Fluid, Electrolyte, Nutrition, and Gastrointestinal Management
Fluids and glucose
Neonates need dextrose-containing isotonic maintenance fluid (commonly D10W with electrolytes) because glycogen stores are small; a glucose-free bolus can precipitate hypoglycemia. Estimate maintenance with the 4-2-1 rule (4 mL/kg/hr for the first 10 kg, 2 for the next 10, 1 thereafter), remembering that neonates and preterm infants often require more per kilogram and that insensible losses rise with phototherapy, fever, and radiant warmers. Check a glucose on every transport and treat hypoglycemia promptly.
Electrolytes and nutrition
Watch sodium (immature kidneys waste it), potassium (hemolysis and tissue injury produce hyperkalemia), and calcium (hypocalcemia is common in prematurity and asphyxia). Feeding may be paused for an unstable infant or a surgical abdomen; do not abruptly stop parenteral nutrition. Human milk and trophic feeds are preferred when feeding is safe.
The surgical abdomen
Bilious emesis in a neonate is malrotation with volvulus until proven otherwise: make the patient NPO, decompress with a nasogastric tube, and move urgently. Distension with feeding intolerance and bloody stools suggests necrotizing enterocolitis - stop feeds, decompress, and give antibiotics. Gastroschisis and omphalocele need a warm, moist, non-adherent dressing plus bowel decompression.
Traps
Never give sterile water or hypotonic fluid as a bolus. In a ventilated neonate, decompress the stomach before transport - a distended abdomen splints the diaphragm.
Rule of thumb
A day-1 term neonate typically receives roughly 60–80 mL/kg/day of dextrose-containing fluid, titrated against weight, urine output, and sodium.