Clinical Guideline Highlights for the Hospitalist: Maintenance Intravenous Fluids in Infants and Children

Sources of Potential Conflict of Interest or Bias

The guideline was developed and funded by the AAP. A formal conflict of interest management policy was followed, and subcommittee members had no conflicts of interests or financial relationships relevant to the guideline to disclose.

Generalizability

Given the large number of patients included in the studies and heterogeneity of the population included, the recommendation applies to most patients cared for by pediatric hospitalists. Several patient exclusions relevant to the pediatric hospitalist deserve mention: neonates, kidney disease, and voluminous diarrhea. Neonates under the age of 28 days, including febrile neonates, are excluded from the guideline because of the immature concentrating abilities of neonatal kidneys. Patients with renal impairment were excluded from the guideline recommendation because several studies excluded patients with kidney disease. Hospitalists often care for children who sustain prerenal acute kidney injury from severe dehydration. In this condition, the kidney conserves water through the release of AVP. While an excluded population, these patients would be even more susceptible to develop hyponatremia if administered hypotonic fluids. Patients with “voluminous diarrhea” are excluded from the guideline because those with gastroenteritis with ongoing losses may require IVFs at rates higher than maintenance, and are particularly vulnerable to electrolyte derangements. The guideline, however, does not define voluminous diarrhea, leaving it to the discretion of the treating clinician.

Finally, it is critical to mention that IVF should be considered a therapy to be judiciously used, and discontinued when possible. While the guideline addresses the choice of fluid composition, alternatives to orally or enterally hydrate a patient are always preferred.

While the guideline strongly recommends isotonic fluids for maintenance therapy, the choice of isotonic fluid remains with the clinician. Most included studies used NS for their isotonic groups, but Hartmann’s solution and Plasmalyte were represented in a few studies. LR, one of the more widely used balanced solutions, though slightly hypotonic (130 mEq/L), was not studied. The exclusion of LR from the included studies is unfortunate, as the benefit of balanced solutions compared to NS after significant fluid resuscitation has been shown in the setting of severe sepsis and shock.⁷ Hyperchloremic metabolic acidosis after fluid resuscitation with NS has raised concern about continuing NS as maintenance fluid and possibly worsening acidosis or hyperchloremia and its adverse effects.⁸ Further studies on the potential benefit of LR as maintenance fluid, or the potential harms of unbalanced solutions as maintenance fluids in the setting of significant resuscitation are needed.

Disclosures

The authors have nothing to disclose.