Fluid Management in ELGANs: Striking the Perfect Balance!

Managing fluid and electrolytes in extremely low gestational age neonates (ELGANs) is often challenging because of their distinctive fluid physiology. Most of the fluid loss in the first week of life is trans-epidermal due to the immature barrier function of the skin. ELGANs also have a developmental tendency for exaggerated diuresis and natriuresis. Allowing an initial weight loss of 6-12% promotes physiological extracellular contraction. Also, restricted fluid intake in the first week of life may decrease the incidence of bronchopulmonary dysplasia, patent ductus arteriosus, and necrotizing enterocolitis. A protocol-based approach for fluid management in ELGANs, developed based on physiology and available evidence, is the best strategy. Based on the estimated dermal and renal losses and desired weight change, the authors recommend initiating total fluids on the first day of life at 100 mL/kg/d in neonates at 26-27 wk gestation and 110 mL/kg/d at 24-25 wk gestation. The subsequent fluid rate is determined based on rigorous monitoring of weight, urine output, and serum sodium, with a typical daily increment in fluids of 10-20 mL/kg and a maximum fluid rate of 150-160 mL/kg/d in 26-27 wk and 160-180 mL/kg/d in 24-25 wk gestation neonates by day 7 of life. Fluid strategy should ideally be revised every 12 h in the first few days of life. A humidified incubator is the ideal care environment to minimize trans-epidermal losses. Since most of these recommendations are not based on concrete evidence from trials, it is advisable to periodically audit the outcomes and devise a unit-specific fluid strategy.