Diuretics in Infants at Risk of Chronic Lung Disease

Publication: 30/11/2006  --
Last review: 28/06/2018  
Next review: 28/06/2021  
Standard Operating Procedure
CURRENT 
ID: 219 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Protocol for the use of diuretics in infants at risk of chronic lung disease

Chronic lung disease is defined as:

  • Ventilated in the first week of life for RDS
  • Oxygen dependent at 28 days
  • Characteristic radiological changes (hyperexpansion,streaks of abnormal density,cystic,emphysematous changes)

Babies at risk of chronic lung disease are:

  • Ventilator dependent or requiring >40% oxygen at 3 weeks of age
  • Characteristic radiological changes

Treatment

If the infant is

  • in >40% oxygen
  • +/- ventilator dependent
  • characteristic X-ray changes

then they should commence a trial of diuretics:

  • Frusemide 1mg/kg bd

  • Spironoloactone 1mg/kg bd

Once tolerating enteral feeds

  •  frusemide should be changed to chlorthiazide
    (12.5 mg/kg bd)
  •  If there is benefit, continue the diuretics for 4 weeks, or until in air for more than a week, whichever is earlier.
  • If diuretics show no benefit, or the infant's clinical condition is deteriorating then consider corticosteroid treatment (see separate protocol).
  • If an infant who has previously shown benefit from diuretics has a significantly increased oxygen requirement (>40%) on stopping the diuretics then they should be recommenced and continued for a further 4 weeks.

 Side Effects

  • Hyponatraemia is a common side effect of frusemide in the newborn. Serum electrolytes should be carefully monitored in the first week of treatment until serum sodium is stabilised. If serum sodium falls below 130mmol/l frusemide should be stopped

  • Nephrocalcinosis may develop in preterm infant receiving loop diuretics. This will usually resolve in the first few years of life but blood pressure and renal function should be monitored. A small number will go on to develop renal dysfunction.
    • Renal USS for any baby on diuretics more than 2 weeks
    • If nephrocalcinosis detected consider stopping/reducing diuretic and avoid other nephrotoxic drugs where possible
    • If there is renal dysfunction at this stage check serum calcium and phosphate and discuss with paediatric nephrology
    • If normal renal function, calcium and phosphate but persistent nephrocalcinosis  then annual USS should be arranged.
    • If not resolved at 2 years then GP follow up for annual  urinalysis and BP and nephrology follow up for ongoing imaging

Provenance

Record: 219
Objective:

This guideline is aimed at optimising diuretic therapy in infants with chronic lung disease.

Clinical condition:

Chronic Lung Disease

Target patient group: Newborn
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

N/A


Evidence base

Diuretics have been shown to improve lung compliance and oxygenation in infants over 3 weeks of age in a number of systematic reviews1,2. Before three weeks there was no consistent benefit. Chronic administration shows continued benefit in compliance and oxygenation3. Risk of ventilation and death was reduced in one subgroup>8 weeks old who had not received steroids. No studies have assessed diuretic use in infants receiving steroids.

1.      Pope JC 4th, Trusler LA, Klein AM, Walsh WF, Yared A, Brock JW 3rd. The natural history of nephrocalcinosis in premature infants treated with loop diuretics. J Urol. 1996 Aug;156(2 Pt 2):709-12.

2.       Brion LP, Primhak RA, Ambrosio-Perez I. Diuretics acting on the distal renal tubule for preterm infants with (or developing) chronic lung disease. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD001817. DOI: 10.1002/14651858.CD001817.

3.      Brion LP, Primhak RA. Intravenous or enteral loop diuretics for preterm infants with (or developing) chronic lung disease. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD001453. DOI: 10.1002/14651858.CD001453.

4.      Rennie J, Roberton's Textbook of Neonatology. Churchill Livingstone · Published June 2005 556-557.

 

 

 

Document history

LHP version 1.0

Related information

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