Sodium range in neonatal TPN

[Naveed Rivas]

Good Day

I Would like to get a reference for sodium level in neonatal tpn. , the sources I have is informing that it should be

2-5 mmol/kg/day

is there any references that have a higher level like 2-8 mmol /kg/day?

Regards ,

[Rani Sudarshana]

As TPN is not for correction of electrolytes so according to my opinion sodium correction through TPN should be discouraged. But i saw in my practice 8 meq/kg/day sodium via TPN. Our neonatologist just simply follow sodium correction and their practices.

[Alchemist]

Dear Naveed,

Below are my thoughts about sodium in Neonatal PN:

1-Premature neonates often have unstable electrolyte requirements. To the best of my knowledge there is no reference stating the ceiling doses of electrolytes in PN. 

2-Maintenance requirement of sodium 2-6 mmol/kg 

3-Adjustment of sodium in PN is based on patient assessment. Patient may require 8-12 mmol/kg of sodium as acetate or chloride.

4-It’s vitally important to identify underlying cause before increasing Sodium in PN. 

5-Factors that may increase sodium requirements include: Prematurity, Renal sodium loss from a high fractional excretion of sodium, Excessive water intake, Excessive maternal fluid intake during delivery. Diuretic therapy, especially loop diuretics. Acute tubular necrosis  (tubular sodium loss) and other causes of renal failure. Excess sodium loss: Diarrhea, Gastric, pleural, CSF)

6-Whenever possible the underlying cause should be treated, rather than just treating the serum sodium concentration.

Hope this will help.

[TDP]

Good points, Thanks for sharing.

[Christian Lancaster]

Dear Naveed,
I agreed with Alchemist, detailed answers to your question. 2-5 mmol/kg/day is the revised recommendation for maintenance for neonate and pediatrics. The dose can be lower or higher than the recommendation and it based on underlying problem. Nora listed the common etiologies for hyponatremia.

Also, you have to consider when there is a situation of high Na requirement, dilutional effect like what you see in CHF, cirrhosis, severe hypoalbunemia that need to minimize fluid intake. Also, you have to pay attention to false hyponatremia like in case of uncontrolled blood glucose, hyperlipidemia, etc.

I advise you if the baby required high sodium supplement to do electrolyte profile at least 2-3 times per day to avoid over correction
in addition to urinary Sodium level

[Heather Blois]

Dear Naveed,

Just after drafting this response, I noticed Alchemist and Christian’s brilliant responses. I eco them below, maybe in a bit different words, I guess no harm of the repeat.

2 – 6 is the maintenance listed in most of references and guidelines. However depending on level of prematurity, hydration status and oliguric versus polyuric phases seen due to prematurity and  renal impairment/recovery, you might need more or less.

Initially right after birth, preterm infants have translucent skin that contributes to dehydration. Those who are extremely premature, might require review to their sodium and fluid status every 6 hrs, this  can result into increasing the fluid intake in response to hypernatremia. Thus the first day PN is almost sodium free, with probably very small amount of sodium (1 mmol/kg) as sodium glycerol phosphate.

This is also to account for the fact that we still give sodium chloride in the form of saline or ½ saline flushes at times of line insertion, to keep arterial lines patent and to flush IV medications. Thus ½ saline is preferred and small flush volumes should be targeted. This might help control the iatrogenic hypernatremia and hyperchloremia early in life.

Neonates who go through renal impairment become oliguric and develop 3^rd spacing. During this phase they are hyponatremic, and you manage that by just giving the maintenance, while restricting the fluid intake in response to the increase in the oedema weight and sodium readings, as well as clinical findings of overload.

When they recover from the renal impairment phase, they start passing a lot of urine, and a lot of sodium with that, they might as well be responding to diuretics initiated during the oedema phase. During that time it might be helpful to respond to low sodium supplementations as much as needed. Calculation of deficiencies gives an idea of how much is needed.

Other instances when the needs are high is when there are stoma losses, as well as sodium losing congenital diarrhoeal diseases.

Now back to how much in PN. Mostly we just supplement the needed daily supplement of 2 – 6 mmol/kg/day, further corrections done outside PN is the optimal, and we can do that when the Total fluid intake allow given that we do not compromise nutrition for that. If you will need a lot of fluid to give side drips, or when there is extreme fluid restriction, correcting in the PN is unavoidable.

Regards,

[Author]

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