Fluidelectrolytes

Fluids, Electrolyte and Fluids, Electrolyte and Nutrition Management in Nutrition Management in

NeonatesNeonates

Dr Varsha Atul ShahConsultant Neonatal and Devt Medicine

FEN Management in NeonatesFEN Management in Neonates

Essentials of life:Essentials of life: – Food (Food (NutritionNutrition))– water (water (Fluid/electrolyteFluid/electrolyte))– shelter (shelter (control of environment - temperature etccontrol of environment - temperature etc))

Essentials of neonatal care:Essentials of neonatal care: – Fluid, electrolyte, nutrition management (Fluid, electrolyte, nutrition management (All babiesAll babies))– Control of environment (Control of environment (All babiesAll babies))– Respiratory /CVS/CNS management (Respiratory /CVS/CNS management (some babiessome babies))– Infection management (Infection management (some babiessome babies))

Why is FEN management Why is FEN management important?important?

Many babies in NICU need IV fluidsMany babies in NICU need IV fluids They all don’t need the same IV fluids They all don’t need the same IV fluids

(either in quantity or composition)(either in quantity or composition) If wrong fluids are given, neonatal If wrong fluids are given, neonatal

kidneys are not well equipped to kidneys are not well equipped to handle themhandle them

Serious morbidity can result from fluid Serious morbidity can result from fluid and electrolyte imbalanceand electrolyte imbalance

Fluids and ElectrolytesFluids and Electrolytes

Main priniciples:Main priniciples:– Total body waterTotal body water (TBW) = Intracellular fluid (TBW) = Intracellular fluid

(ICF) + Extracellular fluid (ECF)(ICF) + Extracellular fluid (ECF)– Extracellular fluidExtracellular fluid (ECF) = Intravascular (ECF) = Intravascular

fluid (fluid (in vessels in vessels : plasma, lymph) + : plasma, lymph) + Interstitial fluid (Interstitial fluid (between cellsbetween cells))

Main goals:Main goals:– Maintain appropriate ECF volume,Maintain appropriate ECF volume,– Maintain appropriate ECF and ICF Maintain appropriate ECF and ICF

osmolality and ionic concentrationsosmolality and ionic concentrations

Things to consider: Things to consider: Normal changes in TBW, ECFNormal changes in TBW, ECF

All babies are born with an excess of All babies are born with an excess of TBW, mainly ECF, which needs to be TBW, mainly ECF, which needs to be removedremoved– Adults are 60% water (Adults are 60% water (20% ECF20% ECF, 40% ICF), 40% ICF)– Term neonates are 75% water (Term neonates are 75% water (40% ECF40% ECF, ,

35% ICF) : lose 5-10 % of weight in first week35% ICF) : lose 5-10 % of weight in first week– Preterm neonates have more water (23 wks: Preterm neonates have more water (23 wks:

90%, 90%, 60% ECF60% ECF, 30% ICF): , 30% ICF): lose 5-15%lose 5-15% of of weight in first weekweight in first week

Things to consider: Things to consider: Normal changes in Renal FunctionNormal changes in Renal Function Adults can concentrate or dilute urine Adults can concentrate or dilute urine

very well, depending on fluid statusvery well, depending on fluid status Neonates are not able to concentrate Neonates are not able to concentrate

or dilute urine as well as adults - at or dilute urine as well as adults - at risk for dehydration or fluid overloadrisk for dehydration or fluid overload

Renal function matures with Renal function matures with increasing:increasing:– gestational agegestational age– postnatal agepostnatal age

Things to consider: Things to consider: Insensible water loss (IWL)Insensible water loss (IWL)

““Insensible” water loss is water loss that Insensible” water loss is water loss that is not obvious (makes sense?): through is not obvious (makes sense?): through skin (2/3) or respiratory tract (1/3)skin (2/3) or respiratory tract (1/3)– depends on gestational age (depends on gestational age (more preterm: more preterm:

more IWLmore IWL))– depends on postnatal age (depends on postnatal age (skin thickens skin thickens

with age: older is better --> less IWLwith age: older is better --> less IWL))– also consider losses of other fluids: Stool also consider losses of other fluids: Stool

(diarrhea/ostomy), NG/OG drainage, CSF (diarrhea/ostomy), NG/OG drainage, CSF (ventricular drainage), etc (ventricular drainage), etc

Assessment of fluid and Assessment of fluid and electrolyte statuselectrolyte status

HistoryHistory:: baby’s F&E status partially baby’s F&E status partially reflects mom’s F&E status (reflects mom’s F&E status (Excessive use of Excessive use of oxytocin, hypotonic IVF can cause oxytocin, hypotonic IVF can cause hyponatremiahyponatremia))

Physical ExaminationPhysical Examination::– Weight: reflects TBW. Not very useful for Weight: reflects TBW. Not very useful for

intravascular volume (intravascular volume (eg. Long term paralysis and eg. Long term paralysis and peritonitis can lead to increased body weight and peritonitis can lead to increased body weight and increased interstitial fluid but decreased intravascular increased interstitial fluid but decreased intravascular volume. volume. Moral Moral : a puffy baby may or may not have : a puffy baby may or may not have adequate fluid where it counts: in his blood vesselsadequate fluid where it counts: in his blood vessels))

Assessment of fluid and Assessment of fluid and electrolyte status (contd.)electrolyte status (contd.)

Physical Examination (contd.)Physical Examination (contd.)– Skin/Mucosa: Altered skin turgor, sunken Skin/Mucosa: Altered skin turgor, sunken

AF, dry mucosa, edema etc are not AF, dry mucosa, edema etc are not sensitive indicators in babiessensitive indicators in babies

– Cardiovascular: Cardiovascular: Tachycardia can result from too much (ECF Tachycardia can result from too much (ECF

excess in CHF) or too little ECF (hypovolemia)excess in CHF) or too little ECF (hypovolemia) Delayed capillary refill can result from low Delayed capillary refill can result from low

cardiac outputcardiac output Hepatomegaly can occur with ECF excessHepatomegaly can occur with ECF excess Blood pressure changes very lateBlood pressure changes very late

Assessment of fluid and Assessment of fluid and electrolyte status (contd.)electrolyte status (contd.)

Lab evaluation:Lab evaluation:– Serum electrolytes and plasma osmolaritySerum electrolytes and plasma osmolarity– Urine output Urine output – Urine electrolytes, specific gravity (not very Urine electrolytes, specific gravity (not very

useful if the baby is on diuretics - lasix etc), useful if the baby is on diuretics - lasix etc), FEFENaNa

– Blood urea, serum creatinine (values in the first Blood urea, serum creatinine (values in the first few days reflect mom’s values, not baby’s)few days reflect mom’s values, not baby’s)

– ABG (low pH and bicarb may indicate poor ABG (low pH and bicarb may indicate poor perfusion)perfusion)

Management of F&EManagement of F&E

Goal: Allow initial loss of ECT over first Goal: Allow initial loss of ECT over first week (as reflected by wt loss), while week (as reflected by wt loss), while maintaining normal intravascular volume maintaining normal intravascular volume and tonicity (as reflected by HR, UOP, and tonicity (as reflected by HR, UOP, lytes, pH). Subsequently, maintain water lytes, pH). Subsequently, maintain water and electrolyte balance, including and electrolyte balance, including requirements for body growth.requirements for body growth.

Individualize approach (no “cook book” Individualize approach (no “cook book” is good enough!)is good enough!)

Management of F&E (contd.)Management of F&E (contd.)

Total fluids required:Total fluids required:– TFI = Maintenance requirements TFI = Maintenance requirements

(IWL+Urine+Stool water) + growth(IWL+Urine+Stool water) + growth

– In the first few days, IWL is the largest componentIn the first few days, IWL is the largest component– Later, solute load increases (80-120 Cal/kg/day = 15-20 Later, solute load increases (80-120 Cal/kg/day = 15-20

mOsm/kg/day => 60-80 ml/kg/day to excrete wastes)mOsm/kg/day => 60-80 ml/kg/day to excrete wastes)– Stool: 5-10 cc/kg/dayStool: 5-10 cc/kg/day– Growth: 20-25 cc/kg/day (since wt gain is 70% water)Growth: 20-25 cc/kg/day (since wt gain is 70% water)

Management of F&E Management of F&E (contd.)(contd.)

Guidelines for fluid therapyGuidelines for fluid therapyFLUIDS & ELECTROLYTES

FluidsFluids TermTermml/kg/dml/kg/d

PreTPreTml/kg/dml/kg/d

D1D1 6060 6060

D2D2 9090 8080

D3D3 120120 100100

D4D4 150150 120120

D5D5 150150 140140

D6D6 150150 150150



Full drip/NBMD1 – Dextrose + 10%CaG 5ml/kgD2 – Dextrose + 10%CaG 2 ml/kg (if N Ca) D3+ - add Na 2 mmol/kg + K 2 mmol/kgUse Calcium Chloride if on inotropes:D1 - Dextrose + 10%CaCl2 2 ml/kgD2 - Dextrose + 0.8 ml/kg (if N Ca)D3+ - add Na 2 mmol/kg + K 2 mmol/kg(1m 20%NaCl=3.4mmol; 1m 7.45%KCl=1mmol)



Usually 10% Dex Preterm <1000g, use 5% Dex SGA babies may need more fluids. Use 50th centile BW for GA as gauge.Asphyxiated babies may need fluid restriction.

Maintenance electrolytesMaintenance electrolytes

Sodium Sodium 2mmol/kg/d 2mmol/kg/d 1ml 20% NaCl = 1ml 20% NaCl = 3.4mmol3.4mmol

Potassium Potassium 2mmol/kg/d2mmol/kg/d1ml 7.45% KCl = 1ml 7.45% KCl = 1mmol1mmol

Calcium 1ml 10% Calcium gluconate = Calcium 1ml 10% Calcium gluconate = 0.23mmol Ca0.23mmol Ca

D1- 5ml/kg 10% Calcium gluconate D1- 5ml/kg 10% Calcium gluconate D2 - 2ml/kg/d (if Ca level is Normal)D2 - 2ml/kg/d (if Ca level is Normal) If Baby on InotropesIf Baby on Inotropes: use 10% Ca Chloride : use 10% Ca Chloride D1 - 2 ml/kg; D2 - 0.8 ml/kg (if Ca is N)D1 - 2 ml/kg; D2 - 0.8 ml/kg (if Ca is N)

Normal values for Normal values for ElectrolytesElectrolytes

Sodium Sodium 135-145mmol/l135-145mmol/l Replacement (mmol) =Replacement (mmol) = 2/3 x (deficit from 140) x weight(kg)2/3 x (deficit from 140) x weight(kg) PotassiumPotassium 3.5-6.0mmol/l 3.5-6.0mmol/l Replacement (mmol) =Replacement (mmol) = 2/3 x (deficit from 5.0) x weight(kg)2/3 x (deficit from 5.0) x weight(kg)

CalciumCalcium

Normal Calcilum 2.27 – 2.79mmol/lNormal Calcilum 2.27 – 2.79mmol/l Correct if total Ca<2.0 mmol/l or Correct if total Ca<2.0 mmol/l or

ionic Ca<1.0 mmol/l: ionic Ca<1.0 mmol/l: 5ml/kg/d 10%Ca Gluconate if on drip 5ml/kg/d 10%Ca Gluconate if on drip On feeds, give Ca Sandoz On feeds, give Ca Sandoz <2.5kg <2.5kg 2.5ml TDS2.5ml TDS

2.5kg 2.5kg 5ml BD 5ml BD

MagnesiumMagnesium

Normal Magnesium Normal Magnesium 0.7-0.95 0.7-0.95 mmol/lmmol/l

Correct if: <0.7mmol/l (symptomatic)Correct if: <0.7mmol/l (symptomatic) <0.55mmol/l <0.55mmol/l

(asymptomatic)(asymptomatic)

IM 0.2ml/kg 50%MgSO4 (dilute to IM 0.2ml/kg 50%MgSO4 (dilute to 25%) 25%)


Factors modifying fluid requirement:Factors modifying fluid requirement:– Maturity--> Mature skin --> reduces IWLMaturity--> Mature skin --> reduces IWL– Elevated temperature (body/environment)--> Elevated temperature (body/environment)-->

increases IWLincreases IWL– Humidity: Higher humidity--> decreases IWL up to Humidity: Higher humidity--> decreases IWL up to

30% (over skin and over respiratory mucosa)30% (over skin and over respiratory mucosa)– Skin breakdown, skin defects (e.g. omphalocele)--Skin breakdown, skin defects (e.g. omphalocele)--

> increases IWL (proportional to area)> increases IWL (proportional to area)– Radiant warmer --> increases IWL by 50% Radiant warmer --> increases IWL by 50% – Phototherapy --> increases IWL by 50%Phototherapy --> increases IWL by 50%– Plastic Heat Shield --> reduces IWL by 10-30%Plastic Heat Shield --> reduces IWL by 10-30%

Let there be lytes!Let there be lytes!

Electrolyte requirements:Electrolyte requirements:– For the first 1-3 days, sodium, For the first 1-3 days, sodium,

potassium, or chloride are not generally potassium, or chloride are not generally requiredrequired

– Later in the first week, needs are 1-2 Later in the first week, needs are 1-2 mEq/kg/day (mEq/kg/day (1 L of NS = 150+ mEq; 150 1 L of NS = 150+ mEq; 150 cc/kg/day of 1/4 NS = 5.9 mEq/kg/day which is cc/kg/day of 1/4 NS = 5.9 mEq/kg/day which is too muchtoo much))

– After the first week, during growth, After the first week, during growth, needs are 2-3 or even 4 mEq/kg/dayneeds are 2-3 or even 4 mEq/kg/day

F&E in common neonatal F&E in common neonatal conditionsconditions

RDS: RDS: Adequate but not too much fluid. Excess leads Adequate but not too much fluid. Excess leads to hyponatremia, risk of BPD. Too little leads to to hyponatremia, risk of BPD. Too little leads to hypernatremia, dehydrationhypernatremia, dehydration

BPD: BPD: Need more calories but fluids are usually Need more calories but fluids are usually restricted: hence the need for “rocket fuel”. If diuretics restricted: hence the need for “rocket fuel”. If diuretics are used, w/f ‘lyte problems. May need extra calcium.are used, w/f ‘lyte problems. May need extra calcium.

PDA: PDA: Avoid fluid overload. If indocin is used, monitor Avoid fluid overload. If indocin is used, monitor urine output.urine output.

Asphyxia: Asphyxia: May have renal injury or SIADH. Restrict May have renal injury or SIADH. Restrict fluids initially, avoid potassium. May need fluid fluids initially, avoid potassium. May need fluid challenge if cause of oliguria is not clear.challenge if cause of oliguria is not clear.

Common ‘lyte problemsCommon ‘lyte problems

Sodium:Sodium:– Hyponatremia (<130 mEq/L; worry if <125)Hyponatremia (<130 mEq/L; worry if <125)– Hypernatremia (>150 mEq/L; worry if >150)Hypernatremia (>150 mEq/L; worry if >150)

Potassium: Potassium: – Hypokalemia (<3.5 mEq/L; worry if <3.0)Hypokalemia (<3.5 mEq/L; worry if <3.0)– Hyperkalemia > 6 mEq/L (non-hemolyzed)Hyperkalemia > 6 mEq/L (non-hemolyzed)

(worry if >6.5 or if ECG changes )(worry if >6.5 or if ECG changes ) Calcium:Calcium:

– Hypocalcemia (total<7 mg/dL; i<4)Hypocalcemia (total<7 mg/dL; i<4)– Hypercalcemia (total>11; i>5)Hypercalcemia (total>11; i>5)

Sodium stuff : Sodium stuff : HyponatremiaHyponatremia

Sodium levels often reflect fluid Sodium levels often reflect fluid status rather than sodium intakestatus 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)

Increasesodium intake

Sodium stuff : Sodium stuff : HypernatremiaHypernatremia

Hypernatremia is usually due to Hypernatremia is usually due to excessive IWL in first few days in excessive IWL in first few days in VLBW infants (micropremies). VLBW infants (micropremies). Increase fluid intake and decrease Increase fluid intake and decrease IWL.IWL.

Rarely due to excessive hypertonic Rarely due to excessive hypertonic fluids (sod bicarb in babies with fluids (sod bicarb in babies with PPHN). Decrease sodium intake.PPHN). Decrease sodium intake.

Potassium stuffPotassium stuff

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

pH affects KpH affects K++: : 0.1 pH change=>0.3-0.6 K0.1 pH change=>0.3-0.6 K++ change (More acid, more K; less acid, less K)change (More acid, more K; less acid, less K)

ECG affected by both HypoK and HyperK:ECG affected by both HypoK and HyperK:– Hypok:flat T, prolonged QT, U wavesHypok:flat T, prolonged QT, U waves– HyperK: peaked T waves, widened QRS, HyperK: peaked T waves, widened QRS,

bradycardia, tachycardia, SVT, V tach, V fibbradycardia, tachycardia, SVT, V tach, V fib

Hypo- and Hyper-KHypo- and Hyper-K

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

Hyperkalemia:Hyperkalemia:– Increased K release from cells following Increased K release from cells following

IVH, asphyxia, trauma, IV hemolysisIVH, asphyxia, trauma, IV hemolysis– Decreased K excretion with renal failure, Decreased K excretion with renal failure,

CAHCAH– Medication error very commonMedication error very common

Management of HyperkalemiaManagement of Hyperkalemia

Stop all fluids with potassiumStop all fluids with potassium Calcium gluconate 1-2 cc/kg (10%) IVCalcium gluconate 1-2 cc/kg (10%) IV Sodium bicarbonate 1-2 mEq/kg IVSodium bicarbonate 1-2 mEq/kg IV Glucose-insulin combinationGlucose-insulin combination Lasix (increases excretion over hours)Lasix (increases excretion over hours) Kayexelate 1 g/kg PR (not with Kayexelate 1 g/kg PR (not with

sorbitol! Not to give PO for premies!)sorbitol! Not to give PO for premies!) Dialysis/ Exchange transfusionDialysis/ Exchange transfusion

Calcium stuffCalcium stuff

At birth, levels are 10-11 mg/dL. Drop normally At birth, levels are 10-11 mg/dL. Drop normally over 1-2 days to 7.5-8.5 in term babies.over 1-2 days to 7.5-8.5 in term babies.

Hypocalcemia:Hypocalcemia: – Early onset (first 3 days):Premies, IDM, Asphyxia Early onset (first 3 days):Premies, IDM, Asphyxia

If asymptomatic, >6.5: Wait it out. Supplement If asymptomatic, >6.5: Wait it out. Supplement calcium if <6.5calcium if <6.5

– Late onset (usually end of first week)”High Late onset (usually end of first week)”High Phosphate” type: Hypoparathyroidism, maternal Phosphate” type: Hypoparathyroidism, maternal anticonvulsants, vit. D deficiency etc. Reduce anticonvulsants, vit. D deficiency etc. Reduce renal phosphate loadrenal phosphate load

Things we aren’t going to Things we aren’t going to discuss (i.e.) homework:discuss (i.e.) homework:

Acid-base disorders: Acidosis or Alkalosis, Acid-base disorders: Acidosis or Alkalosis, Metabolic or Respiratory or MixedMetabolic or Respiratory or Mixed

HypercalcemiaHypercalcemia Magnesium disordersMagnesium disorders Metabolic disordersMetabolic disorders Methods of feeding: Continuous vs. Methods of feeding: Continuous vs.

Intermittent; TP vs OG vs NG vs NJ; Intermittent; TP vs OG vs NG vs NJ; Trophic feeds; Complications of TPNTrophic feeds; Complications of TPN

(We can discuss these, if time permits)(We can discuss these, if time permits)

Common fluid problemsCommon fluid problems

Oliguria : Oliguria : UOP< 1cc/kg/hr. Prerenal, Renal, UOP< 1cc/kg/hr. Prerenal, Renal, or Postrenal causes. Most normal term or Postrenal causes. Most normal term babies pee by 24-48 hrs. Don’t wait that babies pee by 24-48 hrs. Don’t wait that long in sick l’il babies! Check Baby, urine, long in sick l’il babies! Check Baby, urine, FBP. Try fluid challenge, then lasix. Get USG FBP. Try fluid challenge, then lasix. Get USG if no responseif no response

Dehydration: Dehydration: Wt loss, oliguriaWt loss, oliguria++, urine sp. , urine sp. gravity >1.012. Correct deficits, then gravity >1.012. Correct deficits, then maintenance + ongoing lossesmaintenance + ongoing losses

Fluid overload: Fluid overload: Wt gain, often Wt gain, often hyponatremia. Fluid+ sodium restrictionhyponatremia. Fluid+ sodium restriction

NutritionNutrition

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

Nutrient requirements:Nutrient requirements:Energy (Cals)Energy (Cals) CarbohydrateCarbohydrate

WaterWater MineralsMinerals

ProteinProtein VitaminsVitamins

FatFat Trace elementsTrace elements

Energy { E = mcEnergy { E = mc22 }}

Energy needs: Energy needs: depend upon age, weight, depend upon age, weight, maturation, caloric intake, growth rate, activity, maturation, caloric intake, growth rate, activity, thermal environment, and nature of feeds.thermal environment, and nature of feeds.

Growing premies: (Cal/kg/day)Growing premies: (Cal/kg/day)– Resting expenditure: 50 Resting expenditure: 50 – Minimal activity: 4-5Minimal activity: 4-5– Occasional cold stress: 10Occasional cold stress: 10– Fecal loss (10-15%):Fecal loss (10-15%): 1515– Growth (4.5 Cal/g +):Growth (4.5 Cal/g +): 4545

125125

E=energy requiredm =mass of baby c = cry loudness

EnergyEnergy

Stressed and sick infants need more energy Stressed and sick infants need more energy (e.g. sepsis, surgery)(e.g. sepsis, surgery)

Babies on parenteral nutrition need less Babies on parenteral nutrition need less energy (less fecal loss of nutrients, no loss energy (less fecal loss of nutrients, no loss for absorption): 70-90 Cal/kg/day+ 2.4-2.8 for absorption): 70-90 Cal/kg/day+ 2.4-2.8 g/kg/day Protein adequate for growthg/kg/day Protein adequate for growth

Count non-protein calories only! Protein to Count non-protein calories only! Protein to be preferred used for growth, not energybe preferred used for growth, not energy

65% from carbohydrates, 35% from lipids 65% from carbohydrates, 35% from lipids idealideal

>165-180 Cal/kg/day not useful>165-180 Cal/kg/day not useful

CalculationsCalculations

To calculate a neonate’s F,E,& N:To calculate a neonate’s F,E,& N:– First calculate the amount of fluid (Water)First calculate the amount of fluid (Water)– Then calculate how you plan to give it: Then calculate how you plan to give it:

Parenteral (IV) or Enteral (OG/PO)Parenteral (IV) or Enteral (OG/PO)– Then calculate the amount of energy requiredThen calculate the amount of energy required– Decide how to provide the energy: amount Decide how to provide the energy: amount

and nature of carbohydrates and lipidsand nature of carbohydrates and lipids– Provide proteins, vitamins, trace elementsProvide proteins, vitamins, trace elements

Calculations: practical hints Calculations: practical hints for TPNfor TPN

Do not starve babies! The ones who don’t Do not starve babies! The ones who don’t complain are the ones who need it the most.complain are the ones who need it the most.

Use birthweight to calculate intake till birthweight Use birthweight to calculate intake till birthweight regained, then use daily wtregained, then use daily wt

Start TPN on 2nd or 3rd day if the baby will not Start TPN on 2nd or 3rd day if the baby will not be on full feeds by a weekbe on full feeds by a week

Start with proteins (1 g/kg/d) and increase slowly. Start with proteins (1 g/kg/d) and increase slowly. After a few days (3rd or 4th day), add lipids (0.5 After a few days (3rd or 4th day), add lipids (0.5

kg/kg/d)kg/kg/d) Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d

Protein (NPC/N of 150-200)Protein (NPC/N of 150-200)

CarbohydrateCarbohydrate

IV: IV: – Dextrose 3.4 Cal/g = 34 Cal/100 cc of D10W. Dextrose 3.4 Cal/g = 34 Cal/100 cc of D10W. – Tiny babies are less able to tolerate dextrose. Tiny babies are less able to tolerate dextrose.

If < 1 kg, start at 6 mg/kg/min. If 1-1.5 kg, If < 1 kg, start at 6 mg/kg/min. If 1-1.5 kg, start at 8 mg/kg/min. start at 8 mg/kg/min.

– If blood levels >150-180 mg/dL, glucosuria=> If blood levels >150-180 mg/dL, glucosuria=> osmotic diuresis, dehydrationosmotic diuresis, dehydration

– Insulin can control hyperglycemiaInsulin can control hyperglycemia– Hyper- or hypo-glycemia => early sign of Hyper- or hypo-glycemia => early sign of

sepsissepsis– Avoid Dextrose>12.5% through peripheral IVAvoid Dextrose>12.5% through peripheral IV

CarbohydrateCarbohydrate

Enteral: Enteral: – Human milk/ 20 Cal/oz formula = 67 Cal/100 ccHuman milk/ 20 Cal/oz formula = 67 Cal/100 cc– Lactose is carbohydrate in human milk and term Lactose is carbohydrate in human milk and term

formula. Soy and lactose free formula have formula. Soy and lactose free formula have sucrose, maltodextrins and glucose polymerssucrose, maltodextrins and glucose polymers

– Preterm formula has 50% lactose and 50% Preterm formula has 50% lactose and 50% glucose polymers (lactase level lower in premies, glucose polymers (lactase level lower in premies, but glycosidases active) 80Cal/100ccbut glycosidases active) 80Cal/100cc

– Lactose provides 40-45% of calories in human Lactose provides 40-45% of calories in human milk and term formulamilk and term formula

FatFat

Parenteral: Parenteral: – 20% Intralipid (made from Soybean) better than 20% Intralipid (made from Soybean) better than

10% 10% – High caloric density (2 Cal/cc vs 0.34 for D10W)High caloric density (2 Cal/cc vs 0.34 for D10W)– Start low, go slow (0.5-3 g/kg/day)Start low, go slow (0.5-3 g/kg/day)– Avoid higher amounts in sepsis, jaundice, severe Avoid higher amounts in sepsis, jaundice, severe

lung diseaselung disease– Maintain triglyceride levels of < 150 mg/dL. Maintain triglyceride levels of < 150 mg/dL.

Decrease infusion if >200-300 mg/dL.Decrease infusion if >200-300 mg/dL.

FatFat

Enteral:Enteral:– Approximately 50% of the calories are Approximately 50% of the calories are

derived from fat. >60% may lead to derived from fat. >60% may lead to ketosis.ketosis.

– Medium-chain triglycerides (MCT) are Medium-chain triglycerides (MCT) are absorbed directly. Preterm formula have absorbed directly. Preterm formula have more MCT for this reason. more MCT for this reason.

– At least 3% of the total energy should be At least 3% of the total energy should be supplied as EFAsupplied as EFA

ProteinProtein

Term infants need 1.8-2.2 g/kg/dayTerm infants need 1.8-2.2 g/kg/day Preterm (VLBW) infants need 3-3.5 g/kg/day Preterm (VLBW) infants need 3-3.5 g/kg/day

(IV or enteral), ELBW 3-4g/kg/day(IV or enteral), ELBW 3-4g/kg/day Restrict stressed infants or infants with Restrict stressed infants or infants with

cholestasis to 1.5 g/kg/daycholestasis to 1.5 g/kg/day Start early - VLBW neonates may need 1.5-2 Start early - VLBW neonates may need 1.5-2

g/kg/day by 72 hoursg/kg/day by 72 hours Very high protein intakes (>5-6 g/kg/day) Very high protein intakes (>5-6 g/kg/day)

may be dangerousmay be dangerous Maintain NP Calorie/Protein ratio (at least 25-Maintain NP Calorie/Protein ratio (at least 25-

30:1)30:1)

Minerals Minerals (other than Na,K, Cl)(other than Na,K, Cl)

Calcium & Phosphorus:Calcium & Phosphorus:– Third trimester Ca accretion (120-150mg/kg/day) Third trimester Ca accretion (120-150mg/kg/day)

and PO4 (75-85 mg/kg/day) is more than available in and PO4 (75-85 mg/kg/day) is more than available in human milk. Hence, HMF is essential. Premie human milk. Hence, HMF is essential. Premie formula has sufficient Ca/PO4. Ratio should be 1:7:1 formula has sufficient Ca/PO4. Ratio should be 1:7:1 by wt.by wt.

Magnesium: sufficient in human milk & formulaMagnesium: sufficient in human milk & formula Iron: Feed Fe-fortified formula. Start Fe in breast fed Iron: Feed Fe-fortified formula. Start Fe in breast fed

term infants at 4 months of age, and in premies once term infants at 4 months of age, and in premies once full feeds are reached. (Does not prevent Anemia of full feeds are reached. (Does not prevent Anemia of Prematurity )Prematurity )

VitaminsVitamins

Fat soluble vitamins: A, D, E, KFat soluble vitamins: A, D, E, K Water soluble vitamins: Vitamins BWater soluble vitamins: Vitamins B11,B,B22, B, B66, B, B1212, ,

Biotin, Niacin, Pantothenate, Folic acid, Biotin, Niacin, Pantothenate, Folic acid, Vitamin C Vitamin C

All neonates should get vit K at birthAll neonates should get vit K at birth Term neonates: No vitamin supplement Term neonates: No vitamin supplement

required, except perhaps vit Drequired, except perhaps vit D Preterm: Start vitamin supplements once full Preterm: Start vitamin supplements once full

feeds established if on human milk without feeds established if on human milk without HMF. No need if on human milk with HMF, or HMF. No need if on human milk with HMF, or preterm infant formula (except: add vit D if on preterm infant formula (except: add vit D if on SSC24). SSC24).

Trace elementsTrace elements

Zinc, Copper, Selenium, Chromium, Zinc, Copper, Selenium, Chromium, manganese, Molybdenum, Iodinemanganese, Molybdenum, Iodine

Most preterm formulas contain Most preterm formulas contain sufficient amountssufficient amounts

Fluoride supplementation not Fluoride supplementation not required in neonatal periodrequired in neonatal period

Special formulaSpecial formula

Soy formula:Soy formula:– Not recommended for premies: impaired mineral Not recommended for premies: impaired mineral

and protein absorption; low vitamin contentand protein absorption; low vitamin content– Used if galactosemia, CMPI, secondary lactose Used if galactosemia, CMPI, secondary lactose

intolerance following gastroenteritisintolerance following gastroenteritis Alfare: Alfare: (Alimentum is similar, but with sucrose)(Alimentum is similar, but with sucrose)

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

Portagen:Portagen:– Casein; 75% glucose polymers+25% sucrose; 85% Casein; 75% glucose polymers+25% sucrose; 85%

MCTMCT– Useful for persistent chylothorax. Can cause EFA def.Useful for persistent chylothorax. Can cause EFA def.

Special formula (contd.)Special formula (contd.)

Similac PM 60/40:Similac PM 60/40:– Low sodium and phosphate; high Ca/PO4 ratioLow sodium and phosphate; high Ca/PO4 ratio– Used in renal failure, hypoparathyroidismUsed in renal failure, hypoparathyroidism

Similac 27:Similac 27:– High energy with more Protein, Ca/Po4, LytesHigh energy with more Protein, Ca/Po4, Lytes– Used for fluid restricted infants: CHF, BPDUsed for fluid restricted infants: CHF, BPD

Nutramigen:Nutramigen:– Hypoallergenic, lactose and sucrose freeHypoallergenic, lactose and sucrose free– Used for protein allergies, lactose intoleranceUsed for protein allergies, lactose intolerance

MILK FEEDSMILK FEEDS

F/S(M) F/S(M) 0.67cal/ml0.67cal/ml F/S(P)F/S(P) 0.8cal/ml0.8cal/ml EBMEBM 0.67cal/ml0.67cal/ml Neosure 0.73cal/mlNeosure 0.73cal/ml AlfareAlfare 0.7cal/ml0.7cal/ml

SupplementsSupplements

MCT oil (8cal/ml)MCT oil (8cal/ml) Start when iv lipids taken offStart when iv lipids taken off Max 2ml/kgMax 2ml/kg Start as ¼ml alt feed; Start as ¼ml alt feed; ¼ml/feed after 2-3 days ¼ml/feed after 2-3 days S-26 HMF: maxS-26 HMF: max 2 sachets /100ml EBM 0.13cal/ml2 sachets /100ml EBM 0.13cal/ml Similac HMF: maxSimilac HMF: max 4 satchets/100ml EBM 0.15cal/ml4 satchets/100ml EBM 0.15cal/ml For EBM, start fortification as half fortification For EBM, start fortification as half fortification

when EBM reaches 100ml/kg and when EBM reaches 100ml/kg and a week old a week old Full fortification after 2-3 daysFull fortification after 2-3 days

Iron and MultivitaminIron and Multivitamin

Ferrum: start when started on Ferrum: start when started on recormon and feeds started & recormon and feeds started & tolerated tolerated

oror <1500g /not on recormon – on <1500g /not on recormon – on D21D21

5-6mg/kg (1ml Fe=20drops=50mg)5-6mg/kg (1ml Fe=20drops=50mg) Multivitamins: start when off TPN Multivitamins: start when off TPN 1ml om1ml om

Health & Medicine

Fluidelectrolytes