What types of intravenous (IV) fluids are recommended for maintenance in pediatric (peds) patients?

Maintenance IV Fluids in Pediatrics

Use isotonic balanced crystalloid solutions (sodium 131-154 mEq/L) with appropriate glucose and potassium chloride as first-line maintenance IV fluids for pediatric patients aged 28 days to 18 years. 1

Fluid Composition

Tonicity

• Isotonic solutions (sodium 135-154 mEq/L) are strongly recommended over hypotonic fluids to prevent hyponatremia, which significantly reduces morbidity and hospital length of stay 1
• Acceptable isotonic options include 0.9% sodium chloride (154 mEq/L), PlasmaLyte (140 mEq/L), or Hartmann solution (131 mEq/L) 1
• Balanced crystalloid solutions are preferred over 0.9% saline as they slightly reduce length of stay and avoid hyperchloremic acidosis 1, 2
• Hypotonic fluids (0.18%-0.45% saline) should be avoided as they significantly increase hyponatremia risk 1, 3

Essential Additives

• Add glucose (2.5%-5% dextrose) in sufficient amounts to prevent hypoglycemia, with at least daily blood glucose monitoring 1
• Add potassium chloride (1-3 mmol/kg/day) based on clinical status and regular potassium monitoring to prevent hypokalemia 1
• Ensure chloride intake is slightly lower than the sum of sodium and potassium (Na + K - Cl = 1-2 mmol/kg/day) to avoid metabolic acidosis 1

Volume Calculation

Standard Approach

• Use the Holliday-Segar formula as the baseline calculation method 1:
  • First 10 kg: 100 mL/kg/day (4 mL/kg/hour)
  • 10-20 kg: add 50 mL/kg/day (2 mL/kg/hour)
  • Above 20 kg: add 25 mL/kg/day (1 mL/kg/hour)

Volume Restrictions

• For patients at risk of increased ADH secretion (most acutely ill children), restrict maintenance fluids to 65-80% of calculated Holliday-Segar volume to prevent hyponatremia and fluid overload 1, 2
• For patients with heart failure, renal failure, or hepatic failure, restrict to 50-60% of calculated volume 1, 2
• Include ALL fluid sources in total daily calculations: IV medications, line flushes, blood products, and enteral intake (excluding resuscitation fluids) 1, 2

Monitoring Requirements

• Reassess fluid balance and clinical status at least daily 1, 2
• Monitor electrolytes, especially sodium, regularly (at least daily in critically ill patients) 1
• Avoid cumulative positive fluid balance and fluid overload to prevent prolonged mechanical ventilation and extended hospital stays 1, 2

Critical Exclusions

This guideline does NOT apply to:

• Neonates <28 days old or in the NICU 1
• Patients with neurosurgical disorders 1
• Congenital or acquired cardiac disease 1
• Hepatic disease or renal dysfunction 1
• Cancer, diabetes insipidus, severe burns, or voluminous diarrhea 1
• Adolescents >18 years old 1

Common Pitfalls

• Never use hypotonic solutions (0.18%-0.45% saline) as routine maintenance—this practice is outdated and dangerous 1, 3
• Avoid "fluid creep" by failing to account for all IV sources (medications, flushes, blood products) when calculating total maintenance volume 1, 2
• Do not use 0.9% saline exclusively when balanced crystalloids are available, as they reduce hyperchloremic acidosis risk 1, 2
• Avoid lactate-buffered solutions in severe liver dysfunction to prevent lactic acidosis 1