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Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants
1Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA. belle@mail.medadmin.uiowa.edu
Insights
Restricting water intake in premature infants helps manage postnatal weight loss and lowers risks of serious conditions like patent ductus arteriosus and necrotizing enterocolitis, without significantly increasing dehydration risks.
Area of Science:
- Neonatalogy
- Pediatric Fluid Management
- Evidence-Based Medicine
Background:
- Premature infants often lack physiological maturity for self-regulated oral water and nutrient intake.
- Caregivers must precisely determine daily water administration for these vulnerable infants.
Purpose of the Study:
- To review the impact of varying water intake levels on premature infants' postnatal weight loss.
- To assess water intake's effect on risks including dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and mortality.
Main Methods:
- Systematic review of randomized clinical trials comparing different water intake protocols in premature infants.
- Included trials focused on infants receiving primarily parenteral hydration.
- Data extraction and analysis performed by two independent reviewers using RevMan and MetaView software.
Main Results:
- Restricted water intake significantly increased postnatal weight loss.
- Restricted water intake significantly reduced risks of patent ductus arteriosus, necrotizing enterocolitis, and death.
- Trends indicated increased dehydration risk and decreased bronchopulmonary dysplasia risk with restricted intake, though not statistically significant.
Conclusions:
- Careful restriction of water intake in premature infants is recommended to meet physiological needs while avoiding significant dehydration.
- This approach may decrease risks of patent ductus arteriosus, necrotizing enterocolitis, and potentially mortality.
- Adverse consequences are not expected to increase significantly with this cautious fluid management strategy.
Background:
Most premature infants are not sufficiently mature physiologically to take all of their required water and nutrients orally, and so they cannot regulate their own water intake. Thus, the caregiver must determine the amount of water to be given each day to such infants.
Objectives:
The objective of this review is to examine the effects of water intake on postnatal weight loss and on the risks of dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and death in premature infants.
Search Strategy:
Randomized clinical trials were sought that compared the outcomes of interest in groups of premature infants who were given different levels of water intake according to experimental protocol. Such trials were sought in a previous review by one of the authors (Bell EF. Fluid therapy. In: Effective Care of the Newborn Infant, eds JC Sinclair, MB Bracken. Oxford: Oxford University Press, 1992: 59-72, approximately approximately Bell 1992 approximately approximately ), in a list of trials provided by the Cochrane Neonatal Review Group, and in the authors' personal files.
Selection Criteria:
Only randomized clinical trials of varying water intake in premature infants are included. The review was limited to trials that included infants whose water intake was provided mainly or entirely by parenteral means. Studies were included regardless of outcomes examined.
Data Collection And Analysis:
Trials were selected by two reviewers, who also assessed the methodological quality of each trial. Data were independently extracted by the reviewers, and differences were reconciled. The data were then entered into tables using RevMan 3.1 for Windows. The adverse event rates were calculated for the restricted and liberal water intake groups for each dichotomous outcome, and the relative risk was computed. In addition, the maximal weight loss results were recorded, and the weighted mean difference was computed. The analyses (including calculation of relative risk, risk difference, and weighted mean difference) and tests of heterogeneity were accomplished with MetaView 3.1 software and a fixed effects model. No subgroup analyses were conducted.
Main Results:
The analysis of the four studies taken together indicates that restricted water intake significantly increases postnatal weight loss and significantly reduces the risks of patent ductus arteriosus, necrotizing enterocolitis, and death. With restricted water intake, there are trends toward increased risk of dehydration and reduced risk of bronchopulmonary dysplasia, but these trends are not statistically significant.
Reviewer'S Conclusions:
Based on this analysis, the most prudent prescription for water intake to premature infants would seem to be careful restriction of water intake so that physiological needs are met without allowing significant dehydration. This practice could be expected to decrease the risks of patent ductus arteriosus and necrotizing enterocolitis--and perhaps the overall risk of death--without significantly increased risk of adverse consequences.