Remembering the classics: Safety in Pediatric Parenteral Fluid and Electrolyte Administration
Alan Jay Schwartz MD MSEd and Justin L Lockman MD MSEd
At first glance, the March 18, 2025 PAAD “Remembering the Classics: The 4-2-1 rule of IV fluid administration” (https://ronlitman.substack.com/p/the-4-2-1-rule-of-iv-fluid-administration) seemed to be a straightforward review of a fundamental pediatric anesthesia patient care topic. It took but a few days and the March 21, 2025 “Reader response” (https://ronlitman.substack.com/p/reader-response-266) to point out that the topic of effective and safe IV fluid administration to pediatric patients is still very much alive in our minds.
Today’s PAAD1,2 makes good on my assurance that we would revisit more of the key people and publications that guide us to achieve effective and safe fluid administration of fluids to pediatric patients. Myron Yaster MD
Original article
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. doi: 10.1016/S0140-6736(14)61459-8. Epub 2014 Dec 1. PMID: 25472864.
Original article
Feld LG, Neuspiel DR, Foster BA, Leu MG, Garber MD, Austin K, Basu RK, Conway EE Jr, Fehr JJ, Hawkins C, Kaplan RL, Rowe EV, Waseem M, Moritz ML; SUBCOMMITTEE ON FLUID AND ELECTROLYTE THERAPY. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018 Dec;142(6):e20183083. doi: 10.1542/peds.2018-3083. PMID: 30478247.
The classic teaching of the 4-2-1 rule, mentioned in the March 18, 2025 PAAD, was published in 1957 by Holliday and Segar.3 They stressed the need for replacement of water based on the quantitative requirement on the body’s caloric expenditure.
“One of the major objectives of parenteral fluid therapy is provision of water to meet physiologic losses… Since losses of water are a function of expenditure of energy, needs for water must be computed from some function of energy metabolism.”3
Holliday and Segar did not focus on the body’s electrolyte balance. And importantly, their study involved previously healthy children admitted and made NPO – not exactly the patients we admit to our hospitals in 2025!
We have the late and dearly missed Dr. Frederic (Fritz) A Berry4,5 to thank for a more comprehensive consideration of perioperative fluid administration, including the body’s need for both water and sodium balance. In 1975, Berry expounded upon the physiologic underpinnings of pediatric fluid therapy in his classic American Society of Anesthesiologists (ASA) Refresher Course educational publication.
Andrew Davidson’s March 21, 2025 PAAD Reader Response stressed the need for electrolyte (sodium) administration in addition to water as we fluid resuscitate pediatric patients. Labeling sodium-penic half normal saline solutions “Poisonous for children” (https://ronlitman.substack.com/p/reader-response-266) undoubtedly emerged from Davidson and colleagues’ study of hypotonic vs isotonic fluid administration.1 Avoiding the significant morbidity/mortality associated with hyponatremia was their goal because of many publications stating:
“The use of…hypotonic fluid in children has been reported to be a cause of hyponatremia, with some children having severe outcomes such as seizures, cerebral oedema, and death.”1
In the 2015 study, two pediatric groups receiving IV fluids intraoperatively were evaluated in
“…a randomised controlled double-blind trial of children…who needed intravenous maintenance hydration for 6 h or longer…randomly assigned patients (1:1) to receive either isotonic intravenous fluid containing 140 mmol/L of sodium (Na140) or hypotonic fluid containing 77 mmol/L of sodium (Na77) (“half normal saline”)…The primary outcome was occurrence of hyponatremia (serum sodium concentration <135 mmol/L…[a total of 641 patients were studied] …One [1] patient in the Na140 had seizures during the treatment period compared with seven [7] who received Na77…”1
A current guide to parenteral fluid administration has been developed by the American Academy of Pediatrics (AAP).2
The “…goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs.”2
Employing a classic evidence-based evaluation protocol, the AAP guideline concluded
“The Key Action Statement of the subcommittee is as follows: 1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong)”2
It remains incumbent upon pediatric anesthesiology practitioners that while starting with the premise that isotonic fluid solutions are to be administered to our patients, we must maintain a sharp awareness of factors that may vary from normal. These include, among others, excessive fluid losses or overload, electrolyte derangements, physiologic stressors, and renal impairment. Whatever fluids are used (and we support the initial use of isotonic fluids for nearly all children), it’s critical that children on parenteral fluid therapy have volume status and electrolytes monitored and that we adjust the volume and tonicity of the fluids to meet each patient’s individual physiologic needs.
Send your thoughts and comments to Myron at Myasterster@gmail.com who will post in a Friday Reader Response.
PS from Myron: I would recommend taking it a step further. Just get rid of all hypotonic solutions from your workrooms! If you don’t stock them you wont use them. And if you really want to go wild get rid of normal saline as well. Simply too much sodium.
And for those of you who need an even deeper dive into this topic check out this summary in OpenAnesthesia
https://www.openanesthesia.org/keywords/perioperative-fluid-administration-in-children/?search_term=perioperative%20fluid
References
1. McNab S, Duke T, South M, et al. 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 (London, England) 2015;385(9974):1190-7. (In eng). DOI: 10.1016/s0140-6736(14)61459-8.
2. Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics 2018;142(6) (In eng). DOI: 10.1542/peds.2018-3083.
3. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19(5):823-32. (In eng).
4. Mai CL, Yaster M, Chu L, Zulfiqar A, Firth PG. The development of pediatric fluid resuscitation: an interview with Dr. Frederic A. 'Fritz' Berry. Paediatric anaesthesia 2014;24(2):217-23. (In eng). DOI: 10.1111/pan.12309.
5. Berry FA. Intraoperative fluid therapy in pediatrics. ContempAnesthPract 1983;6:85-99.