IV Fluid Running Rate for Pediatric Patients
For acutely and critically ill pediatric patients requiring IV maintenance fluids, use isotonic balanced solutions (0.9% NaCl with glucose) at restricted rates of 65-80% of the traditional Holliday-Segar formula to prevent hyponatremia and fluid overload, with daily monitoring of electrolytes and fluid balance. 1
Maintenance Fluid Rate Calculation
Traditional Holliday-Segar Formula (Baseline Reference)
The traditional calculation is based on weight: 1
- 0-10 kg: 100 mL/kg/day (or 4 mL/kg/hour)
- 10-20 kg: 1000 mL + 50 mL/kg/day for each kg above 10 kg (or 40 mL/hour + 2 mL/kg/hour for each kg above 10)
- >20 kg: 1500 mL + 20 mL/kg/day for each kg above 20 kg (or 60 mL/hour + 1 mL/kg/hour for each kg above 20)
Recommended Restricted Rates (Current Evidence-Based Practice)
For most acutely and critically ill children at risk of increased ADH secretion, restrict maintenance fluid to 65-80% of the Holliday-Segar calculated volume to prevent hyponatremia and fluid overload. 1
For children with heart failure, renal failure, or hepatic failure, restrict further to 50-60% of the Holliday-Segar volume. 1
Fluid Composition
Primary Recommendation
Use isotonic balanced crystalloid solutions (0.9% NaCl or balanced salt solutions like Ringer's lactate) with appropriate glucose supplementation for maintenance fluids. 1
The evidence strongly demonstrates that hypotonic solutions (such as 0.18% or 0.45% NaCl) increase the risk of hyponatremia in hospitalized children. 2, 3 One randomized controlled trial showed that hypotonic dextrose saline produced a significantly greater fall in plasma sodium (3.0 mmol/L difference, 95% CI 0.8-5.1) compared to normal saline. 2
Glucose Supplementation
- Provide sufficient glucose guided by at least daily blood glucose monitoring to prevent hypoglycemia 1
- Avoid excessive glucose to prevent hyperglycemia 1
- Typical glucose concentration: 5% dextrose in isotonic saline 1
Electrolyte Additions
Add potassium (20-40 mEq/L) to maintenance fluids once renal function is confirmed and serum potassium is known, using 2/3 KCl and 1/3 KPO4. 1
Initially withhold potassium, calcium, and phosphate from hydration fluids in patients at risk for tumor lysis syndrome or with hyperkalemia/hyperphosphatemia. 1
Specific Clinical Scenarios
Resuscitation vs. Maintenance (Critical Distinction)
For fluid resuscitation in shock states, administer isotonic crystalloid (0.9% NaCl) boluses of 20 mL/kg over 5-10 minutes, which can be repeated up to 60 mL/kg in the first hour based on clinical response. 4 This is separate from maintenance fluid calculations.
Diabetic Ketoacidosis (DKA)
Pediatric DKA patients should receive 2-3 L/m²/day (or 200 mL/kg/day if <10 kg) of one-quarter normal saline with 5% dextrose, with urine output maintained at 80-100 mL/m²/hour (4-6 mL/kg/hour if <10 kg). 1 Initial reexpansion should not exceed 50 mL/kg over the first 4 hours to minimize cerebral edema risk. 1
Tumor Lysis Syndrome Prevention
Administer vigorous hydration at 2-3 L/m²/day (or 200 mL/kg/day if <10 kg) IV with one-quarter normal saline/5% dextrose, maintaining urine output at 80-100 mL/m²/hour (4-6 mL/kg/hour if <10 kg). 1
Tube Feeding Rates (For Reference)
For continuous tube feedings (not IV fluids), initial rates vary by age: 1
- 0-1 year: Start 10-20 mL/hour, goal 21-54 mL/hour
- 1-6 years: Start 20-30 mL/hour, goal 71-92 mL/hour
- 6-14 years: Start 30-40 mL/hour, goal 108-130 mL/hour
- >14 years: Start 50 mL/hour, goal 125 mL/hour
Monitoring Requirements
Reassess patients receiving IV maintenance fluids at least daily for fluid balance and clinical status, with regular monitoring of electrolytes (especially sodium). 1
Monitor for signs of fluid overload including: 4
- Increased work of breathing
- Rales on auscultation
- Gallop rhythm
- Hepatomegaly
Calculate total daily fluid intake including all IV fluids, blood products, IV medications (infusions and boluses), arterial/venous line flushes, and enteral intake to prevent "fluid creep." 1
Critical Pitfalls to Avoid
Do not use hypotonic solutions (0.18% or 0.45% NaCl) for routine maintenance in hospitalized children, as they significantly increase hyponatremia risk. 1, 2, 3 The evidence over the past two decades consistently demonstrates this complication. 3
Do not apply full Holliday-Segar maintenance rates to acutely ill children with elevated ADH secretion, as this leads to fluid overload and hyponatremia. 1, 5 Critically ill children may require reductions of 40-50% from traditional recommendations. 5
Avoid alkalinization with sodium bicarbonate unless treating documented metabolic acidosis, as it may promote calcium phosphate precipitation. 1
Do not delay monitoring—check electrolytes and fluid balance daily at minimum, more frequently in unstable patients. 1