What is the recommended IV fluid (IVF) bolus and maintenance rate, as well as other admitting orders, for an 8-year-old male patient with moderate dehydration?

IV Fluid Management for 8-Year-Old Male with Moderate Dehydration

Initial Rehydration Strategy

For an 8-year-old with moderate dehydration requiring admission, administer oral rehydration solution (ORS) at 100 mL/kg over 2-4 hours as first-line therapy, reserving IV fluids only if ORS fails or the child cannot tolerate oral intake. 1, 2

Why ORS First?

• ORS is as effective as IV fluids for moderate dehydration and should be attempted before resorting to IV therapy unless severe dehydration, shock, altered mental status, or ileus is present 3, 4
• For moderate dehydration (6-9% fluid deficit), the recommended dose is 100 mL/kg ORS over 2-4 hours 2, 5
• If the child cannot tolerate oral intake but is not in shock, consider nasogastric administration of ORS 1, 3
• ORS therapy can be initiated 21 minutes faster than IV access and has comparable or better outcomes 4

IV Fluid Protocol (If ORS Fails or Cannot Be Given)

Bolus Therapy

If IV fluids are necessary due to ORS failure or inability to tolerate oral intake:

• Administer isotonic crystalloid (0.9% normal saline or lactated Ringer's) at 20 mL/kg bolus 1
• Reassess after each bolus for improvement in perfusion, mental status, and vital signs 1
• May repeat 20 mL/kg boluses as needed until clinical improvement 1

Maintenance IV Fluids

Once initial rehydration is achieved:

• Use isotonic fluids (0.9% saline with 5% dextrose) for maintenance therapy 1, 6
• Calculate maintenance rate using Holliday-Segar formula, but restrict to 65-80% of calculated volume to prevent hyponatremia in hospitalized children at risk of increased ADH secretion 1
• For an 8-year-old (assuming ~25 kg): Standard Holliday-Segar = 1600 mL/24h (100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for remaining 5 kg), so give 1040-1280 mL/24h (65-80% of calculated) 1
• Add potassium (20 mEq/L) to maintenance fluids after confirming adequate urine output and normal renal function 1

Critical Monitoring Points

• Monitor serum sodium at least daily while on IV fluids to prevent iatrogenic hyponatremia 1, 6
• Monitor blood glucose at least daily to prevent hypoglycemia or hyperglycemia 1
• Reassess fluid balance and clinical status at least daily, including weight, vital signs, and signs of dehydration 1, 2
• Account for ALL fluid intake including IV medications, line flushes, blood products, and enteral intake when calculating total daily fluids 1

Additional Admitting Orders

Ongoing Fluid Replacement

• Replace ongoing losses with ORS: For children >10 kg, give 120-240 mL ORS after each diarrheal stool or vomiting episode (up to ~1 L/day) 1, 2
• Continue replacement therapy until diarrhea and vomiting resolve 2, 3

Nutritional Management

• Resume age-appropriate diet immediately after initial rehydration is complete 1, 2
• Do NOT "rest the bowel" through fasting—this delays recovery 2
• Offer food every 3-4 hours 2
• After diarrhea stops, provide one extra meal daily for a week 2

Medications to Consider

• Ondansetron may be given to facilitate oral rehydration tolerance in children >4 years with persistent vomiting 2
• Probiotic preparations may help reduce symptom severity and duration 2
• Avoid antimotility drugs (e.g., loperamide) in all children <18 years 2, 3

Laboratory Monitoring

• Baseline electrolytes (sodium, potassium, chloride, bicarbonate), BUN, creatinine, glucose 1, 6
• Repeat electrolytes at least daily while on IV maintenance fluids 1, 6
• Daily weights to assess adequacy of rehydration 2

Common Pitfalls to Avoid

• Do not use hypotonic fluids (0.18% or 0.45% saline) as they increase risk of iatrogenic hyponatremia 1, 6
• Do not give excessive IV fluids—fluid overload and positive fluid balance prolong mechanical ventilation and length of stay 1
• Do not use popular beverages (apple juice, Gatorade, soft drinks) for rehydration due to high osmolality 1, 2
• Do not delay electrolyte monitoring—children on IV fluids require at least daily sodium checks 1, 6
• Do not automatically default to IV fluids—ORS has equivalent efficacy with fewer complications for moderate dehydration 4