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Albumin Versus Normal Saline for Dehydrated Term Infants with Metabolic Acidosis Due to Acute Diarrhea

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Albumin Versus Normal Saline for Dehydrated Term Infants with Metabolic Acidosis Due to Acute Diarrhea Journal of Perinatology (2009) 29, 444–447 r 2009 Nature Publishing Group All rights reserved. 0743-8346/09 $32 www.nature.com/jp ORIGINAL ARTICLE Albumin versus normal saline for dehydrated term infants with metabolic acidosis due to acute diarrhea JJ Han, HE Yim, JH Lee, YK Kim, GY Jang, BM Choi, KH Yoo and YS Hong Department of Pediatrics, College of Medicine, Korea University, Seoul, Republic of Korea histidine residues with a pKa of approximately 7.4; it shows a Objective: To compare the efficacy of albumin to normal saline (NS) for buffering effect in the acid-base balance and influences the pH.1 initial hydration therapy for dehydrated term infants with severe metabolic Although there is a dispute concerning the efficacy of albumin acidosis due to acute diarrhea. infusion for neonatal metabolic acidosis, albumin infusion to Study Design: We randomized 33 infants presenting with moderate-to- improve pH and/or base deficits in acidotic infants may be 2–6 severe dehydration and metabolic acidosis (pH <7.25 or base excess (BE) clinically useful. However, to date there are no randomized <À15) into two groups, an albumin group (n ¼ 15) and a NS group studies assessing the efficacy of albumin infusion for the treatment (n ¼ 18). For initial hydration treatment, the albumin group received 5% of neonatal metabolic acidosis; in addition, there are no studies on albumin (10 ml kgÀ1), whereas the NS group received NS (10 ml kgÀ1). its efficacy when combined with sodium bicarbonate. Therefore, the aim of our study was to compare the efficacy of Result: After 3 h of treatment, both groups improved. However, the albumin to NS for initial hydration therapy in dehydrated term magnitude of improvement in the pH, BE and HCOÀ levels were not 3 infants with moderate and severe metabolic acidosis, especially with different in comparisons between these two groups. In addition, there were regard to buffering effects. no differences either in the body weight and weight gain 4 days after treatment or in the length of hospital stay. Methods Conclusion: Albumin was not more effective than NS for initial Infants admitted to Ansan Hospital, Korea University Medical Center, hydration treatment of dehydrated term infants with metabolic acidosis who developed moderate-to-severe dehydration with metabolic acidosis, due to acute diarrhea. due to acute watery diarrhea within the first month of life, were Journal of Perinatology (2009) 29, 444–447; doi:10.1038/jp.2008.244; eligible for this study. Patients were enrolled between September 2002 published online 22 January 2009 and December 2003. The study protocol was approved by the local Keywords: albumin; dehydration; metabolic acidosis; neonate research ethics committee at Ansan Hospital, and written parental informed consent was obtained in all cases. The information collected on all of the participating neonates included age, initial birth weight, body weight, complete blood count, electrolytes, blood urea nitrogen, Introduction creatinine, protein, albumin and blood gas analysis, as well as physical findings such as a dry tongue or lips, depressed fontanel, sunken eyes, Although sodium bicarbonate is the most widely used buffer for the decreased urination and decreased activity. treatment of metabolic acidosis, hypovolemic infants with severe Initially, 78 neonates who had symptoms or signs of metabolic acidosis may require intravascular fluid administration as dehydration were eligible for a diagnosis of moderate-to-severe supplemental fluid management to correct their dehydration. dehydration.7 Among them, 33 were included because their initial Therefore, neonates with severe dehydration and metabolic acidosis pH was below 7.25 or their initial base excess (BE) was below À15. require acute intervention to ensure adequate tissue perfusion as well Neonates without metabolic acidosis were excluded. All neonates as correction of metabolic acidosis. Normal saline (NS) is frequently were born full term and were healthy at the time of delivery. used for volume expansion during the neonatal period; however, NS After randomization, 5% albumin (10 ml kgÀ1) and NS has no known buffering capacity. As a serum protein, albumin has (10 ml kgÀ1) were administrated to infants in the albumin group Correspondence: Professor BM Choi, Department of Pediatrics, College of Medicine, Korea (n ¼ 15) and in the NS group (n ¼ 18) as open label initial University, Ansan Hospital, no. 516, Gojan-Dong, Danwon-Gu, Ansan-City, Kyungki-Do hydration therapy. All patients were treated in accordance with our 425-707, Korea. standard treatment protocol that included sodium bicarbonate E-mail: [email protected] Received 24 October 2007; revised 19 July 2008; accepted 20 July 2008; published online supplements (0.3 Â weight (Kg) Â BE Â 1/2), maintenance fluid À1 À1 À1 22 January 2009 (5% dextrose/NaCl 20 mEq l at a rate 4 ml kg h ) and Albumin versus NS for neonatal metabolic acidosis JJ Han et al 445 potassium supplements (if the plasma potassium level was recommended as first-line therapy because of many associated <3.0 mEq lÀ1). problems such as the potential risk of infection, hypersensitivity At 3 h after initial hydration, arterial blood gas analysis was reactions, fluid overload, capillary leakage and high costs. However, performed as a measure of the short-term effects of the 5% the absence of albumin-related mortality has been documented in albumin or NS therapy. If there was a sustained metabolic acidosis the medical literature.8–10 In addition, there is a lack of evidence (pH <7.25 or BE <À15), additional infusion with sodium that albumin is associated with significant side effects such as bicarbonate was carried out. In addition, if patients did not urinate infection.11 The fact that some data in the literature have not during the 3 h after initial hydration, an additional infusion with shown increased mortality with albumin administration does not the same fluids as in initial hydration therapy (10 ml kgÀ1,5% support its use, particularly in neonates with dehydration. albumin or NS) was performed. Studies have shown that NS was as effective as 5% albumin for Body weight and weight gain 4 days after treatment, as well as the treatment of hypotensive preterm neonates during the first the length of hospital stay, were evaluated as long-term outcomes. postnatal days; the albumin-treated infants, however, had a At all times, usual feeding was allowed and oral rehydration decreased ability to appropriately lose weight after treatment.12,13 solutions were administered during the rehydration and Recently, however, Lynch et al.14 reported that preterm infants with maintenance phases, except that severe vomiting made patients hypotension are more likely to respond favorably and to decrease intolerant of oral feeding. Patients who were tolerant toward oral subsequent use of dopamine after albumin bolus infusion rehydration solutions were offered 100 ml kgÀ1 of the oral compared with NS. rehydration solution over 6 h. Ongoing losses due to vomiting and In the case of respiratory disease, albumin has not been shown diarrhea were replaced with an additional 5 and 10 ml kgÀ1 of oral to alter the duration of assisted ventilation and oxygen rehydration solution for each vomiting and diarrhea, respectively. dependency.15 By contrast, the infusion of colloidal fluid during the Pre- and post treatment values were compared using the paired perinatal period in premature infants of median gestational age 27 t-test. Comparisons between the two treatment groups were weeks has been related to an increased duration of oxygen performed by Student’s t-test, Fisher’s exact test and w2 test. dependency and abnormal neurodevelopmental outcomes.16,17 In addition, albumin potentially causes deterioration of the protein leak syndrome of prematurity and lung function by deactivation of Results the surfactant in alveolar spaces.18–20 We found no significant statistical differences between the two There are a few studies on the effects of albumin administration groups in initial body weight at birth, body weight at admission, in neonates with metabolic acidosis. Some studies have shown an electrolytes, blood urea nitrogen, creatinine, total serum protein, increment of pH after albumin infusion. In one study, the albumin levels and the number of hypotensive neonates (Table 1). administration of 4.5% albumin to ventilated, normotensive, very The results of the initial blood gas analysis showed moderate and low birth weight infants with metabolic acidosis (pH <7.25) severe metabolic acidosis and no significant difference between the resulted in an immediate significant increase in pH and a BE 6 h albumin and NS groups. post-infusion.2 However, this study had no control group and the À At 3 h after initial hydration, the pH, BE and HCO3 in both results therefore have limited value. Another study reported that groups were significantly increased compared with the pretreatment albumin significantly increased pH compared with pretreatment values. However, there was no statistically significant difference in values; however, bicarbonate was significantly more effective than À 4 the magnitude of the improvements in the pH, BE and HCO3 levels albumin. Although there was no improvement of pH, Dimitriou between the two groups (Table 2). In addition, there was no et al.3 reported that the infusion of albumin improved the base statistically significant difference in the frequency of sodium deficit in hypotensive, very premature infants. bicarbonate therapy and bolus hydration therapy (albumin
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