elbw,initial management of nutrition, fluid balance

[adelagat]

Hi, i have a 540g baby who i managed with ivf on day 1, then tpn(1 g each of pro and intralipid) and trophic feeds of expressed breast milk starting day2.baby lost 24% of birth wt in the succeeding days.I ended up giving the baby 350 ml/k/d to keep up with the diuresis that ensued. One of my neonatology friends says that in their unit , they are much more aggressive and their babies are managed with 2 g of pro and 1 g of intralipid from day1, then increasing to max 3g/k/d of pro and fat in the next 3 days, and they use only 180ml/k/day of tfr.

I am wondering if this practice is widespread.

BTW, the baby is doing well and is now almost on full feeds(day 14).

[Guest mbayari]

Our policy is intorducing pro as soon as babies are stable (respiratory, heamodynamics, have passes stool...) and increasing regularly and rapidly to reach 3g/kg/d almost at the end of the first week of life; we got the habit to introduce intralip at 3-4th day of life begining at 1g/kg/d and increasing till a maximum of 3g/kg/d. we never reach such a fluid hydration and almost we reach 180-200ml/kg/d; we have to keep in mind the risk of a PDA that may aggravate quickly with such volumes and I believe that "compensating" a great diuresis most be donne carefully (provocative diuresis?).

what's about the type of incubator do you use? what's the level of humidity? are respiratory circuits humidified? do you use "surviving plexi"?...

good luck

[JAMA]

Dear,

I never reach this amount of fluid. Do you start humidification and why the baby require this high TFI, is he lossing too much in urine or though his\her skin?

Regards

[Susmozas]

Hi,

we also star with 2 g of pro and 1g of intralipid, but i would like to ask the same question, how can you give this amount of fluid to a preterm? Where are the losses?

[JAMA]

also was he IUGR baby or AGA?

[Bernhard Bungert]

Hi

The only time when we have needed such a amount of fluid the baby has had antenatale Bartter-Syndrom with Polyhydramnion and iu hydronephrosis on both sides. How`s the Na-Exkretion? I cant believe the reason of this problem depends to the amount of Protein or lipids in TPN. If there is to much loss of fluid over skin try to use plastic bag.

[ammar]

Hi,

You should initially identify why your patient had lost 24% of his BW. So you must recognise condition of pregnancy (hydramnios +++), humidification (%), fluid regimen at day one (ml/kg/day, peripheric or central KT, Na+, K+), glycemia, natremia and Urinary Na+, K+ (blood and urinary), HCO3- and urea/creatinemia, diuerse (ml/kg/day). the only one patient that was managed with 270 ml/kg/day at day 3 had a Bartter syndrome. i think there is no relation between this and TPN with L and P.

In our unit, we begin at 2 gr/kg/day of P rised to 3 and 3.5 at day 3. we introduce slowly L at Day 2 at 1 g/kg rised to 3 g/kg at day 5.