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AAP – No More Hypotonic MIVF

January 17, 2019

Written by Clay Smith

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The AAP now recommends isotonic fluid (+/- KCl and dextrose) in children >28 days to <18 years who need maintenance IV fluid, as opposed to hypotonic solutions.

Why does this matter?
For years (really since the 1950s) hypotonic solutions been recommend for use in children to meet maintenance fluid requirements. This AAP update was much needed.

Big change
This is an AAP Clinical Practice Guideline. Hyponatremia and its associated complications of encephalopathy or edema occur with regularity. Hypotonic fluid increases the risk of hyponatremia. So, the AAP convened a group of experts and performed a comprehensive literature review. They came up with this statement for children requiring maintenance IV fluid.

“The AAP recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride (KCl) and dextrose because they significantly decrease the risk of developing hyponatremia.” This was based on high quality, strong evidence.

Exclusions were: “Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are <28 d old or in the NICU; or adolescents >18 y old.”

They comment on the concern for hyperchloremic metabolic acidosis. This is indeed a concern. Recall that in critically ill children hyperchloremia was associated with increased mortality. They plan to address the issue of lower chloride, balanced solutions in future guidelines.

Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018 Dec;142(6). pii: e20183083. doi: 10.1542/peds.2018-3083.

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