Fluid and Nutrition Management in Children

Fluid Management in Children

Insensible loss of fluid, This is a physiological loss. This loss is more in children as compared to adults because of the more surface area of skin. This is also because infants have an immature skin barrier. If a premature infant weighs <1500gm, the insensible fluid loss can be around 45 to 60 ml per Kg/day. In term infants, the insensible fluid loss can be around 30 to 35 ml per Kg/day.

If a child is placed in the radiant heater or is given phototherapy for hyperbilirubinemia or if the child has respiratory distress, there will be an additional fluid loss. In the first 3 to 5 days of life, there is physiological water loss and it will be equivalent to 10% of the infant's weight.

Maintenance Fluid

Calculation of maintenance fluid

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Urine Output and Osmolarity 

• Urine output and osmolarity help to understand tissue perfusion.
  • Normal urine output
  • Adults: 0.5 to 1 ml/kg/hr
• Children: 1 to 2 ml/Kg/hr
• The maximum urine concentration in infants is 700 mOsm.
• Normal daily sodium and potassium requirements in children
  • Na+: 2 to 4 mEq/Kg
  • K+: 1 to 2 mEq/Kg
• If a child has a predominant gastric loss of fluid
  • The fluid that is given should contain 0.45% NaCl + 5% dextrose + 20 mEq/L of potassium
• If a child has diarrhoea or hepatobiliary loss
  • Isotonic Ringer's lactate solution is considered preferred

Nutrition Management in Children

• An infant needs the necessary energy to grow and this is obtained from the right level of nutrition. Energy requirement for growth
  • 50% of energy in term infants younger than 2 weeks
  • 60% of energy in premature infants <1200g
• If the child does not get the necessary nutrients, there will be a failure to thrive. According to the general guidelines, children should be given 120 calories/kg/day to increase their body weight by 1% per day. One ounce of breast milk/std. formula milk has 20 calories.

Carbohydrates

• Carbohydrates are stored in the form of glycogen in the liver and muscles.
• In an infant, the liver and muscle mass is very less.
• Thus, they are more prone to hypoglycaemia.
• They cannot fast and have reserves only for 1 or 2 days.
• Hypoglycaemia in infants can cause seizures and neurological impairment.
• If a child is unable to eat or if child is on TPN (total parenteral nutrition), then glucose should be given as an infusion
  • The minimum rate of glucose infusion is 4 to 6 mg/kg/min; which can be increased by 1 to 2 mg/kg/min daily; the maximum level should be 10 to 12 mg/kg/min.
  • If the glucose levels beyond the maximum limit are given to the infant, it can cause hyperglycemia, which can lead to hyperosmolarity and dehydration.
  • If the glucose level has not exceeded the upper limit but the child has hyperglycemia, the cause could be sepsis.

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Proteins 

• Average protein intake: 15% of total daily calories
  • In infants - 2 to 3.5 gm/kg/day
  • For 18 year old child - 1gm/kg/day
• Infants need more proteins for proper growth.
• If TPN is considered, protein intake should be as follows:
  • Start with 0.5g/kg/day
  • Increase it by rate of 0.5g/kg/day
  • Maximum level: 3.5g/kg/day

Fats 

• Fat is the major source of non-protein calories.
• The most important essential fatty acid is linoleic acids.
• If the child has a deficiency of linoleic acids, the following features may be observed:
  • Dryness of skin
  • Rash
  • Desquamation
• If TPN is given fat intake should be as follows:
  • Start with 0.5g/kg/day
  • Increase it at the rate of 0.5g/kg/day
  • Maximum level: 2.5 to 3.5g/kg/day
• Extra caution should be taken if the child has unconjugated hyperbilirubinemia.
  • Fat is given with caution
  • Because the fat can displace bilirubin from albumin
  • This will increase the level of free bilirubin
  • Free bilirubin crosses the blood-brain barrier, reaches the brain parenchyma and causes kernicterus.
  • It is associated with mental retardation in the later stages.

TPN 

As the energy reserves in infants do not last for more than 2 to 3 days, thus the threshold for starting TPN is always less.The side effect of TPN is cholestasis; this causes an increase in serum bile acid. Which leads to an increase in direct bilirubin. causing elevation of liver enzymes.Thus, when TPN is given, the liver enzymes have to be monitored. TPN-induced Cholestasis can be prevented by using omega- 3-fat emulsion (omegaven).

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