Maintenance IV Fluids for a 3-Year-Old
Use isotonic balanced crystalloid solution (Plain Lactated Ringer's or Plasma-Lyte) with added glucose and potassium, administered at 65-80% of the Holliday-Segar calculated volume to prevent hyponatremia while avoiding fluid overload. 1, 2
Fluid Composition
Isotonic balanced solutions are the standard of care for maintenance IV fluids in hospitalized children, strongly recommended by both the European Society of Pediatric and Neonatal Intensive Care and the American Academy of Pediatrics to reduce hyponatremia risk and slightly decrease length of stay. 1, 2
- Base solution: Plain Lactated Ringer's or Plasma-Lyte (isotonic balanced crystalloid) 2
- Glucose supplementation: Add dextrose in sufficient amounts to prevent hypoglycemia, typically 5% dextrose concentration 1, 2
- Potassium supplementation: Add potassium based on clinical status and regular monitoring to prevent hypokalemia 1, 2
- Do not add potassium until adequate urine output is confirmed
- Avoid routine supplementation of magnesium, calcium, phosphate, vitamins, or trace elements unless deficiency is present 1
Critical caveat: Do not use lactate-buffered solutions in children with severe liver dysfunction, as this may cause lactic acidosis. 1, 2
Volume Calculation
For a 3-year-old child (typically 12-16 kg), calculate maintenance volume using the Holliday-Segar formula: 2
- First 10 kg: 100 mL/kg/day = 1,000 mL
- Second 10 kg: 50 mL/kg/day (for remaining weight)
- Example for 15 kg child: (10 × 100) + (5 × 50) = 1,250 mL/day
However, administer only 65-80% of this calculated volume to prevent fluid overload and hyponatremia, particularly in acutely or critically ill children who are at risk of increased ADH secretion. 1, 2
- For a 15 kg child: 1,250 mL × 0.65-0.80 = 810-1,000 mL/day
- This translates to approximately 34-42 mL/hour
Further restriction to 50-60% of calculated volume is necessary for children with heart failure, renal failure, or hepatic failure to avoid edematous states. 1, 2
Total Fluid Accounting
Include ALL fluid sources when calculating daily maintenance totals to prevent "fluid creep": 1, 2
- IV maintenance fluids
- Blood products
- All IV medications (continuous infusions and bolus doses)
- Arterial and venous line flush solutions
- Any enteral intake
This comprehensive accounting does not include resuscitation fluids or massive transfusion volumes. 1
Monitoring Requirements
Daily reassessment is mandatory for all children receiving IV maintenance fluids: 1, 2
- Fluid balance calculation (intake minus output)
- Clinical status assessment (edema, perfusion, mental status)
- Electrolytes, especially sodium levels
- Blood glucose monitoring at least daily 1, 2
- Daily weights when feasible 4
Avoid cumulative positive fluid balance, as this is associated with prolonged mechanical ventilation and increased length of stay. 1
Preferred Route Consideration
Prioritize enteral or oral hydration if the child can tolerate it, as this reduces failure rates of vascular access, decreases costs, and may reduce length of stay. 1 Only use IV maintenance fluids when the enteral route is contraindicated or infeasible.
Common Pitfalls to Avoid
- Using hypotonic fluids (0.45% saline or 0.18% saline with dextrose) increases hyponatremia risk significantly compared to isotonic solutions 5, 6, 7
- Administering full Holliday-Segar volumes without restriction in hospitalized children, who typically have elevated ADH levels and reduced activity 1, 6
- Forgetting to account for all fluid sources including medication diluents and line flushes, leading to unintentional fluid overload 1
- Rapid administration of concentrated dextrose peripherally, which can cause phlebitis and thrombosis 3