EM · Paediatric fluid and electrolyte management
Paediatric fluid and electrolyte management
Also known as Paediatric fluid management · Maintenance and deficit fluids in children · Oral rehydration therapy · Paediatric dehydration · Holliday-Segar
Paediatric fluid and electrolyte management is four prescriptions: maintenance, deficit, ongoing-loss, and the sodium-correction rate. Maintenance is Holliday-Segar (100/50/20 mL/kg/day) as an isotonic crystalloid (sodium 131 to 154 mmol/L). Clinical dehydration without shock is rehydrated enterally first. Shock is treated with isotonic boluses in 10 to 20 mL/kg aliquots with reassessment. After the immediate threat, NICE NG29 limits the 24-hour sodium change to 12 mmol/L. Paediatric DKA follows NICE NG18: 10 mL/kg 0.9% saline, deficit over 48 hours, insulin 1 to 2 hours after fluid. ACEM-primary, globally tagged.
Checked against its sources on 1 Sept 2026
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- The sick child and paediatric resuscitation
- Fluid resuscitation in the emergency department
- Paediatric sepsis and septic shock (the septic child in the emergency department)
- Paediatric abdominal emergencies — intussusception, volvulus, appendicitis and pyloric stenosis
- DKA, HHS and hypoglycaemia
- Acute kidney injury
- Electrolyte emergencies — potassium and sodium
- Neonatal emergencies (the sick neonate in the emergency department)
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Red flags
- Maintenance fluid in a child is isotonic, not 0.45 per cent saline — hypotonic maintenance causes hospital-acquired hyponatraemia when non-osmotic ADH is high
- After the immediate threat, do not change plasma sodium by more than 12 mmol/L in 24 hours (NICE NG29) — faster change risks osmotic demyelination or cerebral oedema
- Isotonic boluses are for shock, given as 10 to 20 mL/kg aliquots with reassessment — reflexive bolusing of the non-shocked febrile child was harmful in FEAST
- In paediatric DKA, NICE NG18 gives 10 mL/kg of 0.9% saline (over 30 minutes if not shocked; immediately if shocked) — do not cite FPMS as proof that boluses cause cerebral oedema
- Hypernatraemic dehydration looks less severe than the biochemistry suggests — replace the water deficit over 48 hours and keep the sodium fall at or under 12 mmol/L per 24 hours
- A seizing child with acute hyponatraemia: NICE NG29 uses 2 mL/kg of 2.7% saline (maximum 100 mL), repeatable; after symptoms resolve the 24-hour rise must stay at or under 12 mmol/L
- Weigh the child — every maintenance, deficit and bolus volume is weight-based
Meet the patient
A 9-month-old, 8 kg infant is brought to the resuscitation bay after three days of vomiting and profuse watery diarrhoea. She is lethargic but rousable, capillary refill 4 seconds, mucous membranes dry, and the fontanelle sunken; the bedside glucose is 2.1 mmol per litre. The registrar reaches for a 20 mL per kilogram bolus and a bag of 0.45 per cent saline in dextrose. Treat the hypoglycaemia first with 2 mL per kilogram of 10 per cent glucose (RCH). If she is in shock, the bolus is an isotonic crystalloid — 10 mL per kilogram (NICE NG29) to 20 mL per kilogram (RCH) — not hypotonic 0.45 per cent saline.[16][23][20]
Three questions decide her next hour and every paediatric fluid prescription: is the child in shock? (the bolus is only for shock), what is the maintenance tonicity? (isotonic, never 0.45 per cent), and what is the sodium and its correction ceiling? (the rate that protects the brain). Hold those three and the four prescriptions fall into place.[1]
References24ShowHide
- [1]Holliday MA, Segar WE The maintenance need for water in parenteral fluid therapy Pediatrics, 1957.PMID 13431307
- [2]Glaser N, Fritsch M, Priyambada L, et al. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state Pediatr Diabetes, 2022.PMID 36250645
- [3]Sterns RH Disorders of plasma sodium--causes, consequences, and correction N Engl J Med, 2015.PMID 25551526
- [4]Freedman SB, Adler M, Seshadri R, et al. Oral ondansetron for gastroenteritis in a pediatric emergency department N Engl J Med, 2006.PMID 16625009
- [5]Amer BE, Abdelwahab OA, Abdelaziz A, et al. Efficacy and safety of isotonic versus hypotonic intravenous maintenance fluids in hospitalized children: an updated systematic review and meta-analysis of randomized controlled trials Pediatr Nephrol, 2024.PMID 37365423
- [6]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection N Engl J Med, 2011.PMID 21615299
- [7]Kuppermann N, Ghetti S, Schunk JE, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis N Engl J Med, 2018.PMID 29897851
- [8]Fuchs J, Adams ST, Byerley J Current issues in intravenous fluid use in hospitalized children Rev Recent Clin Trials, 2017.PMID 28814256
- [9]Sarnaik AP, Meert K, Hackbarth R, et al. Management of hyponatremic seizures in children with hypertonic saline: a safe and effective strategy Crit Care Med, 1991.PMID 2055051
- [10]Dalton BG, Gonzalez KW, Boda SR, et al. Optimizing fluid resuscitation in hypertrophic pyloric stenosis J Pediatr Surg, 2016.PMID 26876090
- [11]Bolat F, Oflaz MB, Güven AS, et al. What is the safe approach for neonatal hypernatremic dehydration? A retrospective study from a neonatal intensive care unit Pediatr Emerg Care, 2013.PMID 23823259
- [12]Levin DL Cerebral edema in diabetic ketoacidosis Pediatr Crit Care Med, 2008.PMID 18446108
- [13]Hahn S, Kim Y, Garner P Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea Cochrane Database Syst Rev, 2002.PMID 11869639
- [14]Jain A Body fluid composition Pediatr Rev, 2015.PMID 25834218
- [15]Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society clinical practice guideline J Clin Endocrinol Metab, 2016.PMID 26760044
- [16]National Institute for Health and Care Excellence Intravenous fluid therapy in children and young people in hospital NICE guideline NG29, 2020.Source
- [17]National Institute for Health and Care Excellence Diabetes (type 1 and type 2) in children and young people: diagnosis and management NICE guideline NG18, 2023.Source
- [18]National Institute for Health and Care Excellence Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management NICE guideline CG84, 2009.Source
- [19]Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children Pediatrics, 2018.PMID 30478247
- [20]The Royal Children's Hospital Melbourne Intravenous fluids RCH Clinical Practice Guidelines, 2026.Source
- [21]The Royal Children's Hospital Melbourne Dehydration RCH Clinical Practice Guidelines, 2026.Source
- [22]The Royal Children's Hospital Melbourne Gastroenteritis RCH Clinical Practice Guidelines, 2025.Source
- [23]The Royal Children's Hospital Melbourne Hypoglycaemia RCH Clinical Practice Guidelines, 2025.Source
- [24]The Royal Children's Hospital Melbourne Diabetic ketoacidosis RCH Clinical Practice Guidelines, 2025.Source