Indian Pediatr 2014;51: 964-966
Isnít it Time to Stop Using 0.18% Saline in
Dextrose Solutions for
Intravenous Maintenance Fluid Therapy in Children?
Praveen Narsaria and Rakesh Lodha
Department of Pediatrics, All India Institute of
Medical Sciences, Ansari Nagar, New Delhi 110 029, India.
aintenance intravenous fluids are integral in
management of sick children in whom enteral administration of fluids,
electrolytes and energy needs is not possible or feasible. This
maintenance fluid requirement has commonly been calculated on the basis
of Holliday and Segar formula , based on healthy childrenís energy
expenditure needs. This estimation may not be applicable for sick
children as they have alterations in fluid balance, renal sodium and
water handling. There are non-osmotic stimulants to vasopressin release
in sick children resulting in a tendency to free water retention by
kidney . These factors predispose sick children to hyponatremia and
fluid overload when given maintenance fluids and electrolytes using the
Holliday and Segar formula.
Hyponatremia is the most common dyselectrolytemia in
sick children; it can cause encephalopathy, death and permanent
neurological sequelae. Holiday and Segarís formula suggests adding 3 mEq
of sodium per 100 mL of water for infants; this is equivalent to
administering 0.18% normal saline, which is a hypotonic fluid and
predisposes to development of iatrogenic hyponatremia. However, many
pediatricians use the same fluid for older children as well, which is
inappropriate even by the Holiday and Segarís formula. There is
increasing evidence showing the risk of hyponatremia with administration
of hypotonic maintenance fluids in hospitalized children [3,4], but
hypotonic fluids still remain the most commonly prescribed fluids for
admitted children . While administration of hypotonic fluids alone
cannot explain hyponatremia , administration of isotonic maintenance
fluid is associated with reduced incidence of hyponatremia amongst
admitted children . It is noteworthy that hyponatremia is related
more significantly to the tonicity of administered fluid rather that
volume . Concerns regarding possibility of excessive sodium load and
volume overload with administration of isotonic maintenance fluid have
been allayed in various studies [7,8].
Fluid overload is associated with increased morbidity
and mortality amongst sick children, independent of abnormalities in
serum sodium levels . Maintenance fluid volume calculated using the
Holliday and Segar formula is based on normal urine output and energy
expenditure in children. It does not take into account the effect of
increased vasopressin level, reduced insensible fluid losses, reduced
energy expenditures and increased tendency to fluid retention in a sick
child. The formula consequently over-estimates the maintenance require-ments.
This may predispose children to harmful effects of iatrogenic fluid
overload, especially in circumstances such as Acute respiratory distress
syndrome. The maintenance fluid requirement should be individualized
based on energy expenditures, input-output balance and hemodynamic
In this issue of Indian Pediatrics, Shamin,
et al.  provide further evidence of increased incidence of
hyponatremia associated with commonly practiced method to calculate
daily maintenance fluid requirement in hospitalized children. In a
randomized controlled trial, the authors compared administration of
hypotonic fluid at volume calculated using the Holliday-Segar formula
with administration of isotonic fluid at 60% of the calculated volume.
They also found that children in hypotonic fluid group had a weight gain
as compared to isotonic fluid group who had weight loss, thus indicating
a fluid overload state.
The reason to highlight the above points is to
emphasize that the general approach to intravenous maintenance fluids is
now being questioned. The method of calculation of volume and
composition of maintenance fluids that has been used over half a century
is now being considered inappropriate for sick children. The concept of
a single formulation of fluid for all may be inappropriate, as each
child is different. Intravenous fluids should be tailored according to
childís need and condition. The intravenous fluid prescriptions should
be reviewed, based on electrolytes, fluid balance, hemodynamic status
and weight monitoring at frequent intervals. The National Patient Safety
Agency for England and Wales (UK) in 2007 published guidelines
recommending the use of 0.45% NaCl or 0.9% NaCl as maintenance
intravenous fluids, and to avoid 0.18% NaCl . Despite this
recommendation and growing evidence against use of hypotonic fluids,
practice has not changed much.
To conclude, hyponatremia and fluid overload are
common amongst hospitalized children and are associated with increased
morbidity and mortality. There is enough evidence supporting the
prevention of hyponatremia by use of isotonic maintenance fluids. It is
time that we stopped using hypotonic fluids, especially 0.18% saline in
5% dextrose for maintenance intravenous fluid therapy in children in
general pediatric care; the availability should be limited to critical
care units and specialist wards, for use in limited numbers of
scenarios. This information should be disseminated by the Academy; the
professionals involved in care of sick children also need to be informed
and trained adequately. At present, isotonic fluids are considered safe
for maintenance fluid therapy and the use of hypotonic fluid should be
completely curtailed, except in special circumstances where there is a
need to administer extra free water.
Funding: None; Competing interests: None
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