Maintenance intravenous fluids in children

Key Points:

1. Hospitalized children should receive isotonic fluids such as 0.9% normal saline rather than hypotonic solutions for routine maintenance: This standard practice significantly reduces the risk of iatrogenic hyponatremia caused by non-osmotic antidiuretic hormone secretion.

2. Fluid choice must include 5% dextrose to provide necessary calories and prevent hypoglycemia during acute illness: Regular monitoring of serum electrolytes remains essential to ensure sodium and potassium levels stay within a safe physiological range.

The Risk of Hospital-Acquired Hyponatremia For decades, the standard of care for pediatric maintenance was hypotonic saline based on the Holliday-Segar formula. However, modern research has shown that acutely ill children are highly susceptible to non-osmotic release of antidiuretic hormone (ADH). Factors such as pain, nausea, fever, and post-operative stress trigger the body to retain free water. When hypotonic fluids (like 0.45% saline) are introduced into this environment, the excess free water dilutes the blood, leading to a rapid and dangerous drop in serum sodium.

Evidence-Based Shifts to Isotonic Solutions Major clinical trials and the 2018 American Academy of Pediatrics (AAP) guidelines have shifted the paradigm toward isotonic fluids like 0.9% normal saline (NS). Isotonic solutions have a sodium concentration similar to that of human plasma, which prevents the shift of water into the intracellular space. Studies have confirmed that using D5 NS significantly lowers the incidence of hyponatremic encephalopathy and seizures compared to D5 1/2 NS, without causing an undue increase in hypernatremia or fluid overload in the general pediatric population.

Clinical Application and Monitoring While D5 NS is now the recommended default for most children aged 28 days to 18 years, physicians must maintain vigilance. Maintenance therapy should always include dextrose to prevent catabolism and hypoglycemia, and potassium is usually added unless contraindicated by renal status. Individualization is required for neonates or those with significant cardiac or renal disease. Frequent reassessment of electrolyte panels and volume status ensures that the chosen fluid remains appropriate as the patient’s clinical condition evolves.

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