What is the appropriate dose and administration protocol for 5% Dextrose (D5) intravenous solution in a 25-day-old neonate?

D5W Administration in a 25-Day-Old Neonate

D5W (5% dextrose in water) is not the appropriate concentration for a 25-day-old neonate requiring continuous glucose infusion—D10W (10% dextrose in water) should be used instead at 100 mL/kg per 24 hours (approximately 7 mg/kg per minute). 1

Why D10W Instead of D5W

• The American Academy of Pediatrics specifically recommends D10W-containing IV fluids with appropriate maintenance electrolytes at a rate of 100 mL/kg per 24 hours for newborns requiring continuous dextrose infusion. 2, 1
• D5W is the standard maintenance fluid for adults (approximately 100 mL/hour for a 70 kg adult), but provides insufficient glucose concentration for neonatal metabolic needs. 3
• Neonates have higher glucose requirements per kilogram due to their larger brain-to-body mass ratio and higher metabolic rate. 1

Correct Dosing Protocol for D10W in This 25-Day-Old

Standard Maintenance Infusion

• Start D10W at 100 mL/kg per 24 hours, which delivers approximately 7 mg/kg per minute of glucose. 1
• Add appropriate maintenance electrolytes to the D10W infusion to prevent electrolyte imbalances. 2, 1
• Titrate the infusion rate to achieve normoglycemia, as both hypoglycemia and hyperglycemia have adverse central nervous system effects. 2, 1

Acute Hypoglycemia Treatment (If Applicable)

• For acute hypoglycemia: administer 200 mg/kg as D10W, equivalent to 2 mL/kg of D10W as a bolus. 2, 1
• For more severe hypoglycemia requiring larger glucose loads: give 0.5-1.0 g/kg, which equals 5-10 mL/kg of D10W. 2, 1

Critical Monitoring Parameters

• Monitor blood glucose levels every 1-2 hours initially to ensure the infusion rate maintains normoglycemia. 3
• Target blood glucose above 45 mg/dL to prevent adverse outcomes from repetitive or prolonged hypoglycemia. 1
• Avoid hyperglycemia above 145 mg/dL, as this is associated with increased morbidity and mortality in neonatal ICU patients. 1
• Monitor glucose, sodium, and potassium levels carefully during continuous D10W infusion. 2, 1
• Use blood gas analyzers with glucose modules for the most accurate measurements, as handheld meters have accuracy concerns with high hemoglobin and bilirubin levels common in neonates. 1

Critical Safety Considerations

• Never use D50W in neonates—it is irritating to veins; if higher concentrations are needed, dilute to 25% dextrose (D25W). 2, 1
• Hypoglycemia may recur despite adequate initial treatment depending on the underlying etiology, requiring ongoing vigilance. 2, 1
• Ensure intravenous access is appropriate for the neonate's size and condition, as prolonged IV therapy is common in this population. 4

Alternative Consideration: Oral Dextrose Gel

• If the neonate has asymptomatic hypoglycemia and can tolerate oral intake, 40% dextrose gel (200 mg/kg) massaged to the buccal mucosa reduces the need for IV treatment and mother-infant separation. 5, 6
• This approach increases the likelihood of exclusive breastfeeding after discharge. 6
• However, commercially available gels contain artificial colorants, flavors, and preservatives not ideal for neonates, and concentrations may be inconsistent. 7