Fluid Administration for a 20kg Child with Fever
Critical Distinction: Fever Alone vs. Shock
For a 20kg child with fever but no signs of shock, do NOT administer IV normal saline boluses—oral rehydration is preferred for mild-to-moderate dehydration, and routine IV fluid boluses are not indicated for fever alone. 1, 2
However, if the child shows signs of shock (altered mental status, poor perfusion, hypotension), immediately administer 400 mL (20 mL/kg) of normal saline as a rapid bolus over 5-10 minutes, then reassess. 1, 3
Resuscitation Dosing (If Shock Present)
- Administer 20 mL/kg boluses of 0.9% normal saline rapidly 1, 3
- For a 20kg child: 400 mL per bolus 3
- Initial rate: 5-10 mL/kg in the first 5 minutes (100-200 mL for this child) 3, 2
- Repeat boluses as needed until pulse, perfusion, blood pressure, and mental status normalize 3, 2
- Most children in shock require multiple boluses to achieve hemodynamic stability 3
Hemodynamic Targets for Reassessment
- For children 1-10 years, hypotension is defined as systolic BP <70 + (2 × age in years) mm Hg 3
- Monitor for improved perfusion, mental status, and urine output after each bolus 3
- Do not delay resuscitation while calculating exact weight—use estimated weight and administer 20 mL/kg boluses promptly 3
Maintenance Fluid Dosing (If No Shock)
If the child requires IV fluids for maintenance (e.g., unable to tolerate oral intake due to fever/illness but not in shock):
Use the 4:2:1 formula (Holliday-Segar): 3, 4
- First 10 kg: 4 mL/kg/hr = 40 mL/hr
- Second 10 kg: 2 mL/kg/hr = 20 mL/hr
- Total maintenance rate for 20kg child: 60 mL/hr or 1,440 mL per 24 hours 3
Use 0.9% normal saline (isotonic) rather than hypotonic solutions to prevent iatrogenic hyponatremia 3, 5, 6
Critical Monitoring Parameters
- Establish continuous vital sign monitoring during rapid fluid administration to identify complications 3, 2
- Monitor for signs of volume overload, particularly in patients with underlying cardiac or renal disease 3, 2
- Reassess frequently after each bolus to detect deterioration or inadequate response early 1
Common Pitfalls to Avoid
- Do not use maintenance rates for resuscitation—acute shock situations require rapid boluses (400 mL over 5-10 minutes), not slow infusions (60 mL/hr) 3
- Do not assume one bolus is sufficient—most children in shock require 2-3 boluses (800-1200 mL total for a 20kg child) 3
- Do not give routine IV fluid boluses for fever without shock—this practice is not supported and may cause harm 1
- Oral rehydration solution (ORS) is first-line for mild-to-moderate dehydration: 120-240 mL for each vomiting episode, up to approximately 1L per day 2
Evidence Considerations
The 2015 International Consensus on Cardiopulmonary Resuscitation recommends 20 mL/kg boluses for children with shock (sepsis, severe malaria, dengue shock syndrome) but suggests against routine bolus IV fluids for "severe febrile illness" without shock 1. This recommendation stems from the FEAST trial, which showed potential harm from routine fluid boluses in febrile children without clear shock in resource-limited settings 1. The American Academy of Pediatrics supports up to 30 mL/kg in the first hour for initial resuscitation when shock is present 3.