What are the changes in Intravenous (IV) fluid management in pediatrics?

From the Guidelines

Pediatric IV fluid management should prioritize the use of isotonic solutions, such as 0.9% sodium chloride or Lactated Ringer's with 5% dextrose, to reduce the risk of hyponatremia and other complications, as recommended by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) guidelines 1. The traditional "4-2-1 rule" (4 mL/kg/hr for first 10 kg, 2 mL/kg/hr for next 10 kg, and 1 mL/kg/hr for each additional kg) remains useful for calculating maintenance fluid rates, but the composition of fluids has changed to favor isotonic solutions. Some key points to consider in pediatric IV fluid management include:

• The use of isotonic fluids to reduce the risk of hyponatremia, which can lead to cerebral edema and neurological complications, particularly in children with conditions that increase ADH secretion 1.
• Regular monitoring of electrolytes (especially sodium) is essential, typically every 24 hours for stable patients and more frequently for high-risk patients 1.
• Fluid management should be individualized based on the child's clinical condition, with adjustments for conditions like cardiac disease, renal impairment, or third-spacing 1.
• For resuscitation, boluses of 10-20 mL/kg of isotonic crystalloids remain the standard approach, with reassessment after each bolus 1.
• The ESPNIC guidelines also recommend considering the use of balanced solutions, which provide some glucose and limited amounts of potassium, to meet the needs of children requiring IV-MFT 1.
• The implementation of these recommendations into clinical practice may be challenged by the lack of availability of ready-to-use solutions adapted for children in some European countries, highlighting the need for further research and development in this area 1.

From the FDA Drug Label

If the patient is dehydrated, additional crystalloids must be given,(4) or alternatively, Albumin (Human) 5%, USP (Plasbumin®-5) should be used. Although Plasbumin-5 is to be preferred for the usual volume deficits, Plasbumin-25 with appropriate crystalloids may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed. During the first 24 hours after sustaining thermal injury, large volumes of crystalloids are infused to restore the depleted extracellular fluid volume Beyond 24 hours Plasbumin-25 can be used to maintain plasma colloid osmotic pressure.

The management of IV fluids in pediatrics involves the use of crystalloids and colloids.

• In cases of dehydration, additional crystalloids should be given, or alternatively, Albumin (Human) 5% can be used.
• Plasbumin-25 can be used to maintain plasma colloid osmotic pressure beyond 24 hours after thermal injury.
• The use of Plasbumin-25 with appropriate crystalloids may offer therapeutic advantages in oncotic deficits or in long-standing shock where treatment has been delayed 2. Key points to consider in IV fluid management in pediatrics include:
• The type of fluid used (crystalloid or colloid)
• The volume of fluid administered
• The patient's hemodynamic response and hydration status
• The potential for circulatory overload or fluid depletion 2 2.

From the Research

Changes in IV Fluid Management in Pediatrics

• The management of pediatric parenteral fluids has undergone significant changes in recent years, with a focus on careful consideration of patient-specific factors such as weight, hydration status, and concomitant disease states 3.
• The use of balanced fluids and concentrations of electrolytes in fluids is still a topic of controversy, highlighting the need for individualized fluid plans for pediatric patients 3, 4.
• Dehydration in children can be treated with oral, nasogastric, subcutaneous, or intravenous fluids, with oral rehydration being a viable option for most children 5, 6, 7.
• The selection of oral rehydration solution and techniques for successful oral rehydration are crucial, as well as the appropriate selection and rate of administration of intravenous fluids for different types of dehydration 5, 7.

Disease-Specific Considerations

• Fluid management in hospitalized pediatric patients requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm 4.
• Specific considerations and management strategies are needed for various diseases, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure 4.
• Individualized fluid plans with recurrent evaluations and fluid modifications are essential to provide optimal care for hospitalized children 4.

Advances in Pediatric Dehydration Therapy

• Recent studies have added new information on the assessment, treatment, and evaluation of care for pediatric dehydration, including the use of antiemetics as an adjunct to oral rehydration therapy 6.
• Clinical guidelines incorporate advances in care, but physicians often show poor adherence to these guidelines despite evidence that they improve outcomes and reduce cost 6.
• Efforts to improve oral hydration solution and increase acceptance and usage are ongoing, with oral rehydration solution remaining the anchor of acute watery diarrhea and dehydration management worldwide 7.