What is the appropriate management for edema in infants?

Management of Edema in Infants

The management of edema in infants requires first determining whether the infant is hypovolemic or hypervolemic through clinical assessment, then treating based on the underlying etiology—with congenital nephrotic syndrome managed primarily through concentrated oral nutrition and cautious albumin infusions for hypovolemia, while avoiding routine IV fluids and using diuretics only with extreme caution. 1

Initial Clinical Assessment

The first critical step is distinguishing hypovolemia from hypervolemia:

Hypovolemic indicators include: 1

• Prolonged capillary refill time >2 seconds
• Tachycardia
• Hypotension
• Oliguria
• Abdominal discomfort

Hypervolemic indicators include: 1

• Good peripheral perfusion
• Elevated blood pressure

Evaluate prenatal history for clues to congenital nephrotic syndrome, including enlarged nuchal translucency, increased amniotic fluid alpha-fetoprotein, fetal edema, oligohydramnios, or placental weight >25% of birth weight. 1

Screen for infection (fever, respiratory distress, altered mental status) that could indicate septic shock. 1

Management Based on Etiology

Congenital Nephrotic Syndrome

Fluid Management:

• Avoid routine intravenous fluids and saline completely. 1
• Use concentrated oral fluid intake to provide adequate nutrition while preventing worsening edema. 1
• Prescribe concentrated high-calorie formulas to meet age-related energy needs. 1
• Restrict dietary sodium to <2 g/day (<90 mmol/day) to maximize any diuretic effectiveness. 1

Albumin Therapy:

• Administer albumin infusions (1-4 g/kg/day) ONLY for clinical indicators of hypovolemia, NOT based on serum albumin levels. 1, 2
• Clinical indicators warranting albumin include prolonged capillary refill, tachycardia, hypotension, oliguria, and abdominal discomfort. 2
• Consider administering furosemide (0.5-2 mg/kg) at the end of each albumin infusion, unless marked hypovolemia and/or hyponatremia are present. 2
• When giving furosemide with albumin, infuse over 5-30 minutes to minimize ototoxicity. 2
• For patients requiring long-term therapy via central venous lines, consider prophylactic anticoagulation. 2
• Home administration by trained caregivers is feasible and safe for selected patients. 2

Diuretic Use:

• Use diuretics with extreme caution and ONLY when intravascular fluid overload is confirmed. 1
• Loop diuretics are first-line when diuretics are indicated, with twice-daily dosing preferred over once-daily. 3
• Furosemide is indicated for edema in pediatric patients with nephrotic syndrome when rapid diuresis is needed. 4
• Critical caveat: In premature infants, furosemide may precipitate nephrocalcinosis/nephrolithiasis and increase risk of patent ductus arteriosus persistence. 4
• Monitor renal function and consider renal ultrasonography in pediatric patients receiving furosemide. 4

Septic Shock

Restore normal physiologic parameters: 1

• Normal mental status
• Normal heart rate for age
• Capillary refill <3 seconds
• Palpable distal pulses
• Normal blood pressure for age

Maintain perfusion pressure (MAP minus CVP) above critical threshold to ensure adequate organ blood flow. 1

Monitoring Requirements

Essential monitoring parameters include: 1

• Fluid status assessment
• Electrolytes (particularly potassium and sodium) 1, 3
• Blood pressure
• Kidney function

Specific electrolyte concerns:

• Hypokalemia is the most common electrolyte abnormality with loop diuretic therapy. 3
• Monitor for hyponatremia, though loop diuretics carry lower risk than thiazides. 3

Critical Pitfalls to Avoid

Do not use serum albumin levels to guide albumin administration—base decisions solely on clinical signs of hypovolemia. 1, 2

Avoid diuretics in hypovolemic states, as this worsens renal perfusion and function. 3

Never give routine IV fluids or saline in congenital nephrotic syndrome, as this exacerbates edema. 1

In premature infants, be aware that furosemide carries significant risks including nephrocalcinosis and patent ductus arteriosus persistence. 4

Accept modest creatinine increases (up to 30%) during appropriate diuresis, as this often reflects volume reduction rather than true kidney injury. 3