Fluid Management in Infants

Introduction to Fluid Management

The goal of fluid management in infants is to maintain proper hydration, electrolyte balance, and acid-base status, as recommended by the European Society of Pediatric and Neonatal Intensive Care and the American Academy of Pediatrics 1, 2, 3

Isotonic balanced solutions with sodium concentration of 135-144 mEq/L should be used in infants, as recommended by the European Society of Pediatric and Neonatal Intensive Care, Intensive Care Medicine society, and American Academy of Pediatrics 1, 2, 3
Dextrose (typically 5%) should be included in intravenous maintenance fluids to prevent hypoglycemia in infants, with blood glucose monitoring at least daily, as recommended by the European Society of Pediatric and Neonatal Intensive Care 1
Potassium supplementation (1-3 mmol/kg/day) should be added to maintenance IV fluids, but only after confirming normal renal function and urine output, with regular monitoring of potassium levels, as recommended by the American Academy of Pediatrics 2 and the European Society of Pediatric and Neonatal Intensive Care 1
The Holliday-Segar formula calculates maintenance IV fluids as follows:
Weight Range Fluid Rate
First 10 kg 100 ml/kg/day (4 ml/kg/hour)
Second 10 kg 50 ml/kg/day (2 ml/kg/hour)
Each additional kg 25 ml/kg/day (1 ml/kg/hour)

In infants at risk of increased ADH secretion, maintenance fluid volume should be restricted to 65-80% of calculated volume, as recommended by the European Society of Pediatric and Neonatal Intensive Care 1 and the American Academy of Pediatrics 3
In children with edematous states (heart failure, renal failure, hepatic failure), maintenance fluid volume should be restricted to 50-60% of the calculated volume, according to the European Society of Pediatric and Neonatal Intensive Care 1 and the European Society of Intensive Care Medicine 1
For patients with short bowel syndrome, adding additional sodium (80-100 mEq/L) to the IV solution may be considered, as suggested by Clinical Nutrition and Gastroenterology societies 4, 5
For patients with high-output jejunostomy, glucose-electrolyte solutions can help reduce mineral and water loss, according to the Clinical Nutrition society 4

Assess fluid status, electrolytes, and potassium levels frequently, including monitoring potassium, sodium, phosphate, and magnesium levels, as recommended by the American College of Physicians and the European Society for Clinical Nutrition and Metabolism 6, 7
Monitor for fluid overload in patients with renal or cardiac compromise, and watch for resolution of hyperkalemia-related ECG changes, according to the American College of Physicians 6, 8
Clinical status should be assessed for signs of dehydration or fluid overload, as recommended by the Intensive Care Medicine society 1
Electrolytes, especially sodium, should be monitored at least daily, and fluid balance and daily weights should be tracked, as recommended by the European Society of Pediatric and Neonatal Intensive Care 1
Free water deficit can be calculated using the formula: Water deficit = Total body water × [(Current Na+/Desired Na+) - 1], as stated by the American Association for the Study of Liver Diseases 9
Correction rate should not exceed 9 mmol/L of increase in sodium in 24 hours, with serum sodium monitored every 2-4 hours initially, according to the American Association for the Study of Liver Diseases 9

Failing to consider total fluid intake, including IV medications, line flushes, and enteral intake, can lead to "fluid creep", as warned by the European Society of Pediatric and Neonatal Intensive Care 1
Not transitioning to enteral fluids when possible can lead to complications, according to the European Society of Pediatric and Neonatal Intensive Care 1
Using lactate buffer solutions in patients with liver dysfunction can lead to lactic acidosis, as warned by the European Society of Pediatric and Neonatal Intensive Care 1
Administering free water intravenously without caution, which can increase the risk of hyponatremia and its neurological complications, as per the American Academy of Pediatrics 3

Maintenance intravenous (IV) fluids should be continued while correcting hyperkalemia in hospitalized patients, with appropriate potassium adjustments based on serum levels, according to the American College of Physicians, as recommended by the Mayo Clinic Proceedings 6
Initial stabilization should include IV calcium to stabilize cardiac membranes (10 mL of 10% calcium gluconate) 6
Intracellular shift therapies, such as IV insulin/glucose (10 units + 50 mL dextrose) and nebulized beta-agonists, should be used to treat hyperkalemia 6
Elimination therapies, including diuretics (in non-oliguric patients) and dialysis (in oliguric or ESRD patients), should be considered 6