Neonatal Medicine

Neonatal Medicine

Scenario 1:

You are asked to review Samantha, who is currently day 3 of life. She was born at 27 weeks gestation with a birth weight of 890g. She is on CPAP and having phototherapy, and her current weight is 800g. She is not tolerating oral feeds, has green aspirates of 10ml per day. She is nursed in humidicrib, with humidification of 80%. Her latest results are

– Na 149mmol/l

– K 3mmol/l

– Ca 1.5mmol/l

– Cr 90

– SG 1002

– BSL 8

Outline your considerations on Samantha’s nutritional requirements for the next 24 hours. Consider the following requirements: Na, K, Ca, micronutrients, fluid, calories, fat, protein, carbohydrate and vitamins (minimum and ideal).

Consider all potential losses in the calculations.

Answer:

    Samantha’s sodium is on the higher side (Na>145 mEq/L). The potassium values are normal. Calcium and creatinine values are also normal. Sugars are on the higher side and serum specific gravity is on the lower side (<1.005). These disturbances are because of loss of fluid through nasogastric aspirates. In the next 24 hours, i.e. on Day 4, Samantha will need 120 ml per kg per day of IV fluids plus losses through NG aspirates. So total fluids required on Day-4: 117 ml. The solution used should contain 5 % dextrose (since sugar levels are high) with potassium chloride added (2 mE per kg per day). Since sodium is high, sodium may be with held.

Scenario 2:

Edward is a 10 week old 25 week gestation infant who had a birth weight of 540g. He is currently 900g and is still oxygen dependent, with moderate recession. He is tolerating full feeds, with a mixture of breast milk and infant formula. His latest results are:

– Na 135mmol/l

– K 2.7mmol/l

– Ca 1.9mmol/l

– Cr 60

– SG 1010

– BSL 6.

Outline the considerations on Edward’s nutritional requirements for the next 24 hours. Consider the following requirements: Na, K, Ca, micronutrients, fluid, calories, fat, protein, carbohydrate and vitamins (Minimum and ideal).

Answer:

     Edward in an extremely low birth weight (ELBW) preterm. His weight must be weighed daily, and body length and head circumference measured weekly to track growth. His corrected age now is 35 weeks. Sodium requirements ranges from 3-5 mE/kg/day in preterm neonates after the first week of life. Infact, studies have shown that failure to provide this amount of sodium may be associated with poor weight gain (Chawla et al, 2008). Water requirement for Edward would be 120 to 180 ml/kg/day. Since he has broncho- pulmonary dysplasia, it is better to keep the daily volume to 120 ml/kg/day. His sodium values are borderline low, but we can wait to add supplementation. Sodium requirements ranges from 3-5 mEq/kg/day in preterm neonates after the first week of life. The normal potassium requirements are generally 1- 2.5mE per kg per day. The potassium values in Edward are normal need no further supplementation. The calorie requirements in Edward would be 150 kcal per kg per day. Preterm infants also have very high calcium, phosphorus, sodium and vitamin D requirements. Fortifier will need to be added after 2 weeks of life. The calcium needed is 185-210 mg/kg and protein of 3.5 to 4 g per kg ( Pediatric Nutrition Work Group, 2001). The normal creatinine value in preterm would be 27 to 88 mcmol/L. In Edward, it is 60 which is normal. The serum calcium levels and urine specific gravity is also normal. Preterm infants should have iron supplement by 2 months in a dose of 2 to 4 mg/kg/d. in a dose of 2 to 4 mg/kg/d. Oral supplementation of multi vitamins and minerals is also recommended.

Scenario 4:

You are called to a small hospital within your area health service to review a day 3 neonate who has ongoing low blood sugar levels, despite being on maximum volume of 10% dextrose. You are not sure what fluids the hospital has in stock, so on your way there you calculate how to make up a solution of 15% dextrose from the possible pre-packaged solutions you think they may stock.

Please show your calculations to achieve the final solution of 15% dextrose (being aware that they will have different concentrations of NaCl). Please provide the resources you used to make these calculations:

• O.45% NaCl and 2.5% dextrose

• 0.225% NaCl and 3.75% dextrose

• 0.9% NaCl (normal saline)

• 10% dextrose

Answer:

Day 3 neonate (3 kg) will need 100ml/kg/day of fluids (Chawla et al, 2008). The sodium and potassium requirements are 2 mE/kg/day each. This baby needs 15% dextrose solution. This means that 100ml of the solution given to the baby must have 15 g of glucose and 2- 3mE of sodium and 2 mE of potassium.

To 90ml of  (O.45% NaCl and 2.5% dextrose) if we add 110 ml of 25% dextrose, the solution will contain 15 % dextrose and 3.75 mE per 100 ml of sodium. To this, 2 ml of KCl must be added to give 2 mE of potassium per 100 ml.

Scenario 5:

While you are working at the peripheral hospital a newborn infant with respiratory distress is born. You decide to keep the neonate nil by mouth until you assess the respiratory status and you want to provide a solution of 10% dextrose (being aware that they will have different concentrations of NaCl). Please show your calculations to achieve the final solution of 10% dextrose. Please provide the resources you used to make these calculations:

• O.45% NaCl and 2.5% dextrose

• 0.225% NaCl and 3.75% dextrose

• 0.9% NaCl (Normal saline)

Of the solutions you have made up, which would you choose to give on day 1 and then on subsequent days?

Answer:

In the new born, for the first 24 hours, supplemental sodium, potassium, and chloride are not usually required. A full term infant on intravenous fluids would need to excrete a solute load of about 15 mosm/kg/day in the urine. To achieve this, the baby has to pass 50 ml/kg/day of urine. Allowing for an additional insensible water losses of 20 ml/kg, the initial fluids should be 60-70 ml/kg/day (Aggarwal, n.d.). Hence the newborn must be given 10% dextrose solution only. This should run at the rate of 4-6 mg/kg/min (Aggarwal, n.d.).

At the age of 24 hours, around which time, the urine production is adequate, potassium and sodium may be introduced, but best is to add them after 48 hours. The infant needs 1-2 mEq/kg/d of potassium and 1-3 mEq/kg/d of sodium along with 10%dextrose. From day-2 onwards, there is also fecal loss of water and water is required for the purpose of growth. The fluid requirements increase by 15-20 ml/kg/day till a maximum of 150 ml/kg/day. Sodium and potassium are preferably added after 48 hours after birth. The glucose infusion should be maintained at 4-6 mg/kg/min (Aggarwal, n.d.).

In a neonate with respiratory distress, fluids should be given appropriately. Excessive fluid can lead to hyponatremia and volume overload, thus worsening the pulmonary condition and increasing the risk of developing bronchopulmonary dysplasia (BPD). Similarly, inadequate fluid administration can lead to hypernatremia and dehydration (Ambavalan, 2007).

In this baby, I would give only fluids as follows:

Day-1: 60ml/kg/day of 10% dextrose.

Day-2: 80ml/kg/day of 10% dextrose

Day-3: 100ml/kg/day of fluids, with 10% dextrose and 2 mEq per kg, per day of sodium and potassium.

Calculations for day-3:

Assuming the baby weight to be 3 kg, the total fluids required per day would be 300ml. The dextrose concentration must be 10%. The sodium content should be 2-3mE/kg/day (6-9mE/day) and 2mE per kg per day for potassium. This means that the concentration of sodium must be 2-3mEq in 100ml.

In 0.9% normal saline, there is 150mE of sodium in 1000ml, i.e.,15 mE in 100ml. In 0.45% NS, there is 7.5mEq of sodium and in 0.225% NS, there is 3.75mE of sodium per 100ml..

Of the solutions available in the hospital, 0.225% NaCl and 3.75% dextrose is nearest to the patient requirements as far as sodium is concerned. When we add, 50ml of 25% plain dextrose solution to 100 ml of 0.225% NaCl and 3.75% dextrose solution, the mixture will have approximately 10% dextrose and 2.5mE of sodium per 100ml.

Hence the ideal mixture of fluids for this baby would be 100 ml of (0.225% NaCl and 3.75% dextrose) solution plus 50 ml of 25% dextrose. To this potassium must be added with calculation as follows:

The baby will require 6 mE of potassium per day (2mE/kg/day). This means that in 300 ml of fluid, the potassium should be 6 mE. Hence the amount of potassium to be added in 150ml of above fluid mixture would be 3 mE(1.5ml of KCl solution).

Thus, the final solution would be made from 100 ml of (0.225% NaCl and 3.75% dextrose) solution plus 50 ml of (25% dextrose) plus 1.2 ml of KCl. This should be run @ 12.5 ml per hour for 24 hours.

References

Aggarwal, R., Deodari, A., & Paul, V.K. (n.d.). Fluid and electrolyte management

in term and preterm neonates. Available at: http://www.newbornwhocc.org/pdf/fluid_electrolytes_bablance.pdf [Cited on May 19, 2008]

Ambalavanan, N. (2007). Fluid, Electrolyte, and Nutrition Management of the Newborn. emedicine from WebMD. Available at: http://www.emedicine.com/ped/topic2554.htm [Cited on May 19, 2008]

Chawla, D., Ramesh. A., Ashok, D., & Vinod, P. (2008). Fluid and electrolyte management in term and preterm neonates. The Indian Journal of Pediatrics, 75 (3), pp.255-259.

Pediatric Nutrition Work Group (2001). Nutrition Practice Care Guidelines for Preterm Infants. Child Development and Rehabilitation Center. Available at: http://cdrc.ohsu.edu/nutrition-services/articles/files/5/premie_guidelines_for_WIC.htm [Cited on May 19, 2008]

Siberry, G.K., & Iannone, R. (2000). The Harriet Lane Hand Book. Harcourt Private Limited: Missouri, pp.425

 

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