Pediatric Intravenous Fluid Therapy

- Recommendations

Table 3. Recommendations
A. Amount of maintenance Fluids
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
A	In pediatric patients, what is the appropriate amount of maintenance fluids required?	ESPGHAN/ ESPEN Starship Rch Starship Starship	A1. Normal maintenance* fluid requirements in children and infants beyond the neonatal period: (Holliday and Segar formula) A. the first 10 kg; 100 /kg/day (4ml/kg/hour) B. weight between 10 and 20 kg +50 ml/extra kg/d (+2 ml/extra kg/h) C. weight above 20 kg +20 ml/extra kg/d (+1 ml/extra kg/h) Sum total requirements A +B+ C. A2. 2/3 of normal maintenance rate should be used in most unwell children unless they are dehydrated()(*) *Normal maintenance rates are appropriate for well subjects. Most unwell patients secret excess ADH and need less water to avoid overload & hyponatremia. The following conditions are particularly associated with increased risk of excess ADH secretion and may need further restriction: - Acute CNS conditions: head injuries, CNS infections, tumors - Pulmonary conditions: pneumonia,mbronchiolitis, MV - Trauma & postoperative cases (33). A3. A 20-50% increase in maintenance fluids may be required in patients on radiant heaters. A4. Abnormal losses should be replaced as well. The losses of the preceding 4 hours should be replaced over the following 4 hours.(36) A5. A negative balance (intake below maintenance requirements) is suggested in patients with fluid overload.	Moderate Low Low Low	Strong Weak (conditional) Weak (conditional) Weak (conditional) Good practice statement

(*) Normal maintenance requirements are based on the assumptions of normal hydration status, normal

urine output and absence of abnormal losses.

(**) Maintenance fluids include fluids given from all sources including both oral/enteral and parenteral

routes

(***) Normal maintenance rates are appropriate for well subjects. Most unwell patients secret excess

ADH and need less water to avoid overload & hyponatremia. The following conditions are particularly

associated with increased risk of excess ADH secretion and may need further restriction:

- Acute CNS conditions: head injuries, CNS infections, tumors

- Pulmonary conditions: pneumonia, bronchiolitis, MV

- Trauma & postoperative cases (33)

(****) In patients with anuria and fluid overload, further fluid restriction may be needed. Maintenance

would consist of insensible losses (may be estimated as 300-400 ml/m2/24h) and urine volume (36,

Starship).

Table 4. Recommendations
B. Composition of maintenance fluids
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
B	In Pediatric patients, what is the appropriate composition of maintenance fluids?	AAP ESPGHAN/ESPEN NSW NSW Starship Rch. Starship NSW Starship NSW	B1. Isotonic solutions with appropriate potassium and dextrose are preferred in sick pediatric patients requiring maintenance IV fluids ()(); especially during the first 24h() B2. Fluids with 0.45% sodium chloride content or balanced electrolyte solutions may be considered alternatives B3. Maintenance potassium chloride at 20 mmol/L may be added unless arterial or venous K is greater than 5mmol/L. B4. A final mixture glucose concentration of 5% is recommended when no other source of carbohydrate is provided.()(***) B5. Different concentrations of glucose may be used: In children older than 6 months with any brain problem, glucose should only be added if required. A glucose concentration of 10% is suggested in infants below six months of age. A glucose concentration of 10% is required in Critically ill patients with acute hepatic failure or suspected in-born errors of metabolism.	High Low Moderate Moderate Low Low	Strong Weak (conditional) Strong Strong Weak (conditional) Weak (conditional) Good practice statement

(*) Maintenance fluids normally provide water, sodium, potassium & glucose.

(**) Although maintenance fluids have been prescribed with 30-40mEq/L sodium, matching recommended daily sodium intake (3mEq/ 100 Cal or 100 mL), such fluids are significantly hypotonic and may not be appropriate for acutely ill children as they increase the incidence of hyponatremia.

Isotonic fluids with sodium content similar to plasma are particularly preferred for patients who are at particularly high risk for hyponatremia (27); such as:

- ANY brain problem (32)

- Postoperative and critically ill (28)

- Congenital or acquired heart disease, liver disease, renal failure or dysfunction, adrenal

insufficiency; medication known to impair free-water excretion (27)

(***) This should not delay the initiation of PN if indicated (28). Glucose content of maintenance fluids prevents hypoglycemia & ketosis and may be required to maintain fluid osmolality when sodium content is low. It is neither intended nor sufficient as a source of energy. Nutritional support should be initiated as early as possible.

(****) Glucose concentrations refer to the final concentration in the fluid given.

() These recommendations are for INITIAL fluid prescription. Further fluid therapy should be guided by8measured plasma glucose & electrolytes (36).

Table 5. Recommendations
C. Fluid resuscitation
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
C	In pediatric patients with shock, when and how should fluid resuscitation be given?	ACCM (EAACI) (30) ACCM SSC (30) ACCM ACCM ACCM SSC (32)	C1. Patients with hypovolemic shock or distributive shock (including septic & anaphylactic shock) should receive fluid resuscitation: Amount: 20 mL/Kg per bolus, Type: isotonic crystalloid (eg normal saline) Duration: push or rapid infusion over 5-10 min C2. Patients with cardiogenic shock should only receive fluid resuscitation if they are judged to have preload insufficiency. Cardiac ultrasonography evaluation is recommended during such assessment. Patients with poor cardiac function may also be volume depleted. Smaller boluses (5-10 mL/kg) should be given more slowly (over 10-20 min) for these patients. C3. Fluid resuscitation should be avoided or discontinued when there is evidence of intravascular volume overload: During fluid resuscitation, monitor for the development of increased work of breathing, rales, hypoxemia, cardiac gallop rhythm, hepatomegaly or a diminishing MAP-CVP Initial volume resuscitation should be omitted if rales or hepatomegaly are present. C4. Fluid boluses may be repeated with the goal of normal perfusion, cardiac output and blood pressure provided there are no signs of fluid overload(*) A total of up to 60 mL/Kg may be needed during the first hour.	Moderate Moderate Moderate	Strong Good practice statement (39) (37) Good practice statement (40) Strong Strong

(*) Tests for volume responsiveness (e.g. passive leg rasing) can be used to judge the need for repeated fluid boluses.

Table 6. Recommendations
D. Management of dehydration
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
D	In pediatric patients with dehydration, what is the appropriate fluid management?	NICE (33) NSW	D1. Patients should be assessed for the presence & severity of dehydration and deficits should be replaced according to the degree of dehydration()() D2. Replacement should generally be over 24 hours; however: - Longer duration is required in cases of diabetic ketoacidosis (48h) or hypernatremia (48-72h) - Rapid rehydration over 3-6hrs (min. 6hrs in infants) may be used in cases with gastroenteritis except when rapid fluid administration needs to be avoided (eg heart failure, sodium disturbances) D3. 0.9% saline or a balanced electrolyte solution, with 5% glucose and appropriate potassium, is recommended for replacement of ongoing losses or dehydration. D4. Commercially available rehydration solutions with appropriate (20-30mmol/L) potassium may be an alternative (**)	Low	Good practice statement Good practice statement Weak (conditional) Good practice statement

(*) Total fluids given should cover maintenance requirements, replacement of deficit in dehydrated patients and replacement of ongoing losses (31,36). A negative overall balance may be needed in those with oedema/ overload or SIADH-hyponatremia.

(**) Water deficit can be calculated from the degree of dehydration (% body weight):

Total Deficit (mL) = weight (Kg) x % dehydration x 10 (31,36).

(***) Oral rehydration should be used when appropriate (41).

Table 7. Recommendations
E. Hypo/Hyper natremia
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
E	In pediatric patients with hypo/ hyper natremia, what is the fluid management?	ESPGHAN	E1. Treatment of hyponatremia must be based on the underlying cause. Corrections of severe hyponatremia should be slow, over at least 48- 72h ()()(). E2. Correction of hypernatremia should be addressed using free water replacement. In dehydrated patients, a hypotonic fluid (such as 0.45 saline), with appropriate glucose & potassium, should be given at 1.25-1.5 times normal maintenance (**)	Low	Weak (conditional) Good practice statement (42)

Hyponatremia is defined as plasma sodium less than 135 mmol/litre. Symptoms are most likely to occur with a plasma sodium of less than 125 mmol/litre, or if the plasma sodium has fallen rapidly, at which time the child may present with signs or symptoms of encephalopathy (26).

(*) The rate of correction should not exceed 0.5 mmol/l/h (36), although slower rates (8mmol/l/24h) have been recommended (42)

(**) The following symptoms may be associated with acute hyponatremia, or its development during IV fluid therapy: headache, nausea, vomiting, irritability, convulsions, impaired consciousness (lethargy, confusion, disorientation), coma and apnea.

(***) Hypertonic (2.7%) saline is recommended for emergency treatment of acute symptomatic hyponatremia. Fluid restriction alone is NOT recommended. A 2mL/kg bolus over 10-15 may be given and repeated once if symptoms persist. If symptoms remain after both boluses, check the plasma sodium level and consider a third bolus (36)

Hypernatremia is defined as plasma sodium greater than 145 mmol/litre. The risk of adverse events

increases with the level of sodium and symptoms are usually more noticeable with sodium of over 160 mmol/litre (26). Plasma sodium up to 150mmol/L does not require specific treatment.

(****) Sodium should not be allowed to fall by more than 0.5mmol/litre/hour (12mmol/L per 24 hours). (36).

Table 8. Recommendations
F. Monitoring
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
F	In Pediatric patients receiving IV fluids, what is the recommended monitoring?	RCh ESPGHAN RCh ESPGHAN	F1. Plasma glucose & electrolytes should be checked at the onset of IV fluid therapy() and at least daily(*). F2. Patients receiving IV fluids should be monitored for signs of dehydration, oedema/ overload, daily weight and fluid intake/ output	Moderate moderate	strong strong

(*) Except routine maintenance before elective surgery; unless needed in view of patient’s condition or type of surgery (36)

(**) Glucose & electrolytes must be rechecked within 6h after starting iv fluids in critically ill children, those with large losses or abnormal electrolytes (25). Checking should continue until IV fluids are <50% of normal maintenance (33)(36).