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Main goals:
Maintain appropriate ECF volume, Maintain appropriate ECF and ICF osmolality and ionic concentrations
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% of weight in first week
Things to consider:
Normal changes in Renal Function Adults can concentrate or dilute urine very well, depending on fluid status Neonates are not able to concentrate or dilute urine as well as adults - at risk for dehydration or fluid overload Renal function matures with increasing:
gestational age postnatal age
Things to consider:
Insensible water loss (IWL) Insensible water loss is water loss that is 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
Management of F&E
Goal: Allow initial loss of ECT over first week (as reflected by wt loss), while maintaining normal intravascular volume and tonicity (as reflected by HR, UOP, lytes, pH). Subsequently, maintain water and electrolyte balance, including requirements for body growth. Individualize approach (no cook book is good enough!)
lu id r a t e (
hr
l/ k / d )
>48 hr 1 4 0 -1 9 0 1 2 0 -1 6 0 1 2 0 -1 6 0
2 4 -4 8 h r 1 2 0 -1 5 0 1 0 0 -1 2 0 8 0 -1 2 0
< . 1 .0 - 1 . 5 > 1 .5
-1 0 10 10
1 0 0 -1 5 0 1 0 0 -1 2 0 6 0 -8 0
After the first week, during growth, needs are 2-3 or even 4 mEq/kg/day
RDS: BPD:
PDA:
May have renal injury or SIADH. Restrict fluids initially, avoid potassium. May need fluid challenge if cause of oliguria is not clear.
Asphyxia:
ormal
estrict fluids
eficit
Potassium stuff
Potassium is mostly intracellular: blood levels
do not usually indicate total-body potassium
Hyperkalemia:
Increased K release from cells following IVH, asphyxia, trauma, IV hemolysis Decreased K excretion with renal failure, CAH Medication error very common
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 for premies!) Dialysis/ Exchange transfusion
Calcium stuff
At birth, levels are 10-11 mg/dL. Drop normally over 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. Supplement calcium if 6.5 Late onset (usually end of first week) High Phosphate type: Hypoparathyroidism, maternal anticonvulsants, vit. D deficiency etc. Reduce renal phosphate load
Nutrition
Goals: Normal growth and development (as compared to intrauterine growth for preterm
neonates, or as compared to growth charts for term neonates)
Nutrient requirements:
Energy (Cals) Water Protein Fat Carbohydrate Minerals Vitamins Trace elements
Energy { E = mc
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 for absorption): 70-90 Cal/kg/day+ 2.4- .8 g/kg/day Protein adequate for growth Count non-protein calories only! Protein to be preferred used for growth, not energy 65% from carbohydrates, 35% from lipids ideal >165-180 Cal/kg/day not useful
Calculations
To calculate a neonate s F,E,& N:
First calculate the amount of fluid (Water) Then calculate how you plan to give it: Parenteral (IV) or Enteral (OG/PO) Then calculate the amount of energy required Decide how to provide the energy: amount and nature of carbohydrates and lipids Provide proteins, vitamins, trace elements
Carbohydrate
IV:
Dextrose 3.4 Cal/g = 34 Cal/100 cc of D10W. Tiny babies are less able to tolerate dextrose. If 1 kg, start at 6 mg/kg/min. If 1-1.5 kg, start at 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
Carbohydrate
Enteral:
Human milk/ 20 Cal/oz formula = 67 Cal/100 cc Lactose is carbohydrate in human milk and term formula. Soy and lactose free formula have sucrose, 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% of calories in human milk and term formula
Fat
Parenteral:
20% Intralipid (made from Soybean) better than 10% High caloric density (2 Cal/cc vs 0.34 for D10W) Start low, go slow (0.5-3 g/kg/day) Avoid higher amounts in sepsis, jaundice, severe lung disease Maintain triglyceride levels of 150 mg/dL. Decrease infusion if >200-300 mg/dL.
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 more MCT for this reason. At least 3% of the total energy should be supplied as EFA
Protein
Term infants need 1.8- .2 g/kg/day Preterm (VLBW) infants need 3-3.5 g/kg/day (IV or enteral) Restrict stressed infants or infants with cholestasis to 1.5 g/kg/day Start early - VLBW neonates may need 1.5g/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)
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 get vit K at birth Term neonates: No vitamin supplement required, except perhaps vit D Preterm: Start vitamin supplements once full feeds established if on human milk without HMF. No need if on human milk with HMF, or preterm infant formula (except: add vit D if on SSC24).
Trace elements
Zinc, Copper, Selenium, Chromium, manganese, Molybdenum, Iodine Most preterm formulas contain sufficient amounts Fluoride supplementation not required in neonatal period
Special formula
Soy formula:
Not recommended for premies: impaired mineral and protein absorption; low vitamin content Used if galactosemia, CMPI, secondary lactose intolerance following gastroenteritis
Portagen:
Casein; 75% glucose polymers+25% sucrose; 85% MCT Useful for persistent chylothorax. Can cause EFA def.