Sometimes Ethiopia feels like a book stuck on repeat.

We keep returning to familiar conflicts, familiar arguments, and familiar consequences, while somehow expecting a different outcome.

If the old hypothesis keeps producing the same result, why not test a new one?

Maybe the next chapter deserves dialogue, peace, and development instead.

♾️🇪🇹

I’m seeking clinical perspectives on a highly complex neonatal case being managed in a resource-limited setting.

Patient

• Gestational age: 30+6 weeks
• Admission duration: 11 days
• Admission weight: 1,690 g
• Current weight: 1,255 g
• Weight change: −435 g (~25.7% from admission weight)
• Temperature: 30°C
• HR: 82 bpm
• RR: 32/min
• Respiratory support: Homemade CPAP 5/5 with radiant warmer
• GI: NPO because of suspected NEC
• Blood glucose: 391 mg/dL
• Serum Na: 192 mEq/L
• Creatinine: 4.4 mg/dL
• Renal status: Oliguria/anuria is a concern
• Hemodynamics: Clinically concerning for shock

Laboratory trend

The sodium has been extremely difficult to control:

Na: 165 → 190 → 192 → 188 mEq/L

Creatinine has progressively increased:

Cr: 3.5 → 4.04 → 4.4 mg/dL

The infant has therefore had substantial weight loss together with severe hypernatremia and worsening renal dysfunction.

Main management dilemma

The infant appears to require restoration of adequate perfusion while simultaneously having severe hypernatremia and significant AKI.

Increasing fluid administration may worsen fluid overload if renal output is inadequate, while inadequate resuscitation may worsen systemic and intestinal perfusion.

Additional concerns include:

• Severe hypernatremia requiring controlled correction
• Significant AKI with possible oliguria/anuria
• Suspected NEC requiring NPO management and careful perfusion assessment
• Hypothermia (30°C) with marked bradycardia
• Hyperglycemia (391 mg/dL)
• Limited respiratory support with homemade CPAP
• Limited access to mechanical ventilation and renal replacement therapy

Questions for clinicians experienced in neonatal critical care

1. How would you approach initial stabilization and perfusion when severe weight loss/dehydration may coexist with AKI and possible oliguria?
2. How would you calculate and titrate free-water replacement while avoiding overly rapid sodium correction?
3. How frequently would you monitor sodium and other electrolytes in this situation?
4. How would you distinguish ongoing dehydration from evolving fluid overload when urine output is very low?
5. How would you approach suspected NEC/septic shock in this setting?
6. At what point would you consider peritoneal dialysis or another renal-replacement strategy?
7. If dialysis is unavailable, what practical strategies would you use to balance perfusion, sodium correction and fluid restriction?

I’m particularly interested in approaches that are practical in a resource-limited NICU, where advanced ventilation, dialysis and frequent laboratory testing may not be immediately available.

All patient-identifying information has been omitted. This is an educational case discussion, not a request for remote patient-specific treatment.