A new article published in Pediatrics discussed that maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons, such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state or being moribund from an acute or chronic illness.

The authors stated that despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia.

This article aimed to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings – including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded.

The guidelines specifically address the tonicity of maintenance IVFs in children. The Key Action Statement was – “The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia” (evidence quality: A; recommendation strength: strong).

It was also stated that in patients at high risk for developing electrolyte abnormalities, for instance, those who have undergone major surgery, who are in the ICU or those with large gastrointestinal losses or receiving diuretics, frequent laboratory monitoring may be necessary. If neurologic symptoms that could be consistent with hyponatremic encephalopathy are present, like unexplained nausea, vomiting, headache, confusion or lethargy, electrolytes should be measured.

Source: Pediatrics. 2018 Dec;142(6):e20183083. doi: 10.1542/peds.2018-3083.