Chapter 6

FLUID MANAGEMENT
All babies need maintenance amount of fluids and electrolytes to meet their daily
requirements. This should preferably be provided enterally as breast milk. However, in
certain clinical situations where oral feeds can either not be given or are not tolerated,
intravenous fluids (IV) have to be supplemented.

Learning Objectives

After completion of this module the participant should be able to-

• Identify babies who need IV fluids
• Calculate daily fluid and electrolyte intake
• Administer IV fluids with measured volume set / infusion pump
• Monitor babies receiving IV fluids
• Adjusting IV fluids with enteral feeding

Babies requiring IV fluid therapy

• Neonates with lethargy and refusal to feed

• Moderate to severe breathing difficulty
• Babies with shock
• Babies with severe asphyxia
• Abdominal distension with bilious or blood stained vomiting

Choice of fluids

• Give 10% Dextrose for the initial 48 hours of life.

• After the age of 48 hrs if the baby is passing urine 5 – 6 times a day, use
commercially available IV fluid, such as Isolyte P.
• If the premixed solution is not available or baby requires higher GIR (Glucose
infusion rate),
o Add normal saline (NS) 20 ml/kg body weight (which contains 3meq of Na /kg)
to the required volume of 10% Dextrose. Add 1ml KCl/100ml of prepared fluid.
o To calculate the necessary fluid volume, determine the volume of fluid required
for day of life (refer table 1). Provide this as 20 ml/kg of NS and the remaining as
10% Dextrose.

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Administration of IV fluid

• Use a microdrip infusion set which has a microdropper (where 1 ml = 60 microdrops)

• In this device, number of drops per minute is equal to mL of fluid per hour e.g. If a
baby needs 6mL/hr provide 6 microdrops/minute)
• Before infusing IV fluid, check:-
o The expiry date of the fluid
o The seal of the infusion bottle or bag for its intactness
o That the fluid is clear and free from any visible particles
• Calculate the rate of administration, and ensure that the microdropper delivers the
fluid at the required rate.
• Change the IV infusion set and fluid bag every 24 hours; even if the bag still contains
IV fluid (this can be a major source of infection).

Volume of IV fluids to be given

Determine the required volume of fluid according the birth weight and age (Table 6.1)

Table 6.1: Fluid requirement of neonates (ml/per kg body weight)

Day of Life Birth Weight

>1500 g <1500 g

1 60 80
2 75 95
3 90 110
4 105 125
5 120 140
6 135 150
7 150 150

Example

Calculation for a 4 day old neonate with birth weight of 1200 g needing IV fluids:
Total fluid requirement on Day of life as per Table 6.1 = 125 ml / kg / day

= 125 x 1.2 = 150 ml / day = 6.2 ml / hour

Fluid order: IV Fluid as Isolyte P 150 ml in 24 hrs @ 6.2mL/hr with a syringe pump or 6
udrops/min with a microdrip set

Give this fluid with a microdrip set at a rate of 6 microdrops / minute OR with a infusion
pump at a rate of 6.2 ml / hour

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Monitoring of babies receiving IV fluid

• Inspect the infusion site every hour.

• Look for redness and swelling around the insertion site of the cannula, which
indicates that the cannula is not in the vein and fluid is leaking into the subcutaneous
tissues.
• If redness or swelling is seen at any time, stop the infusion, remove the cannula, and
establish a new IV line in a different vein.
• Check the volume of fluid infused and compare to the prescribed volume, record all
findings.
• Measure blood glucose every nursing shift i.e. 6 – 8 hours.
• If the blood glucose is less than 45 mg/dl, treat for low blood glucose
• If the blood glucose is more than 150 mg/dl on two consecutive readings: - Change
to a 5% Dextrose solution and measure blood glucose again in three hours.
• Weigh the baby daily. If the daily weight loss is more than 5%, increase the total
volume of fluid by 10 ml/kg body weight for one day to compensate for inadequate
fluid administration.
• If there is no weight loss or there is weight gain in the initial 3 days of life, do not
give the daily increment, keep the fluid rate same as the previous day, however, if
there is excessive weight gain (3-5%) decrease the fluid intake by 15-20 ml/kg/day.
• If there are signs of overhydration (e.g. excessive weight gain, puffy eyes, or
increasing oedema over lower parts of the body), reduce the volume of fluid by half
for 24 hours after the overhydration is noted. Check Serum Na, Urine specific gravity
& titrate fluid accordingly.
• Check urine output: Normally a baby passes urine 5 – 6 times everyday. If there is
decreased urine output and weight loss increase fluid intake by 10-20mL/kg;
However, if there is decreased urine output with weight gain, decrease daily fluid
volume by 10mL/kg and evaluate for renal failure.

Adjusting IV fluid with enteral feeding

• Allow the baby to begin breastfeeding as soon as the baby’s condition improves.
• If the baby cannot be breastfed, give expressed breast milk using an alternative
feeding method
• If the baby tolerates the feed and there are no problems, continue to increase the
volume of feeds by 20-30mL/kg/day, while decreasing the volume of IV fluid to
maintain the total daily fluid volume according to the baby’s daily requirement.
• Feed the baby every two hours, adjusting the volume at each feeding accordingly.
• Chart the total fluid requirement per day as per Table 6.1. Subtract the daily volume
of feeds and give the remaining as IV fluid.
• Discontinue the infusion of IV fluid when the baby is receiving more than two-thirds
of the daily fluid volume by mouth and has no abdominal distension or vomiting.
• Encourage the mother to initiate breastfeeding as soon as possible.

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• Eg. 1200 gm baby on day 1:
Total fluid requirement
80 X 1.2 kg = 96 ml
Total feeds 10mL/kg = 12 ml
Feeds are 3 ml 6 hrly i.e.
3 X 4 = 12 ml
(No. of feeds) (Feed vol) = Total feed volume
96 – 12 = 84 ml
Provide this as 10% Dextrose 28 ml 8 hrly @ 3.5 mL/hr or 4 udrops/min

• Day 2:
Total fluid requirement
95 X 1.2 kg = 114 ml
Total feeds 30mL/kg = 36ml
Feeds are 3 ml 2 hrly i.e.
12 X 3 = 36 ml
(No. of feeds) (Feed vol) = Total feed volume
114 – 36 = 78 ml
Provide this as 10% Dextrose 26 ml 8 hrly @ 3.2mL/hr or 3 udrops/min

• Day 3:
Total fluid requirement
110 X 1.2 kg = 132 ml
Total feeds 50mL/kg = 60ml
Feeds are 5 ml 2 hrly i.e.
12 X 5 = 60 ml
(No. of feeds) (Feed vol) = Total feed volume
132 – 60 = 72 ml
Provide this as IV Isolyte P 24 ml 8 hrly @ 3mL/hr or 3 udrops/min

• Day 4
Total fluid requirement
125 X 1.2 kg = 150 ml
Increase feeds by 30mL/kg & reduce fluid accordingly
Total feeds 80mL/kg = 96ml
Increment = 30 X 1.2 Kg = 36 mL i.e. 3 mL q 2hrs
Hence, Oral feeds on D4 = 8 mL 2hrly
12 X 8 = 96 mL
(No. of feeds) (Feed vol) = Total feed volume
150 – 96 = 54 ml
Provide this as IV Isolyte P 18 ml 8 hrly @ 2.3mL/hr or 2 udrops/min

• Day 5
Total fluid requirement
140 X 1.2 kg = 168 ml
Increase feeds by 30mL/kg & reduce fluid accordingly

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Total feeds 110mL/kg = 132ml
Increment = 30 X 1.2 Kg = 36 mL i.e. 3 mL q 2hrs
Hence, Oral feeds on D4 = 11 mL 2hrly
12 X 11 = 132 mL
(No. of feeds) (Feed vol) = Total feed volume
168 – 132 = 36 ml

OMIT IV FLUIDS, ONCE BABY ON >100mL/kg/day Feeds

One can also increase feeds daily by 30mL/kg/day and begin with minimal enteral
nutrition (MEN) @ 10mL/kg and reach 40, 70 and 100ml/kg on D4. Such a baby
receives IV Fluid just for 3 days.

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EVALUATION
Preterm 33 weeks neonate, weighing 1.4 kg with breathing difficulty is brought to SCNU
on D1 of life. The health care provider has decided to provide IV fluids along with other
supportive treatment.

1. What IV fluid you would start? How much volume of IV fluid is needed and at what
rate?
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2. After 48 hours this baby still needs IV fluids. What changes in IV fluids are required?
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3. Baby’s respiratory distress settled on day 3 and he was started on minimal feeds.
Today on day 4 he is on 3 ml 2 hrly feeds of EBM. How will you adjust the IV fluid?
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4. What are the steps of monitoring this baby who is on IV fluids?

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5. On D 7 of life baby is receiving 9 ml of EBM every 2 hours. How will you adjust IV
fluids?
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6. When will you stop IV fluids in this baby?

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