What is the recommended dosing of 3% Normal Saline (NS) in pediatric patients?

Dosing of 3% Normal Saline in Pediatric Patients

The recommended dosing of 3% hypertonic saline (HS) in pediatric patients varies by clinical indication, with bolus dosing of 3-5 mL/kg being most commonly used for acute conditions such as increased intracranial pressure. 1

Dosing by Clinical Indication

Increased Intracranial Pressure/Cerebral Edema

• Bolus dosing: 3-5 mL/kg (median 4.1 mL/kg), typically administered over 15-20 minutes via peripheral IV 1
• Can be safely administered through peripheral IV lines in 96% of cases 2
• For continuous infusion in pediatric traumatic brain injury: target serum sodium concentration of 145-155 mmol/L 3

Symptomatic Hyponatremia

• Bolus approach: 100 mL of 3% saline (can be repeated up to 2 more times based on response) 4
• For children: approximately 3-5 mL/kg per bolus 1
• Bolus administration produces faster elevation of serum sodium and quicker improvement in neurological status (measured by Glasgow Coma Scale) compared to continuous infusion 4

Administration Guidelines

Route of Administration

• Peripheral IV access is appropriate and safe for 3% saline administration in most pediatric patients 2, 1
• No significant complications related to peripheral administration have been reported in transport or emergency settings 2

Rate of Administration

• For acute conditions requiring rapid correction: median administration time of 17 minutes 1
• For bolus therapy: administer over 15-20 minutes, with close monitoring 1
• For continuous infusion: typically 20 mL/hr of 3% saline 4

Monitoring Requirements

• Frequent serum electrolyte monitoring is essential, especially with bolus therapy 4
• Monitor for signs of overcorrection, particularly when multiple boluses are administered 4
• A third saline bolus is associated with greater need for intervention to prevent overcorrection (dextrose/dDAVP administration) 4

Safety Considerations

• No cases of central pontine myelinolysis or osmotic demyelination syndrome have been reported in pediatric patients receiving 3% saline at recommended doses 3, 2
• In studies of continuous infusion, serum sodium levels up to 170.7 mmol/L have been tolerated without adverse effects 3
• Most patients have peak sodium levels <155 mmol/L, with levels typically returning to normal within 24 hours 3
• Children are at higher risk of developing symptomatic hyponatremia due to their larger brain-to-skull size ratio, making appropriate fluid management critical 5

Common Pitfalls and Caveats

• Avoid rapid overcorrection of sodium, which can lead to osmotic demyelination syndrome 4
• Consider underlying conditions that may affect fluid and electrolyte management (e.g., SIADH, cerebral salt wasting) 4
• Ensure proper concentration of hypertonic saline is used (3% contains 513 mEq/L of sodium) 1
• Be aware that administration of a third bolus may significantly increase the risk of overcorrection requiring intervention 4

Remember that while 3% saline is effective in reducing intracranial pressure (Grade A evidence), it has not been shown to improve neurological outcomes (Grade B) or survival (Grade A) in states of raised intracranial pressure 3.