Fluid and Electrolyte Management in Extremely Low Gestational Age Neonates

Managing fluid and electrolyte balance in extremely low gestational age neonates (ELGANs) is often difficult due to their unique fluid physiology. In the first week of life, most fluid loss occurs through the skin, which has an immature barrier. ELGANs tend to experience significant diuresis and natriuresis. Allowing an initial weight loss of 6-12% helps facilitate normal extracellular contraction. Additionally, limiting fluid intake during the first week can reduce the risk of conditions such as bronchopulmonary dysplasia, patent ductus arteriosus, and necrotizing enterocolitis. 

A protocol-driven approach to fluid management, based on physiological principles and existing evidence, is recommended. For neonates at 26-27 weeks gestation, total fluids should start at 100 mL/kg/day, while those at 24-25 weeks should begin at 110 mL/kg/day. Fluid rates should be adjusted according to careful monitoring of weight, urine output, and serum sodium levels, with daily increases of 10-20 mL/kg, and maximum rates of 150-160 mL/kg/day for 26-27 week gestation neonates and 160-180 mL/kg/day for 24-25 week gestation by day 7. Fluid management should ideally be reassessed every 12 hours in the early days. Utilizing a humidified incubator can help minimize fluid loss through the skin. Since many of these guidelines lack strong evidence from clinical trials, it is important to regularly review outcomes and develop a tailored fluid management strategy for each unit.

Source: Prakash S, Kainth D, Verma A. et al. Fluid Management in ELGANs: Striking the Perfect Balance!. Indian J Pediatr (2025). https://doi.org/10.1007/s12098-025-05439-4