Many neonates with severe pneumonia will be unable to
feed well in the acute stage of the illness and require
nasogastric or intravenous fluids. Although there are no
randomised trials to inform fluid management, in infants
with bronchiolitis, free water excretion is noticeably reduced
in the acute stage compared with during convalescence,
suggesting activation of water conservation mechanisms. In
animal models of pneumococcal sepsis, free water excretion
is reduced to 25% of baseline values within hours of
infection. Hyponatraemia is found in about 30% of cases of
pneumonia in some series, is associated with high antidiuretic
hormone secretion, and is more common in children
with cyanosis,50 suggesting that the more severe the
pneumonia, the better the physiological water conservation,
and the less exogenous fluid required to maintain homoeostasis.
Giving fluid by a nasogastric tube allows the
continuation of breast milk feeding and maintenance of
some energy intake, avoidance of hypoglycaemia and the
complications of intravenous fluid administration, and is
cheaper than intravenous fluids. This is preferred unless
there is a true contraindication to feeding, such as frequent
vomiting, intolerance of enteral feeds, or high risk of
aspiration. In these circumstances, isotonic saline plus up
to 10% dextrose run at lower than traditional maintenance
rates may be most appropriate, and feeds introduced as soon
as the contraindication to enteral feeding has resolved