Algorithms for IV fluid therapy in children and young people in hospital

IV FLUID THERAPY IN CHILDREN

INTRODUCTION

Fluid and electrolyte therapy is an essential component of the care of hospitalized children, and a thorough
understanding of the changing requirements of growing children is fundamental in appreciating the many
important pharmacokinetic changes that occur from birth to adulthood. While there are many factors that
contribute to the fluid and electrolyte needs of children, approaching this therapy in a systematic, organized
fashion can help pharmacists meet ongoing as well as changing needs of the patient. Organizing fluid therapy
into maintenance, deficit, and replacement requirements, and then monitoring the patient for response to
therapy makes fluid therapy manageable

PURPOSES

 Whenever possible the enteral route should be used for fluids. These guidelines only apply to children
who cannot receive enteral fluids.
 The safe use of IV fluid therapy in children requires accurate prescribing of fluid and careful
monitoring
 Always check orders that you have written, and ensure that you double check on orders written by
other staff when you take over the child's care
 Incorrectly prescribed or administered fluids are potentially very dangerous. More adverse events are
described from fluid administration than for any other individual drug. If you have any doubt about a
child's fluid orders - ask a senior doctor.
 Remember to check compatibility of intravenous fluid with any intravenous drugs that are being co-
administered.

Assessment of fluid requirements: Unwell children (+/- abnormal hydration) 

How much Fluid?

 Hypovolaemia

Give boluses of 10-20ml/kg of 0.9% sodium chloride (normal saline), which may be repeated.

Do not include this fluid volume in any subsequent calculations

If required, administer an initial bolus(es) of fluid to correct intravascular depletion then:

 Algorithms for IV fluid therapy in children and young people in hospital
Maintenance plus
Deficit (dehydration guidelines), pluse Ongoing losses (dehydration guidelines)

Maintenance

This guideline should be used as a starting point and will need to be adjusted in ALL unwell children.

Generally 2/3 of maintenance rate should be used in unwell children unless they are dehydrated.  This is
because they are likely to be secreting anti-diuretic hormone (ADH), so will need less fluid.  Children with
meningitis or other acute CNS conditions will likely require additional fluid restriction – seek senior advice.

For fluid options in the dehydrated child see dehydration guidelines.

g) Full Maintenance (mL/hour)  2/3 maintenance(mL/hour)Most unwell children eg pneumonia,

Well child eg fasting for theatre 
meningitis

 20  13

 40  27

 50  33

 60  40

 65  43

 70  47

 75  50

 80  53

 85  57

 90  60

 95  63
 Algorithms for IV fluid therapy in children and young people in hospital
 100  67

REMEMBER to consider deficit and ongoing losses - especially in severe gastroenteritis, if there are drain
losses, ileostomies etc.

Fluid  Alter  Uses

native
names

 0.9% sodium chloride  Norma Initial

l saline Replacement of
Replacement of losses

 0.9% sodium chloride and 5% Glucose +/- 20mmol/L KCl Norma Maintenance hydration
l saline
with
glucos
e 

Plasma-Lyte148 and 5% Glucose   Maintenance

(contains 5mmol/L of potassium)  Replacement of deficit

Replacement of losses

Plasma-Lyte148 and 5% Glucose with 20mmol/L potassium Maintenance hydration - should o

for children with hypokalaemia
(15mmol/L of KCl will need to be added to a standard bag to bring the
concentration to 20mmol/L) Replacement of deficit

Replacement of losses

Which Fluid

Some good fluid solutions for sick children include: 

Consider whether potassium is required in the fluid.  This should be avoided, if possible, unless
premade fluid bags containing potassium are available.  Adding potassium to bags of fluid on the ward
is a safety risk.
 Algorithms for IV fluid therapy in children and young people in hospital
Hypotonic fluid (containing a sodium concentration less than plasma) is no longer recommended in children. 
These fluids have been associated with morbidity/mortality secondary to hyponatraemia.  Fluids that should
NOT be given include:

0.18% NaCl with 4% glucose +/- KCl 20mmol/L (or 4% and 1/5 NS) should NOT be given

Monitoring

 All children on IV fluids should be weighed prior to the commencement of therapy, and daily
afterwards. Ensure you request this on the treatment orders.
 Children with ongoing dehydration/ongoing losses may need 6 hourly weights to assess hydration
status
 All children on IV fluids should have serum electrolytes and glucose checked before commencing the
infusion (typically when the IV is placed) and again within 24 hours if IV therapy is to continue.
 For more unwell children, check the electrolytes and glucose 4-6 hours after commencing, and then
according to results and the clinical situation but at least daily.
 Pay particular attention to the serum sodium on measures of electrolytes. If <135mmol/L (or falling
significantly on repeat measures) see Hyponatraemia Guideline. If >145mmol/L (or rising
significantly on repeat measures) see Hypernatraemia guideline. 
 Children on iv fluids should have a fluid balance chart documenting input, ongoing losses and urine
output.

Special fluids

Outside the newborn period, do not use these fluids apart from exceptional circumstances and check
the serum sodium regularly10% Dextrose
Used in neonates (sometimes with additional NaCl). Used in ICU for patients under 12 months (with 0.45%
saline). Sometimes used by infusion in neonates and children with metabolic disorders. Check blood glucose
regularly.

15-20% Dextrose

Very occasionally used by infusion in children with metabolic disorders. Check blood glucose regularly.

25% and 50% Dextrose

Rarely required in children, misuse can cause severe adverse events. Only used in discussion with senior staff
as bolus or low volume infusions (1-2 ml/hr) to correct refractory hypoglycaemia.

Consider consultation with local paediatric team when:

 Algorithms for IV fluid therapy in children and young people in hospital
 Unsure of which fluid/how much fluid to use
 Electrolyte abnormalities
 Using a non-standard 'special' fluid

Consider transfer when:

Children with severe electrolyte or glucose abnormalities.

Children requiring care above the level of comfort of the local hospital.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal
Emergency Retrieval (PIPER) Service: 1300 137 650.

on Specific to RCH

odium chloride and 5% glucose +/- KCl (or 5% and ½ NS) should NOT be given.

n intravenous fluids need daily electrolyte monitoring. 

extrose should not be given outside the ICU or NNU setting without discussion with a consultant.

Additional notes

Calculating maintenance fluid:

Calculating Maintenance fluid rate:Most unwell children should have a restriced (2/3) maintenance rate
prescribed.  The basis from which calculations are made are detailed below

 daily fluid intake which replaces the insensible losses (from breathing, through the skin, and in the
stool)
 allows excretion of the daily production of excess solute load (urea, creatinine, electrolytes, etc) in a
volume of urine that is of an osmolarity similar to plasma.
 volume calculated per kilo.

weight Full Maintenance mls/day   mls/hour

 100 x wt  4 x wt

 1000 plus  50 x (wt-10)  40 plus  2 x (wt-10)

 Algorithms for IV fluid therapy in children and young people in hospital

 1500 plus  20 x (wt-20)  60 plus  1 x (wt-20) [S1] 

Provide fluid and electrolytes
Yes
enterally

100mls/hour (2400mls/day) is the normal maximum amount.

Note: There is often confusion about the difference between oral and iv fluid requirements for young infants.
The water requirement is identical for both routes of administration. The relatively low energy density of milk
means that infants need 150-200mls/kg/day to obtain adequate nutrition. That is why they pass more dilute
urine than older children.

No
Time-critical situation (for example, emergency,
A&E, theatre, criticalNocare)?

Algorithm 1: Assessment and monitoring

Does the patient Can the patient meet their fluid and/or electrolyte
Yes No
need fluid needs enterally?
resuscitation?

Is an accurate calculation of insensible losses

important (for example, weight above 91st centile, Consider using body surface
No
acute kidney injury, known chronic kidney disease Yes area to calculate IV fluid and
or cancer)? electrolyte needs

Algorithm 2: Fluid
resuscitation No
Measure blood glucose at least every 24 hours

Use body weight to calculate IV fluid and electrolyte

needs
Look for clinical dehydration and hypovolaemic
shock
Record assessment and monitoring criteria on the
fluid balance and prescription chart
Patient needs fluids for routine Patient has complex fluid or
maintenance electrolyte replacement or
abnormal distribution issues Measure more frequently if
Measure plasma electrolyte concentrations using
electrolyte disturbances exist
laboratory tests when starting IV fluids, and then at
least every 24 hours

Measure blood glucose more

Yes frequently than every 24 hours
Risk of hypoglycaemia?

Yes
Consider using point-of- care
testing for plasma electrolyte
concentrations and blood
glucose
Algorithms for IV fluid therapy in children and young people in hospital

Algorithm 3: Routine maintenance Algorithm 4: Replacement and

redistribution
 Algorithm 2: Fluid resuscitation

Term neonate, child or young person requires IV fluid

resuscitation?

No Yes

Pre-existing condition (for example,

cardiac or kidney disease)?

No Yes

Take into account pre- existing

conditions as smaller fluid volumes
may be needed

Use glucose-free crystalloids that contain

sodium in the range 131–
154 mmol/litre, with a bolus of 20 ml/kg over
less than 10 minutes for children and young
people, and 10–20 ml/kg over less than 10
minutes for term neonates

Algorithm 1: Assessment and

Reassess after bolus completed
monitoring

Seek expert advice (for example, from the

paediatric intensive care team) if 40–
60 ml/kg or more is needed as part of the initial
fluid resuscitation
 Algorithm 3: Routine maintenance

Measure plasma electrolyte concentrations and blood glucose when starting IV fluids (except
before most elective surgery) and at least every 24 hours thereafter

Term neonate aged 8 Child or young person

days or over*

Using body weight to calculate IV fluid

needs?
Calculate routine maintenance IV fluid rates using
the following as a guide:
From birth to day 1: 50–60 ml/kg/day No Yes
Day 2: 70–80 ml/kg/day
Day 3: 80–100 ml/kg/day
Day 4: 100–120 ml/kg/day
When using body surface Calculate routine maintenance IV
Day 5–28: 120–150 ml/kg/day
area to calculate needs, fluid rates for children and young
estimate insensible losses people using the Holliday–Segar
Is the neonate in a critical postnatal within the range 300– formula:
adaptation phase (for example respiratory 400 ml/m2/24 hours plus 100 ml/kg/day for the first 10 kg of
distress syndrome, meconium aspiration, urinary output weight
hypoxic ischaemic encephalopathy)? 50 ml/kg/day for the second 10 kg of
weight
20 ml/kg/day for the weight over 20
No Yes kg.
Be aware that over a 24-hour period,
males rarely need more than 2500
Initially use isotonic Give no or minimal ml and females rarely need more
crystalloids that sodium until than 2000 ml.
contain sodium in postnatal diuresis
the range 131– with weight loss
154 mmol/litre with occurs
5–10% glucose
Initially use isotonic crystalloids that contain sodium in
the range 131–154 mmol/litre

Risk of water retention associated with non-osmotic antidiuretic hormone secretion?

*For term neonates up to

7 days, use professional
N Y
judgement, taking into
o e
account:
• the individual
circumstances, and Consider either:
• for term neonates in the
 restricting fluids to 50–80% of routine
first days of life, a maintenance needs or
sodium content of 131–
 reducing fluids, calculated on the basis
154 mmol/litre may be
of insensible losses within the range
too high (or sodium may
300–400 ml/m2/24 hours plus urinary
not be needed) and a
glucose content of 5– output
10% may be too low.

Base any subsequent IV fluid prescriptions on the plasma electrolyte concentrations and blood glucose
measurements
Algorithm 4: Replacement and redistribution

Adjust the IV fluid prescription to account for existing fluid and/or electrolyte deficits
or excesses, ongoing losses or abnormal distribution

Consider isotonic crystalloids that contain sodium in the range 131–

154 mmol/litre for redistribution.

Need to replace ongoing losses?

No Yes

Use 0.9% sodium chloride

containing potassium to
replace ongoing losses

Base subsequent fluid composition on plasma electrolyte concentrations and blood

glucose measurements
Algorithm 5: Managing hypernatraemia (plasma sodium more than 145
mmol/litre) that develops during IV fluid therapy

If hypernatraemia develops, review the fluid status

Fluid status uncertain?

No Yes

Measure urine sodium

and osmolality

Evidence of dehydration?

No
If using an isotonic solution, consider Calculate the waterYes
deficit and replace it
changing to a hypotonic solution (for over 48 hours, initially with 0.9% sodium
example, 0.45% sodium chloride with chloride
glucose)

Yes
Ensure the rate of fall of plasma sodium does not exceed
12 mmol/litre in a 24-hour period

Hypernatraemia worsening or unresponsive?

No

Measure plasma electrolyte concentrations every 4–6 hours for the first 24 hours, and after this base the
frequency of further plasma electrolyte measurements on the treatment response
 Algorithm 6: Managing hyponatraemia (plasma sodium less than 135
mmol/litre) that develops during IV fluid therapy

Be aware that the following symptoms are associated with acute hyponatraemia:
Headache.
Nausea and vomiting.
Confusion and disorientation.
Irritability.
Lethargy.
Reduced consciousness.
Convulsions.
Coma.
Apnoea.

Hyponatraemia symptoms?

No Yes

Seek immediate expert advice (for example, from the

If a child is prescribed a hypotonic fluid, change to
paediatric intensive care team)
an isotonic fluid (for example, 0.9% sodium
chloride)
Consider a bolus of 2 ml/kg (maximum 100 ml) of 2.7%
sodium chloride over 10–15 minutes

If hypervolaemic or at risk of hypervolaemia,

restrict maintenance IV fluids by either: No
Symptoms still present after the initial bolus?
restricting maintenance fluids to 50–80% of
routine maintenance needs or
reducing fluids, calculated on the basis of Yes
insensible losses within the range 300–400
ml/m2/24 hours plus urinary output.
Consider a further bolus of 2 ml/kg(maximum of 100 ml)
of 2.7%plasma
Check sodiumsodium
chloride over
level the
and next 10–15
consider minutes
a third bolus of 2
ml/kg (maximum of 100 ml) of 2.7% sodium chloride over
10–15 minutes Symptoms still present after the second bolus?
Measure plasma sodium concentration at least hourly No
Yes

As symptoms resolve, decrease the frequency of plasma

sodium measurements based on the response to treatment

Ensure that the rate of increase of plasma sodium does not

exceed 12 mmol/litre per 24 hours