0.2% NaCl Should NOT Be Used for Treating Sodium Disorders in Children
0.2% sodium chloride (hypotonic saline) is contraindicated for treating sodium disorders in children and should be avoided in favor of isotonic solutions (0.9% NaCl) to prevent iatrogenic hyponatremia and its potentially devastating neurological complications. 1, 2
Evidence Against Hypotonic Solutions
Risk of Iatrogenic Hyponatremia
The majority of hospital-acquired hyponatremia in children is iatrogenic, caused primarily by administering hypotonic fluids to patients with elevated arginine vasopressin levels (common in postoperative states, volume depletion, pulmonary disease, and CNS conditions). 2
Over 50 cases of death or permanent neurological injury from hospital-acquired hyponatremia have been documented, with hypotonic fluid administration being the main contributing factor. 1
In children with gastroenteritis treated with hypotonic IV fluids (including 0.2% and 0.3% saline), 18.5% of initially isonatremic patients developed hyponatremia, with serum sodium dropping by an average of 5.7 mEq/L. 3
Neurological Complications
Hyponatremic encephalopathy can develop at mildly hyponatremic values in children with risk factors such as hypoxia or CNS involvement, making prevention through appropriate fluid selection critical. 2
Neurological damage from dysnatremias is usually preventable with proper fluid management. 1
Recommended Alternative: Isotonic Saline (0.9% NaCl)
Evidence Supporting Isotonic Solutions
Multiple prospective studies in over 500 surgical patients demonstrate that 0.9% sodium chloride effectively prevents postoperative hyponatremia, while hypotonic fluids consistently result in falling serum sodium levels. 1
The 2022 ESPNIC guidelines meta-analysis showed isotonic solutions (0.9% NaCl or balanced crystalloids) significantly reduce the risk of hyponatremia compared to hypotonic solutions in acutely and critically ill children. 4
In children with gastroenteritis, isotonic saline (0.9% NaCl with 20 mEq/L KCl) as both bolus and maintenance fluid prevented dysnatremia without causing hypernatremia, and significantly improved sodium levels in baseline hyponatremic patients. 5
Safety Profile
No cases of hypernatremia were documented when isotonic saline was used appropriately for maintenance and deficit replacement. 5
Isotonic solutions are effective regardless of baseline sodium status (hyponatremic or isonatremic). 5
Specific Clinical Scenarios
Acute Gastroenteritis
- Administer 20 cc/kg 0.9% isotonic saline as bolus, followed by 0.9% isotonic saline with 20 mEq/L KCl for maintenance plus deficit replacement. 5
Salt-Wasting Conditions (CKD with Polyuria)
- Children with obstructive uropathy or renal dysplasia require sodium supplementation at 1-5 mmol Na/kg/day, adjusted based on biochemistry. 4
- Home preparation of sodium chloride supplements using table salt is NOT recommended due to potential formulation errors that could cause hypo- or hypernatremia. 4
Infants on Peritoneal Dialysis
- All infants with CKD stage 5D on PD therapy should receive sodium supplements due to substantial sodium losses through ultrafiltration. 4
Hypertension in CKD
- Sodium restriction (1-2 mmol/kg/day, equivalent to 1,500-2,400 mg/day for a standard adult) is indicated for children with CKD and hypertension or prehypertension. 4
Critical Pitfalls to Avoid
Never use hypotonic solutions (0.2%, 0.3%, or 0.45% NaCl) as maintenance fluids in hospitalized children, particularly those with postoperative status, respiratory illness, CNS disease, or volume depletion. 1, 2
Do not treat symptomatic hyponatremic encephalopathy with fluid restriction alone—this is a medical emergency requiring hypertonic saline (3% NaCl at 2 cc/kg, maximum 100 cc as intermittent bolus). 2
Avoid assuming normal serum sodium levels rule out sodium depletion in salt-wasting conditions—supplementation may still be necessary. 4