Fluid and electrolytes At 12 weeks of gestation, the fetus has a total body water content that is 94% of body

weight. This amount decreases to 80% by 32 weeks gestation and 78% by term. A further 3% to 5% reduction in total body water content occurs in the first 3 to 5 days of life. Body water continues to decline and reaches adult levels (approximately 60% of body weight) by 1 years of age. Extracellular water also declines by 1 to 3 years of age. These water composition changes progress in an orderly fashion in utero. Premature delivery requires the newborn to complete both fetal and term water unloading tasks. Surprisingly, the premature infant can complete fetal water unloading by 1 week after birth. Postnatal reduction in extracellular fluid volume has such a high physiologic priority that it occurs even in the presence of relatively large variations of fluid intake. Glomerular Filtration Rate The glomerular filtration rate (GFR) of newborns is slower than that of adults. From 21 mL/min/1,73 m2 at birth in the term infant, GFR quickly increases to 60 mL/min/1,73 m2 by 2 weeks of age. A preterm infant has a GFR that is only slightly slower than that of a full term infant. In addition to this difference in GFR, the concentrating capacity of the preterm and the full-term infant is well below that of the adult. An infant responding to water deprivation increases urine osmolarity to a maximum of only 600 mOsm/kg. This is in contrast to the adult, whose urine concentration can reach 1200 mOsm/kg. It appears that the difference in concentrating capacity is due to the insensitivity of the collecting tubules of the newborn to antidiuretic hormone. Although the newborn cannot concentrate urine as efficiently as the adult, the newborn can excrete very dilute urine at 30 to 50 mOsm/kg. Newborns are unable to excrete excess sodium, an inability thought to be due to a tubular defect. Term infants are able to conserve sodium, but premature infants are considered salt wasters because they have an inappropriate urinary sodium excretion, even with restricted sodium intake. Insensible Water Loss Insensible water loss from the lungs can be essentially eliminated by humidification of inspired air. Transepithelial water loss occurs by the diffusion of water molecules through the stratum corneum of the skin.Owing to the immature skin, preterm infants of 25 to 27 weeks gestation can lose more than 120 mL/kg/day of water by this mechanism. Transepithelial water loss decreases as age increases. Neonatal Fluid Requirements To estimate fluid requirements in the newborn requires an understanding of (1) preexisting fluid deficit on excess, (2) metabolic demands, and (3) losses. Because these factors change quickly in the critically ill newborn, frequent adjustments in fluid management are necessary. Hourly monitoring of intake and output allows early recognition of fluid balance that will affect treatment decisions. This dynamic approach requires two components, and initial hourly fluid intake that is safe and a monitoring system to detect the patients response to the treatment program selected. A table of initial volumes expressed in rates of milliliters per kilogram per 24 hours for various surgical conditions has been developed as a result of a study of a large group of infants followed during their first 3 postoperative days. The patients

were divided into three groups by condition: (1) moderate surgical conditions, such as colostomies, laparotomies, and intestinal atresia; (2) severe surgical conditions, such as midgut volvulus or gastroschisis; and (3) necrotizing enterocolitis with perforation of the bowel or bowel necrosis requiring exploration. No normal urine output exists for a given neonate. Ideal urine output can be estimated by measuring the osmoral load presented to the kidney for excretion and calculating the amount of urine necessary to clean this load, if the urine is maintained at an isotonic level of 280 mOsm/Dl After administering the initial hourly volume for 4 to 8 hours, depending on the newborns condition, he or she is reassessed by observing urine output and concentration. With these two factors, it is possible to determine the state of hydration of most newborns and their responses to the initial volume. In more difficult cases, changes in serial serum sodium (Na), blood urea nitrogen (BUN), creatinine, and osmolarity along with urine Na, creatinine, and osmolarity make it possible to assess the infants response to the initial volume and to use fluid status to guide the next 4 to 8 hours fluid intake. Illustrative Examples Insufficient fluid A 1 kg premature infant, during the first 8 hours post-operatively, has 0,3 mL/kg/hr of urine output. Specific gravity is 1,025. Previous initial volume was 5 mL/kg/hr. Serum BUN has increased from 4 mg/dl; hematocrit value has increased from 35% to 37%, without transfusion. This child is dry. The treatment is to increase the hourly volume to 7 mL/kg/hr for the next 4 hours and to monitor the subsequent urine output and concentration to reassess fluid status. Inappropriate antidiuretic hormone response A 3 kg newborn with congenital diaphragmatic hernia during the first 8 hours postoperatively has a urine output of 0,2 mL/kg/hr, with a urine osmolarity of 360 mOsm/L. The previous initial volume was 120 mL/kg/day (15 mL/hr). The serum osmolarity value has decreased from 300 mOsm preoperatively to 278 mOsm/L; and BUN has decreased from 12 to 8 mg/dL. The inappropriate antidiuretic hormone response requires reduction in fluid volume from 120 to 90 mL/kg/day for the next 4 to 8 hours. Repeat urine and serum measurements will guide the further adjustment of fluid administration. Overhydration A 3 kg newborn, 24 hours after operative closure of gastroschisis, had an average urine output of 3 mL/kg/hr over the previous 4 hours. During that time period, the infant received fluids at a rate of 180 mL/kg/day. The specific gravity of the urine has decreased to 1,006; serum BUN is 4 mg/dL; hematocrit value is 30%, down from 35% preoperatively. The total serum protein concentration is 4,0 mg/Dl, down from 4,5 mg/dL. This child is being overhydrated. The treatment is to decrease the fluid to 3 mL/kg/hr for the next 4 hours and then to reassess urine output and concentration.