What is the recommended fluid management approach for pediatric patients?

Pediatric Fluid Management Guidelines

Isotonic balanced solutions should be used as the first-choice maintenance fluid therapy in acutely and critically ill children to reduce the risk of hyponatremia and slightly reduce length of stay. 1

Fluid Type Selection

• Isotonic saline should be the first-choice fluid for resuscitation in neonates and children with hypovolemia 1
• Balanced solutions are preferred when prescribing intravenous maintenance fluid therapy in both acutely and critically ill children 1
• Lactate buffer solutions should be avoided in children with severe liver dysfunction to prevent lactic acidosis 1
• For children with diabetic ketoacidosis, 0.9% saline is recommended over hypertonic saline for initial fluid therapy 2

Fluid Volume Guidelines

Resuscitation Volumes

• For hypovolemic shock, pediatric advanced life-support guidelines recommend up to 60 ml/kg fluid resuscitation 1, 3
• Initial fluid therapy should be 10-20 ml/kg of isotonic saline in children, with repeated doses based on clinical response 3
• In children with shock and without coma, volume resuscitation with 20-40 ml/kg of isotonic saline safely corrects hemodynamic features 1
• For any child with persisting features of shock despite 40 ml/kg of fluid, elective intubation, ventilation, and central venous catheter placement are recommended 1

Maintenance Volumes

• In acutely and critically ill children, restrict maintenance fluid therapy volume to 65-80% of the volume calculated by the Holliday and Segar formula to avoid fluid overload, especially in children at risk of increased ADH secretion 1
• For children with heart failure, renal failure, or hepatic failure, restrict maintenance fluid volume to 50-60% of the Holliday-Segar calculation 1
• Total daily maintenance fluid therapy should include all sources: IV fluids, blood products, IV medications, arterial and venous line flush solutions, and enteral intake 1
• Avoid fluid overload and cumulative positive fluid balance to prevent prolonged mechanical ventilation and extended length of stay 1

Fluid Composition

Electrolytes and Additives

• Include appropriate potassium supplementation in maintenance fluid therapy based on clinical status and regular monitoring to avoid hypokalemia 1
• Glucose provision should be sufficient to prevent hypoglycemia but not excessive to avoid hyperglycemia, guided by at least daily blood glucose monitoring 1
• Routine supplementation of magnesium, calcium, phosphate, vitamins, and trace elements in maintenance fluid therapy is not recommended without signs of deficiency 1

Monitoring and Assessment

• Reassess acutely and critically ill children receiving intravenous maintenance fluid therapy at least daily for fluid balance and clinical status 1
• Monitor electrolytes regularly, with special attention to sodium levels 1
• Use clinical parameters to assess response to fluid therapy: heart rate, blood pressure, capillary refill time, skin temperature, mental status, and urine output 3, 4
• Urine output <1 ml/kg/hour (without urinary retention or established renal failure) indicates impaired renal perfusion and can guide fluid management 1

Special Considerations

• In children with coma and shock, human albumin solution may be considered as the resuscitation fluid of choice 1
• Isotonic fluids significantly decrease the risk of iatrogenic hyponatremia compared to hypotonic fluids (20.6% vs 5.1% at 24 hours) 5
• Current evidence shows that isotonic maintenance fluids do not increase the risk of hypernatremia compared to hypotonic fluids 6, 7, 5

Common Pitfalls and Caveats

• Avoid excessive fluid administration without evaluating response, as this can lead to fluid overload and pulmonary edema 4
• Static measurements like central venous pressure alone are not reliable guides for fluid resuscitation 3
• Recognize that the traditional approach of using hypotonic fluids for maintenance therapy has been associated with iatrogenic hyponatremia 8, 6
• Be aware that many hospitalized children may have increased ADH production on admission, increasing their risk of hyponatremia if given hypotonic fluids 6
• The distribution of body fluids in neonates differs from adults, but the principles of fluid resuscitation remain similar 3