1) Maintenance fluid therapy aims to prevent dehydration, electrolyte disturbances, and protein degradation in sick infants and children whose oral intake is uncertain. 2) Fluid requirements are calculated based on weight and age using the "4-2-1 rule" or Holliday-Segar formula. Common maintenance fluids include 0.45% saline with potassium chloride. 3) Careful monitoring of weight, urine output, and serum sodium is important when administering intravenous fluids to avoid complications like hyponatremia. Replacement fluids should promptly replace ongoing losses from vomiting, diarrhea, or altered renal output.

1. Fluid Therapy in
Paediatrics
Moderated by: Dr. G.K. Verma
Presented by: Dr. Deepak Singh

2. OBJECTIVES
To know the difference in physiology of children.
To know the Goals of maintenance fluid therapy.
Able to Calculate total fluid requirement & do
monitoring of the patient.
To know Variations in maintenance water &
electrolytes.
To order Replacement fluids in “common”
situations.

3. WHY THE INFANTS ARE MORE VULNERABLE?*
Physiological inability to concentrate urine.
Higher metabolic rate & larger surface area.
Cant express thirst for more fluids.
Larger turnover.
*IAP text book of Pediatrics 5th edition

4. WHOM TO GIVE MAINTENANCE FLUIDS?
Infants who are sick & whose
uncertain.
oral intake is
Babies who are kept NPO for
respiratory distress etc.
the surgery, with
neonates kept under radiant warmer.

5. GOALS OF MAINTENANCE FLUIDS*
Prevent dehydration
Prevent electrolyte disturbance
Prevent ketoacidosis
Prevent protein degradation
*Nelsons Text book of pediatrics 19th edition

6. AT BIRTH…
75 % of the
Next 2 – 3 Days
total body weight
Obligatory diuretic phase
65 % of the
At the end of Ist year
total body weight
60 % of the total body weight

8. BACK TO PHYSIOLOGY…
Total Body Water 60%*
Intra cellular
(ICF)
40%
fluid Extra cellular fluid
(ECF)
20%
Interstitial
15%
Intravasular
5%
*IAP text book of Pediatrics 5th edition

9. DISTRIBUTION OF BODY WATER
Intravascular (5%)
ECF
Interstitial (15%)
Intracellular (40%)
ICF
Na+
Cl-
K+

10. ELECTROLYTE CONCENTRATIONS
Component ECF ICF
Na+ High Low
K+ Low High
Ca++ Low Low (higher
than ECF)
Proteins High High

11. KEY LEARNING POINT*
Sodium is the Principle electrolyte
[140mEq/L (+/- 5)]
in ECF
Potassium is the Principle electrolyte in ICF
[150mEq/L (+/- 5)]

12. Maintenance fluids consists of-
Water
Glucose
i.
ii.
iii. Sodium
iv. Potassium
Advantages –
Simplicity, long shelf life, low cost, compatibility.
Routinely used maintenance therapy fluid
doesn’t
provide calcium, phosphorus, magnesium or
bicarbonate.*

13. FLUID LOSSES IN INFANTS
LUNGS
URINE, FECES SKIN

14. CONCEPT OF MAINTENANCE OF WATER
Crucial component of maintenance fluid therapy.
Maintenance water = Measurable loss of water 65%
(Urine 60%, stools 5%) + Insensible loss of water 35%
(skin & lungs)

15. FOR NEONATES
Day 1 60 ml/kg/day
Day 2 90 ml/kg/day
Day 3 120 ml/kg/day
Day 4 150 ml/kg/day (maximum for term infants)
Day 5 to 3 months 150 ml/kg/day

16. MAINTENANCE REQUIREMENTS
Weight Requirement
0-10 kg 100ml/kg/24hr
11-20 kg 1000 +
50ml/kg/24hr
>20 kg
Upper limit 2400cc/24hrs
1500 +
20ml/kg/24hr

17. Maintenance Fluids
Hourly Maintenance Fluid Requirement*
“4 - 2 -1 rule”
WEIGHT
0 - 10 kg
FLUID
4 ml/kg/hr
10 - 20 kg 40ml/hr + 2 ml/kg/hr
> 20 kg 60ml/hr + 1 ml/kg/hr
Upper limit 100cc/hr
*Nelsons Text book of pediatrics 19th edition

18. CONCEPT OF MAINTENANCE OF
ELECTROLYTES
Insensible water loss contains no electrolytes
So, sodium & potassium present in the urine, stools
& sweat would be the amount to be replaced plus
the sodium & potassium required for
metabolism of the body.
normal
3mEq of sodium in 100 ml
&
2mEq of potassium in 100
of fluid
ml of fluid

19. CONCEPT OF MAINTENANCE OF GLUCOSE
Maintenance fluids usually contains 5% dextrose
gm/100ml) providing 17 calories/ 100 ml of fluid.
(5
Which is approx. 20% of the daily caloric needs.
Prevents ketone production.

20. COMMONLY USED FLUIDS FOR
MAINTENANCE
0.9% Normal Saline –
Principal fluid used for intravascular resuscitation and replacement
of salt loss e.g diarrhoea and vomiting
I.
Contains: Na+ 154 mmol/l, Cl- - 154 mmol/l; K+ - Absent,
K+ is often added
But
IsoOsmolar compared to normal plasma
Distribution: Stays almost entirely in the Extracellular space
Does not provide free water or calories. Restores NaCl deficits.

21. CONTENTS OF IV FLUID PREPARATIONS*
Na K Cl HCO3 Dextrose mOsm/L
(mEq/L) (mEq/L) (mEq/L) (mEq/L) (gm/L)
NS 154 154 308
DNS 154 154 50 564
½ NS 77 77 143
5%D + 77 77 50 350
1/2NS
D5W 50 278
Ringers 130 4 109 28 50 273
Lactate
(RL)
Iso P 23 20 23 30 50 367
Iso M 37 35 37 30 50 415.5

22. COMMONLY USED FLUIDS FOR MAINTENANCE
Lactated Ringer’’s (RL): Isotonic, 273 mOsm/L.II.
Contains 130 mEq/L Na+, 109 mEq/L Cl, 28 mEq/L lactate, and 4
mEq/L K+, 3 mEq/L Ca++
Lactate is used instead of bicarb because it's more stable in IVF
during storage.
Lactate is converted readily to bicarb by the liver.
Has minimal effects on normal body fluid composition and pH. More
closely resembles the electrolyte composition of normal blood serum.
Does not provide calories.

23. HOW TO CHOOSE?*
0.9% sodium chloride Suitable for initial volume resuscitation in hypovolaemia
and for ongoing fluid therapy in older children with
normal serum glucose. Fluid of choice in patients with
head injury
5% dextrose + 0.9%
sodium
chloride
Suitable for ongoing fluid therapy in infants and
children, including post-operative cardiac patients. Use
in head injured patients with hypoglycaemia.
5% dextrose + 0.45%
sodium
chloride
Suitable for ongoing fluid therapy in infants and
children, including post-operative cardiac patients
10%dextrose + 0.45%
sodium
chloride
Suitable for ongoing fluid therapy in neonates or older
infants who are hypoglycaemic, including post-operative
cardiac patients

24. MONITORING WHILE ADMINISTERING FLUIDS*
Child should be weighed prior to the commencement of
therapy, and daily afterwards.
Children with ongoing dehydration/ongoing losses may
need 6 hourly weights to assess hydration status
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.
*Royale Children’s Hospital Melbourne Guidelines

25. MONITORING WHILE ADMINISTERING FLUIDS
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.
Pay particular attention to the serum sodium on measures
of electrolytes. If <135mmol/L (or falling significantly on
repeat measures) If >145mmol/L (or rising significantly
repeat measures)
on
Children on iv fluids should have a fluid balance chart
documenting input, ongoing losses and urine output.

26. MAINTENANCE FLUIDS & HYPONATREMIA*
Production of ADH leading to water retention
leading to water intoxication.
Patients producing ADH due to subtle volume
depletion can be safely treated with fluids
containing higher sodium concentration, decrease
in fluid rate or the combination of both.
Persistent ADH production due to underlying
disease requires less than total maintenance fluids
Individualization & careful monitoring is must.

27. VARIATIONS IN MAINTENANCE WATER &
ELECTROLYTES
Source Causes of increased water Causes of decreased water
needs needs
Skin Radiant warmer Incubator
Phototherapy
Fever
Sweat
Burns
lungs Tachypnea Humidified ventilator
Tracheastomy
GI tract Diarrhea
Vomiting
Nasogastric secretion
renal Polyuria Oligo/anuria
Misc. Surgical drain hypothyroidism
Third spacing

28. REPLACEMENT FLUIDS
In addition to normal maintenance fluid
requirements, unwell children may need:
Fluid resuscitation for shock
Replacement of pre-existing fluid losses
Replacement of ongoing fluid losses

29. REPLACEMENT FLUIDS
GI losses are accompanied with loss of potassium,
bicarbonate leading to metabolic acidosis.
Impossible to predict the loses for next 24 hrs, so
measure & replace excess GI losses as they occur.
So each ml of the diarrheal stool or the vomitus
should be replaced by the same amount every 1 to
6 hourly.

30. REPLACEMENT FLUIDS
*Nelsons Text book of pediatrics 19th edition
Replacement fluid for Diarrhea*
Average composition of Diarrheal stools (except cholera)
Na 55 mEq/l K 25
mEq/l Bicarbonate 15
mEq/l
Approach to Replacement of Ongoing Losses
D5 0.2% NS + 20 mEq/l sodium bicarbonate + 20 mEq/l KCl
Replace stools ml/ml every 1 to 6 hrs

31. REPLACEMENT FLUIDS
*Nelsons Text book of pediatrics 19th edition
Replacement fluid for Emesis or Nasogastric losses*
Average composition of Gastric Fluid
Na 60 mEq/l K 10
mEq/l Chloride 90
mEq/l
Approach to Replacement of Ongoing Losses
NS + 10 mEq/l KCl
Replace Output ml/ml every 1 to 6 hrs

32. REPLACEMENT FLUIDS
Replacement fluid for Altered Renal Output*
Oligouria / Anuria
Place patient on insensible fluids (25 to 40% of maintenance)
Replace Urine output ml/ml by half NS
Polyuria
Place patient on insensible fluids (25 to 40% of maintenance)
Measure urine electrolytes
Replace Urine output ml/ml by solution based on measured urine
electrolytes
*Nelsons Text book of pediatrics 19th edition

33. TACHYPNEA
Respiratory Alkalosis
Increase in rate and
depth of breathing
Loss of CO2
Causes of hyperventilation
anemia
(tachypnea): Fear, pain, fever, CHF,

34. FEVER
Each degree of fever increases basal
metabolic rate (BMR) 10%, with a
corresponding fluid requirement

35. VOMITING
Metabolic Alkalosis
Loss of acid from stomach
pH
HCO3
H+
Treatment: Prevent further
electrolytes
losses and replace lost

36. DIARRHEA
Metabolic Acidosis
loss of HCO3 from G.I. Tract
pH
HCO3
Treatment: Correct base
deficit, replace losses of
with NaHCO3

37. TAKE HOME MESSAGE
Fluid is like “prescription” so give it with caution.
Children are more vulnerable for rapid fluid loss.
Maintenance calculation by “4-2-1” rule or Holliday
formula.
Segar’s
Vigilant Monitoring of WEIGHT, URINE OUTPUT, SERUM
SODIUM CONCENTRATION while giving fluid is must.
As far as possible try to give maintenance fluid requirement
orally.
0.45% DNS + 20 mEq/l KCl is ideal fluid in most of the children
requiring maintenance therapy.
Replacement of fluids should be prompt & appropriate.