Total Fluid Intake and Feeds
Total Fluid Intake and Feeds
Fluid management in specific instances
Total daily volumes for neonates
Milk feeds volumes for neonates
The goal of fluid therapy over the first week of life is to allow a gradual weight loss (diuresis) and maintain urine output (≥1ml/kg/hr) after the first 24 hours of life. Term infants may lose 5-10% of birth weight and preterm infants 10-15% of birth weight in the first 5-7 days of life. (More than 3% per day is abnormal).
Term infants should regain birth weight by day 7 and preterm infants by 14 days of life. Thereafter adequate growth is a gain of 15-20g/kg/day. Infants with BPD or congenital heart disease have higher caloric requirements due to higher resting energy expenditure.
Make sure that infant has a good urine output and appropriate weight loss, otherwise adjust appropriately. Changes in fluid rates should be based on urine output, weight loss and/or serum electrolytes. All babies on IVI fluids should have a U+E done after 24hrs and repeated dly if abnormal. If there is excessive weight loss >3% per day, hypernatraemia or poor urine output, then add extra 10% to daily fluids and repeat electrolytes in 12-24hrs (depending on severity of abnormalities).
Once the preterm/IUGR baby is on full feeds, the total fluid volume can be increased up to 180ml/kg/day and supplements should be added (see below).
Fluid management in specific instances:
- Asphyxia – may result in increased secretion of ADH (SIADH) and asphyxiated infants are at increased risk to develop cerebral oedema and renal failure. Therefore in infants with stage 2 or 3 HIE, fluid intake should be kept at 40-60ml/kg/day for the first 48-72 hours. Treatment of hyponatraemia due to SIADH is fluid restriction. Treatment of renal failure due to ATN is fluid restriction. However, consider emergency sodium supplementation if Na <125 and seizures occur. Discuss with consultant.
- Suspected PPHN – Intravascular volume should be increased by 20ml/kg normal saline fluid bolus and 20ml/kg/day added to normal daily maintenance. Consider inotropes to maintain MAP >50 early on and discuss with consultant urgently.
Total daily volumes for neonates
| Gestation | First day | Following days | Total |
| Term and near term infants (>34weeks or >1800g) | 60ml/kg/day | Increase daily by 20ml/kg/day | 150ml/kg/day by day 6 of life |
| 32-34 weeks (1500g-1800g) | 80ml/kg/day | 150ml/kg/day by day 5 of life | |
| 28-31 weeks (1000g-1500g) | 80ml/kg/day | 150ml/kg/day by day 5 of life | |
| <28 weeks (<1000g) | 100ml/kg/day | 150ml/kg/day by day 4 of life |
Milk feeds volumes for neonates
| Gestation | Milk volumes | Type and route | IV fluids |
| Term and near term infants (>33weeks or >1700g) | Breast feed at lib or EBM | Breastfeeding or cup | None |
| 32-33 weeks (1500g-1700g) | 30-40ml/kg day 1 Increase daily by 30-40ml/kg (8 feeds - 3 hourly) | Cup feeds, otherwise via NGT should swallowing be inadequate. | Rest of daily requirements should be given as IVI 10% NNL |
| 28-31 weeks (1000g-1500g) | 20ml/kg day 1 Increase by 20ml/kg/day (12 feeds - 2 hourly) | Start with NGT feeds until swallowing is adequate, then change to cup feeds. | |
| <28 weeks (<1000g) | Start with Trophic feeds 0.5ml 4 hourly and increase by 20ml/kg/day | Consider continuous feeds via syringe pump in feeding intolerance |
Feeds
Breast milk (mother’s own/PEBM/DEBM) is the best feed for both term and premature babies. 10% NNL fluid does not contain enough nutrients even to maintain current healthy body tissues (in effect it causes a normoglycaemic, but catabolic state of the body and the brain). It is therefore crucial that feeds be introduced asap and increased in a safe, but maximal increments.
Initiation of feeds:
Trophic feeds (1ml 2hrly) should be started asap unless there is an absolute contra-indication eg bowel obstruction. “Proper” initiation of feeds at 20ml/kg/day should be delayed for 24hrs only in babies with severe HIE (grade 2-3) or infants with severe respiratory distress.
Once a preterm/IUGR baby is on no more IVI fluids (ie 150ml/kg/day) is reached, the feeds can be increased up to 180ml/kg/day. Nutritional supplementation should be started and aminophylline should be changed to caffeine.
Monitoring for intolerance
- Intolerance in feeds may be associated with vomiting, gastric residuals, abdominal distension and watery diarrhoea. These signs may also be seen in infants with NEC, therefore it can be difficult to differentiate NEC from feeding intolerance,
- Vomiting is fairly common in neonates. Therefore, it should only be considered significant if persistent, bilious or associated with abnormal clinical examination eg lethargy/abdominal distension, apnoea or respiratory distress.
- Gastric residuals of <2ml are generally insignificant even if a baby is on very small feeds. Gastric aspirate residuals > 20% of feeds on 2 or more consecutive feeds should be considered significant, therefore feeds must be omitted and the infant assessed.
- “Coffee ground” aspirates usually require no intervention.
- Any gastric aspiration requires attention if bile stained and/or associated with abdominal signs/ blood in the stool. Feeds must be discontinued immediately, the stomach should be emptied completely and the NGT left on open drainage. IVI fluids must be started and the baby fully worked up for NEC/bowel obstruction/septic ileus.
- If a baby is unable to feed for longer than 3 days, TPN is indicated and the baby should be transferred to TBH.
Nutritional Supplementation
Start oral supplements when infants are on full enteral feeds
Supplements for all preterm infants (consider also in IUGR)
- On breastmilk feeds: ratio FM85 1-1.5g (1-1.5scoops) per 20 ml
- Vidaylin 0.6ml/day until the chronological age of 1 year
- Iron until the chronological age of 1 year