General Guidelines for Fluid Management in Pediatric Age Group
For pediatric patients requiring fluid management, initial boluses of 10-20 mL/kg should be administered for shock states, with subsequent reassessment to guide further therapy, while maintenance fluids should be calculated based on weight and adjusted according to clinical condition. 1
Fluid Resuscitation in Shock States
Septic Shock Management
- Initial fluid bolus: 20 mL/kg of crystalloid for infants and children with shock 1
- Maximum volume:
- With ICU availability: 40-60 mL/kg total in first hour
- Without ICU availability: 40 mL/kg total in first hour
- Administration rate: Fluid boluses should be delivered within 5 minutes when possible 2
- Delivery methods: Both pressure bag (maintained at 300 mm Hg) and manual push-pull systems are effective for rapid fluid delivery 2
- Monitoring: Continuous reassessment after each bolus for:
- Clinical response
- Signs of fluid overload
- Hemodynamic parameters
Important Considerations
- Titrate fluid therapy to patient response
- Discontinue boluses if signs of fluid overload develop
- For non-hypotensive children without ICU availability, avoid bolus fluids and provide maintenance fluids only 1
- Gravity administration is inadequate for emergency fluid resuscitation 2
- Children >40 kg may require alternative strategies as rapid bolus delivery is more challenging 2
Maintenance Fluid Requirements
Calculate maintenance fluids based on weight:
- 100 mL/kg/day for first 10 kg
- 50 mL/kg/day for next 10 kg
- 20 mL/kg/day for each kg above 20 kg
For example:
- 10 kg child: 1000 mL/day
- 20 kg child: 1500 mL/day
- 30 kg child: 1700 mL/day
Special Considerations for Specific Conditions
Diabetic Ketoacidosis (DKA)
- Initial fluid: 10-20 mL/kg of isotonic saline (0.9% NaCl) in first hour 1
- Maximum initial expansion: Should not exceed 50 mL/kg over first 4 hours 1
- Subsequent fluids: Once glucose reaches 250 mg/dL, change to 5% dextrose with 0.45-0.75% NaCl 1
- Electrolyte supplementation: Include 20-40 mEq/L potassium (2/3 KCl or potassium-acetate and 1/3 KPO₄) once renal function is confirmed and serum potassium is known 1
- Monitoring: Frequent assessment of cardiac, renal, and mental status to avoid iatrogenic fluid overload 1
Tumor Lysis Syndrome Prevention
- Hydration volume: 2-3 L/m²/day (or 200 mL/kg/day if <10 kg) 1
- Fluid composition: One-quarter normal saline/5% dextrose 1
- Target urine output: 80-100 mL/m²/hour (4-6 mL/kg/hour if <10 kg) 1
- Monitoring: Maintain urine-specific gravity at 1.010 1
- Electrolyte considerations: Initially withhold potassium, calcium, and phosphate from hydration fluids due to risks of hyperkalemia, hyperphosphatemia, and calcium phosphate precipitation 1
Physiological Differences in Pediatric Fluid Handling
Children have different fluid handling characteristics compared to adults:
- Higher plasma clearance (approximately 4 times higher than adults) 3
- Higher renal clearance of crystalloid solutions (approximately 7 times higher than adults) 3
- More rapid excretion of administered fluids 3
These differences suggest that children may tolerate weight-based fluid volumes at least equal to adult recommendations, but require more careful monitoring for dehydration.
Pitfalls and Caveats
Fluid overload risk: Excessive fluid administration can lead to:
- Interstitial edema
- Capillary leak syndrome
- Multiple organ dysfunction 4
- Particularly dangerous in small children with acute kidney injury
Inadequate resuscitation: Insufficient fluid replacement can lead to:
- Persistent shock
- End-organ damage
- Increased mortality
Monitoring challenges: Physical assessment of hydration status in children can be difficult and requires evaluation of multiple parameters:
- Skin turgor
- Mucous membrane moisture
- Capillary refill
- Urine output
- Mental status
- Vital signs
Delivery method limitations: Standard gravity infusion is inadequate for emergency fluid resuscitation, particularly in children >40 kg 2
The management of pediatric fluid therapy requires careful attention to the child's age, weight, clinical condition, and ongoing response to therapy, with frequent reassessment to prevent both under-resuscitation and fluid overload.