Paediatric IV Fluid Therapy
NICE guideline [NG29] Intravenous fluid therapy in children and young people in hospital. Last updated: Jun 2020.
Assessment and Monitoring
Assessment
The following should be assessed and documented if neonates, children and young people who are receiving IV fluids
- Daily body weight (actual / estimated)
- Fluid input + output
- Fluid status
- Blood tests
- FBC
- U&E
- Blood glucose
- Urinary electrolyte concentrations
Body weight is considered one of the most reliable and practical markers of fluid status in paediatric patients.
Clinical Features
| Clinical dehydration | Hypovolaemic shock |
|---|---|
Red flags:
Other features:
|
Any of the following:
|
IV Fluid Therapy
Fluid Resuscitation
Choice of fluid: glucose-free crystalloids (most commonly used: 0.9% NaCl)
Fluid rate: 10 mL/kg over <10 min
Maintenance Fluid
Children and Young People
Choice of fluid: isotonic crystalloids (0.9% NaCl – most commonly used / Hartman's solution)
Calculate fluid requirement with the Holliday-Segar formula:
- First 10kg → 100 mL/kg/day
- Next 10kg → 50 mL/kg/day
- Weight over 20 kg → 20 mL/kg/day
Fluid requirement calculation example 1 (child weighing 8kg):
- Since the child weighs less than 10kg, only use the 100 mL/kg/day bit
- 100mL x 8 = 800 mL/day
Fluid requirement calculation example 2 (child weighing 25kg):
- First 10kg = 1000 mL/day
- Second 10kg = 500 mL/day
- Remaining 5kg = 5×20 = 100 mL/day
- Total: 1000 + 500 + 100 = 1600 mL/day
Neonates (≤28 days)
Choice of fluid: isotonic crystalloids (0.9% NaCl – most commonly used / Hartman's solution)
- From birth to day 7, 10% dextrose is usually used
Calculate fluid requirement based on their age:
| Age | Fluid requirement |
|---|---|
| Birth to day 1 | 50-60 mL/kg/day |
| Day 2 | 70-80 mL/kg/day |
| Day 3 | 80-100 mL/kg/day |
| Day 4 | 100-120 mL/kg/day |
| Day 5-28 | 120-150 mL/kg/day |
Hypernatraemia and Hyponatraemia Management
Hypernatraemia (that develops during IV fluid therapy)
Measure urine sodium and osmolality if fluid status is uncertain.
Manage according to fluid status:
- Hypovolaemic → calculate water deficit and replace with 0.9% NaCl
- Isotonic → consider changing to a hypotonic fluid (e.g. 0.45% NaCl with glucose)
When correcting hypernatraemia, ensure the rate of sodium reduction does NOT exceed 12 mmol/L per 24 hours due to the risk of cerebral oedema.
Hyponatraemia (that develops during IV fluid therapy)
Asymptomatic cases:
- If prescribed a hypotonic fluid → change to an isotonic fluid
- If hypervolaemic → restrict maintenance fluid to 50-80% of routine needs
Symptomatic cases:
- Give 2.7% sodium chloride (hypertonic) 2mL/kg over 10-15 min
- Monitor plasma sodium concentration at least hourly
When correcting hyponatraemia, ensure the rate of sodium does NOT increase more than 12 mmol/L per 24 hours due to the risk of osmotic demyelination syndrome (central pontine myelinolysis)