Maintenance fluid therapy in children

Author: Michael J Somers, MD

Section Editor: Tej K Mattoo, MD, DCH, FRCP
Deputy Editor: Melanie S Kim, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2018. | This topic last updated: Jan 19, 2018.

INTRODUCTION — The goal of fluid therapy is to preserve the normal volume and

electrolyte composition of body fluids. Fluid therapy is usually divided into two
components:

● 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 fluid therapy, including alterations in maintenance requirements, will be

reviewed here. Assessment of hypovolemia and repletion therapy are discussed
elsewhere. (See "Clinical assessment and diagnosis of hypovolemia (dehydration) in
children" and "Treatment of hypovolemia (dehydration) in children".)

COMPONENTS OF FLUID THERAPY

Water

Normal physiologic needs — Homeostatic control for water is dependent on

antidiuretic hormone (ADH) release, the kidney's ability to regulate urinary water losses,
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.

Historically, water requirements for children receiving parenteral fluid therapy were directly
derived in relationship to caloric energy expenditures of hospitalized children on bed rest
[1]. 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.

Daily caloric expenditure for healthy children varies directly with body weight, with the rate
changing over several broad weight ranges.

● Weight less than 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 increased 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/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 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 — Methods to calculate water requirements are based on the

historic observation of caloric energy expenditures of hospitalized children requiring
parenteral fluid therapy on bed rest in the 1950s [1]. 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, 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. 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:

• Weight less than 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− 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 1):

• Weight less than 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

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]).

Caveats that should be taken into consideration when calculating water needs for children
using either method are:

● 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 liters daily.

● 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 'Hospitalized
children' below.)

Electrolytes — Maintenance electrolyte requirements for parenteral fluid therapy, like water

requirements, were derived based upon caloric energy expenditure in hospitalized children
at bedrest [1]. 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 added to maintenance fluids when the clinician decides to provide

an additional source of glucose to the patient. 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 does not remain in the intravascular space. As a
result, dextrose is not a relevant factor when considering tonicity of intravenous (IV) fluid
compared to sodium. As a result, in this topic, references to isotonic fluid only apply to the
sodium content and disregard the dextrose composition.
Dextrose should not be used in patients with uncontrolled diabetes, which may increase
glucose levels, or hypokalemia. In the latter case, administration of dextrose stimulates
the release of insulin which drives extracellular potassium into the cells.

Changes in maintenance needs — Changes in fluid maintenance are required when water

losses or the normal homeostatic mechanisms for water balance (eg, inappropriate ADH
release) are altered.

Changes in water loss — The following clinical conditions can affect maintenance

water needs due to changes with insensible or sensible water losses (table 1):

● Prematurity – Premature 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.

● Mechanical ventilation – Patients on ventilators with prehumidified air will have

decreased insensible water losses, which normally occur with respiration.

● Gastrointestinal illness – Diarrhea will increase sensible stool fluid losses. Patients
with a colostomy or ileostomy also will have increased sensible stool water losses
due to an inability to reabsorb intestinal fluid that is usually presented to more distal
regions of the digestive tract.

● 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 composes
almost all sensible output.

● Sweating due to intense exercise or exertion results in increased fluid loss from the
skin.

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). (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'.)

Impaired ADH action — The normal physiologic release and response to ADH may be
impaired in a variety of clinical settings resulting in changes in urinary volume excretion
(table 2). In these cases, fluid therapy is adjusted based on the underlying alteration to
ADH secretion and renal response to ADH.

● Nonphysiologic increased release of ADH (also referred to as the syndrome of

inappropriate ADH release [SIADH]) that commonly occurs in hospitalized children
who were previously healthy results in diminished free water excretion and potentially
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, fluid therapy
will consist of administration of isotonic solution, and fluid restriction.

Although less common, there are children with chronic neurologic disorders that have
a lower threshold for ADH release. In these patients, the mainstay of therapy is fluid
restriction. (See "Pathophysiology and etiology of the syndrome of inappropriate
antidiuretic hormone secretion (SIADH)", section on 'Etiology'.)

● Lack of appropriate release of ADH (referred to as central diabetes insipidus [DI])

results in polyuria and potentially serum hyperosmolality (hypernatremia) due to
dehydration. Children with CNS tumors or injury, congenital brain abnormalities or
certain genetic disorders, 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'.)

● Impaired renal response to ADH (referred to as nephrogenic DI) results 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 pediatric 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'.)

● Enhanced response to ADH is extremely rare and has been reported in children with
gain of function mutations 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 PARENTERAL FLUID THERAPY

General principles — In our practice, these general principles are used when prescribing
maintenance parenteral fluid therapy for children. These principles are in agreement with
the practice guidelines of NICE [3].

● No single solution can provide maintenance water and electrolyte needs for all
children. As discussed above, individual clinical circumstance must always be
 considered prior to prescribing therapy, and the appropriateness of any parenteral
fluid therapy needs to be regularly re-evaluated while it is provided.

• Identify any changes in the usual maintenance water needs of the child so that
the prescribed daily fluid intake can be altered to maintain fluid balance. Changes
in fluid maintenance needs are required when the normal water losses or
homeostatic mechanisms for water balance (eg, inappropriate antidiuretic
hormone [ADH] release) are altered. In particular, ill children, particularly those
who are hospitalized or post-surgery are at risk for nonphysiologic increased
(inappropriate) ADH release. (See 'Hospitalized children' below.)

Unreplaced water losses will lead to volume depletion and hypernatremia, while
water intake in excess of excretory capacity will lead to free water retention and
hyponatremia (table 1 and table 2). (See 'Changes in maintenance needs' above.)

• Ongoing assessment that includes net volume balance (ie, difference between
input and output as an accounting ledger of gains and losses). Often, clinicians
may focus on specific parameters, such as urine flow, with a common
misperception that urine output exceeding 0.5 to 1 mL/kg per hour corresponds
to good renal output. However, the appropriateness of urine volume over any unit
of time directly corresponds to the patient's intravascular volume and solute load,
and the concomitant ongoing fluid and/or solute losses. Thus, a large volume of
fluid in a normovolemic patient should normally lead to diuresis. In contrast, the
hypovolemic patient given a similar large volume of fluid will have a limited urine
output until the volume depletion is corrected.

● Recognition that maintenance fluids are not provided to correct derangements in fluid
balance, and decisions regarding necessary fluid therapy for aberrant clinical
conditions should be made in addition to plans for maintenance therapy. (See
"Treatment of hypovolemia (dehydration) in children".)

Hospitalized children

Isotonic versus hypotonic solution — Historically, most hospitalized children who

received parenteral maintenance fluid were provided hypotonic saline solutions with a
potassium salt additive to meet the daily water and electrolyte requirements derived from
caloric energy expenditure [1]. However, there has been increasing awareness that this
approach may be dangerous, especially as children who receive parenteral fluid are
commonly at risk for inappropriate ADH release resulting in free water retention and
hyponatremia (table 2). Based on evidence demonstrating the increased risk of
hyponatremia associated with the use of hypotonic solution, isotonic saline is the
preferred initial fluid choice when administrating parenteral fluid to hospitalized or
postoperative children except for those with hypertension or kidney disease [4-12].
Systematic reviews of clinical trials showed that hospitalized children who received
hypotonic fluids had an increased risk of hyponatremia compared with those who received
isotonic fluids [4-6]. This was illustrated in one meta-analysis in which of the risk of
hyponatremia was greater in children who received hypotonic solutions compared to
those who received isotonic solution (34 versus 17 percent, relative risk [RR] 2.08, 95% CI
1.67-2.63) [5].

In a subsequent large Australian trial of 690 hospitalized children, the use of half isotonic
saline compared to isotonic saline increased the risk of hyponatremia (11 versus 4
percent, odds ratio [OR] 0.31, 95% CI 0.16-0.61) [7]. In this study, there was no clinically
apparent episode of cerebral edema in either group, and there was no difference in the
incidence of hypernatremia between the two groups. Adverse events occurred in four
patients in the hypotonic solution group, none of which were thought to be related to the
intravenous (IV) solution. There were eight adverse events in the isotonic solution group,
including two in which overhydration contributed to clinical deterioration. These findings
not only confirm the increased risk of hyponatremia with hypotonic solution but also
underscore the need for regular re-evaluation of any prescribed fluid therapy to ascertain
its ongoing appropriateness.

Isotonic therapy: maintenance volume versus volume restriction — Although the

traditional approach to inappropriate ADH secretion is fluid restriction, in hospitalized or
postoperative children there is a need to provide fluid to prevent hypovolemia from fluid
losses or third spacing (accumulation of fluid in the interstitial space between the skin
and fascia that is not normally perfused with fluids) (table 2). In the majority of
hospitalized children, the use of isotonic saline at a maintenance rate reduces the risk of
hyponatremia and hypovolemia for patients with acute medical and surgical conditions. In
addition, ongoing assessment is needed to detect changes in the clinical status of the
child (eg, alterations in ADH secretion).

The advantage of isotonic fluid therapy at maintenance volume was illustrated by a study
of 124 children hospitalized for surgery [10]. In this study, children provided half-
maintenance fluid volumes were more likely to develop hypovolemia than those who
assigned maintenance volumes. In addition, the risk of hyponatremia was greater for the
patients treated with 0.45 percent saline solution compared to those who received
isotonic saline (30 versus 10 percent) regardless of the volume of fluid therapy. In this
cohort, initial postsurgical ADH levels were two to four times normal but fell back to
expected levels by 24 hours after surgery. These results highlight that an initial approach
of providing isotonic fluid at maintenance fluid volume is preferred to avoid hypovolemia
and hyponatremia especially while ascertaining the patient's needs, including the status of
ADH release.

Our approach — Our approach in prescribing parenteral fluid therapy in hospitalized

children consists of the following steps:

● Initial assessment of the patient's clinical condition and volume status [3,4,13].
 ● For children who are volume depleted, therapy is first directed at repleting any
estimated deficit with an isotonic solution [14] (see "Clinical assessment and
diagnosis of hypovolemia (dehydration) in children" and "Treatment of hypovolemia
(dehydration) in children"). Volume repletion will remove any physiologic hypovolemia-
induced stimulus to ADH release, thereby improving the ability to excrete free water. If
a volume depleted child in a hyper-ADH state is provided hypotonic fluids, there is the
risk of hyponatremia developing because of avid water reabsorption.

● In hospitalized or postoperative euvolemic children with normal renal function and

blood pressure, isotonic fluid at maintenance fluid volumes should be used initially as
these patients are at risk for hyponatremia due to inappropriate increased ADH
secretion (table 2) and hypovolemia [3,15].

● The initial rate of fluid therapy is calculated based on the weight of the child
(calculator 1). (See 'Methods for calculation' above.)

● The rate and tonicity of therapy are readjusted based upon ongoing and frequent
clinical assessment of the child's fluid and electrolyte status, and alterations in the
normal homeostatic mechanisms.

• In children with impaired renal function or hypertension, the risk of clinically

significant volume overload or exacerbating hypertension must be considered. In
this population, more frequent fluid and electrolyte assessment and
readjustment (often decrease in volume) are necessary.

• In children with impaired ADH action, fluid volume adjustment may be required.
(See 'Impaired ADH action' above.)

● In children with normal serum potassium levels and renal function, levels, 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. 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'.)

SUMMARY AND RECOMMENDATIONS — Maintenance fluid therapy replaces the ongoing

losses of water and electrolytes occurring via normal physiologic processes. These losses
are based upon insensible losses from the respiratory tract and skin, and sensible losses
from urine and stool. (See 'Normal physiologic needs' above.)

● Water requirements are estimated in direct relation to caloric energy expenditures,

which vary directly with body weight. 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 1). (See
'Methods for calculation' above.)
● Water maintenance needs vary with physical exertion and clinical conditions that alter
insensible or sensible water losses (table 1). These include diabetes insipidus,
prematurity, diarrhea, a colostomy or ileostomy, oliguric renal failure, mechanical
ventilation, and the syndrome of inappropriate antidiuretic hormone (SIADH).
Increased ADH release, which is also referred to as nonphysiologic ADH release,
commonly occurs in hospitalized or postoperative children. (See 'Changes in
maintenance needs' above and 'Hospitalized children' 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.)

● The management of maintenance parenteral fluid therapy in children include the

following steps (see 'Our approach' above):

• 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 2).

• The initial rate of fluid therapy is calculated based on the weight of the child
(calculator 1). (See 'Methods for calculation' above.)

• The rate and tonicity of therapy are readjusted based upon ongoing and frequent
clinical assessment of the child's fluid and electrolyte status, and alterations in
the normal homeostatic mechanisms (eg, inappropriate ADH secretion). In
particular, infants and young children require frequent surveillance as they are at
risk for hypervolemia and hypernatremia than older patients.

• Potassium chloride supplementation is added based on the child's renal status

and serum potassium level. (See "Management of hyperkalemia in children" and
"Hypokalemia in children", section on 'Management'.)
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