Intravenous Fluid Therapy for a 21-Month-Old Child
For a 21-month-old child, isotonic balanced fluid such as Plain Lactated Ringer's solution with added glucose should be administered at a maintenance rate of 80-120 mL/kg/day (restricted to 65-80% of calculated volume) to prevent hyponatremia and fluid overload. 1, 2
Fluid Composition
- Use isotonic balanced fluids as the standard maintenance fluid to prevent hospital-acquired hyponatremia and hyponatremic encephalopathy 2, 1
- Plain Lactated Ringer's solution is recommended as the first-line isotonic fluid for maintenance therapy 1
- Add glucose to prevent hypoglycemia - typically D5 (5% dextrose) is appropriate 2, 1
- Add potassium (1-3 mmol/kg/day) based on the child's clinical status and regular potassium monitoring 2, 1
Volume Calculation
For a 21-month-old child (falls in the 1-2 year age group):
- Recommended maintenance fluid volume: 80-120 mL/kg/day 2
- This volume should be restricted to 65-80% of the calculated amount to avoid fluid overload and prevent hyponatremia in acutely ill children 2, 1
- For children at risk of increased ADH secretion (pain, nausea, stress, postoperative state), fluid restriction is particularly important 2
Holliday-Segar Formula (Alternative Calculation Method)
- First 10 kg: 100 mL/kg/day (4 mL/kg/hour) 2, 1
- Second 10 kg: 50 mL/kg/day (2 mL/kg/hour) 2, 1
- Each kg above 20 kg: 25 mL/kg/day (1 mL/kg/hour) 2
Administration Guidelines
- Include all sources of fluid in the total daily maintenance calculation: IV fluids, blood products, IV medications, line flush solutions, and any enteral intake 2, 1
- Monitor the child daily for fluid balance, clinical status, and electrolytes (especially sodium levels) 2, 1
- For children with heart failure, renal failure, or hepatic failure, restrict maintenance fluid volume further to 50-60% of the calculated volume 2
Common Pitfalls and Caveats
- Avoid hypotonic fluids (e.g., 0.2% NaCl, 0.45% NaCl) as they increase the risk of hospital-acquired hyponatremia and potentially fatal hyponatremic encephalopathy 2, 3
- Recognize that many hospitalized children have conditions that increase ADH secretion, impairing free water excretion and placing them at risk for hyponatremia when given hypotonic fluids 2
- Monitor blood glucose at least daily to prevent both hypoglycemia and hyperglycemia 2, 1
- Be aware that fluid overload and cumulative positive fluid balance can lead to prolonged mechanical ventilation and increased length of stay 2
- Traditional maintenance fluid practices using hypotonic saline solutions are outdated and potentially dangerous 2, 3
Special Considerations
- If the child is minimally dehydrated and able to tolerate oral intake, transition to oral hydration as this is preferred over IV maintenance fluids 1
- For children with ongoing losses (vomiting, diarrhea, etc.), additional replacement fluids may be needed beyond maintenance requirements 4, 5
- Consider the child's underlying condition when selecting fluid composition and volume 2, 1