1.

Kebutuhan cairan pada neonatus

1. Fluid and Electrolyte Management

in the Newborn
Edward F. Bell, MD and Michael J. Acarregui, MD
Peer Review Status: Internally Peer Reviewed

Careful fluid and electrolyte management is essential for the well being of the sick
neonate. Inadequate administration of fluids can result in hypovolemia,
hypersomolarity, metabolic abnormalities and renal failure. In the near term and term
neonate excess fluid administration results in generalized edema and abnormalities
of pulmonary function. Excess fluid administration in the very low birth weight infant
is associated with patent ductus arteriosis and congestive heart failure,
intraventricular hemorrhage, necrotizing enterocolitis and bronchopulmonary
dysplasia. A rational approach to the management of fluid and electrolyte therapy in
term and preterm neonates requires the understanding of several physiologic
principles.

Physiology
1. Body Composition and Surface Area
a. The body composition of the fetus changes during gestation with a smaller
proportion of body weight composed of water as gestation progresses.
b. The preterm fetus or neonate is in a state of relative total body water and
extracellular fluid excess. After birth this excess water must be mobilized and
excreted.
c. A proportion of the diuresis observed in both term and preterm infants during the first
days of life should be regarded as physiologic.
d. 4. The surface area of the newborn is relatively large and increases with decreasing
size. Therefore, insensible water losses will be greatest with small size and
decreased gestational age.

2. Hormonal Effects:
a. The Renin-angiotensin system is very active in the first week of neonatal life
resulting in increased vascular tone and elevated levels of aldosterone
b. Increased aldosterone levels enhance distal tubular reabsorption of sodium resulting
in an impaired ability to excrete a large, or acute, sodium load.
c. Arginine vasopressin (AVP, ADH) levels rise after birth. AVP secretion is increased
in response to stress, such as birth, asphyxia, RDS, positive pressure ventilation,
pneumothorax and intracranial hemorrhage.

3. Renal Hemodynamics: After birth, renal blood flow increases in response to

increased blood pressure (renin-angiotensin) with a secondary increase in
glomerular filtration rate. However, the neonatal kidney is less efficient at excreting
an acute sodium or water load than the kidney of an infant or child.
4. Sodium Homeostasis:
a. Sodium is required for fetal growth with an accretion rate of 1.2 mEq/kg/day between
31-38 weeks.
b. Sodium retention is aided by increased aldosterone levels in newborns.
c. In preterm infants <34 weeks sodium reabsorption is decreased, the fractional
excretion of Na may exceed 5%. However, the preterm infant is unable to rapidly
increase sodium excretion in response to high sodium levels or a large sodium load.

5. Water Handling: Both term and preterm infants are able to excrete dilute urine.
Conversely, preterm infants are able to concentrate urine to ~ 600 mOsm/L and the
term infant to ~ 700 mOsm/L. (Adults can concentrate to ~ 1300 mOsm/L.)
Therefore, both preterm and term neonates generally have the capacity to regulate
their intravascular volume within a range of fluid intakes.

Based on the above principles

1. One should expect a 10-15% weight loss over the first 5-7 days of life (up to 20% in
infants <750 g).
2. Infants which experience significant intrapartum stress will be slow to void and will
therefore require less fluid over the first 24-48 hours.
3. The small or extremely immature infant <1000 g will experience increased insensible
water losses (IWL). IWL = (I-O) - (± Δwt).
4. As the preterm and term infant is able to regulate urine output in response to
hypovolemia, urine output will reflect intravascular volume. In other words, the infant
 will generally not maintain inappropriately high urine output in the face of
intravascular volume depletion.

Recommendations
1. Initiate fluid therapy at 60-80 ml/kg/d with D10W, (80-150 ml/kg/d for infants ≤ 26
weeks).
2. Infants <1500 g should be covered with a saran blanket and strict I&O should be
followed. For infants < 26 weeks the saran blanket should be applied directly upon
the infant to minimize IWL.
3. Infants <1000 g should have electrolytes and weights recorded every 6-8 hours;
every 12 hours for infants 1000-1500 grams.
4. For serum Na+ >145 mEq/L, increase infusate by ~10 mL/kg/d without Na+ in the
infusate.
5. Increase fluids for urine output <0.5 mL/kg/hr by ~10 mL/kg or, in infant ≤ 26 weeks,
calculate IWL and change fluids accordingly.
6. Infuse Na+ free fluids (including flushes) until serum Na+ <145 and good urine
output is established (post diuretic phase). Then add 3-5 meq/kg/d Na+.
7. Add KCl (2-3 meq/kg/d) to IV fluids after urine output is well established and K+ <5
mEq/L (usually 48-72 hours).
8. Increase fluid administration gradually over the first week of life to 120-130 cc/kg/d
by day 7, allowing for expected physiologic weight loss.

Special Cases
While the above guidelines are more directed toward the LBW infant, especially
<1000 g, they are generally applicable to most neonates; however, there are
instances where these guidelines should be modified. Some of the more common
modifications are noted below:

1. Postoperative abdominal surgery: Fluid requirements may be twice or three times

that noted above. The more extensive the procedure the greater the needs! These
infants may require 125-150 ml/kg/day immediately postoperative with subsequent
increases as determined by blood pressure measurements and urine output. Isotonic
saline also may be required because of third spacing of fluid into tissues and other
spaces, e.g., the bowel lumen. Strict I&O is mandated. Gastric drainage is replaced
q8-12h, depending on volume, with isotonic saline. Colloid also may be needed
because of rapid fluid shifts, decreases in arterial pressure, and increases in
capillary filling time (i.e., > 3 sec.).
2. Asphyxiated infants: These infants may have increased secretion of arginine
vasopressin (which is likened to SIADH) and are thought to be at increased risk for
cerebral edema. Their fluid intake should be kept on the low side for 48-72 h, i.e., ≤
60 ml/kg/day, or until seizures are no longer considered a problem. These infants
require close monitoring of serum sodium and weight. Treatment of SIADH is by
restriction of fluids, not increased sodium intake.
3. Infants of diabetic mothers: These infants receive i.v. glucose because of
increased danger of hypoglycemia; however, they frequently do not receive sodium
and have been found to develop rather substantial hyponatremia at 24 h if this is not
added at or before this time. This danger is greater the greater rate of glucose
needed to maintain blood glucose. Addition of sodium should be considered at 16-18
h.

2. Fluid Therapy in the Neonate

Edward F. Bell, MD and Michael J. Acarregui, MD
Peer Review Status: Internally Peer Reviewed

Fluid therapy for the neonate can be rationally planned if several physiologic
jkconcepts are kept in mind. Firstly, the neonate has an excess of total body water at
birth, particularly extracellular water, which must be redistributed and excreted. The
renin-angiotensin system is in high gear during the first week after birth; thus not only
is plasma angiotensin II likely to be elevated, but also aldosterone, which is a
mineralocorticoid and has the potential to modulate sodium excretion/reabsorption.
The surface of the newborn is large and increases with decreasing size; therefore
there is a greater likelihood of excess insensible water loss (IWL), which may be
exaggerated as birth weight and gestational age decrease and open radiant warmers
rather than incubators are used. Finally, in most instances the neonatal kidney has
the capacity to not only dilute urine, but also to concentrate it, reaching values of
600-700 m0sm/L (specific gravity ≤ 1.015). It should be noted, however, that this is
less than that seen in adults or term infants. These observations are contrary to
previous "beliefs," and each of these aspects of the neonate are reviewed elsewhere
(J Pediatr 101:387, 1982).

Our goal in the low-birth-weight (LBW) infant ≤1599 g is to allow a gradual weight
loss over the first week, i.e., 5-6% over the first 24 h and 12-15% by the end of the
first week. We also attempt to maintain urine output ≥ 0.5 ml/kg hr. If IWL plus urine
output significantly exceeds intake, weight loss may be greater than desired and
occur more rapidly in the preterm LBW infant. This in turn may result in development
of hypernatremia since fluid losses through the skin are essentially free water. To
take each of these into account, the first approach to fluid therapy is adequate
monitoring and appropriate supportive care. Thus, all infants ≤1000 g birth weigh
should be maintained on a bed scale, kept on "strict" input and output
measurements, and covered with a "saran blanket" to minimize IWL, especially if
cared for in an open radiant warmer.

It is estimated that the nongrowing neonate requires 60-75 kcal/kg/day and that fluid
losses are closely related to caloric expenditure. Thus, in the first 1-3 days after birth
fluid requirements are likely to be in the range of 65-75 ml/kg/day in a neutral thermal
environment. To accomplish this we use 10% dextrose in water (D10W). Therefore,
at 24 h the fluid should be changed to D10 with 1/4 isotonic saline. The addition of
KCl to the infusate should be considered by day 3 if there are no contraindications,
e.g., poor renal function or hemolytic disease, at 2-3 mEq/kg/day. Although negative
potassium balance occurs with this approach it is quickly corrected.

Our approach to fluid therapy has been to gradually increase the volume to
approximately 75-80 ml/kg/day on day 2, 90-95 ml/kg/day on day 3, and -125
ml/kg/day by day 7. At 14 days most infants are receiving about 135 ml/kg/day.

2. Dosis Ampicillin dan Gentamicin

Ampicillin dose

Neonates (<28 Days)

<7 days
 <2 kg: 50-100 mg/kg/day IV/IM divided q12hr
 >2 kg: 75-150 mg/kg/day IV/IM divided q8hr
>7 days
 <1.2 kg: 50-100 mg/kg/day IV/IM divided q12hr
 1.2-2 kg: 75-150 mg/kg/day IV/IM divided q8hr
 >2 kg: 100-200 mg/kg/day IV/IM divided q6hr

Source : https://reference.medscape.com/drug/ampi-omnipen-ampicillin-
342475

Gentamicin dose :
<30 weeks' gestation
 0-28 days: 2.5 mg/kg/day IV/IM
 >28 days: 3 mg/kg/day IV/IM
30-36 weeks' gestation
  0-14 days: 3 mg/kg/day IV/IM
 >14 days: 5 mg/kg/day IV/IM divided q12hr
>36 weeks' gestation
 0-7 days: 5 mg/kg/day IV/IM divided q12hr
 >7 days: 7.5 mg/kg/day IV/IM divided q8hr
injectable solution
 10mg/mL
 40mg/mL

Source : https://reference.medscape.com/drug/gentak-garamycin-
gentamicin-342517

3. Komplikasi fototerapi !

Zhongguo Dang Dai Er Ke Za Zhi. 2012 May;14(5):396-400.

[Side effects of phototherapy for neonatal

hyperbilirubinemia].
[Article in Chinese]

Xiong T1, Tang J, Mu DZ.

Author information
Abstract
Blue light has been widely used for the treatment of neonatal hyperbilirubinemia since the 1950s.
Neonatal phototherapy can decrease plasma unconjugated bilirubin level, thus preventing
bilirubin encephalopathy, and greatly reduces the exchange transfusion rate. Generally, it is
accepted that the side effects of neonatal phototherapy are not serious and seem to be well
controlled, however recent research has provided new evidence. The short-term side effects of
phototherapy include interference with maternal-infant interaction, imbalance of thermal
environment and water loss, electrolyte disturbance, bronze baby syndrome and circadian
rhythm disorder. In addition, phototherapy may be associated with some long-term side
effects such as melanocytic nevi and skin cancer, allergic diseases, patent ductus
arteriosus and retinal damage. Therefore, it is necessary to develop evidence-based
guidelines, new light devices and alternative agents, as well as individualized treatments,
to minimize the side effects of phototherapy.