Albumin Replacement in Pediatric Patients
Albumin infusion in pediatric patients should generally be avoided as first-line volume replacement therapy and should only be considered in specific clinical scenarios with a recommended dose of 0.5-2 g/kg when indicated. 1
Indications for Albumin Replacement in Children
Albumin replacement should be limited to the following specific scenarios:
Symptomatic hypovolemia in children with conditions causing significant protein loss (e.g., congenital nephrotic syndrome) 1
- Clinical indicators: prolonged capillary refill time, tachycardia, hypotension, oliguria, abdominal discomfort
- Note: Serum albumin levels alone should not guide therapy
Plasmapheresis replacement fluid 2, 3
- Often used in combination with fresh frozen plasma to maintain hemostasis
Large-volume paracentesis (>5L) in children with liver disease 1, 4
- Dose: 8g albumin/L of ascites removed
Failed crystalloid resuscitation in specific shock states 1, 4
- Only as second-line therapy after crystalloids have failed
Dosing and Administration Guidelines
When albumin is indicated:
- Initial dosing: 0.5-2 g/kg per dose 1
- Severe cases: May require up to 1-4 g/kg daily in divided doses 1
- Administration rate: Infuse over 2-4 hours to minimize circulatory overload
- Concentration: 5% solution for volume expansion; 20-25% for fluid-restricted patients
Contraindications and Scenarios Where Albumin Should Be Avoided
Albumin should NOT be used for:
- Routine treatment of hypoalbuminemia without specific indications 1, 4, 5
- Initial treatment of hypotension in neonates 5
- Respiratory distress in neonates 1, 5
- Nutritional supplementation 4, 2
- Priming cardiovascular bypass circuits in pediatric cardiac surgery 1
- Volume replacement in preterm neonates (≤32 weeks or ≤1,500g) 1
Special Considerations for Different Pediatric Populations
Critically Ill Children
- Evidence from a large RCT showed excess mortality with both albumin and saline boluses compared to no bolus strategy in children with severe febrile illness and impaired perfusion 1
- Consider crystalloids as first-line fluid therapy
Neonates
- Albumin is not recommended for preterm neonates with respiratory distress and low serum albumin levels 1
- Not recommended for volume replacement in preterm neonates (≤32 weeks or ≤1,500g) 1
Children with Congenital Nephrotic Syndrome
- May require regular albumin infusions to prevent clinical consequences of hypovolemia and failure to thrive 1
- Base frequency and dosage on clinical indicators of hypovolemia, not serum albumin levels 1
- Consider diuretics (furosemide 0.5-2 mg/kg) at the end of albumin infusion to enhance effect 1
Monitoring During Albumin Administration
- Vital signs: Heart rate, blood pressure, respiratory rate
- Fluid status: Capillary refill time, urine output, edema
- Electrolytes: Particularly sodium and potassium
- Renal function: Creatinine, BUN
- Signs of fluid overload: Respiratory distress, pulmonary crackles
Potential Complications
- Fluid overload: Especially in renal impairment
- Electrolyte disturbances: Particularly with rapid infusion
- Allergic reactions: Though rare with modern preparations
- Thrombotic events: Particularly in nephrotic syndrome patients
- Respiratory dysfunction: Due to rapid volume expansion
Important Caveats
- The use of vascular access should be carefully considered in children requiring regular albumin infusions, with central venous lines avoided when possible to preserve vasculature for future dialysis access 1
- When regular albumin infusions are necessary, prophylactic anticoagulation should be considered while central venous lines are in place 1
- Diuretics should be used cautiously and only in cases of intravascular fluid overload to avoid inducing hypovolemia and promoting thrombosis 1, 4
Remember that albumin administration does not address the underlying cause of hypoalbuminemia, and treatment should focus on the primary condition whenever possible.