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Indian Pediatr 2015;52: 442

Ideal Maintenance Intravenous Fluid in Children: Authorís Reply

Ahmar Shamim

Mahatma Gandhi Mission Medical College, Navi Mumbai, Maharashtra, India.
Email: ahmar_shamim@yahoo.com


Readers have raised some very valid points: our reply is as follows:

1. In our study [1], exclusions were made for the conditions that already have protocol-based management e.g. hyponatraemia, hypernatremia, shock congestive heart failure). Some of the conditions, were excluded to prevent sampling bias e.g. (pre-existing diuretic use or edema). Therefore, results of our study can be used for empirical fluid therapy in most sick children. However, large randomized trials with multiple arms may determine the appropriate empirical fluid therapy in remaining situations.

2. Energy expenditure in critically ill children has been found to be as low as 50- 60 Kcal/Kg/day, by indirect calorimetric measurements [2]. Fluid requirement is much less in critically ill children for a variety of reasons such as physical immobility, the use of muscle relaxants and sedatives, mechanical ventilation, and additional factors such as nonessential or facultative metabolism. Moreover, fluid requirement is further decreased because of inappropriate increase in arginine vasopressin which impairs the kidneyís ability to excrete free water.

3. There is enough evidence to support high incidence of hyponatremia with the use of 0.18% NaCl in 5% Dextrose as maintenance fluid. Therefore, we agree that its use is no longer justified in current pediatric practice.

Further studies with a larger sample size and an additional control arm using standard volume isotonic fluids may determine the overall benefit and safety of volume reduction and other queries not addressed by our trial.


1. Shamim A, Afzal K, Ali M. Safety and efficacy of Isotonic (0.9%) vs hypotonic (0.18%) saline as maintenance intravenous fluids in children: A randomized controlled trial. Indian Pediatr. 2014;51:969-74.

2. Briassoulis G, Venkataraman S, Thompson AE. Energy expenditure in critically ill children. Pediatr Crit Care Med. 2000;28:1166-72.


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