Bridging evidence and practice: implementation science and bundled care strategies for fluid management in critically ill neonates

Fluid overload (FO) is a common and modifiable risk factor in critically ill neonates. FO is associated with prolonged mechanical ventilation, multi-organ dysfunction, and increased mortality. Despite substantial observational evidence and consensus-driven guidelines, standardized fluid management strategies are inconsistently applied across neonatal intensive care units (NICUs). A critical knowledge gap exists between evidence and practice. Early single-center studies suggest bundle feasibility and effectiveness but are limited in scope and generalizability. 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. Pragmatic, multicenter studies that utilize EHR-based approaches are needed to help determine how to best implement functional fluid management strategies that improve patient-centered outcomes. 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. 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.