Pediatric Fluid Balance

Fluid balance is fundamental to life. Monitoring and maintaining fluid balance in sick children
requires an understanding of normal requirements and losses and of the effect of different clinical
problems on fluid balance. Fluid requirements differ between infants and older children, therefore
it is essential that children’s nurses have a sound understanding of fluid balance.

Background:

1. Whenever possible the enteral route should be used for fluids. These guidelines only
apply to children who cannot receive enteral fluids.
2. The safe use of IV fluid therapy in children requires accurate prescribing of fluid and
careful monitoring
3. Always check orders that you have written, and ensure that you double check on orders
written by other staff when you take over the child's care
4. Incorrectly prescribed or administered fluids are potentially very dangerous. More
adverse events are described from fluid administration than for any other individual drug.
If you have any doubt about a child's fluid orders - ask a senior doctor.
5. Remember to check compatibility of intravenous fluid with any intravenous drugs that
are being co-administered.

Indications for IV fluid replacement:

1. Nil by mouth
2. Excessive gastrointestinal or urinary losses (vomiting, diarrhea)
3. Loss due to trauma or surgery
4. Insensible losses for patients with burns.
5. Insensible losses in jaundiced neonates undergoing phototherapy to conjugate bilirubin.
6. Increased insensible losses due to decreased thickness of the stratum corneum (outermost
layer of the skin), leading to increased loss of fluid through the skin (greater risk in
premature neonates)
7. Decreased absorption of enteral feeds due to immature gastrointestinal function in
premature neonates, or in neonates with gastrointestinal abnormalities such as
gastroschisis or malrotation

Assessing fluid requirements:

The amount of IV fluid required by a child will depend on the indication, his or her level of
dehydration and any concurrent conditions. Maintenance fluid requirements are calculated based
on a child’s body weight. Neonatal fluid requirements should be calculated by a neonatologist,
since both volume and glucose concentration can vary depending on a neonate’s clinical
condition.
 Fluid Maintenance for Paediatric and Children

Patients weight Full Maintenance mls/day mls/hour

3 to 10 kg 100x wt 4 x wt

10-20kg 1000 plus 50 x (wt-10) 40 plus 2 x (wt-10)

>20kg 1500 plus 20 x (wt-20) 60 plus 1x (wt-20)

100 mls/hour (2400mls/day) is the normal maximum amount.

Assessing dehydration in children

Findings Mild (3-5%) Moderate (6-9%) Severe (>/=10%)

Pulse Full, normal rate Rapid Rapid and weak

Systolic BP Normal Normal to low Low

Respirations Normal Deep, rate may be Deep, tachypnea

increased
Buccal mucosa Tacky or slightly dry Dry Parched

Ant fontanelle Normal Sunken (infants aged Markedly sunken

under 2 years)
Eyes Normal Sunken Markedly sunken

Skin turgor Normal Reduced Tenting

Skin Normal Cool Cool, mottled,

acrocyanosis
Urine Output Normal or mildly Markedly reduced Anuria
reduced (fewer nappy changes
needed than normal)
 Systemic signs Increased thirst Listlessness, Grunting, lethargy,
irritability coma

A Guide to Paediatric Urine Output

Normal Paediatric Urine Output

Infants and toddlers = 2-3 ml/kg/hour

Preschool and young school age = 1-2 ml/kg/hour
School age and adolescents = 0.5-1 ml/kg/hour

Minimum Paediatric Urine Output

Minimum urine output is defined as the minimum amount of urine production needed to ensure
adequate renal function to clear the body of waste products. The child with a health alteration
may have less than normal urine output.

Infants and children weighing < 30 kg= 1 ml/kg/hour

Older children and adolescents 30-60kg = 0.5 ml/kg/hour
Children weighing >60 kg = 30 ml per hour

Monitoring

1. All children on IV fluids should be weighed prior to the commencement of therapy, and
daily afterwards. Ensure you request this on the treatment orders.
2. Children with ongoing dehydration/ongoing losses may need 6 hourly weights to assess
hydration status
3. All children on IV fluids should have serum electrolytes and glucose checked before
commencing the infusion (typically when the IV is placed) and again within 24 hours if
IV therapy is to continue.
4. For more unwell children, check the electrolytes and glucose 4-6 hours after
commencing, and then according to results and the clinical situation but at least daily.
5. Pay particular attention to the serum sodium on measures of electrolytes. Hyponatremia
or Hypernatremia. 
6. Children on IV fluids should have a fluid balance chart documenting input, ongoing
losses and urine output.