Fluid Restricting Babies

A study published online first in the Journal of Pediatrics questions a common practice, the practice of fluid restricting babies who have a patent ductus arteriosus.

De Buyst J, Rakza T, Pennaforte T, Johansson AB, Storme L: Hemodynamic Effects of Fluid Restriction in Preterm Infants with Significant Patent Ductus Arteriosus. J Pediatr 2012(0).

Julie De Buyst studied 18 very preterm babies before and 24 hours after a major reduction in their fluid intakes, from between 140 and 160 mL/kg/d to between 100 and 120 mL/kg/d.

Although this practice is frequent it is something I have never really been able to understand. We know that renal physiology in preterm babies is limited in many ways, but after the first couple of days, during which GFR is rapidly increasing, there is little limitation in the ability to excrete a water load. So giving more fluids has no real effect on total body water, it just increases urine output. Although the ability to concentrate the urine is more limited, with maximal concentrations far less than those seen in older children, administration of fluids within the range down to 100 mL/kg/d generally leads to no change in total body water, it just decreases urine output, leading to a more concentrated urine. How this is supposed to affect PDA patency or the hemodynamic effects of a PDA I do not understand. If we restrict a baby from 160 to 100 mL/kg/d then every hour they receive 2.5 mL/kg less fluid, and make 2.5 mL/kg less urine. Unless they are severely enough restricted to go beyond the renal concentrating ability, and become truly dehydrated, there will be no effect on circulating blood volume. The same arguments can be made for fluid restriction in BPD, and the lack of any likely effect on pulmonary function, more of which later.

So not surprisingly Julie De Buyst and her collaborators found no effect of fluid restriction on any of the ductal measurements, they did show a decrease in SVC flow, which I have difficulty understanding, it certainly is not likely to be a beneficial change; but there were several comparisons made, so perhaps it is a type 1 error.

To go back to the history of why people started fluid restricting babies with a PDA we probably need to return to studies done in the mid to late 1970’s.

There are a few small or modestly sized studies examining how much fluid we should give to preterm infants in the first few days of life. On first look there seems to be some evidence that giving less fluid might reduce the occurrence of a PDA (which is not the same thing as helping to manage it once it has occurred!) If the studies are examined carefully, however, the administration of sodium was also different between groups in several of the studies. Also the diagnosis of a PDA was often made clinically in some of the earlier studies, which we now know is very inaccurate.

Sodium administration, and sodium restriction have more effect on total body water than how much water is given, because babies have more limitations in their ability to excrete (or retain) sodium than water. In fact this is true throughout life, so adults with congestive heart failure are not told to restrict their water intake, but may be counselled to restrict their sodium intake. So, for example, the study of Tammela (Tammela OK, Koivisto ME. Fluid restriction for preventing bronchopulmonary dysplasia? Reduced fluid intake during the first weeks of life improves the outcome of low-birth-weight infants. Acta Paediatr. 1992;81(3):207-12. Epub 1992/03/01.) was a study of fluid restriction in 100 low birth weight babies (<1750g), but there was a standard concentration of sodium in the fluids (3 mmol/100mL for the fluid restricted group and for most of the high fluid group, but 4 mmol/kg for the infants in the high fluid group who were <1000g), so when fluids were restricted so was sodium. They showed more BPD and death in the high fluid/high sodium group, and more PDA 9/50 compared to 5/50.

In the study of fluid restriction by Jack Lorenz and others (Lorenz JM, Kleinman LI, Kotagal UR, Reller MD: Water balance in very low-birth-weight infants: Relationship to water and sodium intake and effect on outcome. J Pediatr 1982, 101(3):423-432http://www.sciencedirect.com/science/article/pii/S0022347682800784) babies were given no sodium on day one, but then the high fluid group also received more sodium than the low fluid group. In this study 88 babies 750 to 1500 grams were enrolled; the high fluid/high sodium group had slightly more PDA, and slightly more BPD.

On the other hand Vasiliki Kavvadia (Kavvadia V, Greenough A, Dimitriou G, Hooper R: Randomised trial of fluid restriction in ventilated very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2000, 83(2):F91-96.) randomized 168 VLBW infants to high or low fluid regimes, and gave no sodium to either group in the first 24 hours, and individualized the sodium intakes thereafter. They showed no difference in mortality or BPD. On the other hand the group that got more free water made more urine; see physiology works!

The study by Ed Bell (Bell EF, Warburton D, Stonestreet BS, Oh W: Effect of fluid administration on the development of symptomatic patent ductus arteriosus and congestive heart failure in premature infants. N Engl J Med 1980, 302(11):598-604.) randomized 170 babies between 750 and 2000 g birth weight to high and low fluid intakes starting at 72 hours of age. The paper doesn’t clearly describe how the sodium was managed. This is the only one that really showed a difference in PDA, but it seems that many of the diagnoses were clinical, which we know is not very sensitive, nor specific.

The other side of the evidence are the studies comparing different sodium intakes without changing fluid intakes. There are 2 (Costarino AT, Jr., Gruskay JA, Corcoran L, Polin RA, Baumgart S: Sodium restriction versus daily maintenance replacement in very low birth weight premature neonates: a randomized, blind therapeutic trial. J Pediatr 1992, 120(1):99-106http://www.sciencedirect.com/science/article/pii/S0022347605806110 and Hartnoll G, Betremieux P, Modi N: Randomised controlled trial of postnatal sodium supplementation on oxygen dependency and body weight in 25-30 week gestational age infants. Arch Dis Child Fetal Neonatal Ed 2000, 82(1):F19.)

Both of these show adverse effects of giving more sodium earlier in life. The earlier sodium supplementation groups had more BPD in both studies, and more PDA, but not statistically significant. The Costarino study was tiny (17 babies) and the Hartnoll study was small (44 babies), nevertheless the differences in resolution of lung disease were significant. The high sodium babies lost less weight, even though fluid intakes were the same.

To get back to my point, it seems, from my evaluation of the evidence, that restricting sodium intake in the first few days of life leads to greater weight loss, a lower incidence of PDA and less BPD; but restricting fluids without changing sodium administration does nothing to PDA, or indeed to any other outcome.

The implications of this are as follows, during the first 3 days of life, babies need little or no exogenous sodium. They should be managed with as little sodium as possible, but the total volume of fluids is relatively unimportant, especially after ths first 24 hours during which renal blood flow, urine output, and glomerular filtration increase rapidly.

When a PDA becomes evident, several days later, there is no evidence whatsoever to support fluid restriction. This is a practice without physiologic rationale, without clinical studies to support it, and is potentially harmful. Effective renal solute load is increased by decreasing free water. If macro and micro nutrients are also restricted then the risks of undernutrition, undermineralization etc. are serious. In Ed Bell’s article from 1980, the calorie administration in the restricted group were substantially less than the non-restricted group (and both were far below what we would consider acceptable today). So babies with a PDA should NOT be fluid restricted.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Neonatal Research and tagged , , , , , . Bookmark the permalink.

5 Responses to Fluid Restricting Babies

  1. MOBianchi says:

    What do you suggest to do with the arterial lines where we keep little amount of sodium (meaning large for tiny premies) for the first days of life? Any experience with D5 solution?

    • That is a good question, in order to minimize hemolysis you need something that is isotonic. the hemolysis is an issue when you aspirate the perfusate and blood into a syringe, and then re-infuse it. One group has studied using an isotonic amino acid solution instead of saline or dextrose. That has the advantage that you can still measure glucose from the catheter, the baby gets a bit more protein, and there is very little sodium load.
      We did that when I was at the Royal Victoria Hospital in Montreal and it worked quite well. You need to have pharmacy services that will co-operate. The group that looked at in vitro hemolysis also published a small trial showing that it was well tolerated and that the blood levels of free hemoglobin were lower than when using half normal saline.
      Jackson JK, Biondo DJ, Jones JM, Moor PJ, Simon SD, Hall RT, Kilbride HW: Can an alternative umbilical arterial catheter solution and flush regimen decrease iatrogenic hemolysis while enhancing nutrition? A double-blind, randomized, clinical trial comparing an isotonic amino acid with a hypotonic salt infusion. Pediatrics 2004, 114(2):377-383.

      In general I think D5 would be an OK choice, it is slightly hypotonic, and makes it impossible to be sure about the blood sugar from an arterial specimen, but I can’t think of any other problem with using D5, many of the small premies who get arterial lines are the ones who tend to become hyperglycemic, so you might need to take that in consideration.

  2. juan carlos vidal says:

    Hi, I’m Juan Carlos Vidal, head of the neonatology service at the Ana Goitia Hospital in Avellaneda Buenos Aires, Argentina. I am writing to tell you that we have finished editing the clinical guidelines of the service, and that much of what we read in your blog was a source of inspiration to do so, I am very much in agreement with your way of thinking, so it would be an honor give us some small words to include in our clinical guidelines we would like a reflection on the custom of water restriction and sodium control in the first days of life to avoid dap and bpd.
    Thank you very much, I hope not to be too bold with our request. you at a distance encourages us to be critical of the bibliography.

    • Thank you very much for the kind words. I have visited Buenos Aires 3 times now, and always found the Argentinian people delightful! One day I hope to see more of your beautiful country.
      Your question about sodium and water restriction is quite relevant, I am currently revising a number of articles and a blog post will probably appear very soon! I think there is good evidence to limit sodium intake in the first days of life, and that may reduce BPD, NEC and mortality, but I am not sure there is an effect on PDA. The volume of water given to the extremely preterm infant in the first few days is not very evidence based, and varies hugely depending on whether you can keep the baby in a high humidity environment, whether you use skin waterproofing agents (Aquaphor), and how much sodium you give. We have a relatively low incidence of major hypernatremia in our extremely preterm babies in my unit, but I think we often over-react to weight loss during that period. Preterm kidneys, after the first 24 hours or so, are pretty good at eliminating a water load, and not bad at reacting to reduced fluid intake, so I think the first 24 to 28 hours are the most important for avoiding excessive water intake, and avoiding dehydration.

  3. juan carlos vidal says:

    Good morning, Dr. Barignton, who is surprised to find your answer so soon.
    I tell him doctor that my intensions in the order were to conclude the chapter of hydroelectrolytic balance with a small reflection on sodium and liquid restiction with a nice dedication.
    I appreciate the explanation that gave us, and it is interesting to know more about the use and safety of aquaphor

    I do not want to abuse your time some lines reach me, and if added to this could give us the prologue would be the brooch for our standards, no more than a single issue topic on bioethics or probiotics what you decide.

    Greetings, I adapt to your time and will,
    Juan Carlos Vidal and all the maternity service.

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