Guideline

Ministry of Health, NSW

73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059
Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/

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Standards for Paediatric Intravenous Fluids: NSW Health (second

edition)
space
Document Number GL2015_008
Publication date 31-Aug-2015
Functional Sub group Clinical/ Patient Services - Medical Treatment
Clinical/ Patient Services - Baby and child
Summary The Standards address the appropriate choice of IV fluids and measures
related to their procurement, storage and safe administration. The key
changes in the second edition of the Standards regarding the content of
IV fluids for children and neonates include: incorporating further evidence
supporting the use of isotonic saline solutions in IV maintenance therapy;
standardising the use of 1000mL bags in the care of children beyond the
specialist children's hospitals; and incorporating Special Care Nursery
practice and clarification around IV fluids for neonates.
Replaces Doc. No. Standards for Paediatric Intravenous Fluids: NSW Health [GL2014_009]
Author Branch NSW Kids and Families
Branch contact NSW Kids and Families 02 9424 5978
Applies to Local Health Districts, Specialty Network Governed Statutory Health
Corporations, Public Hospitals
Audience All medical and nursing staff and pharmacy and procurement staff
Distributed to Public Health System, Divisions of General Practice, NSW Ambulance
Service, Ministry of Health, Private Hospitals and Day Procedure Centres,
Tertiary Education Institutes
Review date 31-Aug-2020
Policy Manual Patient Matters
File No. H15/18617
Status Active

Director-General
 GUIDELINE SUMMARY

STANDARDS FOR PAEDIATRIC IV FLUIDS: NSW HEALTH

PURPOSE
Intravenous fluids are important components of appropriate care for hospitalised
children. Reports in the medical literature and warnings issued in other countries
have highlighted the risks associated with use of low sodium content fluids. The
importance of appropriate glucose content has also been identified.
The NSW Chief Paediatrician was tasked to engage clinical experts, HealthShare
and a range of other partners in the development of state wide standards across all
NSW facilities. The resulting Standards for Paediatric IV Fluids: NSW Health
addresses fluid content, bag size, labelling, administration, procurement and storage.
Emerging new evidence and clinical experience motivated an early revision of the
Standards, resulting in this second edition.

KEY PRINCIPLES
The intended outcomes of the first edition of the standards regarding the content of
IV fluids in children and neonates included:
• Reducing the risk of hyponatremia through increased sodium content and
limiting the use of low sodium containing fluids
• Addressing glucose requirements of children and neonates through increased
glucose content
• Consistent inclusion of potassium chloride as early as considered safe and
appropriate.
The key changes in the second edition of the Standards regarding the content of IV
fluids for children and neonates include:
• Incorporating further evidence supporting the use of isotonic saline solutions
in IV maintenance therapy
• Standardising the use of 1000mL bags in the care of children beyond the
specialist children’s hospitals
• Incorporating Special Care Nursery practice and clarification around IV fluids
for neonates
The Statement of the Standards for Paediatric Intravenous Fluids: NSW Health
(page 8) provides a summary of the recommended standards.

GL2015_008 Issue date: August-2015 Page 1 of 2

 GUIDELINE SUMMARY

USE OF THE GUIDELINE

The following priorities have been identified to facilitate the implementation of
Standards for Paediatric Intravenous Fluids: NSW Health (second edition) into all
relevant clinical areas; Communication, Education and Raising Awareness,
Integration into Practice, Procurement and Monitoring.

REVISION HISTORY
Version Approved by Amendment notes
August 2015 Deputy Secretary, Further evidence supporting the use of isotonic saline
(GL2015_008) Population and solutions in IV maintenance therapy in paediatrics.
Public Health
June 2014 Deputy Secretary, New evidence
(GL2014_009) Population and
Public Health

ATTACHMENTS
1. Standards for Paediatric Intravenous Fluids: NSW Health (second edition)

GL2015_008 Issue date: August-2015 Page 2 of 2

+PAEDIATRIC IV
Standards for

FLUIDS
Second Edition

GUIDELINE

Issue date: August 2015 GL2015_008

L2014_XXX Issue date: August 2014

Page 2 of 30
Revision due: August 2019
NSW Kids and Families
73 Miller Street
NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000
Fax. (02) 9391 9101
http://www.kidsfamilies.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an
acknowledgement of the source. It may not be reproduced for commercial usage or sale.

Reproduction for purposes other than those indicated above requires written permission from NSW Kids and Families.

© NSW Health 2015

SHPN: (NKF) 150412

ISBN is 978-1-76000-241-1(Print), 978-1-76000-242-8(Online)

Further copies of this document can be downloaded from www.kidsfamilies.health.nsw.gov.au

August 2015

A revision of this document is due in 2020

L2014_XXX Issue date: August 2014
Page 2 of 30
Revision due: August 2019
 Standards for Paediatric IV Fluids: NSW Health
(second edition)

CONTENTS
1. EXECUTIVE SUMMARY ................................................................................................... 1
2. INTRODUCTION ............................................................................................................... 2
3. FLUID CONTENT: INTENDED OUTCOMES .................................................................... 2
4. LABELLING ...................................................................................................................... 3
5. FLUID BAG SIZE AND INTRAVENOUS FLUID THERAPY ADMINISTRATION .............. 3
6. SAFETY ............................................................................................................................ 4
6.1. Additional Measures For Low Sodium Content Products .......................................... 4
6.2. Plasma-Lyte 148 ....................................................................................................... 4
7. DEVELOPMENT OF THE STANDARDS AND THE HEALTHSHARE NSW
CONTRACT....................................................................................................................... 4
8. SYSTEM-WIDE ENGAGEMENT ....................................................................................... 5
9. RELATIONSHIP WITH NATIONAL INTERIM GUIDELINES ............................................. 5
10. SUMMARY STATEMENT OF STANDARDS FOR PAEDIATRIC INTRAVENOUS
FLUIDS (Second Edition) ................................................................................................. 6
11. TABLE OF PAEDIATRIC INTRAVENOUS SOLUTIONS (Fluids incorporated in the
Summary Statement of Standards for Paediatric IV Fluids: NSW Health) ................... 7
12. APPENDICES ................................................................................................................... 8
12.1. Appendix 1 – Standards For Paediatric IV Fluids: NSW Health Working Group
And Implementation Taskforce Membership ............................................................. 8
12.2. APPENDIX 2 - Consultation Undertaken Formally With Relevant Organisations In
Developing The Standards For Paediatric IV Fluids: NSW Health (First Edition)..... 12
12.3. APPENDIX 3 – Labelling Practice ........................................................................... 13
12.4. APPENDIX 4 – Summary Table Of Stages In Development Of The Standards For
Paediatric IV Fluids ................................................................................................. 17
12.5. APPENDIX 5 – References..................................................................................... 18

GL2015_008 Issue date: August 2015 Contents Page

 Standards for Paediatric IV Fluids: NSW Health
(second edition)

1. EXECUTIVE SUMMARY
Intravenous fluids are important components of appropriate care for hospitalised children.
Reports in the medical literature and warnings issued in other countries have highlighted
the risks associated with use of low sodium content fluids. The importance of appropriate
glucose content has also been identified, and some evidence suggests risks associated
with high chloride in particular circumstances.
Individual or facility based responses to the changing literature, along with the interim
recommendations of a national expert group convened under the auspices of Children’s
Healthcare Australasia (CHA), had led to variable practices across NSW Health hospitals
with consequent inconsistencies and risks. The NSW Chief Paediatrician was tasked to
engage clinical experts, HealthShare NSW and a range of other partners in the
development of statewide standards across all NSW facilities. The resultant Standards for
Paediatric IV Fluids: NSW Health (first edition) addressed fluid content, bag size, labelling,
administration, procurement and storage.
The intended outcomes of the Standards (first edition) regarding the content of IV fluids in
children and neonates included:
 Reducing the risk of hyponatraemia through increased sodium content and limiting
the use of low sodium containing fluids
 Addressing glucose requirements of children and neonates through increased
glucose content
 Consistent inclusion of potassium chloride as early as considered safe and
appropriate.
Following the introduction of the first edition of the Standards, clinician expert feedback,
clinical incident reviews and product usage were closely monitored. Emerging new
evidence confirmed the safety and efficacy of the use of isotonic solutions for intravenous
fluid maintenance therapy in infants and children. The consequent early revision of the
Standards has led to a second edition.
While at the time of the publication of the first edition consensus was readily reached for
recommendations regarding fluid content across NSW, the proposed size of paediatric
fluid bags (500mL v 1000mL) was left to the discretion of Local Health Districts (LHDs)
and Speciality Health Networks (SHNs). The fluid types and volumes purchased following
the introduction of the Standards across the State were monitored and further discussions
followed. In the second edition consensus was reached by clinicians with regard to
paediatric fluid bag sizes of 1000mL. The safety concerns associated with the larger bags
for children were alleviated by the widespread and consistent use of IV pumps and inline
burettes. For neonates, 500mL bags (or less) continue to be recommended.
The key changes in the second edition of the Standards for Paediatric IV Fluids include:
 Incorporating further evidence supporting the use of isotonic saline solutions in IV
maintenance therapy
 Standardising the use of 1000mL bags in the care of children, beyond the specialist
children’s hospitals
 Incorporating Special Care Nursery practice and clarification of neonatal IV fluids
A succinct Summary Statement of the Standards presents the key messages and
related actions on a single page.

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 Standards for Paediatric IV Fluids: NSW Health
(second edition)

2. INTRODUCTION
Intravenous (IV) fluids are frequently used in hospitalised children, predominantly to
maintain hydration and haemodynamic stability as well as for glucose replacement.
Historically, low sodium content fluids have been used for both maintenance and deficit
replacement. However, burgeoning medical literature has highlighted the risk of
hyponatraemia with their use and the particular dangers of fluids with extremely low
sodium content1-9,15,16,18. A number of countries have issued warnings against this practice10-
12
. Increasingly, the published information1-12 supports the use of higher sodium content
isotonic fluids to prevent hyponatraemia10,16,18, as well as the need for adequate glucose
delivery to prevent hypoglycaemia6. Studies in critically ill adult patients13, as well as in
children15, have also suggested a preference for balanced salt solutions, as exemplified by
Plasma-Lyte148, to address risk of hyperchloraemia. As evidence continues to emerge
and best practice evolves, clinician discretion, informed by appropriate clinical and
laboratory data, is vital in all situations.
In response to the growing literature and in recognition of adverse events, clinicians
undertook to supplement existing manufactured fluids within paediatric facilities. This
practice introduced considerable risk of both dosing error and infection. A national expert
group was convened under the auspices of CHA and interim guidelines were developed
recommending appropriate fluid content. Commencing in 2010, the recommendations
were adopted by the Children’s Hospitals in NSW, who are members of CHA. They added
a further change to exclusively utilise the 1000mL bag size in order to improve both quality
and efficiency. Traditionally, 500mL bags have been used for children and neonates in
NSW, a distinguishing feature from adult practice. The resultant disconnect between the
Children’s Hospitals and other facilities highlighted the importance of standardisation of IV
fluids across all NSW services. The risks and confusion were compounded by the regular
rotations of junior medical staff and other workforce mobility as well as the very frequent
movement of patients between secondary and tertiary paediatric facilities. By the time of
the second edition of the Standards, the practice of 1000mL bags in paediatrics had
begun to extend beyond the Children’s Hospitals.

3. FLUID CONTENT: INTENDED OUTCOMES

The intended outcomes of the Standards (first edition) regarding the content of IV fluids in
children and neonates included:
 Reducing the risk of hyponatraemia through increased sodium content and limiting
the use of low sodium containing fluids
 Addressing glucose requirements of children and neonates through increased
glucose content
 Consistent inclusion of potassium chloride as early as considered safe and
appropriate

The key changes in the second edition of the Standards regarding the content of IV fluids
for children and neonates include:
 Incorporating further evidence supporting the use of isotonic saline solutions in IV
maintenance therapy

GL2015_008 Issue date: August 2015 Page 2 of 20

 Standards for Paediatric IV Fluids: NSW Health
(second edition)

 Standardising the use of 1000mL bags in the care of children, beyond the specialist
children’s hospitals
 Incorporating Special Care Nursery practice and clarification of neonatal IV fluids

4. LABELLING
Subsequent to the tendering process and contractual agreements completed by
HealthShare NSW, further consultation with the contracted manufacturers, Baxter
Healthcare Australia, was undertaken. This led to revisions of bag labelling practice with
substantial clarification and improvement. The important messages and changes in
labelling are highlighted in the Summary Statement of Standards and in Appendix 3.
The National Recommendations for User-applied Labelling of Injectable Medicines, Fluids
and Lines (Labelling Recommendations) aim to enhance patient safety with clear,
practical labelling and identify, what should be labelled, what should be included on the
label and where the label should be placed. The Labelling recommendations refer to user
(clinician) applied labels. All paediatric and neonatal intravenous fluids are to be labelled
as per the Labelling Recommendations17,19.

5. FLUID BAG SIZE AND INTRAVENOUS FLUID THERAPY

ADMINISTRATION
While consensus on fluid content across NSW was readily reached for the first edition of
the standards, the proposed size of the fluid bag (500mL v 1000mL) was more
contentious. The fluid types and volumes purchased following the introduction of the first
edition of the Standards across the State were monitored and movement towards 1000mL
bags was noted. The previous challenges to reach consensus to standardise fluid bag
sizes for children have been alleviated, as safety concerns have been addressed by the
widespread availability and consistent use of IV pumps and inline burettes for paediatric
IV fluid therapy. In the second edition consensus on paediatric fluid bag sizes was reached
by clinicians with 1000mL bags for use in children being consistently recommended.
This recommendation supersedes the prior Policy Directive PD2010_034, Section 3.3.11
mandate of 500mL bag size for all paediatric use. For neonates 500mL bags (or less)
continue to be recommended.
In accordance with NSW Health Policy Directive PD2010_034, Section 3.3.10: “Paediatric
infusion sets with an inline burette must be used for all children requiring intravenous
therapy. An infusion pump should be used in all children”. These aspects of the Policy
Directive are maintained and strongly reinforced. Current settings where variations of this
policy are recognised include Ambulance Service of NSW, operating theatres and acute
resuscitation scenarios. For the safety of paediatric and neonatal patients, the use of both
infusion pumps AND inline burettes is strongly recommended with all maintenance
and replacement fluids.
Fluids should be administered with the same caution that is used with any intravenous
drug, taking into consideration, the type, dose, indications, contraindications, potential for
toxicity, and cost13. IV fluids containing potassium chloride are potentially hazardous and
should be administered with extreme caution. Hourly observations of the IV fluids being
administered and IV cannula site should be documented on the NSW paediatric fluid
balance chart.

GL2015_008 Issue date: August 2015 Page 3 of 20

 Standards for Paediatric IV Fluids: NSW Health
(second edition)

6. SAFETY

6.1. ADDITIONAL MEASURES FOR LOW SODIUM CONTENT

PRODUCTS
An important development in the NSW Standards is deliberately restricting access to
extremely low sodium content products, such as 0.225%, 0.22% and 0.18% sodium
chloride. A 0.22(5)% sodium chloride product will continue to be used in neonatal practice
with 10% glucose. Accordingly, LHDs/ SHNs are being asked to ensure that such products
be stored only in dedicated maternity/neonatal storage unit. Since adult practice may also
include such products, it is proposed that discussions take place, informed by the broader
literature, to explore their potential future alignment with paediatric initiatives. In the
meantime, the manufacturers will take steps to ensure that the labels of any such
products include a warning regarding low sodium content.

6.2. PLASMA-LYTE 148

The Standards acknowledge the emerging evidence for the use of balanced salt solutions,
in particular, Plasma-Lyte 14813,15. This option is incorporated in the revised Standards as
an alternative for both maintenance and rehydration, but only under the direction of a
Specialist. The results of compatibility studies with Plasma-Lyte 148 and commonly used
medications are awaited to inform any firmer recommendations related to the use of
Plasma-Lyte148 in paediatric and neonatal care.

Plasma-Lyte 148 is the only form of Plasma-Lyte considered appropriate in children. It is

available with or without 5% glucose. Plasma-Lyte 148 and Plasma-Lyte 148 + 5%
glucose contain 5mmol/L potassium chloride. The need for a product with a higher
potassium chloride content is also under consideration.

7. DEVELOPMENT OF THE STANDARDS AND THE HEALTHSHARE

NSW CONTRACT
The NSW Chief Paediatrician was tasked to lead a process of consensus, standardisation
and appropriate implementation of practice across all NSW facilities. The process
undertaken included extensive consultation and input from a range of experts across
medical, nursing, pharmacy and management domains from a variety of metropolitan and
rural settings. The composition of the NSW Standards for Paediatric IV Fluids Working
Party, subsequent Implementation Taskforce and Committee memberships for the second
edition are detailed in Appendix 1. Formal organisational consultations are listed in
Appendix 2.
Partnering with HealthShare NSW in understanding and informing procurement
requirements was identified as an essential, albeit complex, component. HealthShare
NSW undertook a formal tendering process leading to an appropriate contract,
incorporating the recommended paediatric IV fluids. The contracted products are detailed
in Table 1. HealthShare NSW continues to provide procurement advice to Local Health
Districts (LHDs).
Following the introduction of the first edition of the Standards, clinician expert feedback,
clinical incident reviews and product usage were closely monitored. An Information

GL2015_008 Issue date: August 2015 Page 4 of 20

 Standards for Paediatric IV Fluids: NSW Health
(second edition)

Bulletin (IB2014_066) was published to advise clinicians and managers about the
products and address procurement challenges associated with the implementation of the
Standards. It is important to recognise that costs, and consequently pricing, will be
influenced by, and modified according to, consumption across NSW and nationally.
Emerging new evidence and clinical experience motivated the early revision of the
Standards, with the resulting second edition 15,16.

8. SYSTEM-WIDE ENGAGEMENT
The Standards described in this document address the appropriate choice of IV fluids and
measures related to their procurement, storage and safe administration. The Summary
Statement of Standards for Paediatric IV Fluids: NSW Health presents the key
messages and related actions on a single page (Page 6). These are not clinical practice
guidelines and do not address clinical assessment, calculations of fluid or electrolyte
requirements or their monitoring and appropriate responses to such data. It is noted,
however, that a number of existing clinical practice guidelines, educational resources and
other documents that specifically mention IV fluid content may need to be updated.
The NSW Paediatric IV Fluid Ordering chart is being revised to be consistent with the
Standards. The Paediatric IV Fluids education module in the Skills in Paediatrics (SkIP)
program is being revised. In addition, the DETECT Junior education resources (part of the
Between the Flags program) will be updated to reflect these Standards. The development
of any related resources by the Health Education and Training Institute (HETI) will also be
informed by these Standards. Educational resources related to the content and use of
Plasma-Lyte148 will be developed, as appropriate, to accompany future
recommendations for its use in paediatrics and neonates.
The related communication strategy includes correspondence to LHD Chief Executives,
SHNs, Pillars, clinician organisations as well as all partners engaged in the consultation
process.

9. RELATIONSHIP WITH NATIONAL INTERIM GUIDELINES

A number of changes have emerged from the CHA interim guidelines to the Standards for
Paediatric IV Fluids: NSW Health (first and second editions). These are summarised in
Appendix 4 In particular, while the CHA recommendations did not include neonatal
practice, the first edition of the Standards incorporated appropriate practice for neonates
presenting to emergency departments and/or readmitted to children’s wards. The practice
in special care and intensive care nurseries was not addressed in either document. The
second edition of the Standards incorporates special care nurseries but not intensive care
nurseries. Although CHA made certain recommendations for intra-operative and post-
operative fluid management, this is considered beyond the remit of the Standards at this
time. It is acknowledged that Hartmann’s Solution is used in peri-operative and intensive
care settings and balanced salt solutions are incorporated into the NSW Standards as
alternatives but only under the direction of medical specialists.

GL2015_008 Issue date: August 2015 Page 5 of 20

 Standards for Paediatric IV Fluids: NSW Health
10. SUMMARY STATEMENT OF STANDARDS FOR PAEDIATRIC INTRAVENOUS FLUIDS (Second Edition)
The purpose of these standards is to enable safe and appropriate use of IV fluids for children and neonates across NSW.
IV FLUID CONTENT
FOR CHILDREN (excluding neonates)
Specialist consultation recommended if prescribing for infants < 3 months, when neonatal
fluids may be more appropriate.
For Resuscitation / Bolus
• 0.9% sodium chloride
Alternatively and ONLY under direction of Specialist:
• other crystalloids, e.g. balanced salt solutions, or colloids may be used
For Replacement Fluids (dehydration or ongoing losses)
• 0.9% sodium chloride + 5% glucose +/- potassium chloride 20mmol/L
Alternatively and ONLY under direction of Specialist:
• Plasma-Lyte148 + 5% glucose
For Maintenance Fluids
• 0.9% sodium chloride + 5% glucose +/- potassium chloride 20mmol/L
Alternatively and ONLY under direction of Specialist:
• 0.45% sodium chloride + 5% glucose +/- potassium chloride 20mmol/L or
• Plasma-Lyte148 + 5% glucose
If electrolytes are outside the normal range, discussion with a specialist is necessary
IV FLUID CONTENT
FOR NEONATES (less than one month of age corrected)
For neonates in neonatal nurseries (excluding neonatal intensive care), or presenting to
emergency departments, or admitted to paediatric wards
For Resuscitation / Bolus
• 0.9% sodium chloride
For Replacement (dehydration or ongoing losses) or Maintenance
Special Care Nurseries - DAY 1
• 10% glucose
Special Care Nurseries – DAY 2 onwards
• 0.225% sodium chloride + 10% glucose +/- potassium chloride 10mmol/500mL
Emergency Departments
• 0.45% sodium chloride + 10% glucose (NO potassium chloride)
Paediatric Wards
• 0.45% sodium chloride + 10% glucose +/- potassium chloride 10mmol/500mL
If electrolytes are outside the normal range, discussion with a specialist is necessary
GL2015_008
(second edition)
IV FLUID BAGS PROCUREMENT AND USE
• It is strongly recommended that pre-packaged bags of appropriate IV fluids are available and
used with the correct concentrations of sodium, glucose and potassium, across all NSW facilities,
avoiding the practice of local additives, whenever possible.
• Fluids for children are recommended in 1000mL bags
• Fluids for neonates are recommended in 500mL bags
IV FLUID BAG LABELLING
• The content of the IV fluid bag will be clearly indicated in an easy to read font and a prominent
location on the IV fluid bag. Suitability for use in children will be indicated, where appropriate.
• IV fluids containing potassium chloride will clearly identify this additive.
• IV fluids containing 0.225%, 0.22% or 0.18% sodium chloride include a low sodium content warning.
• Bags used in children & neonates are expected to include ‘Infusion Pump Recommended’ on the label.
IV FLUID ADMINISTRATION
• NSW Health PD2010_034, states that “Paediatric infusion sets with inline burette must be used for all
children requiring intravenous therapy. An infusion pump should be used for all children”. For the
safety of paediatric and neonatal patients, both infusion pumps AND inline burettes are strongly
recommended with all maintenance and replacement fluids.
• All user-applied Labelling of Injectable Medicines, Fluids and Lines to follow the national Labelling
Recommendations.
• Hourly observations of the IV fluids and IV cannula site should be documented.
EDUCATION AND COMMUNICATION
• The Skills in Paediatrics (SkIP) education module is being updated.
• Relevant current education and information resources will be updated to reflect the second edition of
the Standards.
• The Standards are available via the NSW Kids and Families website.
ADDITIONAL SAFETY MEASURES
• If a child or neonate is prescribed IV Fluids not recommended in the Standards then please
clarify reason and document in medical notes.
• LHDs/ SHNs have been asked to ensure that, as a low sodium containing product for neonates,
0.225% sodium chloride should only be available with 10% glucose and be stored only in dedicated
maternity / neonatal storage unit.
• Fluids with 0.225%, 0.22% or 0.18% sodium chloride may continue to be used in adult practice but
should NOT be available for children.
• IV fluids containing potassium chloride are potentially hazardous and should be administered with
extreme caution.
Issue date: August 2015 Page 6 of 20
 Standards for Paediatric IV Fluids: NSW Health
(second edition)

11. TABLE OF PAEDIATRIC INTRAVENOUS SOLUTIONS (Fluids incorporated in the Summary

Statement of Standards for Paediatric IV Fluids: NSW Health)
CHILDREN NEONATES
Potassium Potassium
chloride 20mmol 20mmol chloride
10mmol 10mmol
5mmol

10% 10% 10% 10% 10%

Glucose 5% 5% 5% 5% 5% Glucose

Sodium
0.9% 0.9% 140mmol 0.9%

Sodium Chloride Sodium

chloride 0.45% 0.45% 98mmol 0.45% 0.45% chloride
0.22% 0.225%

Magnesium 1.5mmol Magnesium

Acetate 27mmol Acetate

Gluconate 23mmol Gluconate

1000mL 1000mL 1000mL 1000mL 1000mL 1000mL

Bag size 500mL 500mL 500mL 500mL 500mL 500mL Bag size

0.9% 0.9% 0.45% 0.45% Plasma-Lyte 0.9% 10% 0.22% 0.225% 0.45% 0.45%
Sodium Sodium Sodium Sodium 148 + 5% Sodium Glucose Sodium Sodium Sodium Sodium
chloride + chloride + chloride + chloride + Glucose Chloride (500mL) chloride + chloride + Chloride + chloride +
5% Glucose 5% Glucose 5% Glucose 5%+ (1000mL) (500mL or 10% 10% 10% 10%
(1000mL) + 20mmol (1000mL) Glucose 1000mL) Glucose Glucose + Glucose Glucose +
Potassium 20mmol (500mL) 10mmol (500mL) 10mmol
chloride Potassium Potassium Potassium
(1000mL) chloride chloride chloride
(1000mL) (500mL) (500mL)

Please refer to the latest iteration of the 904 contract Guide and the Product & Pricing Schedule for up-to-date product & pricing information.

For further information please contact your contract manager at: HSNSW -contract904@health.nsw.gov.au. Demand is to be monitored for future value proposals.

NSW Health Administration Corporation Contract 904 Intravenous and Parenteral Nutritional Fluids plus Irrigating Solutions

Suppliers: contact Baxter Healthcare Australia for sole supply fluids and Baxter Pharmacy Services for compounded fluids (please note that there are multiple suppliers on the 904 contract for glucose 10% 500mL & sodium chloride 0.9% 500mL & 1000mL fluids)

GL2015_008 Issue date: August 2015 Page 7 of 20

 Standards for Paediatric IV Fluids: NSW Health
(second edition)

12. APPENDICES
12.1. Appendix 1 – Standards for Paediatric IV Fluids: NSW Health
Working Group and Implementation Taskforce Membership

Committee membership (Second Edition)

Name Position
Prof Les White NSW Chief Paediatrician, NSW Kids and Families
Chair
Sandra Babekuhl Paediatric Clinical Nurse Consultant, Mid North Coast LHD
Peter Barclay Director of Pharmacy, Sydney Children’s Hospitals Network,
Westmead
Pauline Best Paediatric Nurse Educator, St George Hospital, SESLHD
Dr Srinivas Bolisetty Senior Staff Specialist, Newborn Services, Royal Hospital for Women
Dr Paul Craven Neonatologist, Hunter New England LHD
Dr Stuart Crisp Rural Paediatrician, Western NSW LHD
Mandy Crowley Baxter Healthcare
Deborah Endean Pharmaceutical Contracts Manager, HealthShare NSW
Dr Joanne Ging Head of General Medicine, Sydney Children's Hospitals Network,
Westmead
Dr Robert Guaran Neonatologist, NSW Pregnancy and newborn Services Network
Catherine Jones Standardisation of Care Coordinator, Paediatric Healthcare Team,
NSW Kids and Families
Margaret Kelly Senior Manager, Paediatric Healthcare Team, NSW Kids and
Families
Tina Kendrick Clinical Nurse Consultant, Newborn & paediatric Emergency
Transport Service
Gail Mondy Director, Maternal, Child & Family Health, NSW Kids and Families
Dr Rob Morton Rural GP, VMO, Southern NSW LHD
Dr Kristen Neville Endocrinologist, Sydney Children’s Hospitals Network, Randwick
Dr Susan Phin Staff Specialist, Emergency Department, Sydney Children's
Hospitals Network, Westmead
Tomas Ratoni Paediatric Clinical Nurse Consultant, Northern NSW LHD
Dr David Schell Intensivist, PICU, Sydney Children’s Hospitals Network, Westmead
Natalie Tasker Medication Safety Pharmacist, Sydney Children’s Hospitals Network
Jane Wardle Neonatal Clinical Nurse Consultant, Gosford Hospital, Central Coast
LHD
Ian Wright Professor of Paediatrics, Wollongong Hospital, Illawara Shoalhaven
LHD

GL2015_008 Issue date: August 2015 Page 8 of 20

 Standards for Paediatric IV Fluids: NSW Health
(second edition)

Neonatal IV Fluids sub-committee membership (Second Edition)

Name Position
Dr Paul Craven Neonatologist, Hunter New England LHD
Chair
Pauline Best Paediatric Nurse Educator, St George Hospital, South Eastern
Sydney LHD
Dr Srinivas Bolisetty Senior Staff Specialist, Newborn Services, Royal Hospital for Women
Dr Stuart Crisp Rural Paediatrician, Western NSW LHD
Dr Joanne Ging Head of General Medicine, Sydney Children’s Hospitals Network,
Westmead
Dr Robert Guaran Neonatologist, NSW Pregnancy and newborn Services Network
Dr Keith Howard Paediatrician, Hunter New England LHD/ Medical Lead Children’s
Healthcare Network, Northern

Catherine Jones Standardisation of Care Coordinator, Paediatric Healthcare Team,

NSW Kids and Families
Tina Kendrick Clinical Nurse Consultant, Newborn & paediatric Emergency
Transport Service
Dr Rob Morton Rural GP, VMO, Southern NSW LHD
Dr Matthew O’Meara Head of Emergency, Sydney Children’s Hospitals Network,
Randwick
Dr Susan Phin Staff Specialist, Emergency Department, Sydney Children's
Hospitals Network, Westmead
Tomas Ratoni Paediatric Clinical Nurse Consultant, Northern NSW LHD
Dr Robert Slade Paediatrician, Northern Sydney LHD/ Medical Lead Children’s
Healthcare Network, Southern

Helen Stevens Paediatric Clinical Nurse Consultant, Hunter New England LHD
Jane Wardle Neonatal Clinical Nurse Consultant, Gosford Hospital, Central Coast
LHD
Ian Wright Professor of Paediatrics, Wollongong Hospital, Illawarra Shoalhaven
LHD

GL2015_008 Issue date: August 2015 Page 9 of 20

 Standards for Paediatric IV Fluids: NSW Health
(second edition)

Working Group membership (First Edition)

Name Position
Dr Kristen Neville Endocrinologist, Sydney Children’s Hospitals Network, Randwick
Co-Chair
Dr Joanne Ging Clinical Director, Division of Women’s Children’s and Family
Co-Chair Health, Hornsby Ku-ring-gai Health Service, Northern Sydney
LHD
Prof Les White NSW Chief Paediatrician, NSW Kids and Families
Sponsor
Dr Chris Webber Deputy Medical Director, Newborn & paediatric Emergency
Transport Service and Emergency Physician, Sydney Children’s
Hospitals Network
Dr Damien McKay Chief Resident Medical Officer, Sydney Children’s Hospitals
Network, Westmead
Elizabeth Kepreotes Clinical Improvement Coordinator, John Hunter
Children’s Hospital, Kaleidoscope
Karyn Fahy Co-ordinator, Western Child Health Network
Pauline Best Paediatric Nurse Educator, St George Hospital, South Eastern
Sydney LHD
Peter Barclay Deputy Director of Pharmacy, Sydney Children’s Hospitals
Network, Westmead
Dr Richard Lennon Emergency Specialist, Royal North Shore Hospital, Northern
Sydney LHD
Dr Rob Morton Rural GP, VMO, Southern NSW LHD
Robert Pearce Director of Pharmacy, John Hunter Children’s Hospital, Hunter New
England LHD
Sandra Babekuhl Paediatric Clinical Nurse Consultant, Mid North Coast LHD
Dr Sean Kennedy Nephrologist, Sydney Children’s Hospitals Network, Randwick
Dr Stuart Crisp Rural Paediatrician, Western NSW LHD
Dr Susan Phin Staff Specialist, Emergency Department, Sydney Children’s
Hospitals Network, Westmead
Trish Boss Program Manager, Paediatric Services, Statewide and Rural
Health Services and Capital Development Branch, NSW
Ministry of Health (MoH)
Dr Bruce King Endocrinologist, John Hunter Children’s Hospital, Hunter New
England LHD

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Implementation taskforce membership (First Edition)

Name Position
Prof Les White NSW Chief Paediatrician, NSW Kids and Families
Chair
Roger Oswald Team Leader, Business Procurement Services, HealthShare NSW
Deborah Endean Pharmaceutical Contracts Manager, HealthShare NSW
Dr Kristen Neville Endocrinologist, Sydney Children’s Hospitals Network, Randwick
Dr Joanne Ging Clinical Director, Division of Women’s Children’s and Family
Health, Hornsby Ku-ring-gai Health Service, Northern Sydney
LHD
Trish Boss Program Manager, Paediatric Services, Statewide and Rural
Health Services and Capital Development Branch, NSW
Ministry of Health
Peter Barclay Deputy Director of Pharmacy, Sydney Children’s Hospitals
Network, Westmead

Sandra Babekuhl Paediatric Clinical Nurse Consultant, Mid North Coast LHD
Dr Rob Morton Rural GP, VMO, Southern NSW LHD
Dr Stuart Crisp Rural Paediatrician, Western NSW LHD
Pauline Best Paediatric Nurse Educator, St George Hospital, South Eastern
Sydney LHD
Margaret Kelly Greater Eastern and Southern Child Health Network

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12.2. APPENDIX 2 - Consultation Undertaken Formally With Relevant

Organisations in Developing the Standards for Paediatric IV
Fluids: NSW Health (First Edition)

Position Organisation
Chief Executive Ambulance Service of NSW
Chair Anaesthetic Advisory Group
Medical Science Liaison, Baxter Healthcare Australia Pty Ltd
Medication Delivery; Market
Manager, Medication Delivery;
Business Manager
Chief Executive Children’s Healthcare Australasia
Chief Executive Clinical Excellence Commission
Pharmaceutical Contracts Manager; HealthShare NSW
Team Leader Business Procurement
Services

Chair Metropolitan Level 4 Paediatric Units

State Director Newborn and paediatric Emergency Transport
Service
Coordinators and CNCs NSW Children’s Healthcare Network
Chief Pharmacist NSW Health
Chair NSW Health Forms Committee
Operations Manager NSW Pregnancy and newborn Services Network
Chair NSW Rural Doctors Network
Chair Paediatric Intensive Care Advisory Group
Chair Pharmacy Advisors Group, NSW Ministry of Health
President Rural Doctors Association
Director Critical Care Sydney Children’s Hospitals Network, Randwick
Director of Anaesthesia Sydney Children’s Hospitals Network, Westmead

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12.3. APPENDIX 3 – Labelling practice

For base fluids (proposed label with paediatric advisory statement*)

Advisory statements
added for paediatrics

Reverse printing in product

label to differentiate from
other solutions

Batch, expiry and recyclable symbol denoted here

* Product label for AHB1064 as it currently appears in the Paediatric Standards is not an approved TGA product label

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For high risk additives

Emphasis on high-risk
active ingredient

Barcode added

Red ink to be used to

highlight potassium
content

Advisory statements
added for paediatrics

Critical information moved Standardisation of units

to the bottom which remains used, keeping in mind TGA
visible as the bag empties requirements for future
registration

Batch, expiry and recyclable symbol denoted here

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For low sodium solutions

Australian made symbol

added

Cautionary statement
differs for low sodium
containing solutions

Batch, expiry and recyclable symbol denoted here

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 Standards for Paediatric IV Fluids: NSW Health
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For balanced salt solutions

The new format

minimises label
clutter, placing
emphasis on
important clinical
information such
as solution
ingredients,
concentration and
tonicity.

Batch, expiry and recyclable symbol denoted here

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12.4. APPENDIX 4 – Summary table of stages in development of the Standards for Paediatric IV Fluids
st
Indication CHA Recommendation NSW Standards for Paediatric IV Fluids (1 Edition) NSW Standards for Paediatric IV Fluids (2nd Edition)
Resuscitation/ 0.9% sodium chloride or 0.9% sodium chloride 0.9% sodium chloride
Bolus Hartmann’s (NO glucose) OR
Alternatively and ONLY under direction of Specialist:
Hartmann’s Solution or Plasma-Lyte 148 (NO glucose)
 other crystalloids, e.g. balanced salt solutions, or colloids may be used

Replacement 0.9% sodium chloride +5% 0.9% sodium chloride +5% glucose +/-20mmol/L potassium chloride OR 0.9% sodium chloride + 5% glucose +/- potassium chloride 20mmol/L
(dehydration or glucose +/-20mmol/L potassium
ongoing losses) chloride Plasma-Lyte148 + 5% glucose (Children’s Hospitals only) Alternatively and ONLY under direction of Specialist:
 Plasma-Lyte148 + 5% glucose

If electrolytes are outside the normal range, discussion with a specialist is necessary

Maintenance 0.45% sodium chloride +5%
glucose +/-20mmol/L potassium
chloride
0.45% sodium chloride + 5% glucose +/- 20mmol/L potassium chloride
(note discretionary use of potassium chloride consistent with CHA recommendation)
OR especially where there is pre-existing hyponatraemia, or non-osmotic ADH
secretion (e.g. post-op, respiratory, CNS disease)
0.9% sodium chloride + 5% glucose +/- potassium chloride 20mmol/L
Alternatively and ONLY under direction of Specialist:
 0.45% sodium chloride + 5% glucose +/- potassium chloride 20mmol/L,
 or Plasma-Lyte148 + 5% glucose

0.9% sodium chloride + 5% glucose +/- 20mmol/L potassium chloride OR Plasma- If electrolytes are outside the normal range, discussion with a specialist is necessary
Lyte148 + 5% glucose (Children’s Hospitals only)

Peri and intra- 0.9% sodium chloride +1% 1% glucose solutions NOT supported
operative period glucose
Further consultation with paediatric anaesthetic professional and state organisations No change from 1st Edition
recommended. Hartmann’s solution often used peri-operatively.

Neonates (<1 month corrected) (The 2nd Edition Standards for Paediatric IV Fluids: NSW Health incorporates Special Care Nursery practices (not NICU)
Resuscitation/ 0.9% sodium chloride or 0.9% sodium chloride
Bolus Hartmann’s (NO glucose) 0.9% sodium chloride

Replacement No recommendation 0.45% sodium chloride +10% glucose +/- 20mmol/L potassium chloride OR Special Care Nurseries - DAY 1
10% glucose
(dehydration or 0.9% sodium chloride +10% glucose +/- 20mmol/L potassium chloride may be used
ongoing losses) Special Care Nurseries – DAY 2 onwards
with expert supervision. 0.225% sodium chloride + 10% glucose +/- potassium chloride 10mmol/500mL

Maintenance No recommendation (Day1-3) 10% glucose Emergency Departments

(>3 days) 0.225% sodium chloride +10% glucose +/- 20mmol/L potassium chloride OR
0.45% sodium chloride +10% glucose +/- 20mmol/L potassium chloride, where there is
pre-existing or risk of hyponatraemia or non-osmotic ADH secretion (e.g. post-op,
respiratory, CNS diseases).
0.45% sodium chloride + 10% glucose (NO potassium chloride)
Paediatric Wards
0.45% sodium chloride + 10% glucose +/- potassium chloride 10mmol/500mL
If electrolytes are outside the normal range, discussion with a specialist is necessary

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12.5. APPENDIX 5 – References

1. Moritz ML, Ayus JC. Prevention of Hospital-Acquired Hyponatremia: A Case for Using
Isotonic Saline. Pediatrics, 2003;111(2):227-30.
2. Neville KA, Verge CF, Rosenberg AR, O’Meara MW, Walker JL. Isotonic is better than
hypotonic saline for intravenous rehydration of children with gastroenteritis: a
prospective randomised study. Archives of Disease in Childhood, 2006;91(3):226-32.
3. Choong K, Kho ME, Menon K, Bohn D. Hypotonic versus isotonic saline in hospitalised
children: a systematic review. Archives of Disease in Childhood, 2006;91(10):828-35.
4. Montañana PÁ, Modesto i Alapont V, Ocón AP, López PO, López Prats JL, Toledo
Parreño JD. The use of isotonic fluid as maintenance therapy prevents iatrogenic
hyponatremia in pediatrics: A randomized, controlled open study. Pediatric Critical
Care Medicine, 2008;9(6):589-97.
5. Yung M, Keeley S. Randomised controlled trial of intravenous maintenance fluids.
Journal of Paediatrics and Child Health, 2009;45(1-2):9-14.
6. Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL.
Prevention of Hyponatremia during Maintenance Intravenous Fluid Administration: A
Prospective Randomized Study of Fluid Type versus Fluid Rate. The Journal of
Pediatrics, 2010;156(2):313-9.
7. Drysdale S, Coulson T, Cronin N, Manjaly Z-R, Piyasena C, North A, et al. The impact
of the National Patient Safety Agency intravenous fluid alert on iatrogenic
hyponatraemia in children. Eur J Pediatr, 2010;169(7):813-7.
8. Moritz M, Ayus J. Improving intravenous fluid therapy in children with gastroenteritis.
Pediatr Nephrol, 2010;25(8):1383-4.
9. Moritz ML, Ayus JC. Prevention of Hospital-Acquired Hyponatremia: Do We Have the
Answers? Pediatrics, 2011;128(5):980-3.
10. National Patient Safety Agency UK. Reducing the risk of hyponatraemia when
administering intravenous infusions to children. Patient Safety Alert, 2007.
11. Institute for Safe Medication Practices Canada. Hospital-Acquired Acute
Hyponatremia: Two Reports of Pediatric Deaths. ISMP Canada Safety Bulletin,
2009;9(7).
12. Institute for Safe Medication Practices (US). Plain D5W or hypotonic saline solutions
post-op could result in acute hyponatremia and death in healthy children. Medication
Safety Alert Acute Care, 2009.
13. Myburgh JA, Mythen MG. Critical Care Medicine Review: Resuscitation Fluids. N Engl
J Med, 2013: 369: 1243-51.

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14. Plasma-Lyte 148 Replacement IV Infusion. Baxter Product Information 05JUL2013

http://www.baxterhealthcare.com.au/downloads/healthcare_professionals/cmi_pi/
plasmalyte148_pi.pdf
15. McNab S, Duke T, South M, Babl FE, Lee KJ, Arnup SJ, Young S, Turner H, Davidson
A. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous
fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial.
Lancet. 2015 Mar 28;385(9974):1190-7
16. McNab S, Ware RS, Neville KA, Choong K, Coulthard MG, Duke T, Davidson A,
Dorofaeff T. Isotonic versus hypotonic solutions for maintenance intravenous fluid
administration in children (Review). Cochrane Library 2014, Issue 12
17. Australian Commission on Safety and Quality in Health Care, National
Recommendations for User-applied Labelling of Injectable Medicines, Fluids and
Lines, 2012
18. Friedman JN, Beck CE, DeGroot J, Geary DF, Sklansky DJ, Freedman SB,
Comparison of Isotonic and Hypotonic Intravenous Maintenance Fluids: A
Randomized Clinical Trial, JAMA Pediatr. Published online March 09, 2015.
19. User applied Labelling of Injectable Medicines, Fluids and Lines, NSW Health
(PD2012_007)

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