Fluid and Parenteral Nutrition Practices in Extreme Preterm Neonates in India

Neonatal care requires meticulous management of fluids, electrolytes, and nutrition, particularly for extremely preterm neonates who are most vulnerable. Guidelines vary widely, such as the Australian Consensus Guidelines suggesting an initial fluid rate of 60 mL/kg/day, with adjustments of 20-30 mL/kg/day. Meta-analyses indicate the benefits of restricted fluids in reducing certain complications, but the direct application is challenging due to clinical variability. Titration of fluids is often based on clinical parameters. High amino acid intake has shown benefits in growth and reducing retinopathy of prematurity. Lipids play a protective role, yet not all initiate them on day one. 

Inadequate calcium and phosphorus supplementation can lead to metabolic bone disease; however, many practitioners do not routinely add phosphorus to parenteral nutrition. Micronutrient supplementation practices also vary, with some guidelines recommending them from day one, while others suggest after two weeks of parenteral nutrition. 

A recent survey conducted online aimed to ascertain the fluid and parenteral nutrition practices in extremely preterm neonates across India. 

This web-based survey received input from 123 neonatology practitioners throughout the subcontinent. Among neonatologists caring for neonates weighing 750-1000 g, 67% favored an initial fluid rate of 80 mL/kg/day. Half of them adjusted fluid rates if weight loss exceeded 2% per day. Nevertheless, the practice approaches differed significantly across various contexts.

The findings highlight the necessity for guidelines tailored to specific clinical circumstances. Traditionally, a weight loss of 10-15% is deemed acceptable in preterm neonates. Some authors consider a postnatal weight loss of less than 6% indicative of inadequate diuresis. The results supported these estimates – with 63% indicating that a weight loss of 11-15% is ideal. Preferences for daily weight loss varied, with 45% favoring 1-2% and 43% opting for 2-3%.

The wide range of practices observed underscores significant variability. Consensus was not achieved on any question, emphasizing the urgency of developing comprehensive practice guidelines applicable across diverse settings. This is particularly crucial given the critical role of parenteral nutrition in this vulnerable population. In the surveyed practitioners, almost half reported not routinely adding micronutrients to total parenteral nutrition––with some opting to do so only for prolonged parenteral nutrition needs.

Source: Chinnappan A, Sahoo T, Mohanty P, Som T, Devi U. Indian Pediatrics. 2024 Feb;61(2):171-4.