Maintenance Fluid Recommendations for Pediatric Patients
Isotonic fluids (sodium 130-154 mEq/L) with appropriate dextrose and potassium should be used for maintenance intravenous fluid therapy in pediatric patients aged 28 days to 18 years. 1
Fluid Composition
The American Academy of Pediatrics strongly recommends isotonic solutions over hypotonic fluids because they significantly reduce the risk of hospital-acquired hyponatremia, which has caused over 50 deaths and significant neurologic morbidity in children. 1, 2
Specific Fluid Selection
Balanced crystalloid solutions (PlasmaLyte or lactated Ringer's) should be preferred over 0.9% sodium chloride because they reduce length of stay in both acutely and critically ill pediatric patients. 3, 2
Isotonic solutions contain sodium concentrations of 130-154 mEq/L, similar to plasma (135-144 mEq/L). 1, 3
Add 2.5-5% dextrose to prevent hypoglycemia, lipid mobilization, and ketosis. 2, 4
Add appropriate potassium chloride based on clinical status and regular monitoring to prevent hypokalemia. 1, 2
Volume Calculation
Use the Holliday-Segar Formula for standard maintenance rates: 2
- First 10 kg: 100 mL/kg/day (4 mL/kg/hr)
- Second 10 kg (10-20 kg): Add 50 mL/kg/day (2 mL/kg/hr)
- Each kg above 20 kg: Add 25 mL/kg/day (1 mL/kg/hr)
Volume Adjustments for High-Risk Patients
Restrict maintenance fluids to 65-80% of calculated Holliday-Segar volume in children at risk for increased ADH secretion, including those with: 3, 2
- Pneumonia or CNS infections
- Postoperative state
- Dehydration
Restrict to 50-60% of calculated volume in patients with heart failure, renal failure, or hepatic failure. 3
Monitoring Requirements
Check serum sodium and other electrolytes at least daily to detect hyponatremia or hypernatremia early. 2
Monitor blood glucose at least daily to guide glucose provision. 3, 2
Reassess fluid balance, clinical status, weight, and intake/output daily to avoid fluid overload. 3, 2
Critical Pitfalls to Avoid
Never use hypotonic fluids (sodium <130 mEq/L) as standard maintenance therapy. Hypotonic solutions significantly increase hyponatremia risk and have directly caused fatal hyponatremic encephalopathy in children. 1, 2, 5
Account for all fluid sources including IV medications, flushes, and blood products when calculating total daily intake, as "fluid creep" leads to unintended volume overload. 3, 2
Do not continue full maintenance rates in children with established fluid overload, oliguria, or ongoing ADH secretion. 3, 2
Evidence Quality
The recommendation for isotonic fluids is based on Level A evidence from well-designed randomized controlled trials and meta-analyses showing isotonic fluids reduce hyponatremia incidence from 16.7% to 7.5% compared to hypotonic fluids. 1, 5, 6
Excluded Populations
This guideline does not apply to: 1
- Neonates <28 days old or in the NICU
- Patients with neurosurgical disorders, congenital/acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns
- Adolescents >18 years old
These patients require individualized fluid management with close monitoring, though isotonic fluids may still be preferred with careful attention to volume. 1
Special Considerations
Hypotonic fluids may be required in rare situations including nephrogenic diabetes insipidus (to prevent hypernatremia), voluminous diarrhea, severe burns with free-water losses, or active correction of hypernatremia. 1
Patients on high-risk medications (desmopressin, carbamazepine, cyclophosphamide, vincristine) require isotonic fluids with particularly close sodium monitoring due to increased hyponatremia risk. 1