Intravenous fluid therapy in children and young people in hospital

This guideline covers general principles for managing intravenous (IV) fluids for children and young people under 16 years, including assessing fluid and electrolyte status and prescribing IV fluid therapy. It applies to a range of conditions and different settings. It does not include recommendations relating to specific conditions. This guideline represents a major opportunity to improve patient safety for children and young people having IV fluid therapy in hospital.

# Recommendations
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# Principles and protocols for intravenous fluid therapy
For guidance on the principles and protocols for intravenous (IV) fluid therapy, see the principles and protocols for intravenous fluid therapy section in NICE's guideline on intravenous fluid therapy in adults (recommendations 1.1.1, 1.1.2, 1.1.3, 1.1.5, 1.1.6, 1.1.7 and 1.1.8 apply to all ages).
Offer IV fluid therapy as part of a protocol (see algorithms for IV fluid therapy in children and young people in hospital):
Assess fluid and electrolyte needs following algorithm 1: Assessment and monitoring.
If term neonates, children and young people need IV fluids for fluid resuscitation, follow algorithm 2: Fluid resuscitation.
If term neonates, children and young people need IV fluids for routine maintenance, follow algorithm 3: Routine maintenance.
If term neonates, children and young people need IV fluids to address existing deficits or excesses, ongoing abnormal losses or abnormal fluid distribution, follow algorithm 4: Replacement and redistribution.
If hypernatraemia develops, follow algorithm 5: Managing hypernatraemia that develops during IV fluid therapy.
If hyponatraemia develops, follow algorithm 6: Managing hyponatraemia that develops during IV fluid therapy.

# Assessment and monitoring
Use body weight to calculate IV fluid and electrolyte needs for term neonates, children and young people.
Consider using body surface area to calculate IV fluid and electrolyte needs if accurate calculation of insensible losses is important (for example, if the weight is above the 91st centile, or with acute kidney injury, known chronic kidney disease or cancer).
In term neonates, children and young people who are receiving IV fluids, assess and document the following:
Actual or estimated daily body weight. Record the weight from the current day, the previous day, and the difference between the two. If an estimate was used, the actual weight should be measured as soon as clinically possible.
Fluid input, output and balance over the previous 24 hours.
Any special instructions for prescribing, including relevant history.
An assessment of the fluid status.
The results of laboratory and pointofcare assessments, including:
full blood count
urea
creatinine
plasma electrolyte concentrations (including chloride, sodium and potassium; see recommendation 1.2.4)
blood glucose (see recommendation 1.2.5)
urinary electrolyte concentrations.
Details of any ongoing losses (see recommendation 1.5.1 and the diagram of ongoing losses).
Calculations of fluid needs for routine maintenance, replacement, redistribution and resuscitation.
The fluid and electrolyte prescription (in ml per hour), with clear signatures, dates and times.
Types and volumes of fluid input and output (urine, gastric and other), recorded hourly and with running totals.
-hourly fluid balance subtotals.
-hourly fluid balance totals.
-hourly reassessments of:
the fluid prescription
current hydration status
whether oral fluids can be started
urine and other outputs.
Measure plasma electrolyte concentrations using laboratory tests when starting IV fluids, and then at least every 24 hours or more frequently if there are electrolyte disturbances.
Measure blood glucose when starting IV fluids, and then at least every 24 hours or more frequently if there is a risk of hypoglycaemia.
Consider point-of-care testing for measuring plasma electrolyte concentrations and blood glucose in timecritical situations when IV fluids are needed (for example, during emergency situations and in A&E, theatre and critical care).
Diagnose clinical dehydration and hypovolaemic shock using the clinical features listed in table 1, but be aware that it can be difficult to identify the clinical features in term neonates.
No clinically detectable dehydration
Clinical dehydration
Hypovolaemic shock
Alert and responsive
Red flag
Altered responsiveness (for example, irritable, lethargic)
Decreased level of consciousness
Appears well
Red flag
Appears to be unwell or deteriorating
Eyes not sunken
Red flag
Sunken eyes
Moist mucous membranes (except after a drink)
Dry mucous membranes (except for 'mouth breather')
Normal blood pressure
Normal blood pressure
Hypotension (decompensated shock)
Normal breathing pattern
Red flag
Tachypnoea
Tachypnoea
Normal capillary refill time
Normal capillary refill time
Prolonged capillary refill time
Normal heart rate
Red flag
Tachycardia
Tachycardia
Normal peripheral pulses
Normal peripheral pulses
Weak peripheral pulses
Normal skin turgor
Red flag
Reduced skin turgor
Normal urine output
Decreased urine output
Skin colour unchanged
Skin colour unchanged
Pale or mottled skin
Warm extremities
Warm extremities
Cold extremities
Notes:
Within the category of 'clinical dehydration' there is a spectrum of severity indicated by increasingly numerous and more pronounced clinical features. For hypovolaemic shock, 1 or more of the clinical features listed would be expected to be present. Dashes () indicate that these features do not specifically indicate hypovolaemic shock. This table has been adapted from the assessing dehydration and shock section of NICE's guideline on diarrhoea and vomiting in children.

# Fluid resuscitation
If children and young people need IV fluid resuscitation, use glucosefree crystalloids that contain sodium in the range 131154 mmol/litre, with a bolus of 10 ml/kg over less than 10 minutes. Take into account preexisting conditions (for example, cardiac disease or kidney disease), as smaller fluid volumes may be needed.Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information.
If term neonates need IV fluid resuscitation, use glucosefree crystalloids that contain sodium in the range 131154 mmol/litre, with a bolus of 1020 ml/kg over less than 10 minutes.Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information.
Do not use tetrastarch for fluid resuscitation.
For guidance on using IV fluids for fluid resuscitation in children and young people with diabetic ketoacidosis, see the diabetic ketoacidosis section of NICE's guideline on diabetes (type 1 and type 2) in children and young people.
Reassess term neonates, children and young people after completion of the IV fluid bolus, and decide whether they need more fluids.
Seek expert advice (for example, from the paediatric intensive care team) if 4060 ml/kg of IV fluid or more is needed as part of the initial fluid resuscitation.

# Routine maintenance
Calculate routine maintenance IV fluid rates for children and young people using the HollidaySegar formula (100 ml/kg/day for the first 10 kg of weight, 50 ml/kg/day for the next 10 kg and 20 ml/kg/day for the weight over 20 kg). Be aware that over a 24hour period, males rarely need more than 2,500 ml and females rarely need more than 2,000 ml of fluids.
Calculate routine maintenance IV fluid rates for term neonates according to their age, using the following as a guide:
From birth to day 1: 50 to 60 ml/kg/day.
Day 2: 70  to 80 ml/kg/day.
Day 3: 80 to 100 ml/kg/day.
Day 4: 100 to 120 ml/kg/day.
Days 5 to 28: 120 to 150 ml/kg/day.
If children and young people need IV fluids for routine maintenance, initially use isotonic crystalloids that contain sodium in the range 131 to 154 mmol/litre.Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information.
Measure plasma electrolyte concentrations and blood glucose when starting IV fluids for routine maintenance (except before most elective surgery), and at least every 24 hours thereafter.
Be aware that plasma electrolyte concentrations and blood glucose are not routinely measured before elective surgery unless there is a need to do so, based on the child's medical condition or the type of surgery.
Base any subsequent IV fluid prescriptions on the plasma electrolyte concentrations and blood glucose measurements.
If term neonates aged 8 days or over need IV fluids for routine maintenance, initially use isotonic crystalloids that contain sodium in the range 131154 mmol/litre with 510% glucose. For term neonates aged up to 7 days, use professional judgement, taking into account:
the individual circumstances, and
for term neonates in the first days of life, a sodium content of 131 to 154 mmol/litre may be too high (or sodium may not be needed) and a glucose content of 5% to 10% may be too low. Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information. 
For term neonates in critical postnatal adaptation phase (for example, term neonates with respiratory distress syndrome, meconium aspiration, hypoxic ischaemic encephalopathy), give no or minimal sodium until postnatal diuresis with weight loss occurs.
If there is a risk of water retention associated with nonosmotic antidiuretic hormone (ADH) secretion, consider either:
restricting fluids to 50% to 80% of routine maintenance needs or
reducing fluids, calculated on the basis of insensible losses within the range 300400 ml/m2/24 hours plus urinary output.
When using body surface area to calculate IV fluid needs for routine maintenance (see recommendation 1.2.2), estimate insensible losses within the range 300400 ml/m2/24 hours plus urinary output.
For a short explanation of why the committee made the 2020 change to recommendation 1.4.7, see the rationale on routine maintenance .
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# Replacement and redistribution
If term neonates, children and young people need IV fluids for replacement or redistribution, adjust the IV fluid prescription (in addition to maintenance needs) to account for existing fluid and/or electrolyte deficits or excesses, ongoing losses (see the diagram of ongoing losses) or abnormal distribution, for example, tissue oedema seen in sepsis.
Consider isotonic crystalloids that contain sodium in the range 131 to 154 mmol/litre for redistribution. Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information.
Use 0.9% sodium chloride containing potassium to replace ongoing losses (see the diagram of ongoing losses).
Base any subsequent fluid prescriptions on the plasma electrolyte concentrations and blood glucose measurements.

# Managing hypernatraemia that develops during intravenous fluid therapy
If hypernatraemia develops in term neonates, children and young people, review the fluid status and take action as follows:
If there is no evidence of dehydration and an isotonic fluid is being used, consider changing to a hypotonic fluid (for example, 0.45% sodium chloride with glucose). Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information.
If dehydration is diagnosed, calculate the water deficit and replace it over 48 hours, initially with 0.9% sodium chloride.
If the fluid status is uncertain, measure urine sodium and osmolality.
If hypernatraemia worsens or is unchanged after replacing the deficit, review the fluid type and consider changing to a hypotonic solution (for example, 0.45% sodium chloride with glucose).
When correcting hypernatraemia, ensure that the rate of fall of plasma sodium does not exceed 12 mmol/litre in a 24hour period.
Measure plasma electrolyte concentrations every 4 to 6 hours for the first 24 hours, and after this base the frequency of further plasma electrolyte measurements on the treatment response.

# Managing hyponatraemia that develops during intravenous fluid therapy
If asymptomatic hyponatraemia develops in term neonates, children and young people, review the fluid status and take action as follows:
If a child is prescribed a hypotonic fluid, change to an isotonic fluid (for example, 0.9% sodium chloride).
Restrict maintenance IV fluids in children and young people who are hypervolaemic or at risk of hypervolaemia (for example, if there is a risk of increased ADH secretion) by either:
restricting maintenance fluids to 50% to 80% of routine maintenance needs or
reducing fluids, calculated on the basis of insensible losses within the range 300400 ml/m2/24 hours plus urinary output.
Be aware that the following symptoms are associated with acute hyponatraemia during IV fluid therapy:
Headache.
Nausea and vomiting.
Confusion and disorientation.
Irritability.
Lethargy.
Reduced consciousness.
Convulsions.
Coma.
Apnoea.
If acute symptomatic hyponatraemia develops in term neonates, children and young people, review the fluid status, seek immediate expert advice (for example, from the paediatric intensive care team) and consider taking action as follows:
Use a bolus of 2 ml/kg (maximum 100 ml) of 2.7% sodium chloride over 1015 minutes.
Use a further bolus of 2 ml/kg (maximum 100 ml) of 2.7% sodium chloride over the next 10 to 15 minutes if symptoms are still present after the initial bolus.
If symptoms are still present after the second bolus, check the plasma sodium level and consider a third bolus of 2 ml/kg (maximum 100 ml) of 2.7% sodium chloride over 10 to 15 minutes.
Measure the plasma sodium concentration at least hourly.
As symptoms resolve, decrease the frequency of plasma sodium measurements based on the response to treatment.
Do not manage acute hyponatraemic encephalopathy using fluid restriction alone.
After hyponatraemia symptoms have resolved, ensure that the rate of increase of plasma sodium does not exceed 12 mmol/litre in a 24hour period.

# Training and education
For guidance on training and education for healthcare professionals involved in prescribing and delivering IV fluid therapy, see the training and education section of NICE's guideline on intravenous fluid therapy in adults.

## Algorithms for IV fluid therapy in children and young people in hospital
There is a PDF containing 6 algorithms for IV fluid therapy in children and young people in hospital.

## Diagram of ongoing losses for children and young people
There is a PDF diagram of ongoing losses for children and young people.

## Intravenous fluid types for children and young people
Note that fluids given are examples of appropriate fluids; for further details, see the BNFc information on fluids and electrolytes.
Fluid type
Osmolality (compared with plasma)
Tonicity (with reference to cell membrane)
Sodium content (mmol/litre)
Potassium content (mmol/litre)
% sodium chloride
Isosmolar
Isotonic
Hartmann's solution
Isosmolar
Isotonic
Fluid type
Osmolality (compared with plasma)
Tonicity (with reference to cell membrane)
Sodium content (mmol/litre)
Potassium content (mmol/litre)
% sodium chloride with 5% glucose
Hyperosmolar
Isotonic
Fluid type
Osmolality (compared with plasma)
Tonicity (with reference to cell membrane)
Sodium content (mmol/litre)
Potassium content (mmol/litre)
% sodium chloride with 5% glucose
Hyperosmolar
Hypotonic
% sodium chloride with 2.5% glucose
Isosmolar
Hypotonic
% sodium chloride
Hyposmolar
Hypotonic
% glucose
Isosmolar
Hypotonic
% glucose
Hyperosmolar
Hypotonic

# Terms used in this guideline

## Neonates, children and young people are defined as follows:
neonates: infants aged 28 days and under (born at term; or born prematurely who have a corrected age of term or more)
children: 29 days to under 12 years
young people: 12 to under 16 years.# Rationale

# Routine maintenance
Recommendation 1.4.7
In 2020 NICE checked whether the guideline needed updating and decided that it did not. When we consulted on this decision, concerns were raised about recommendation 1.4.7 on IV fluids for routine maintenance in term neonates. Specifically, that for term neonates in the first days of life, the sodium content may be too high and the glucose content too low. Evidence in this area was very limited when the guideline committee made the original recommendation in 2015, with no evidence at all in term neonates aged 0 to 48 hours. The committee therefore made a recommendation based on consensus.
We found no further evidence in this area in 2020. After discussion with topic experts, the recommendation has been revised to reduce the potential for incorrect use of isotonic crystalloids in the youngest neonates. We may revisit this area if we become aware of any relevant new evidence in future.
Return to recommendations# Context
Correct fluid and electrolyte balance is essential to maintain physiological function. Normally, children and young people get the fluid they need by drinking. Many children and young people admitted to hospital may be too ill to drink so may need intravenous (IV) fluid therapy to correct or maintain their fluid and electrolyte balance.
Children and young people may need IV fluids to account for losses of red blood cells, plasma, water or electrolytes beyond the usual losses in urine, stools and sweat. These losses can come from burns, diarrhoea, vomiting or leakage of fluid into the interstitial space. In these cases the aim is to replace any depleted fluids and restore electrolyte balance. Conditions such as cardiac dysfunction, liver disease, inappropriate antidiuretic hormone secretion and nephrotic syndrome can result in an excess of fluids in the body, known as fluid overload. If this happens, the aim is to rebalance and redistribute fluids and ensure the correct levels of electrolytes.
Whether IV fluid therapy is needed for fluid resuscitation, routine maintenance, replacement or redistribution, it is vital that the correct composition, volume and timing of IV fluid therapy is used. IV fluid types include colloids, crystalloids and combinations of fluids, and different types of fluids are appropriate for different situations (see the MHRA Drug Safety Alert for hydroxyethyl starch intravenous infusions). Errors in prescribing or administering IV fluids can result in inadequate or excessive provision, leading to hypovolaemia and poor organ perfusion, or hypervolaemia, oedema and heart failure. Failing to correct imbalances in electrolytes can lead to disturbances in intracellular or extracellular electrolyte balance, particularly in children and young people with reduced liver or kidney function. Failing to deliver correct fluids can therefore have a significant impact on morbidity and mortality.
Surveys have shown that many staff who prescribe IV fluids know neither the likely fluid and electrolyte needs of individual patients, nor the specific composition of the many choices of IV fluids available to them. There is little formal training and education in IV fluid management to support correct prescribing.
There is also a wide variation in the charts used to prescribe fluids and to record fluid and electrolyte status. Monitoring children and young people is often challenging: it may be difficult to assess urine output accurately, and blood tests can be painful, distressing and difficult to repeat. Assessment and monitoring is often suboptimal, and fluid and electrolyte status may not be recorded accurately. Changes in patients' fluid needs may not be reassessed appropriately or at the correct intervals, which can lead to fluids being prescribed incorrectly. Clinical staff need to ensure that appropriate identification, treatment and monitoring of changes in fluid and electrolyte status is maintained and documented. There is a need for a standardised approach to assessing patients' fluid and electrolyte status and prescribing IV fluid therapy in the NHS. This guidance represents a major opportunity to improve patient safety for children and young people having IV fluid therapy in hospital.# Recommendations for research
The guideline committee has made the following recommendations for research. The committee's full set of research recommendations is detailed in the full guideline.

# Complications of IV fluid therapy
What is the incidence of complications during, and as a consequence of, IV fluid therapy in children and young people?

## Why this is important
Every day, children and young people are prescribed IV fluid therapy for a variety of reasons. However, there is little evidence on IV fluids in children and young people, and the limited evidence available is of very poor quality.
Complications of IV fluid therapy can lead to mortality and significant morbidity for the patient. This, in turn, represents a cost burden for the NHS in terms of critical care admissions, prolonged inpatient stays or the potential need for longterm followup and care by medical and allied healthcare professionals.

# Glucose concentration
What is the most appropriate glucose concentration in IV fluids for children and young people of different ages?

## Why this is important
In recent years, the use of glucosecontaining hypotonic IV fluids in children and young people has been questioned, because of the risk of hyponatraemia. Many children and young people are now prescribed nonglucosecontaining isotonic IV fluids for maintenance. However, there are several groups of children and young people, in particular, neonates and some children in the perioperative period (for example, those who underwent prolonged fasting preoperatively, and those who had central blocks during anaesthesia), who may benefit from glucosecontaining IV solutions to prevent hypoglycaemia. A blanket prescription of 5 or 10% glucose solution for all may result in hyperglycaemia in some children and young people. However, the use of IV fluids containing lower concentrations of glucose may be sufficient to prevent hypoglycaemia and also avoid unnecessary hyperglycaemia. This may have a clinical application across all age groups, including neonates.

# Fluid balance charts
For children and young people receiving IV fluids, does the use of a standardised national fluid balance chart reduce the rate of complications arising as a result of prescription and/or administration errors?

## Why this is important
The National Confidential Enquiry into Perioperative Deaths reports in 1999 and 2009 identified problems in fluid management in patients in the UK. A lack of consistency in prescribing and recording IV fluids may contribute to this. A lack of familiarity of 'mobile' medical and nursing staff with fluid balance charts in different hospital settings may further increase the likelihood of prescription and administration errors.
A prospective cohort of children and young people receiving IV fluids, prescribed and documented on a standardised national fluid balance chart, or a casecontrol study comparing the use of a standardised national fluid balance chart with nonstandard 'local' fluid balance charts is needed to assess the clinical and cost effectiveness of using a standardised national fluid balance chart. Outcomes should include complications of IV fluid therapy (hypovolaemia, hypervolaemia, electrolyte abnormalities, neurological complications and hypoglycaemia) and incidence of prescription errors. If using a standardised national fluid balance chart resulted in better fluid prescription and clinical outcomes in children and young people, this could potentially lead to significant cost savings for the NHS.

# Training and education of healthcare professionals
Does ensuring that all hospital healthcare professionals involved in prescribing and delivering IV fluids for children and young people are appropriately trained in the principles of fluid prescribing and IV fluid therapyrelated complications lead to a reduction in IV fluidrelated complications and associated healthcare costs?

## Why this is important
Assessing patients' IV fluid needs, as well as prescribing and delivering IV fluids, are essential daily tasks on most paediatric wards. These are complex responsibilities that entail careful clinical assessment, good understanding of the physiology of fluid homeostasis both in health and disease, and appropriate supervision and training. There is currently no standard training provided for healthcare professionals working in the UK. Any teaching at both undergraduate and postgraduate level is currently delivered ad hoc, and in many cases may be limited. If fluid management in hospitalised children and young people is to improve, standardised training is likely to be needed. Any educational interventions made would need to be evaluated to assess whether practice had subsequently improved.