Fluid and Electrolyte Therapy in the Very Low-birthweight Neonate

John M. Lorenz
Neoreviews 2008;9;e102
DOI: 10.1542/neo.9-3-e102

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Article fluids and electrolytes

Fluid and Electrolyte Therapy in

the Very Low-birthweight
Neonate
John M. Lorenz, MD*
Objectives After completing this article, readers should be able to:

1. Characterize insensible water loss in extremely preterm neonates.

Author Disclosure 2. Compare the renal function of preterm and term neonates.
Dr Lorenz did not 3. Describe the changes in total body water and electrolytes with the transition from fetal
disclose any financial to neonatal life.
relationships relevant 4. Use the phases of renal, fluid, and electrolyte adaptation to determine appropriate
to this article. fluid and electrolyte therapy for preterm neonates.

Abstract
The transition from fetal to neonatal life is associated with major changes in water and
electrolyte homeostasis. Fluid and electrolyte management is particularly challenging
for very preterm neonates in whom water loss is large, highly variable, and, in large
part, not subject to feedback control. In addition, preterm neonates kidneys have a
more limited ability to compensate for water and electrolyte imbalances than term
neonates. Insensible water loss is a much larger component of the total water
requirement in extremely preterm infants than in term infants. The weight loss seen in
preterm infants during the first postnatal week results, in large part, from an abrupt
and absolute decrease in total body water volume, and hyperkalemia is a common
finding in the first 24 to 72 hours after birth. Fluid and electrolyte adaptation in most
very low-birthweight newborns generally occurs in three phases, and awareness of the
changes associated with each phase can aid clinicians in determining appropriate
adjustments in fluid and electrolyte therapy.

Introduction
Fluid and electrolyte management is an important and challenging part of the initial
management of any very preterm or critically ill newborn. The transition from fetal to
neonatal life is associated with major changes in water and electrolyte homeostasis. Before
birth, the fetus has a constant and ready supply of water and electrolytes from the mother
across the placenta; fetal water and electrolyte homeostasis is largely a function of maternal
and placental homeostatic mechanisms. After birth, the newborn rapidly must assume
responsibility for fluid and electrolyte balance in an environment in which water and
electrolyte availability depends on the knowledge and experience of the physician. Fluid
and electrolyte management is particularly challenging for very preterm neonates in whom
water loss is large, highly variable, and, in large part, not subject to feedback control and
whose kidneys ability to compensate for water and electrolyte imbalances is more limited
than even the term newborns. Superimposed on these more gradual maturational limita-
tions of renal function are acute changes in the first few postnatal days in the ability of the
neonate to excrete water and electrolytes. Moreover, major changes in total body fluid and
electrolyte balances occur with the transition from fetal to neonatal life in the preterm
infant. Thus, the goal of fluid and electrolyte therapy in the immediate postnatal period is
not to maintain fluid and electrolyte balance, but to allow the appropriate changes to occur
without detrimental perturbations in fluid and electrolyte status.

*Professor of Clinical Pediatrics, College of Physicians and Surgeons, Columbia University, Morgan Stanley Childrens Hospital of
New York, New York, NY.

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Table 1. Insensible Water Loss in Appropriate-for-gestational Age Newborns*
Gestational
Age (wk) <1 1 3
25 to 27 57 to 214 62 to 171 59 to 96
28 to 30 22 to 75 23 to 68 20 to 57
31 to 36 8 to 29 8 to 28 10 to 27
37 to 41 8 to 18 11 to 14 11 to 14
*Ninety-five percent confidence limits for infants nursed naked in an incubator with 50% ambient humidity, ambient air temperature in the neutral thermal
range, and constant air flow of 8 L/min.
Reprinted with permission from Lorenz JM. Fluid and electrolyte therapy in the newborn infant. In: Burg FD, Polin RA, Ingelfinger JR, Gershon A, eds.
Current Pediatric Therapy 17. Philadelphia, Pa: WB Saunders; 2002. Calculated from the data of Hammarlund K, Sedin G, Stromberg B. Transepidermal
water loss in newborn infants. VIII. Relation to gestational age and post-natal age in appropriate and small for gestational age infants. Acta Paediatr Scand.
1983;72:721728 and Riesenfeld T, Hammarlund K, Sedin G. Respiratory water loss in relation to gestational age in infants on their first day after birth. Acta
Paediatr Scand. 1995;84:1056 1059.
Special Considerations
Insensible Water Loss (IWL)
IWL is a major consideration in fluid and electrolyte
therapy of extremely preterm neonates. First, it repre-
sents a much larger component of the total water re-
quirement than in term infants. Second, it is highly
variable. IWL occurs transepidermally and across upper
airway epithelium. Transepidermal loss is the larger and is
affected principally by gestational and postnatal age (1)
and ambient water vapor pressure. (2) Antenatal steroids
also decrease IWL at any given gestational age. (3) Upper
airway epithelial loss is a function of minute ventilation
(independent of maturity) (4) and the water vapor pres-
sure of inspired gas. Third, the infant has no ability to
modulate IWL in response to water balance. Therefore,
IWL is obligate free water loss.
Table 1 describes IWL as a function of gestational and
postnatal age from the first day after birth. No compara-
ble data are available for neonates of 23 to 24 weeks of
gestation or for neonates under radiant warmers. How-
ever, IWL surely is higher in neonates of 23 to 24 weeks
gestation at any given postnatal age and higher in ambi-
ent humidity, as is typical under radiant warmers. The
same group of investigators whose data were used to
construct Table 2 found IWL to be 15% to 35% higher
during the first 3 postnatal weeks under a radiant warmer
(5) compared with the humidified environment specified
in Table 2.
Renal Function
Although even the very preterm neonate can maintain
water and sodium balance within a relatively narrow
range over a relatively broad range of water and sodium
intakes, (6)(7)(8) the ability of the immature kidney to
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fluids and electrolytes fluid and electrolyte therapy
Postnatal Age (days)
5 7 14 21 28
43 to 72 31 to 68 18 to 59 14 to 55 8 to 53
19 to 48 16 to 45 12 to 37 9 to 34 9 to 34
10 to 27 10 to 27 9 to 22 10 to 19 11 to 16
11 to 14 11 to 14 11 to 14 12 to 13 11 to 16
compensate for changes in water and electrolyte intake is
limited. Glomerular filtration rate is lower in the preterm
than the term neonate. It increases with gestational and
postnatal age. (9) The sodium reabsorptive capacity of
the proximal nephron is limited in the preterm infant,
thereby limiting the ability to conserve sodium with a
normal extracellular volume compared with term infants
and adults. This capacity is related directly to gestation.
(9)(10)
Even low-birthweight (and presumably preterm) in-
fants are capable of urinary potassium excretion at a rate
in excess of the rate of potassium filtration across the
glomerulus during potassium or sodium bicarbonate
loading in the first postnatal month, indicating net tubu-
lar potassium secretion. (11) However, the rate of potas-
sium excretion per unit body or kidney weight during
exogenous potassium loading is lower in the immature
than mature animal. (12) In general, the limited potas-
sium secretory capacity of the immature distal nephron is
clinically relevant only under conditions of potassium
excess or when potassium shifts from the intracellular
fluid (ICF) space to the extracellular fluid (ECF) space
in the immediate period after birth in extremely preterm
infants. On the other hand, potassium reabsorption in-
creased in parallel with the increase in the filtered potas-
sium load with increasing gestational age in a study of
infants of 23 to 31 weeks of gestation on postnatal days
4 to 5, with urinary potassium excretion remaining low
and unchanged over this period of gestation. (13)
Although preterm infants can dilute their urine
nearly as much as term infants and adults can, they
cannot concentrate their urine to nearly the same de-
gree. Adults can achieve a maximum urine osmolality of
1,500 mOsm/L, term infants concentrate their urine to
NeoReviews Vol.9 No.3 March 2008 e103
fluids and electrolytes fluid and electrolyte therapy

Postnatal Renal, Fluid, and Electrolyte Adaptation in Very Low-

Table 2.

birthweight Infants
Phase Prediuretic Diuretic/Natriuretic Homeostatic
Age Birth to 2 days 1 to 5 days After 2 to 5 days
Urine output Low Abrupt increase Decreases, then proportional to
intake
Sodium excretion Minimal Abrupt increase Decreases, then proportional to
intake
Potassium excretion Minimal Abrupt increase Decreases, then proportional to
intake
Water balance Less than intake minus IWL Markedly negative Approximately proportional to
sodium balance
Sodium balance Slightly negative Markedly negative Stable, then positive with growth
Potassium balance Slightly negative Markedly negative Stable, then positive with growth
Extracellular fluid volume Stable or slightly decreases Abruptly decreases Proportional to sodium balance;
increases with growth
Glomerular filtration rate Low Abruptly increases Decreases, then gradually
increases with maturation
Fractional excretion of Variable Increased Gradual decrease
sodium
Fractional excretion of Variable No change No change
potassium
Urine osmolality Moderately hypo-osmotic Moderately hypo-osmotic Moderately hypo-osmotic
Common Problems Water intoxication with Hypernatremia Water and sodium retention
lower IWL than Hyperglycemia with chronic lung disease,
anticipated patent ductus arteriosus
Hypernatremia with higher Water and sodium depletion
IWL than anticipated with or without hyponatremia
Hyperkalemia Hypokalemia

IWLinsensible water loss

Adapted from Lorenz JM. Fluid and electrolyte management in the first week of life. In: Polin RA, Yoder MC, Burg FD, eds. Workbook in Practical
Neonatology. 3rd ed. Philadelphia, Pa: WB Saunders Company; 2001.

only approximately 600 mOsm/L, and preterm infants
concentrate it to only approximately 500 mOsm/L. As a
result, the minimal water requirement to excrete a given
solute load is greater in the preterm than term infant.
Thus, the preterm infant has a limited ability to conserve
free water.
Changes in Total Body Water and Electrolytes
With the Transition from Fetal to Neonatal
Life
A 10% to 20% weight loss is common in preterm in-
fants during the first postnatal week. Although inade-
quate caloric intake may contribute somewhat to this
weight loss, it results, in large part, from an abrupt and
absolute decrease in total body water volume in the first
few days after birth. (14)(15)(16)(17)(18)(19) The best
evidence suggests that a disproportionate loss of this
water occurs from the ECF compartment in appropriate-
for-gestational age very low-birthweight infants (Fig-
ure). (14)(15)(16)(17)(18)(19)(20) The decrease in
ECF volume is the result of a decrease in interstitial fluid
(ISF) volume without a change in plasma volume. (16)
The reason for this contraction is not understood. The
magnitude of the contraction of the ECF space is roughly
inversely proportional to gestational age.
Although physiologic correlates of postnatal diuresis
and natriuresis have been described, (20)(21)(22)(23)
(24)(25)(26) the reason for this phenomenon is un-
known. The disproportionate decrease in ECF precludes
ascribing this decrease solely to catabolism. That it is
physiologic is suggested by several observations. First,
relatively large differences in water and caloric intake are
required to moderate this weight loss. (6)(7)(8) Further,
higher caloric intake has been correlated with less post-
natal weight loss, but no difference in the magnitude of
ECF contraction. (18) Moreover, increases in ICF and
body solids per kilogram of body weight, but not in ECF
per kilogram body weight occur with subsequent weight

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Figure. Body weight (g) and extracellular water volume (vol-
ume of distribution of sucrose) (mL) in 13 preterm
appropriate-for-gestational age infants within the first
12 hours after birth (left) and when postnatal weight loss
exceeded 5% (right) at an average age of 84 hours. Error bars
are standard deviations. *P<0.001 versus respective values
within the first 12 hours after birth. Mean weight loss was the
same as the mean decrease in extracellular water volume.
Adapted from Bauer K, Versmold H. Postnatal weight loss in
preterm neonates <1599 g is due to isotonic dehydration of
the extracellular volume. Acta Paediatr Scand Suppl. 1989;
360:37.
gain. (15)(16)(19) Finally, fluid and sodium intakes high
enough to prevent this decrease in ECF volume (27)
have been associated with increased morbidity in preterm
newborns. (8)(28)(29)
Some 25% to 50% of infants whose birthweights are
less than 1,000 g or who are born at less than 28 weeks of
gestation develop hyperkalemia in the first 24 to
72 hours after birth, even in the absence of exogenous
potassium intake or renal failure. (30)(31)(32)(33) This
is the result of a potassium shift from the ICF to ECF
space in the immediate postnatal period. The magnitude
of this shift correlates roughly with the degree of prema-
turity, but it does not seem to occur (or at least is not
clinically significant) after 30 to 32 weeks of gestation.
(34) The reason for and physiologic appropriateness of
this shift is not known. However, because of this phe-
nomenon, exogenous potassium should not be adminis-
tered to extremely preterm infants until urine output is
established and the serum potassium concentration is
normal and confirmed not to be rising.
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fluids and electrolytes fluid and electrolyte therapy
Phases of Renal, Fluid, and Electrolyte
Adaptation
In most preterm infants, the excretion of water and
sodium that occurs as the result of contraction of the
ECF space in the first few postnatal days does not occur
gradually. In fact, a characteristic pattern of fluid and
electrolyte adaptation, which is largely independent of
fluid and electrolyte intake, is observed in the first post-
natal week in most very low-birthweight (and probably
most) newborns. Usually, three phases can be distin-
guished. (25)(27) Awareness of these phases is helpful in
anticipating changes in fluid and electrolyte homeostasis
and guiding fluid and electrolyte therapy. Table 2 sum-
marizes the changes in fluid and electrolyte balances,
ECF volume, and renal function associated with each
phase, their implications for fluid and electrolyte man-
agement, and common fluid and electrolyte problems to
anticipate during each phase.
Fluid and Electrolyte Guidelines
Guidelines for initiating and subsequently adjusting fluid
and electrolyte therapy during the prediuretic and
diuretic/natriuretic phases are summarized in Table 3.
Water requirements are higher in neonates nursed under
radiant warmers.
The maturation limitations of renal function are man-
ifested in the homeostatic phase. In this phase, IWL is
lower than immediately after birth. On the other hand,
urinary water loss is higher than immediately after birth
and depends on the urine concentration and renal solute
load, which ranges from approximately 25 mL/kg per
day in growing breastfed infants to approximately
50 mL/kg per day in catabolic infants receiving par-
enteral nutrition. Thus, the basal water requirement dur-
ing the homeostatic phase usually is slightly lower than
that required in the prediuretic phase in the most imma-
ture infants and slightly greater than that in the predi-
uretic phase in the most mature infants. Often, however,
water intake needs to be higher to deliver adequate
calories for growth. Basal sodium requirements to re-
place renal sodium losses in the homeostatic phase range
from 3 to 6 mmol/kg per day in the most immature
neonates. The basal potassium requirement ranges from
1 to 3 mmol/kg per day. All requirements are higher
with growth.
It must be emphasized that appropriate fluid and
electrolyte management during the first week after birth
requires anticipation of likely fluid and electrolyte losses
and changes in water and electrolyte balance that are
appropriate. Consideration of these factors allows esti-
mation of the water, sodium, and potassium require-
NeoReviews Vol.9 No.3 March 2008 e105
fluids and electrolytes fluid and electrolyte therapy

Guidelines for Initiating and Adjusting Fluid and Electrolyte

Table 3.

Therapy in Newborns*
Adjustment During the Prediuretic Adjustment During the Diuretic/
Postnatal Day 1 Phase Natriuretic Phase
Water <25 wk: 150 mL/kg per Increase if: weight loss is 2%/day or Increase by 10 to 30 mL/kg per day
day serum sodium increases if: weight loss is 5%/d or
25 to 27 wk: 120 mL/kg Decrease if: weight increases or serum serum sodium is 150 mEq/L
per day sodium decreases (150 mmol/L) with no sodium
28 to 30 wk: 100 mL/kg intake
per day Decrease by 10 to 30 mL/kg per
31 to 36 wk: day if: weight loss is 1%/d
80 mL/kg per day
>36 wk: 60 mL/kg per
day
Sodium None Usually no sodium is required Begin 1 to 2 mmol/kg per day if:
serum sodium is 135 mEq/L
(135 mmol/L) with weight loss or
serum sodium is 130 mEq/L
(130 mmol/L) with no change or
gain in weight
Potassium None Usually no potassium is required Begin 1 to 2 mmol/L per day if:
serum potassium is 5 mEq/L
(5 mmol/L) and not increasing
and urine output is 1 mL/kg
per hour
*Newborns nursed naked in an incubator with 50% ambient humidity and ambient air temperature in the neutral thermal range.
Reprinted with permission from Lorenz JM. Fluid and electrolyte therapy in the newborn infant. In: Burg FD, Polin RA, Ingelfinger JR, Gershon A, eds.
Current Pediatric Therapy 17. Philadelphia, Pa: WB Saunders; 2002.

ments. Such requirements vary substantially among in-
fants. Therefore, intakes must be individualized and
evaluation of fluid and electrolyte balance that results
from the estimated intakes must be re-evaluated period-
ically to make appropriate adjustments in fluid and elec-
trolyte intake. Parameters useful in evaluating fluid and
electrolyte balance include changes in body weight, in-
takes and outputs, and plasma and urine electrolyte and
creatinine concentrations.
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fluids and electrolytes fluid and electrolyte therapy

NeoReviews Quiz
1. A 6-hour-old preterm neonate, whose birthweight is 640 g at an estimated gestational age of 24 weeks, is
being observed under a radiant warmer. Ambient humidity is 80%. The infant requires mechanical
ventilation, a fraction of inspired oxygen of 0.42, and an indwelling nasogastric tube for suction. No
anomalies or syndromic features are suspected. You are estimating the infants fluid-electrolyte needs. Of
the following, the major consideration in fluid-electrolyte management for this infant is:
A. Gastric drainage water loss.
B. Insensible water loss.
C. Stool water loss.
D. Sweat water loss.
E. Urinary water loss.

2. A preterm neonate typically loses 10% to 20% of body weight during the first week after birth. This
weight loss is considered physiologic. Of the following, the physiologic weight loss in the preterm neonate
is best attributed to a postnatal decrease in:
A. Body fat.
B. Caloric intake.
C. Interstitial fluid volume.
D. Intracellular fluid volume.
E. Plasma volume.

3. Some 25% to 50% of neonates who weigh less than 1,000 g at birth or whose gestational age is less than
28 weeks develop hyperkalemia in the first 24 to 72 hours after birth. Of the following, the most likely
cause of hyperkalemia in such preterm neonates is:
A. High exogenous potassium intake.
B. High proximal tubular reabsorption of potassium.
C. Low distal tubular excretion of potassium.
D. Low glomerular filtration of potassium.
E. Shift of potassium from intracellular to extracellular fluid.

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 Fluid and Electrolyte Therapy in the Very Low-birthweight Neonate
John M. Lorenz
Neoreviews 2008;9;e102
DOI: 10.1542/neo.9-3-e102

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