BASIC SCIENCE

Paediatric fluid and

electrolyte therapy
guidelines

Importantly the NPSA wanted all stocks of 4% glucose with

0.18% saline removed from non-specialized areas and this
should now have happened (Table 2).

Postoperative fluid prescriptions e new regulations

The NPSA say that postoperative fluid prescriptions should never
include 4% glucose with 0.18% saline or 0.45% saline with 5%
glucose and outside the neonatal period can only be chosen from:

0.9% saline

0.9% saline with 5% glucose

Ringers lactate/Hartmanns solution

4.5% albumin.
For neonates 10% glucose with 0.18% saline and 0.45% saline
with 5% glucose remain options.

Anthony Lander

Abstract
The advice in this article is based on a multidisciplinary consensus
opinion generated by the Association of Paediatric Anaesthetists and
on a National Patient Safety Agency (NPSA) recommendation of March
2007 entitled Reducing the risk of hyponatraemia when administering
intravenous infusions to children. To this has been added advice from
our specialist hospital fluid policy.

Prescribing intravenous (IV) fluids

IV fluids should be prescribed with the same care and attention
as given to other drugs. No one prescribes analgesics when antibiotics are needed and no one should prescribe maintenance
fluids when replacement fluids are intended.
Fluids are given intravenously for the following four reasons:

circulatory support in resuscitating vascular collapse

replacement of previous fluid and electrolyte deficits

maintenance

replacement of ongoing losses.

Keywords Hyponatraemia; intravenous fluids; paediatrics

The National Patient Safety Agency (NPSA) Alert of 2007 was expected to bring about a widespread change in postoperative
maintenance fluid administration such that children would receive
solutions containing 0.9% saline or Hartmanns solution rather
than solutions containing 0.18% or 0.45% saline in glucose. Telephone surveys show that practice has changed such that 0.18%
saline has mostly been removed from wards but that the preferred
postoperative fluid is often 0.45% saline with 5% dextrose.
The potential benefit of the recommendations is that the
chances of serious error from bad prescribing will be reduced.
However, hypernatraemia or hyperchloraemia should be looked
for in those children having 0.9% saline or Hartmanns solution
for protracted periods and instances reported appropriately.

IV fluid prescriptions
Practice should be determined locally and ideally IV fluids should be
prescribed daily by the team involved in the childs care either at the
morning round or in the early evening before handover.
Fluids should not be being prescribed by the night team who
will not be as familiar with the patient unless the fluid management requires fine-tuning in response to the clinical situation
or as a result of investigations. Such a patient would then have
had a detailed and specific handover.

NPSA: The dangers of 4% glucose 0.18% saline

Potassium
Potassium 20 mmol/litre (0.15%) (10 mmol in each 500-ml bag)
should be included in maintenance fluids and in replacement
fluids unless there are specific contraindications. If there are
special reasons not to give potassium these should be detailed in
the notes. Potassium is not included in the first 24 hours of life
nor traditionally in the first 24 hours after surgery. However, it
will be given if Hartmanns solution is prescribed. Remember
that most potassium is intracellular and so a slightly lower serum
level than normal may indicate marked potassium depletion.

The NPSA reminded clinicians of the dangers of the use of lowsodium-containing fluids such as 0.18% saline with 4% glucose.
This fluid has always been inappropriate when used for resuscitation or when used to replace most fluid and electrolyte deficits or
when given at excessive rates when maintenance fluids were
intended. The risk is one of precipitating hyponatraemia which can
be fatal. Sadly even in university and tertiary centres local audits
have shown that inappropriate prescriptions like this are not rare.
Many surgeons have traditionally used 4% glucose with
0.18% saline as a maintenance fluid when given at appropriate
rates in well children based on their weight. This or 0.45% saline
with 5% glucose has been traditionally given at reduced rates in
the postoperative period.
The term isotonic is now to be considered in relation to the
tonicity of the electrolyte components of fluids. Thus 0.18% saline with 4% glucose and 0.45% saline with 5% glucose are now
to be considered hypotonic since the glucose is ignored.

Monitoring
Monitoring of the patients weight is important and particularly
helpful in managing rehydration. Urine specific gravity is also a
good guide to rehydration.
Daily electrolytes are mandatory in those solely on IV fluids
for more than a day. The electrolytes should be looked at in the
context of previous results and not simply in relation to the
normal values. Typically when the serum sodium falls fluid restriction is appropriate and when it rises fluid rates can be
increased. This is particularly relevant in managing fluids in the
postoperative period. A falling sodium is usually a sign of over
administration of fluid and not of giving too little sodium.

Anthony Lander PhD FRCS (Paed) DCH is a Consultant Surgeon at Birmingham Childrens Hospital, Birmingham, UK. Conflicts of interest:
none declared.

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BASIC SCIENCE

Normal water, electrolyte, energy and protein requirements

Body weight

Water
(ml/kg/day)

Sodium
(mmol/kg/day)

Potassium
(mmol/kg/day)

Energy
(kcal/kg/day)

Protein
(g/kg/day)

First 10 kg
Second 10 kg
Subsequent kg

100
50
20

2e4
1e2
0.5e1

1.5e2.5
0.5e1.5
0.2e0.7

75
75
30

3.00
1.50
0.75

Table 1

Circulatory support in shock

necessary followed by a slower correction of residual dehydration with an isotonic fluid, taking into account ongoing losses,
serum electrolytes and urine output.

The following fluids are appropriate for bolus administration at

10 or 20 ml/kg given over periods of up to 20 minutes:

0.9% saline

Ringers lactate or Hartmanns solution

blood

4.5% albumin

colloid or blood.
It is inappropriate to use low-sodium-containing fluids in these
situations. 0.18% saline or 0.45% saline in glucose is not to be
used for circulatory resuscitation. Hyponatraemia can result and
this can be fatal.
Monitoring is typically based on the clinical response, blood
pressure, capillary refill, blood gasses, etc. Serum electrolytes
should be checked in anyone needing circulatory resuscitation.

Maintenance fluid requirements in children

Maintenance fluid requirements are still to be calculated
according to the recommendations of Holliday and Segar
(Table 1). Table 1 is a starting point only and the individual
childs response to fluid therapy should always be monitored and
appropriate adjustments made.
In children outside the neonatal period 0.45% saline in glucose
or Hartmanns solution or 0.9% saline are options supported by the
NPSA. However, in the postoperative period it recommends not
using 0.45% saline. These fluids give more than the daily requirements of sodium, but the risks of this are considered to be less
than the risks of hyponatraemia if 0.18% saline is administered. Our
preferred fluid is Hartmanns solution since this gives less chloride.
In term neonates during the first 48 hours of life 10% glucose
should be given at a rate of 60 ml/kg/day unless there is a
clinical indication for increased or decreased fluid administration. Sodium would be added to IV fluids on day 2e3 depending
on renal function, serum sodium and weight.
From day 3 of life maintenance fluid should be 0.18% saline with
10% glucose given at a rate of 4 ml/kg/hour or 100e120 ml/kg/day.
Preterm babies or those under 2 kg may require higher rates of
administration and should be assessed at least daily by assessment of weight and electrolytes.

Correcting previous fluid and electrolyte deficits

However estimated, previous losses are typically between 5 and
15% of body weight. Sometimes the weight loss is accurately
known. The fluid used to replace this deficit should be isotonic
0.9% sodium chloride or Ringers lactate/Hartmanns solution.
A 15-kg child who is 5% dehydrated has a water deficit of 750 ml.
Audits have shown that it is not an uncommon misconception that
10% dehydration can be corrected by increasing maintenance fluid
rates by 10%! This is clearly incorrect.
Hypovolaemia, should be corrected with an initial fluid bolus
of 10e20 ml/kg of an isotonic fluid or colloid, repeated as

Commonly available crystalloid fluids

Fluid

Saline 0.9% (normal saline)

Saline 0.9% 0.15% KCl
Saline 0.9% 0.15% KCl 5% glucose
Hartmanns solution
Saline 0.45%, glucose 2.5%
Saline 0.45%, glucose 5%
Saline 0.18%, glucose 4%
Saline 0.18%, glucose 4%, 10 mmol KCl/500 ml (0.15%)
Glucose 5%
Glucose 10%
Saline 0.18%, glucose 10%
Glucose 20%

Isotonic
Isotonic
Isotonic
Isotonic
Hypotonic
Hypotonic
Hypotonic
Hypotonic
Hypotonic
Hypotonic
Hypotonic
Hypotonic

NaD
(mmol/litre)

KD
(mmol/litre)

ClL
(mmol/litre)

Energy
(kcal/litre)

Other

150
150
150
131
75
75
30
30
0
0
30
0

0
20
20
5
0
0
0
20
0
0
0
0

150
170
170
111
75
75
30
50
0
0
30
0

0
0
200
0
100
200
160
160
200
400
400
800

Lactate
0
0
0
0
0
0
0
0

Note: The tonicity ignores the glucose component. This is the view of the National Patient Safety Agency (NPSA).

Table 2
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Maintenance fluid requirements may need to be increased in

children with pyrexia, excess sweating, hypermetabolic states
such as burns or when radiant heaters or phototherapy is used.
There is no consensus on whether maintenance fluid requirements should be reduced in children on a paediatric intensive
care unit (PICU) who are sedated and ventilated with humidified
gases.
Simple calculations will show that the electrolyte requirements are met if 0.18% NaCl, 0.15% KCl is administered at
the prescribed rates. But the dangers of hyponatraemia are
considered to outweigh the benefits of restricting the sodium and
chloride content of the fluid.

Fluid rates in the postoperative period are still to be calculated

using Holliday and Segars formula, and may be restricted to
70% of full maintenance if required.
Ongoing losses from drains or nasogastric tubes should be
replaced with an isotonic fluid such as 0.9% sodium chloride.
It is possible that this change in practice may lead to high serum
chlorides and these should be monitored. Hyperchloraemia can
give rise to headaches, but it is less dangerous than hyponatraemia.
Oral fluids should be started and increased after surgery whilst
IV fluids are reduced and then discontinued. The rate at which
this happens depends upon the child and the surgery.

Monitoring of fluid therapy

Fluids given during operations

Serum electrolytes do not need to be measured in all preoperatively healthy children prior to elective surgery
where IV fluids are to be given for the duration of surgery
and for a short period thereafter.

If there has been bowel preparation or there is unshunted
hydrocephalus, electrolytes should be checked preoperatively

Serum electrolytes need to be measured preoperatively in
all children presenting for elective or emergency surgery
who require IV fluid to be administered prior to surgery.

Children should be weighed prior to fluids being prescribed.

Serum electrolytes should be measured every 24 hours in
all children on IV fluids or more frequently if abnormal.

Children should be weighed daily while on IV fluids unless
this is difficult.

A fluid input/output chart must be carefully maintained
and checked by the prescribing doctor.

During surgery the majority of children may be given fluids

without glucose. Blood glucose should be monitored.
Maintenance fluid used during surgery should be isotonic
such as 0.9% sodium chloride or Ringers lactate/Hartmanns solution.

Neonates in the first 48 hours of life should be given
glucose during surgery.

Preterm and term infants already receiving glucose-containing solutions should continue with them during surgery.

Infants and children on parenteral nutrition preoperatively
should continue to receive parenteral nutrition during
surgery or change to a glucose-containing maintenance
fluid and blood glucose monitored.

Children of low body weight (less than third centile) or
having prolonged surgery should receive a glucosecontaining maintenance fluid (1e2.5% glucose) or have
their blood glucose monitored during surgery.

Children having extensive regional anaesthesia with a
reduced stress response should receive a glucosecontaining maintenance fluid (1e2.5% glucose) or have
their blood glucose monitored.

All losses during surgery should be replaced with an
isotonic fluid such as 0.9% sodium chloride, Ringers
lactate/Hartmanns solution, a colloid or blood, depending
on the childs haematocrit.

In children over 3 months of age the haematocrit may be
allowed to fall to 25%. Children with cyanotic congenital
heart disease may need a higher haematocrit to maintain
oxygenation.

Common electrolyte derangements

Hyponatraemia

Hyponatraemia (serum Na <135 mmol/litre) may occur in
a number of situations, but is commonly seen when
inappropriate fluids have been administered or following
surgery with any fluid regime.

Low-sodium-containing (0.18% NaCl) (hypotonic) maintenance fluids are more likely to precipitate hyponatraemia
if fluids rates are inappropriately high.

Presenting features of hyponatraemia include seizures or
respiratory arrest. Headache is a consistent early sign of
hyponatraemia in adults, but is rarely reported in children.

Hyponatraemic encephalopathy should be managed as a
medical emergency on PICU.

Hyponatraemic seizures respond poorly to anticonvulsants
and initial management is to give an infusion of 3% sodium
chloride solution. One ml/kg of 3% sodium chloride will
normally raise the serum sodium by 1 mmol/litre. Serum Na
should be raised quickly until the child has regained consciousness and has stopped fitting or the serum Na is above
125 mmol/litre. The amount of Na required can be calculated
according to the following formula:

Postoperative fluid management

Some preoperative surgical conditions are associated with
increased antidiuretic hormone (ADH) production: empyema,
sepsis, shock, etc. Operative trauma, pain, nausea and vomiting
also contribute to ADH release.
The NPSA alert has recommended that 0.18% and 0.45% saline
in glucose should not be used for postoperative maintenance as
they may cause hyponatraemia due to retention of free water
released after metabolism of glucose from the solution.
It recommends that the following fluids alone should be prescribed:

0.9% saline

0.9% saline 5% glucose

Ringers lactate/Hartmanns solution

4.5% albumin.

SURGERY 31:12

mmol of Na required 130  present serum Na  0:6

 weight kg

Once seizures have stopped, a slower Na correction should
take place using 0.9% sodium chloride solution.

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BASIC SCIENCE

Asymptomatic hyponatraemia does not require active

correction with 3% sodium chloride solution. The dehydrated
child may be treated with enteral fluids or if not tolerated, with
IV 0.9% sodium chloride solution.

The child with asymptomatic hyponatraemia and normal or
increased volume status, if taking oral fluids should be volume restricted or if on IV fluids should have fluid administered at 50% of maintenance rate. If eating, salt can be added
to the food.

Removal of potassium from the body can be achieved by

giving 1 g/kg calcium resonium rectally or orally, by use of
furosemide 1 mg/kg or by dialysis or haemofiltration.
Calcium imbalance

Hypocalcaemia (corrected total Ca <2 mmol/litre or
<1.5 mmol/litre in neonates) may produce symptoms of
twitching and jitteriness, perioral, finger and toe paraesthesia, masseter and carpopedal spasm, prolonged QT interval and reduced cardiac contractility.

Immediate treatment is with 10% calcium gluconate 0.5
ml/kg to a maximum of 20 ml over 10 minutes or 10%
calcium gluconate 0.2 ml/kg to a maximum of 10 ml over
10 minutes. Warning: there is a danger of extravasation
causing tissue injury.

The central venous route should be considered for injection with continuous ECG monitoring during injection.

Calcium levels appear low in the newborn because of low
albumin levels. There is a normal physiological fall in calcium concentration after birth which rises after the second
day. Causes of hypocalcaemia in the newborn are encephalopathy, renal failure, Di George syndrome, disordered
maternal metabolism or maternal diabetes mellitus.

Hypernatraemia

Hypernatraemia (serum Na >150 mmol/litre) commonly occurs as a result of excessive water loss, restricted water intake
or an inability to respond to thirst. It may also occur in infants
given incorrectly made feeds. Hypernatraemia can be fatal.

Signs of hypernatraemia are more severe when it develops
rapidly or when the serum Na is greater than 160 mmol/
litre. Chronic hypernatraemia is often well tolerated
because of cerebral compensation.

The true degree of dehydration is often underestimated if
clinical signs alone are used compared to loss of weight.
Intravascular volume is often well preserved during the initial
stages.

The management of hypernatraemic dehydration consists
of initial volume replacement with 0.9% sodium chloride
given in boluses of 20 ml/kg to restore normovolaemia.

Complete correction should then be done very slowly over
at least 48 hours to prevent cerebral oedema, seizures and
brain injury. The serum Na should be corrected at a
reduction of no more than 12 mmol/litre/day with 0.45%
sodium chloride or 0.9% sodium chloride in glucose.

In hypernatraemic dehydration it is important to give
maintenance fluid alongside fluid to correct dehydration.

Pyloric stenosis: hypochloraemia correction

Children with pyloric stenosis typically present with a mild
hypochloraemic alkalotic dehydration. Resuscitation can be
based on the serum chloride in most children.
Calculate the chloride deficit and replace over 12e48 hours
depending on severity.
 

Chloride deficit 2=3  weight kg  110  Cl :
Use 0.9% saline 0.15% K (170 mmol Cl/litre) or 0.45% saline,
5% glucose 0.15% K (95 mmol Cl/litre).

Potassium imbalance

Hypokalaemia (serum K <3.5 mmol/litre) produces
symptoms of cramp, arrhythmias, reduced cardiac
contractility and paralytic ileus. If possible oral supplements of 3e5 mmol/kg/day should be given. Orange juice
and bananas are rich in potassium.

In severe hypokalaemia (serum K <3 mmol/litre), IV
correction should be no faster than 0.25 mmol/kg/hour
using a maximum peripheral concentration of 40 mmol/
litre KCl (as per British National Formulary for Children).
For a more rapid correction, the patient should be in PICU
and the infusion administered via a central line.

Hyperkalaemia (serum K >5.5 mmol/litre) causes skeletal
muscle weakness and electrocardiography (ECG) changes
when serum K is greater than 7 mmol/litre.

Immediate treatment of hyperkalaemia is to antagonize
membrane effects by giving 100 mg/kg of 10% calcium
gluconate. This equates to 0.5 ml/kg of a 10% solution (1
ml 10% calcium gluconate contains 0.22 mmol calcium)
Advanced Paediatric Life Support (APLS) recommendation).

Alongside this it is important to increase intracellular shift
of potassium by giving 1e2 mmol/kg of sodium bicarbonate, an infusion of 0.3e0.5 g/kg/hour of glucose with 1
unit of insulin for every 5 g of glucose or to give 2.5e5 mg
nebulized salbutamol (5 mg/kg in neonates IV).

SURGERY 31:12

Example: a 3.3-kg child is mildly dehydrated with a ClL of

85 mmol/litre:

deficit[2=333:33110L85[55 mmol ClL

This is contained in 55/170 [ 325 ml of 0.9% saline with
0.15% KD.
If this fluid is given at 180 ml/kg/day [ 25 ml/hour, the child
will receive 55 mmol ClL in 13 hours.
Alternatively if 0.45% saline, with 5% glucose and 0.15% KD is
used at 180 ml/kg/day, they will receive 55 mmol ClL in 23
hours.
If the serum chloride is then remeasured and the bicarbonate
checked, they will most likely be corrected.
When corrected use appropriate maintenance fluids, but continue
to replace nasogastric losses with 0.9% saline 0.15% KD.

Summary
Great care and respect should be given to IV fluid management. It
is important to understand the basic science, the risks and now
the national guidelines which have been outlined here and
expanded with other consensus statements.
A

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