Fluid Management in a NYI (Chapter 12)

Learning Objectives

After completion of this chapter the participant should be able to:


Exclusive breastfeeding is recommended in the majority of cases as it provides the best fluids, nutrition, and protection from disease whilst promoting growth and development. Term infants that are well should be breastfed on demand. If this is not possible e.g., mother or infant is sick, then expressed breast milk should be given. Maintenance fluid is the amount of fluid required to replace losses and is calculated on the age and weight of the infant.

During the first few days of life, feeds are given in small amount and gradually increased.

Calculation of Feeds for NYI (breast milk):

Day of Life How to calculate maintenance fluid requirements (1)
Day 1 60 ml/kg per day
Day 2 90 ml/kg per day
Day 3 120 ml/kg per day
Day 4 150 ml/kg per day
Day 7 and LBW When the infant tolerates oral feeds well,
the amount of fluid may
be increased to 180 ml/kg
per day after some days.

Feeds are given every two or every three hours by naso/oro-gastric tube or cup feeding depending upon the maturity of the baby. Premature infants <34 weeks may not be able to breastfeed and will require tube or cup feeds.

Premature infants should be fed smaller volumes, more frequently as their stomach volume is small, ideally every two hours or occasionally every hour.

See wall charts for the volume of feeds to give NYI depending on their age, maturity, and the planned frequency of their feeding.

Intravenous Fluids

If there is a contraindication to oral feeding (including naso/oro-gastric tube and cup feeing) give IV fluids. Contraindications to oral feeds may be medical or surgical.

Possible reasons for not feeding by mouth or gastric tube:

Medical Surgical
  • Bowel obstruction
  • Necrotizing enterocolitis
  • Abdominal wall defects
    (relative contra-indication)
  • Tracheo-oesophageal fistula

Which fluid?

Maintenance fluid is the amount of fluid required to replace losses and is calculated based on the age and weight of the infant. However, IV fluids can run too fast or deliver too much fluid quickly and overhydrate a NYI and needs close monitoring.

Generally, we do not exceed 100 ml/kg per day when administering maintenance fluids by the IV route to NYI.

See wall charts for the volume of fluids per hour based on the child’s weight and age.

How to calculate the rate of an IV fluid infusion if no syringe pump is available.

How many drops in one ml of fluid?

In Malawi there are 3 different giving sets.

1 ml of fluid = 20 drops (most common)
1 ml of fluid = 15 drops (for giving blood)
1 ml of fluid = 60 drops (paediatric)

The plastic wrapper of the giving set tells you drops per ml in tiny writing in a corner.

Amount of fluid to give multiplied by number of drops/ml in giving set divided by time in minutes to give the fluid

E.g., If we want to give 40ml/hr with a giving set of 20 drops/ml:

(40 × 20)/60 = 40/3 = 13 drops/minute

Monitor the IV infusion very carefully (ideally through an in-line burette or syringe pump):

Monitor the NYI clinical status:

Weight and urine output are the best overall clinical guides to assessing the adequacy of therapy. Introduce milk feeding by oro-gastric tube or breastfeeding as soon as it is safe to do so. Oral feeds are slowly increased while IV fluids are gradually withdrawn. The oral intake must be taken into account when calculating the IV rates. Reduce the IV fluid rates as the volume of milk feeds increases in infants on oro-gastric feeds. Discontinue IV fluids once oral intake reaches 2/3rd total requirements.

Introducing enteral feeds when the baby has been on IV fluids:

If stable and feeds are not contraindicated If there is a contraindication to oral fluids/feeds
Start enteral feeds 10 mls/kg/day Continue IV fluids according to age
Measure the residual volume before the next
feed by aspirating the stomach.
Do not increase fluids and consider restricting
fluids if there is:

(If >25% of total feed still in stomach and/or
there is abdominal distension do not increase
the volume.)

If the feed is tolerated, slowly increase the
enteral feeds and wean and stop the IV fluids
when the baby is on 2/3rds maintenance.

  • Weight gain
  • Tachycardia
  • Fast breathing
  • Oedema
  • Puffy eyes
  • Excessive urine output
If there is vomiting, consider restarting IV
fluids and stopping enteral feeds.

E 10 Use of the Syringe Driver (Pump) – Kasupe

Here the principles of using a syringe driver (pump) are presented.