Bridging Evidence and Practice: Implementation Science and Bundled Care Strategies for Fluid Management in Critically Ill Neonates

Amelia C Pak^1*Javier A Neyra²Jeremiah R Brown³Colm P Travers⁴Michelle Starr⁵Matthew W Harer⁶Iben Sullivan⁷Todd A MacKenzie⁸Tiago K Colicchio⁹Russell Griffin¹⁰David J Askenazi¹

• ¹Department of Pediatrics, Division of Pediatric Nephrology, The University of Alabama at Birmingham, Birmingham, United States
• ²Department of Nephrology, The University of Alabama at Birmingham, Birmingham, United States
• ³Department of Epidemiology, Dartmouth Center for Implementation Science, Dartmouth College Geisel School of Medicine, Hanover, United States
• ⁴Department of Pediatrics, Division of Neonatology, The University of Alabama at Birmingham, Birmingham, United States
• ⁵Department of Pediatrics, Division of Pediatric Nephrology, Indiana University School of Medicine, Indianapolis, United States
• ⁶Department of Pediatrics, Division of Neonatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, United States
• ⁷Dartmouth College Geisel School of Medicine, Hanover, United States
• ⁸Department of Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, United States
• ⁹Department of Biomedical Informatics and Data Science, The University of Alabama at Birmingham, Birmingham, United States
• ¹⁰Department of Pediatrics and Department of Epidemiology, The University of Alabama at Birmingham, Birmingham, United States

Fluid overload (FO) is a common and modifiable risk factor in critically ill neonates that is associated with prolonged mechanical ventilation, multi-organ dysfunction, and increased mortality. Despite This is a provisional file, not the final typeset article substantial observational evidence and consensus-driven guidelines, standardized fluid management strategies are inconsistently applied across neonatal intensive care units (NICUs). Early single-center studies suggest bundle feasibility and effectiveness but are limited in scope and generalizability. Such bundles integrate evidence-based interventions that collectively identify high-risk patients, track, prevent, and treat FO. A structured pathway is needed to enhance scalability and uptake, systematically address barriers, tailor strategies to local contexts, and engage interdisciplinary teams. Incorporating implementation science frameworks and electronic health record (EHR) data pipeline integration can strengthen adoption, fidelity, adaptation, and sustainability of these interventions across diverse NICU settings. Rather than presenting new efficacy data, this perspective focuses on the translational gap and maximizing how existing evidence can be operationalized through bundles, data infrastructure, and implementation science to enable future multicenter trials. Pragmatic, multicenter studies that utilize EHR-based approaches are needed to determine how to best implement fluid management strategies that improve patient-centered outcomes. Bridging the gap between evidence and implementation through collaborative, pragmatic research has the potential to meaningfully reduce FO-related morbidity and mortality and advance neonatal critical care.