Maintenance Intravenous Fluid Therapy in Children

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Maintenance intravenous fluid therapy in children

Author: Michael J Somers, MD
Section Editor: Tej K Mattoo, MD, DCH, FRCP
Deputy Editor: Melanie S Kim, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2020. | This topic last updated: Jun 19, 2019.
INTRODUCTION
The goal of fluid therapy is to preserve the normal body water volume and its electrolyte composition:
● Maintenance therapy replaces the ongoing daily losses of water and electrolytes occurring via
physiologic processes (urine, sweat, respiration, and stool), which normally preserve
homeostasis. Maintenance requirements vary depending on the patient's underlying clinical
status and setting, especially in postoperative or hospitalized children, due to changes in their
physiologic responses (eg, excess antidiuretic hormone [ADH] secretion).
● Repletion therapy corrects water and acute electrolyte deficits that have accrued via illness or
physiologic abnormality. Repletion returns the patient to a normal volume and electrolyte status.
Maintenance intravenous fluid therapy, including alterations in maintenance requirements, will be

reviewed here. Assessment of hypovolemia and repletion therapy and management of fluid and
electrolytes in neonates are discussed elsewhere. (See "Clinical assessment and diagnosis of
hypovolemia (dehydration) in children" and "Treatment of hypovolemia (dehydration) in children" and
"Fluid and electrolyte therapy in newborns".)
COMPONENTS OF MAINTENANCE FLUID THERAPY
Historically, water and electrolyte requirements were initially directly derived from the caloric energy
expenditures of hospitalized normally healthy children on bed rest who were receiving intravenous
(IV) fluids [1]. These data form the basis of IV maintenance fluid therapy in children that have
uptodate.searchbox.science/contents/maintenance-intravenous-fluid-therapy-in-children/print?search=bronchiolitis&topicRef=6020&source=see_link 1/19
undergone modifications based on clinical experience and observation and encompass these
components:
● Water.
● Electrolytes – Cations typically include sodium and potassium. Chloride is the usual
accompanying anion. Other anions used occasionally include bicarbonate, acetate, and lactate.
● Dextrose.
Water
Normal physiologic needs — Homeostatic control for water is dependent on antidiuretic

hormone (ADH) release, the kidney's ability to regulate urinary water losses via its response to ADH,
and water intake based on thirst (see "General principles of disorders of water balance (hyponatremia
and hypernatremia) and sodium balance (hypovolemia and edema)", section on 'Regulation of water
and sodium balance'). These regulatory mechanisms allow for variability in the daily water intake in
healthy children without adverse effect.
Under normal physiologic conditions, combined daily insensible and sensible losses equal about 100
mL for every 100 kcal/kg of energy expended. This includes the minimal daily obligate urine volume
of 25 mL for every 100 kcal of energy expenditure necessary to excrete the solutes generated by
dietary intake and cell metabolism (table 1).
Daily caloric expenditure for healthy children varies directly with body weight, with the rate changing
over several broad weight ranges.
● Weight <10 kg − 100 kcal/kg
● Weight >10 kg to 20 kg − 1000 kcal for first 10 kg of body weight plus 50 kcal/kg for any
increment of weight above 10 kg
● Weight >20 kg to 80 kg − 1500 kcal for first 20 kg of body weight plus 20 kcal/kg for any
increment of weight above 20 kg
● Weight >80 kg − 2700 kcal/day with adjustments made as clinically pertinent for either increase
or decrease caloric needs to meet metabolic demands
Daily water needs replace insensible water losses from the respiratory tract and skin and sensible
water losses in urine and stool output [2].
● Daily insensible losses (loss that is not perceived by the individual and cannot be usually
measured) account for approximately 45 mL per 100 kcal of energy expended. In patients
greater than 10 kg, the insensible needs are also often calculated based upon body surface area
at a rate of about 300 to 400 mL/m2 per day. The insensible losses can be further delineated into
skin or respiratory losses:
• Skin losses, due to evaporation from convection and conduction, account for two-thirds of
the insensible losses (30 mL per 100 kcal). Infants and small children have a proportionally
greater body surface area per unit of body weight than larger children and adults, resulting in
a relatively higher insensible skin loss of water.
• Respiratory losses due to the warming and humidification of inspired air account for one-
third of insensible losses (15 mL per 100 kcal).
● Daily sensible water losses (losses that are perceived by the senses and can be measured)
account for approximately 55 mL per 100 kcal of energy expenditure. Since water loss from stool
is negligible in healthy children, sensible water loss is primarily due to the daily urinary water
losses required to excrete the solute load generated from typical dietary intake and cellular
metabolism. This estimate is based on a few assumptions:
• A normal and age-appropriate dietary solute load and urine that is isosmotic to plasma
(approximately 290 mosmol/L).
• Normal urinary concentrating mechanisms in terms of both ADH release from the pituitary
and renal response to ADH availability. Thus, maximal stimulation of ADH release
accompanied by a maximal renal concentrating response (urine osmolality of 1200 to 1400
mosmol/L) are required to excrete the daily solute load in a minimal daily obligate urine
volume. Patients with a diminished ability to concentrate urine due to low release or renal
response to ADH require a larger urine volume for excretion of daily solute load. Inadequate
ADH release or renal responsiveness to ADH may result in dehydration and hypernatremia,
and inappropriate (excessive) release of ADH results in free water retention and
hyponatremia.
Methods for calculation — The two methods that are routinely used to prescribe parenteral fluid
therapy assume that approximately 100 mL of exogenous water are needed to replace insensible and
sensible losses for every 100 kcal/kg of energy expended. Both methods take into account the
relationship between caloric expenditure and total body weight based on three broad weight ranges,
as noted above. These calculations also assume urinary losses are isosmotic to plasma and that
there is no ongoing aberrant physiologic process such as inappropriate ADH release (see 'Changes
in normal maintenance needs' below). Since the normal kidney can both concentrate and dilute the
urine, healthy children generally tolerate fluid volumes below or above these calculated values, but
these calculations serve as a starting point to prescribe maintenance fluid volume.
One method calculates a total daily volume of water and the other provides fluid needs based on an
hourly rate.
● Method 1 – Maintenance fluid needed on an hourly basis (calculator 1):
• Weight <10 kg − 4 mL/kg per hour
• Weight >10 kg to 20 kg − 40 mL/hour for first 10 kg of body weight plus 2 mL/kg per hour for
any increment of weight over 10 kg
• Weight >20 kg to 80 kg − 60 mL/hour for first 20 kg of body weight plus 1 mL/kg per hour for
any increment of weight over 20 kg, to a maximum of 100 mL/hour (up to a maximum of
2400 mL daily)
● Method 2 – Maintenance fluid volume for a 24-hour period (calculator 2):
• Weight <10 kg − 100 mL/kg
• Weight >10 kg to 20 kg − 1000 mL for first 10 kg of body weight plus 50 mL/kg for any
increment of weight over 10 kg
• Weight >20 kg to 80 kg - 1500 mL + 20 mL/kg for every kg over 20 (up to a maximum of

2400 mL daily)
At body weights >65 kg, water requirements do not show the same incremental increase as with
lower weights. As a result, for individuals with a body weight >65 kg, total maintenance water needs
are generally capped at 2.4 L daily for each method.
The total daily volume of water prescribed by the hourly format is a bit lower than the daily format, but
the difference is almost always of no clinical significance. For example, the maintenance water needs
for a 12 kg child are calculated using both methods as follows:
● Utilizing the hourly method, the maintenance needs would be 44 mL per hour or 1056 mL for 24
hours (40 mL/hour for the first 10 kg of body weight, plus 4 mL/hour for the next 2 kg [2 mL/kg
per hour for each kg of body weight between 10 and 20 kg]).
● Utilizing the 24-hour method, the maintenance needs would be slightly higher at 1100 mL for 24
hours (1000 mL for the first 10 kg, plus 100 mL for the next 2 kg [50 mL/kg per day for each kg of
body weight between 10 and 20 kg]).
In children who are hospitalized or who are postoperative, the risk for inappropriate (excessive) ADH
release is high. As a result, a routine calculation of maintenance water volumes in hospitalized or
postoperative children may predispose to hyponatremia if water or sodium replacement is not

adjusted. (See 'Alterations of therapy' below.)
Electrolytes — In children, the daily sodium, chloride, and potassium requirements can be related to
daily water needs as follows:
● Sodium and chloride − 2 to 3 mEq/100 mL of water per day

● Potassium − 1 to 2 mEq/100 mL of water per day
Urinary electrolyte losses account for the majority of maintenance electrolyte needs, with fewer
electrolyte losses normally accompanying the typical insensible water losses in sweat and stool. As is
the case with water balance, maintenance electrolyte intake may vary from day to day, depending on
clinical circumstance. For example, sodium and potassium intake may need to be reduced in patients
with oliguric renal failure to prevent volume expansion and hyperkalemia; conversely, their intake may
need to be increased in patients with diarrhea or burns to prevent volume depletion and hypokalemia.
Dextrose — Dextrose is generally added to maintenance fluids, especially if the child is likely to be
fasting for a lengthy period of time or if there are clinical concerns for hypoglycemia. This is
particularly pertinent with smaller and younger children who have higher relative glucose
requirements compared with older children. Under normal circumstances, 5 to 10 percent dextrose
solution administered at a maintenance rate is safe, as this amount of dextrose is taken up rapidly by
cells and metabolized. Therefore, dextrose remains only for a short time in the intravascular space
and is not a relevant factor when considering tonicity of IV fluid, especially when compared with
sodium. As a result, in this topic, references to isotonic fluid only apply to the sodium content even if
the fluid contains dextrose.
Patients with type 1 diabetes mellitus who are receiving IV hydration with dextrose-containing fluids
should have frequent blood glucose monitoring. Management of patients with type 1 diabetes in the
settings of acute illness, medical procedures, or diabetic ketoacidosis is discussed in greater detail
separately. (See "Treatment and complications of diabetic ketoacidosis in children and adolescents".)
CHANGES IN NORMAL MAINTENANCE NEEDS
Most children who are hospitalized are acutely ill, and adjustments in fluid therapy maintenance are
required due to alterations of water losses or the normal homeostatic mechanisms for water balance
(eg, inappropriate antidiuretic hormone [ADH] release).
Changes in water loss — The following clinical conditions can affect maintenance water needs due
to changes with insensible or sensible water losses (table 2):
● Increased water needs:
• Preterm birth – Preterm infants have increased insensible water losses from the skin due to
an increased surface area for mass and a thinner dermis. Water losses from the skin are
also accentuated if the infant is cared for in an open radiant heater or is receiving
phototherapy. (See "Fluid and electrolyte therapy in newborns".)
• Burns – Patients with burns will have increased insensible water and electrolyte losses from
areas of affected skin.
• Fever – Patients with fever will also have increased insensible water losses from skin and
respiratory tract.
• Gastrointestinal illness – Diarrhea will increase sensible stool fluid losses. Emesis and
losses from a colostomy or ileostomy also will increase sensible stool water losses due to an
inability to reabsorb intestinal fluid that is usually presented to more distal regions of the
digestive tract.
• Sweating – Sweating due to intense exercise or exertion results in increased fluid loss from
the skin.
• Polyuria – Patients with polyuria have excessive urinary water loss.
● Decreased water needs:
• Mechanical ventilation – Patients on ventilators with prehumidified air will have decreased
insensible water losses, which normally occur with respiration.
• Oliguria – Patients with oliguric renal failure will have decreased urinary water losses and
thus may have little or no sensible water losses since urine output comprises almost all
sensible output.
Changes in water homeostasis — Most children with an imbalance between daily water intake and
losses are able to maintain overall body water balance by regulating urinary water loss via ADH and
thirst mechanisms through osmoreceptors. The threshold for physiologic ADH release is about 280 to
290 mosmol/kg (figure 1). However, the normal physiologic osmotic release and response to ADH
may be impaired in a variety of clinical settings, particularly in children who are hospitalized (table 3).
(See "General principles of disorders of water balance (hyponatremia and hypernatremia) and sodium
balance (hypovolemia and edema)", section on 'Regulation of water and sodium balance'.)
● Syndrome of inappropriate ADH release (SIADH) is caused by nonphysiologic increased

release of ADH that commonly occurs in hospitalized children who were previously healthy. This
results in diminished free water excretion and potential hypo-osmolality (hyponatremia). In

particular, children who are postoperative or immobilized, have central nervous system (CNS) or
pulmonary disease, or have significant pain, stress, and anxiety are at risk for SIADH. In this
setting of transient SIADH, initial fluid therapy consists of isotonic solution, and some patients
may require fluid restriction.
Although less common, there are children with chronic neurologic disorders that have a lower
threshold for ADH release referred to as "reset osmostat." (See "Hyponatremia in children:
Etiology and clinical manifestations", section on 'Reset osmostat'.)
● Central diabetes insipidus (DI) is caused by the lack of appropriate release of ADH resulting in
polyuria and potential serum hyperosmolality (hypernatremia) due to hypovolemia. Children with
CNS tumors or injury, congenital brain abnormalities, certain genetic disorders or syndromes,
and anorexia nervosa may present with central DI. The clinical manifestations and management
of children with central DI are discussed separately. (See "Clinical manifestations and causes of
central diabetes insipidus", section on 'Causes' and "Treatment of central diabetes insipidus",
section on 'Children'.)
● Nephrogenic DI is caused by impaired renal response to ADH resulting in polyuria and

hyperosmolality (hypernatremia). Pediatric causes of nephrogenic DI include genetic mutations
of the renal receptor genes for vasopressin and disorders that result in renal tubular injury. The
clinical manifestations and management of nephrogenic DI are discussed separately. (See
"Clinical manifestations and causes of nephrogenic diabetes insipidus", section on 'Causes' and
"Treatment of nephrogenic diabetes insipidus", section on 'Treatment'.)
● Nephrogenic or hereditary SIADH is extremely rare and is caused by an enhanced renal

response to ADH due to a gain-of-function mutation in the renal receptor for vasopressin. (See
"Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone secretion
(SIADH)", section on 'Hereditary SIADH'.)
PRESCRIBING MAINTENANCE INTRAVENOUS (IV) FLUID THERAPY
Goal — Maintenance IV (parenteral) fluid therapy is provided to hospitalized children who are not
expected to be able to adequately take in enteral (oral) fluids. The goal of IV maintenance fluid
therapy is to preserve water and electrolyte balance in the euvolemic patient and to avoid
hypoglycemia by providing sufficient glucose (dextrose). In our practice, the general principles
outlined in the following sections are used when prescribing maintenance IV fluid therapy for children.
These principles are in agreement with the practice guidelines of National Institute for Health and
Care Excellence (NICE) and the 2018 American Academy of Pediatrics (AAP) clinical practice
guidelines [3,4].
Choice of initial fluid: Isotonic solution — Although no single solution can provide maintenance
water and electrolyte needs for all children, strong evidence has shown that isotonic solutions (normal
saline or lactated Ringer's solution) are the preferred initial fluid choice when administrating IV fluid to
hospitalized or postoperative children. The shift from the historic use of hypotonic solutions is based
on the increasing awareness and evidence demonstrating the increased risk of hyponatremia with the
use of hypotonic solution, as hospitalized children are commonly at risk for inappropriate antidiuretic
hormone (ADH) release, resulting in free water retention (table 3) [4-13]. The initial use of isotonic
solution is consistent with clinical practice guidelines published by the AAP [4]. (See "Hyponatremia in
children: Etiology and clinical manifestations", section on 'Hypotonic hyponatremia'.)
Exceptions — The AAP guidelines, however, do not apply to subsets of children who were not
included in the prospective studies that support the recommendation of isotonic solution as the
preferred initial choice for maintenance IV fluid therapy. These include individuals with neurosurgical
disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction,
diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28
days old or in the neonatal intensive care unit; or adolescents older than 18 years of age [4].
In addition, a minority of children with excessive water loss may require initial hypotonic solution.
These include children with polyuria due to renal concentrating defects (eg, nephrogenic diabetes
insipidus) or inability to release ADH (central diabetes insipidus), and those with nonrenal causes of
abnormally large ongoing water loss (individual with severe burns or severe watery diarrhea). For
these patients who require free water to replace their losses, the use of isotonic solutions may result
in hypertonicity. (See 'Changes in water homeostasis' above and "Hypernatremia in children", section
on 'Excess water losses'.)
Potassium — In children with normal serum potassium levels and renal function, potassium
chloride is usually added to maintenance fluids at a concentration of 10 mEq/L for small children with
weights <10 kg, and for larger children with weights ≥10 kg, a concentration of 10 to 20 mEq/L is
provided. This will generally ensure the provision of maintenance potassium needed to prevent
evolving hypokalemia over time.
In children who are considered potassium replete and in whom the duration of IV fluid administration
will be brief prior to allowing intake of potassium-containing fluids or solids, potassium-free fluids can
be considered. However, if there is a delay in restarting oral intake, fluid therapy should be changed.
Children with abnormal potassium levels or impaired renal function require more individualized
potassium prescription. (See "Management of hyperkalemia in children" and "Hypokalemia in

children", section on 'Management'.)
Dextrose — Dextrose is typically added as a 5 percent solution to provide sufficient glucose to

avoid hypoglycemia while IV fluids are administered. Dextrose concentration can be increased to 10
percent for patients who develop hypoglycemia or are at risk for hypoglycemia (eg, infants) or for
additional caloric intake for patients in whom there is an expectation of prolonged IV fluid therapy.
Rate of initial fluid therapy — The initial rate of fluid therapy is based on the usual daily energy
expenditure of the child, which varies with body weight (table 1). Two calculators are typically used in
determining the initial rate of IV maintenance fluid therapy (calculator 2). (See 'Methods for
calculation' above.)
In the majority of hospitalized children with acute medical or surgical conditions, the initial use of
isotonic saline at a maintenance rate reduces the risk of hyponatremia and hypovolemia [11]. Despite
the observation that many hospitalized children have persistent transient ADH release, assessment
for inappropriate ADH release is not typically performed. As a result, the traditional approach of fluid
restriction is usually not initiated and appears not to be needed to maintain serum sodium levels in
most children with acute illnesses or postoperative children who are expected to fully recover in a
timely manner [11]. Nevertheless, ongoing assessment is needed to determine whether the rate of
therapy requires modification as discussed below.
In determining a child's full daily volume, all sources of fluid intake need to be considered, including
parenteral medications and blood products and oral intake for children who are able to eat and drink.
In these settings, the volume and rate of IV fluid administration must be adjusted to account for these
alternate sources of fluids.
Alterations of therapy — The initial assumptions of the appropriateness of initial fluid therapy need
to be confirmed as clinical conditions may alter water loss (table 2). In some cases, this may be due
to impaired release of ADH and renal response to ADH (table 3). Management is altered when the
initial therapy does not maintain a stable euvolemic state based on ongoing assessment that monitors
volume status (ie, net fluid balance and changes in body weight and serum sodium). (See 'Monitoring'
below.)
● Euvolemia – The appropriateness of the choice of initial therapy (isotonic solution and initial
maintenance rate) is confirmed for the stable euvolemic patient. These patients have no change
in serum sodium or body weight, and have a neutral net volume balance. No modification of
therapy is needed if these parameters remain stable and the child continues to require
maintenance IV fluid.
● Hypovolemia – Children with unreplaced increased water losses (eg, watery diarrhea) leading to
volume depletion (hypovolemia) present with an increase in serum sodium, negative net volume
balance, and a decrease in body weight. For these patients, alterations based on the clinical
setting include increased change from isotonic to hypotonic solution and/or increase in the rate of
therapy resulting in the administration of more water. Initially unanticipated water losses may be
seen in patients with fever, watery diarrhea, burns, and those with significant drainage from
nasogastric tube.
● Hypervolemia – Children with a decrease in water loss (eg, syndrome of inappropriate secretion
of ADH [SIADH] resulting in decrease urinary volume) leading to water retention (hypervolemia)
present with a decrease in serum sodium, positive net volume balance, and an increase in body
weight. For these patients, isotonic solution is continued at a decreased rate (fluid restriction).
Water retention may be observed in children with SIADH, significant renal impairment, heart
failure, cirrhosis, and nephrotic syndrome.
Monitoring — As mentioned above, assessment of fluid therapy is based on monitoring the child's
volume status that includes ongoing evaluation of changes in serum sodium and body weight, and
assessing net fluid balance. The frequency of assessment is based on the severity of illness, the
vulnerability of the child to fluid fluctuations, and the need to alter fluid therapy.
● Serial sodium measurements assess the changes in free water. Increases in serum sodium
represent decreases in total body water and a need to replace water losses, whereas decreases
in serum sodium represent water retention and a need for fluid restriction. Serum sodium is
typically obtained initially and between 6 to 12 hours after the initiation of IV fluid therapy [4]. The
frequency of subsequent measurements is dependent on whether there are ongoing changes in
fluid therapy based on unanticipated changes to water losses, and the severity of illness. For
patients who are critically ill with ongoing changes, serial sodium may be obtained as frequently
as every four to six hours. In contrast, serum sodium may be obtained daily for patients who are
stable on IV fluid therapy.
● To maintain euvolemia, this net difference reflects the volume of insensible fluid loss resulting in
no change in fluid balance (neutral net fluid balance) and no change in weight. For patients who
are cared for in a critical care setting, assessment of the net fluid balance may be as frequent as
three times a day. For less ill patients, assessment may be made on a daily basis.
● Initial weights on admission and then daily for the first 48 hours can complement clinical
assessment of volume changes. Acute increases in body weight are indicative of water retention,
whereas decreases suggest loss of free water that has not been adequately replaced. Ongoing
daily body weights are usually obtained for hospitalized patients who remain on IV fluid therapy
for a more extensive period of time (greater than 48 hours).
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Fluid and electrolyte disorders in
children".)
SUMMARY AND RECOMMENDATIONS
● Maintenance fluid therapy replaces the ongoing losses of water and electrolytes occurring via
normal physiologic processes with a goal of preserving water and electrolyte balance in the
euvolemic patient. Homeostatic control for water is dependent on antidiuretic hormone (ADH)
release, the kidney's ability to regulate urinary water losses via its response to ADH, and water
intake based on thirst. (See 'Normal physiologic needs' above.)
● Components of maintenance fluid therapy are water, electrolytes, and dextrose. (See
'Components of maintenance fluid therapy' above.)
• Normal water requirements are estimated in direct relation to caloric energy expenditures,
which vary directly with body weight. Daily water needs replace insensible water losses from
the respiratory tract and skin and sensible water losses in urine and stool output.
In children, specific water requirements change over three broad weight ranges. Two
methods based upon the child's weight are generally used by clinicians to calculate
maintenance water (calculator 2). (See 'Methods for calculation' above.)
• Electrolyte maintenance is also based upon caloric energy expenditures and includes
sodium and chloride requirements of 2 to 3 mEq/100 mL of water and potassium
requirements of 1 to 2 mEq/100 mL of water. (See 'Electrolytes' above.)
• Dextrose is added usually as a 5 percent solution to avoid hypoglycemia in children who are
likely to be fasting for a lengthy period of time. (See 'Dextrose' above.)
● Most children who are hospitalized are acutely ill, and adjustments in fluid therapy maintenance
are required due to alterations of water losses (table 2) or the normal homeostatic mechanisms
for water balance (eg, inappropriate release of antidiuretic hormone) (table 3). (See 'Changes in
normal maintenance needs' above.)
● The management of maintenance fluid therapy in children include the following and are
consistent with the practice guidelines of National Institute for Health and Care Excellence
(NICE) and the American Academy of Pediatrics (AAP):
• Choice of initial fluid – For hospitalized children, we recommend the initial use of isotonic
fluid as maintenance fluid therapy (Grade 1B). The risk of hyponatremia is increased with
the use of hypotonic solution because increased ADH release is a common occurrence in
hospitalized children (table 3). Exceptions to the use of isotonic solutions as initial fluid
therapy include children with polyuria due to renal concentrating defects (eg, nephrogenic
diabetes insipidus) or inability to release ADH (central diabetes insipidus), and those with
nonrenal causes of abnormally large ongoing water loss (individual with severe burns or
severe watery diarrhea). In these patients, hypotonic solution may be more appropriate to
replace excess water loss. (See 'Choice of initial fluid: Isotonic solution' above.)
In children with normal serum potassium levels and normal renal function, potassium
chloride is usually added to maintenance fluids at a concentration of 10 mEq/L for small
children with weights <10 kg, and for larger children with weights ≥10 kg, a concentration of
10 to 20 mEq/L. (See 'Potassium' above.)
Dextrose is typically added as a 5 percent solution to provide sufficient glucose to avoid

hypoglycemia while intravenous fluids are administered. (See 'Dextrose' above.)
• The initial rate of fluid therapy is calculated based on the weight of the child (table 1)
(calculator 2). (See 'Methods for calculation' above.)
• The rate and tonicity of therapy are readjusted as needed based upon ongoing and frequent
clinical assessment of the child's fluid and electrolyte status. Management is altered when
the initial therapy does not maintain a stable euvolemic state, based on ongoing assessment
that monitors net volume balance and changes in body weight and serum sodium (measure
of tonicity). (See 'Alterations of therapy' above and 'Monitoring' above.)
- Euvolemia – No change in therapy is required for patients who remain euvolemic as

manifested by stable serum sodium, net neutral fluid balance, and no change in weight.
- Hypovolemia – Changes that increase free water delivery are needed for children who
are volume depleted due to unreplaced water losses resulting in an increase in serum
sodium, negative net fluid balance, and decrease in body weight.
- Hypervolemia – Rate of fluid therapy is decreased (fluid restriction) for children with
evidence of water retention with a lower serum sodium, positive net fluid balance, and
increase in body weight.
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REFERENCES
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Fluids in Children. Pediatrics 2018; 142.
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373:1350.
Topic 6122 Version 38.0
GRAPHICS
Normal daily fluid requirements for children based on body weight
Weight Daily water need based on caloric expenditure
≤10 kg 100 mL/kg
>10 to 20 kg 1000 mL for first 10 kg of body weight plus 50 mL/kg for any increment of weight above 10 kg
>20 to 80 kg 1500 mL for first 20 kg of body weight plus 20 mL/kg for any increment of weight above 20 kg
>80 kg 2700 mL/day
Under normal physiologic conditions, daily water need is equal to about 100 mL based on daily caloric expenditure of
every 100 kcal/kg, which varies with body weight as noted above. This daily water requirement is based on combined
daily insensible and sensible water losses. Daily insensible losses from the respiratory tract and skin account for
approximately 45 mL per 100 kcal of energy expended. Daily sensible water losses (urine and stool) account for
approximately 55 mL per 100 kcal of energy expended.
Graphic 121670 Version 1.0
Factors affecting water maintenance needs in children and infants
Source Increased water needs Decreased water needs
Skin Burns Enclosed incubator

Fever Mist tent
Phototherapy
Prematurity
Radiant heater
Sweat
Lungs Tachypnea Humidified air

Tracheostomy
Gastrointestinal tract Diarrhea

Emesis
Ileostomy
Nasogastric suction
Renal Polyuria Oliguria/anuria
Miscellaneous Surgical drain Sedation

Increased activity Hypothyroidism
Osmotic regulation of ADH release and thirst
Relation between plasma ADH concentration and plasma osmolality in normal humans in
whom the plasma osmolality was changed by varying the state of hydration. The osmotic
threshold for thirst is a few mosmol/kg higher than that for ADH.
ADH: antidiuretic hormone.
Data from Robertson GL, Aycinena P, Zerbe RL. Neurogenic disorders of osmoregulation. Am J
Med 1982; 72:339.
Conditions affecting antidiuretic hormone (ADH) release and action in children
Affect on
Action Condition or disease category
urinary volume
Nonphysiologic or Decrease in urinary Postoperative state

inappropriate ADH volume CNS disease – Meningitis, brain tumors, head injury
release Pulmonary disease – Pneumonia, bronchiolitis, asthma
Immobilization
Drugs
Antidepressants (eg, SSRI)
Antipsychotics (eg, haloperidol)
Seizure medications (eg, carbamazepine)
Chemotherapeutic agents (eg, vincristine, cisplatin, vinblastine)
Opiates
Response to pain, stress, or anxiety
Enhanced renal ADH Decease in urinary Nephrogenic SIADH – Gain-of-function mutations in the renal V2
receptor response volume receptor gene
Lack of adequate ADH Increase in urinary CNS tumors (eg, craniopharyngioma)

release/central volume Congenital brain abnormalities (eg, septo-optic dysplasia)
diabetes insipidus Brain trauma or injury (eg, complication of brain surgery)
Genetic diseases
Anorexia nervosa
Lack of renal ADH Increase in urinary Congenital disorders (eg, loss-of-function mutation in renal V2
receptor volume receptor gene, renal tubulopathy [Bartter syndrome])
response/nephrogenic Drugs (eg, lithium toxicity, foscarnet, ifosfamide)
diabetes insipidus Renal disorders (eg, bilateral urinary tract obstruction, sickle cell
nephropathy)
CNS: central nervous system; SSRI: selective serotonin release inhibitors; SIADH: syndrome of inappropriate antidiuretic
hormone secretion; V2: vasopress-2.
Contributor Disclosures
Michael J Somers, MD Nothing to disclose Tej K Mattoo, MD, DCH, FRCP Consultant/Advisory Boards: Kite
Medical Limited [Vesicoureteral reflux (Bioimpedance)]. Melanie S Kim, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
Conflict of interest policy

Maintenance Intravenous Fluid Therapy in Children - UpToDate

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Maintenance intravenous fluid therapy, including alterations in maintenance requirements, will be

COMPONENTS OF MAINTENANCE FLUID THERAPY

Normal physiologic needs — Homeostatic control for water is dependent on antidiuretic

● Weight <10 kg − 100 kcal/kg

● Method 1 – Maintenance fluid needed on an hourly basis (calculator 1):

• Weight <10 kg − 4 mL/kg per hour

● Method 2 – Maintenance fluid volume for a 24-hour period (calculator 2):

• Weight <10 kg − 100 mL/kg

• Weight >20 kg to 80 kg - 1500 mL + 20 mL/kg for every kg over 20 (up to a maximum of

postoperative children may predispose to hyponatremia if water or sodium replacement is not

● Sodium and chloride − 2 to 3 mEq/100 mL of water per day

CHANGES IN NORMAL MAINTENANCE NEEDS

● Increased water needs:

• Polyuria – Patients with polyuria have excessive urinary water loss.

● Decreased water needs:

● Syndrome of inappropriate ADH release (SIADH) is caused by nonphysiologic increased

results in diminished free water excretion and potential hypo-osmolality (hyponatremia). In

● Nephrogenic DI is caused by impaired renal response to ADH resulting in polyuria and

● Nephrogenic or hereditary SIADH is extremely rare and is caused by an enhanced renal

PRESCRIBING MAINTENANCE INTRAVENOUS (IV) FLUID THERAPY

potassium prescription. (See "Management of hyperkalemia in children" and "Hypokalemia in

Dextrose — Dextrose is typically added as a 5 percent solution to provide sufficient glucose to

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

Dextrose is typically added as a 5 percent solution to provide sufficient glucose to avoid

- Euvolemia – No change in therapy is required for patients who remain euvolemic as

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Topic 6122 Version 38.0

Normal daily fluid requirements for children based on body weight

Weight Daily water need based on caloric expenditure

≤10 kg 100 mL/kg

>80 kg 2700 mL/day

Graphic 121670 Version 1.0

Factors affecting water maintenance needs in children and infants

Source Increased water needs Decreased water needs

Skin Burns Enclosed incubator

Lungs Tachypnea Humidified air

Gastrointestinal tract Diarrhea

Renal Polyuria Oliguria/anuria

Miscellaneous Surgical drain Sedation

Graphic 72500 Version 2.0

Osmotic regulation of ADH release and thirst

ADH: antidiuretic hormone.

Graphic 65195 Version 5.0

Conditions affecting antidiuretic hormone (ADH) release and action in children

Nonphysiologic or Decrease in urinary Postoperative state

Lack of adequate ADH Increase in urinary CNS tumors (eg, craniopharyngioma)

Graphic 104673 Version 2.0

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