Abstract
Fluid overload (FO) in neonates is understudied, and its management requires nuanced care and an understanding of the complexity of neonatal fluid dynamics. Recent studies suggest neonates are susceptible to developing FO, and neonatal fluid balance is impacted by multiple factors including functional renal immaturity in the newborn period, physiologic postnatal diuresis and weight loss, and pathologies that require fluid administration. FO also has a deleterious impact on other organ systems, particularly the lung, and appears to impact survival. However, assessing fluid balance in the postnatal period can be challenging, particularly in extremely low birth weight infants (ELBWs), given the confounding role of maternal serum creatinine (Scr), physiologic weight changes, insensible losses that can be difficult to quantify, and difficulty in obtaining accurate intake and output measurements given mixed diaper output. Although significant FO may be an indication for kidney replacement therapy (KRT) in older children and adults, KRT may not be technically feasible in the smallest infants and much remains to be learned about optimal KRT utilization in neonates. This article, though not a meta-analysis or systematic review, presents a comprehensive review of the current evidence describing the effects of FO on outcomes in neonates and highlights areas where additional research is needed.
Highlights
In adults and pediatric patients, Fluid overload (FO) is associated with adverse outcomes including respiratory failure, cardiovascular events, prolonged hospitalization, and mortality [1,2,3,4]
Their meta-analysis demonstrated an increased risk of mortality in patients who received peritoneal dialysis (PD) post-operatively compared with those who were supported with diuretics, but a larger proportion of infants in this group came from centers that implemented PD following failed diuretic response and may represent a group at higher risk for poor outcomes
In a secondary analysis of the AWAKEN cohort [42], Selewski et al demonstrated multiple measurements of positive fluid balance as risk factors for the need for mechanical ventilation at the end of the first week of life [30, 31]; every 1% increase in peak fluid balance led to a 12–14% increased risk of requiring mechanical ventilation on postnatal day 7, suggesting even incremental fluid changes can adversely affect lung function
Summary
In adults and pediatric patients, FO is associated with adverse outcomes including respiratory failure, cardiovascular events, prolonged hospitalization, and mortality [1,2,3,4]. A recent systematic review and meta-analysis by Flores et al highlighted the challenges associated with using available data to guide clinical decision making around the use of PD [43] Their meta-analysis demonstrated an increased risk of mortality in patients who received PD post-operatively compared with those who were supported with diuretics, but a larger proportion of infants in this group came from centers that implemented PD following failed diuretic response and may represent a group at higher risk for poor outcomes. Multiple studies have found increased risk of BPD in infants who received higher total fluid intakes and less postnatal weight loss through the first 10 days of life [9, 10, 27, 28]. In a secondary analysis of the AWAKEN cohort [42], Selewski et al demonstrated multiple measurements of positive fluid balance as risk factors for the need for mechanical ventilation at the end of the first week of life [30, 31]; every 1% increase in peak fluid balance led to a 12–14% increased risk of requiring mechanical ventilation on postnatal day 7, suggesting even incremental fluid changes can adversely affect lung function
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