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Paediatric IV Fluid Therapy

NICE guideline [NG29] Intravenous fluid therapy in children and young people in hospital. Last updated: Jun 2020.

Assessment and Monitoring

The following should be assessed and documented if neonates, children and young people who are receiving IV fluids
  • Daily body weight (actual / estimated)
  • Fluid input + output
  • Fluid status
  • Blood tests
    • FBC
    • U&E
    • Blood glucose
  • Urinary electrolyte concentrations

 

Body weight is considered one of the most reliable and practical markers of fluid status in paediatric patients.

Clinical dehydration Hypovolaemic shock
Red flags:
  • Altered responsiveness (e.g. irritable, lethargic)
  • Unwell appearance / deteriorating
  • Sunken eyes
  • Tachypnoea
  • Tachycardia
  • ↓ Skin turgor

Other features:
  • Dry mucous membranes
  • ↓ Urine output
 Any of the following:
  • ↓ Level of consciousness
  • Hypotension
  • ↑ Capillary refill time
  • Weak peripheral pulses
  • Pale / mottled skin
  • Cold extremities
 

IV Fluid Therapy

Choice of fluid: glucose-free crystalloids (most commonly used: 0.9% NaCl)

Fluid rate: 10 mL/kg over <10 min

Choice of fluid: isotonic crystalloids (0.9% NaCl - most commonly used / Hartman's solution)

Calculate fluid requirement with the Holliday-Segar formula:
  • First 10kg → 100 mL/kg/day
  • Next 10kg → 50 mL/kg/day
  • Weight over 20 kg → 20 mL/kg/day

 

Fluid requirement calculation example 1 (child weighing 8kg):

  • Since the child weighs less than 10kg, only use the 100 mL/kg/day bit
  • 100mL x 8 = 800 mL/day
 

Fluid requirement calculation example 2 (child weighing 25kg):

  • First 10kg = 1000 mL/day
  • Second 10kg = 500 mL/day
  • Remaining 5kg = 5x20 = 100 mL/day
  • Total: 1000 + 500 + 100 = 1600 mL/day 

Choice of fluid: isotonic crystalloids (0.9% NaCl - most commonly used / Hartman's solution)
  • From birth to day 7, 10% dextrose is usually used

Calculate fluid requirement based on their age:
 
Age Fluid requirement
Birth to day 1 50-60 mL/kg/day
Day 2 70-80 mL/kg/day
Day 3 80-100 mL/kg/day
Day 4 100-120 mL/kg/day
Day 5-28 120-150 mL/kg/day

Hypernatraemia and Hyponatraemia Management

Measure urine sodium and osmolality if fluid status is uncertain.

Manage according to fluid status:
  • Hypovolaemic → calculate water deficit and replace with 0.9% NaCl
  • Isotonic → consider changing to a hypotonic fluid (e.g. 0.45% NaCl with glucose)

 

When correcting hypernatraemia, ensure the rate of sodium reduction does NOT exceed 12 mmol/L per 24 hours due to the risk of cerebral oedema.

Asymptomatic cases:
  • If prescribed a hypotonic fluid → change to an isotonic fluid
  • If hypervolaemic → restrict maintenance fluid to 50-80% of routine needs

Symptomatic cases:
  • Give 2.7% sodium chloride (hypertonic) 2mL/kg over 10-15 min
  • Monitor plasma sodium concentration at least hourly

 

When correcting hyponatraemia, ensure the rate of sodium does NOT increase more than 12 mmol/L per 24 hours due to the risk of osmotic demyelination syndrome (central pontine myelinolysis)

References

Author: Adams Lau
Reviewer:
Last edited: 23/08/25