Management of Intravenous Fluid Overinfusion in Young Children

Immediate Actions

Discontinue the hypotonic D5 infusion immediately and replace it with an isotonic maintenance solution (e.g., 0.9 % saline + 5 % dextrose or a balanced isotonic solution) while beginning close monitoring of serum sodium and glucose. [1][2]
The American Academy of Pediatrics (AAP) guideline (2018) gives Grade A evidence that isotonic solutions should be the default maintenance fluid for all children aged 28 days to 18 years. [2][3]

Isotonic fluids containing 130–154 mEq/L sodium markedly lower the incidence of hyponatremia compared with hypotonic fluids and do not increase other adverse effects. 2
Hypotonic fluids (e.g., D5W, 0.18 % saline, 0.45 % saline) are contraindicated as standard maintenance fluids in acutely ill children because they substantially raise the risk of life‑threatening hyponatremia. [2][3]
Even when isotonic fluids are used, hyponatremia can still develop if concurrent IV medications or enteral intake provide free water. 3

Serum sodium should be measured immediately; hyponatremia (Na < 135 mEq/L) occurs in 15–30 % of hospitalized children receiving hypotonic fluids. 2
Blood glucose must be checked at least daily (more frequently if symptomatic) to avoid hypoglycemia or hyperglycemia from excess dextrose. [1][4]
Serum electrolytes, including potassium, should be measured regularly; potassium supplementation is added based on the child’s clinical status. [1][4]
Neurologic assessment for hyponatremic encephalopathy (e.g., nausea, vomiting, headache, confusion, lethargy, altered mental status) is essential because untreated encephalopathy can be fatal or cause irreversible brain injury. [3][2]
Acute illness often triggers increased endogenous ADH secretion, impairing free‑water excretion and heightening vulnerability to hyponatremia. [2][3]

Calculate total fluid intake comprehensively (all IV fluids, medication infusions/boluses, line flushes, blood products, and enteral feeds). [1][4]
For children at risk of ADH‑mediated water retention, restrict maintenance volume to 65–80 % of the Holliday‑Segar estimate to prevent fluid overload. [1][4]
Avoid a cumulative positive fluid balance, as it is associated with prolonged mechanical ventilation and longer hospital stay. [1][4]
Reassess fluid balance and overall clinical status at least once daily while on IV maintenance fluids. [1][4]
Perform regular electrolyte monitoring, with particular attention to sodium trends. [1][4]3
Children undergoing major surgery, ICU admission, large gastrointestinal losses, or receiving diuretics require more frequent laboratory surveillance. 3

Provide adequate glucose (typically 5 % dextrose) in the maintenance solution to prevent hypoglycemia, which is more common in young children. [1][4]
Watch for clinical signs of fluid overload such as peripheral edema, respiratory distress, or unexpected weight gain. [1][4]