Anaes · Paediatric anaesthesia
Paediatric fluids, fasting, and glucose: Holliday-Segar and safe maintenance
Also known as Holliday-Segar · Paediatric maintenance fluids · Paediatric fasting guidelines
Exact Holliday-Segar 4-2-1 maintenance, AAP isotonic maintenance guidance, perioperative fasting including liberalised clear fluids, glucose monitoring in infants, and prevention of hospital-acquired hyponatraemia for fellowship exams.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Hypotonic maintenance fluids risk hospital-acquired hyponatraemia — use isotonic maintenance.
- Prolonged fasting causes hypoglycaemia in neonates and small infants.
- Replace ongoing losses thoughtfully; protocolised isotonic boluses for resuscitation.
- Never use adult fixed litre orders without weight-based calculation.
- Postoperative ADH elevation makes free water dangerous.
Meet the patient
An 18 kg four-year-old for myringotomy arrives on your list, clear fluids 90 minutes ago. The ward nurse has written up 0.18% saline with dextrose at half maintenance because the child has been fasting. Two things are wrong with that order, and both are dangerous.[2]
First, 0.18% saline is hypotonic maintenance — the classic wrong fluid. Second, a well child with clear fluids 90 minutes ago does not need a large NPO catch-up. The examiner wants you to calculate 4-2-1 (56 mL/h), choose isotonic, and explain why the hypotonic bag causes hospital-acquired hyponatraemia.[2]
References8ShowHide
- [1]Holliday MA, Segar WE The maintenance need for water in parenteral fluid therapy. Pediatrics, 1957.PMID 13431307
- [2]Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics, 2018.PMID 30478247
- [3]Coté CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis. Anesthesiology, 1995.PMID 7717551
- [4]Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial Lancet, 2016.PMID 26507180
- [5]Sikich N, Lerman J Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology, 2004.PMID 15114210
- [6]Disma N, Frykholm P, Cook-Sather SD, et al. Pro-Con Debate: 1- vs 2-Hour Fast for Clear Liquids Before Anesthesia in Children. Anesth Analg, 2021.PMID 34403386
- [7]Dalal PG, Malviya S, Cravero J, et al. Reviewing "Nil Per Os" Guidance for Clear Fluids in Children Before Anesthesia: Survey of the Pediatric Anesthesia Leadership Council. Anesth Analg, 2025.PMID 39773771
- [8]McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet, 2019.PMID 30782342