Fluids%252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252520in%252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252525252520pediatrics

# Fluids in Pediatrics ## Overview Intravenous fluid therapy in pediatrics is divided into resuscitation (treating hypovolemia/shock) and maintenance (providing daily water/electrolytes). Evidence shifted significantly in 2018 (e.g., *NEJM* SMMART study) favoring isotonic crystalloids over hypotonic solutions to prevent hospital-acquired hyponatremia. ## Primary Indications * **Resuscitation:** Hypovolemic, septic, or distributive shock. * **Maintenance:** Patients unable to tolerate oral intake. * **Replacement:** Correcting ongoing losses (NG drainage, diarrhea) or pre-existing deficits. ## Adult Dosing * **Resuscitation:** 30 mL/kg isotonic crystalloid (NS or LR) boluses. * **Maintenance:** Varies by renal function and clinical state; typically 25–35 mL/kg/day. ## Pediatric Dosing **Maintenance (Holliday-Segar Method):** * 0–10 kg: 100 mL/kg/day. * 11–20 kg: 1000 mL + 50 mL/kg for each kg >10 kg. * >20 kg: 1500 mL + 20 mL/kg for each kg >20 kg. * *Note:* Often reported as hourly rates (divide total/24). Use isotonic solutions (e.g., D5-NS or D5-LR) rather than hypotonic solutions (e.g., 0.45% NaCl). **Resuscitation:** * Initial: 20 mL/kg isotonic crystalloid (NS or LR) bolus over 5–20 minutes. * Redosing: Repeat 10–20 mL/kg boluses guided by clinical exam (perfusion, capillary refill, mental status). * Maximums: No rigid cap if shock persists, but monitor for fluid overload and signs of pulmonary edema. ## Dose Adjustments * **Cardiac/Renal Impairment:** Reduce volume/rate to avoid fluid overload. * **Ongoing Losses:** Replace volume for volume (e.g., NG losses) using fluids matching the electrolyte composition of the lost fluid. ## Contraindications * **Severe Fluid Overload:** Pulmonary edema, congestive heart failure. * **Hypotonic fluids for maintenance:** Generally contra-indicated as maintenance in hospitalized children due to risk of iatrogenic hyponatremia. ## Adverse Effects * **Hyperchloremic metabolic acidosis:** Associated with large volumes of 0.9% NaCl (unbuffered). * **Fluid overload:** Hypertension, pulmonary edema, exacerbation of congestive heart failure. * **Electrolyte disturbances:** Hyponatremia (hypotonic fluids), hypernatremia (inappropriate replacement). ## Key Drug Interactions * **Incompatibility:** Many medications are physically incompatible with specific fluids (e.g., calcium-containing fluids with ceftriaxone or bicarbonate). Always consult Y-site compatibility charts. ## Monitoring * **Clinical:** Weight monitoring (daily), intake/output, heart rate, blood pressure, capillary refill, skin turgor, and signs of edema. * **Laboratory:** Serum electrolytes (Na, K, Cl), BUN/Cr, glucose (especially in neonates/infants), and acid-base status. ## Clinical Pearls * **Follow Facility Protocol:** Most institutions follow strict pediatric fluid guidelines; always defer to the specific policy of your facility. * **Isotonic Preference:** Standard of care for pediatric maintenance is now isotonic fluids (e.g., D5-0.9% NaCl or Plasmalyte). * **Glucose:** Infants and smaller children have limited glycogen stores; maintenance fluids should contain 5% dextrose (D5) to prevent hypoglycemia unless clinically contraindicated (e.g., DKA, where glucose may be variable). * **Avoid Over-Maintenance:** In cases of SIADH or cerebral edema, maintenance rates are often restricted to 50–75% of calculated needs. *** **Disclaimer:** This information is for educational purposes only. Intravenous fluid calculations and resuscitation protocols must be verified against current institutional policies, clinical guidelines (e.g., AAP or SCCM), and the patient's individualized clinical status. Consult a licensed pharmacist or medical professional before prescribing.