neonatal liver normally produces 6-8 mg/kg/min of glucose. This is approximately the basal requirement of a newborn infant.
Hypoglycaemia is severe if it persists despite an intake of >10 mg/kg/min. Calculate the glucose intake: See also the Glucose Calculator

Glucose intake (mg/kg/min) =	% Dextrose x Volume (ml/kg/day) 144
or
Glucose intake (mg/kg/min) =	% Dextrose x Hourly Rate Weight (Kg) x 6

Intake (ml/kg/day)	5% Dextrose	10% Dextrose	12.5% Dextrose
Intake (ml/kg/day)	mg/kg/min of Dextrose
60	2.1	4.2	5.2
75	2.6	5.2	6.5
90	3.1	6.3	7.8
105	3.7	7.3	9.1
120	4.2	8.3	10.4
150	5.2	10.4	13.0
180	6.3	12.5	15.6

To get concentrated glucose solutions: See also the Fluid and Electrolytes calculator

Solution	10% Dextrose	50% Dextrose
12.5%	450 ml	30 ml
15 %	420 ml	60 ml
20 %	400 ml	135 ml
Solution	5% Dextrose	50% Dextrose
7.5%	450ml	30ml

Dextrose solutions of >10% are best administered through central venous lines.
- Peripheral IVs do not last long, and extravasation can result in tissue damage.

Insensible Water Loss

This varies greatly with gestation and depends on the thermal environment. It decreases markedly over the first few days.
Very preterm infants should be placed in humidified incubators in a neutral thermal environment as soon as practical after birth.

Gastrointestinal Losses

If there are significant gastric aspirates, replace these ml for ml with 0.9% NaCl plus 10mmolKCl per 500ml.

Chest and/or Peritoneal Drains

If there are significant fluid losses from these, measure the volume and replace with 4% albumin as indicated.
Monitor serum albumin concentrations.
Monitor the composition of the fluid being lost as this may assist with calculating requirements

Renal Impairment

Restrict intake to insensible water loss + urine output.
Monitor fluid balance, serum electrolytes and weight carefully.

In early Acute Tubular Necrosis, consider a pre-renal cause. Fractional excretion of sodium may help sort this out.
- FE Na⁺≥2.5% in term infants suggests renal failure.
- FE Na⁺<2.5% in term infants suggests pre-renal failure.
- FE Na⁺ is high in preterm infants because of tubular immaturity.

FE Na⁺ =

Urine [Na] x Serum Creatinine
Serum [Na⁺] x Urine Creatinine

x 100%

References

1	Bell EF, Acarregui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD000503. DOI: 10.1002/14651858.CD000503.
2	Hartnoll G, Betremieux P, Modi N. Randomised controlled trial of postnatal sodium supplementation on oxygen dependency and body weight in 25-30 week gestational age infants. Arch Dis Child Fetal Neonatal Ed 2000;82(1):F19-23.
3	Hartnoll G, Betremieux P, Modi N. Randomised controlled trial of postnatal sodium supplementation on body composition in 25 to 30 week gestational age infants. Arch Dis Child Fetal Neonatal Ed 2000;82(1):F24-8.
4	Hartnoll G, Betremieux P, Modi N. Randomised controlled trial of postnatal sodium supplementation in infants of 25-30 weeks gestational age: effects on cardiopulmonary adaptation. Arch Dis Child Fetal Neonatal E. 2001;85(1):F29-32.
5	Costarino AT Jr, Gruskay JA, Corcoran L, Polin RA, Baumgart S. Sodium restriction versus daily maintenance replacement in very low birth weight premature neonates: a randomized, blind therapeutic trial. J Pediatr 1992;120(1):99-106.

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