Many unanswered questions remain regarding fluid bolus therapy and subsequent fluid management in neonatal critical care, similar to pediatric and adult critical care. A review by Grace E. and Keir AK. explores the known key clinical aspects of fluid bolus therapy and fluid balance in the first seven days of life and provides suggestions for further work in this area. It also explains the potential harms of excessive intravenous fluids, which may prove relevant to neonatology. Current data suggest that fluid bolus therapy and early-life positive fluid balance in neonates may pose some harm.

This study highlights that the large variation in fluid bolus practice makes current practice unlikely to be the best practice. There needs to be more high-quality evidence to support the development of best practice guidelines for fluid bolus therapy. It is reasonable to prefer Restrictive intravenous fluid practices within the first seven days of life. Fluid management must aim to avoid fluid overload, reduce morbidities and mortality, and improve longer-term outcomes.

This study also suggests some changes in current practice to improve outcomes. It states that standardizing a conservative approach to fluid therapy will be beneficial while awaiting higher-quality evidence from future research studies. It recommends using fluid bolus therapy judiciously outside the setting of hypovolaemia in preterm and term infants (GRADE C) and considering restrictive intravenous fluid practices within the first seven days of age (GRADE B).

Since Fluid therapy in neonatology has a limited evidence base, a pilot randomized study is needed to evaluate the feasibility of fluid bolus therapy compared to no fluid bolus therapy for the management of suspected hemodynamic compromise outside the setting of hypovolaemia. Further studies on a negative fluid balance during the first seven days of life are warranted. 

Grace E, Keir AK. Fluid Therapy: Friend or Foe?. Clinics in Perinatology. 2020;47(3): 515-528. https://doi.org/10.1016/j.clp.2020.05.005.