Routine maintenance fluid
Choice of fluid
Child (>28 days of age)
For a child (>28 days of age), first line maintenance fluid is usually isotonic crystalloids + 5%
glucose (e.g. 0.9% sodium chloride + 5% glucose).
Term neonate (<28 days of age)
The choice of fluid depends on the clinical situation:
No critical illness:10% dextrose +/- additives
Critical illness (e.g. infantile respiratory distress syndrome, meconium aspiration): seek
expert advice (use fluids with no/minimal sodium initially)
Calculation of fluid requirements
There are specific formulae for calculating the volumes of maintenance fluids in paediatrics.
There are different formulae for patients in the neonatal period, which is up to 28 days of age, and
for those who are older.
Children (>28 days of age)
Routine maintenance fluids for children are calculated by weight using the Holliday-
Segar formula:1,5
100 ml/kg/day for the first 10kg of weight
50 ml/kg/day for the next 10kg of weight
20 ml/kg/day for weight over 20kg
Worked example: maintenance fluid
Calculate the 24-hour maintenance fluids and hourly infusion rate for a 40kg child:
1000 mL/day for the first 10kg
500 mL/day for the next 10kg
400 mL/day for the final 20kg
Total = 1900 mL/24h
The next step is to calculate the infusion rate in mL/hour
For the above case, this would be 1900/24 which equals 79 mL/h
Neonates (<28 days of age)
Maintenance for term neonates is calculated according to their age and weight: 1
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
Days 5-28: 120-150 mL/kg/day
Replacement fluid (dehydration)
For patients with dehydration without clinical features of shock, rehydration via the oral or
nasogastric route is preferred.
If this is impractical or contraindicated, IV fluid therapy may be considered with volumes based on
the percentage-dehydration.
Choice of fluid
Replacement fluids should be adjusted according to existing electrolyte excess or deficit and any
anticipated ongoing losses (e.g. diarrhoea).
Use isotonic crystalloid that contains sodium with added glucose (e.g. 0.9% sodium chloride + 5%
glucose).
If there are ongoing losses (e.g. diarrhoea, vomiting) supplement with potassium (e.g. 10 mmol/L).
The U&Es and plasma glucose should be monitored at least every 24 hours, or more frequently if
there are electrolyte abnormalities.
Fluid deficit (mL) = % dehydration x weight (kg) x 10
Total fluid requirement (mL) = maintenance fluids (mL) + fluid deficit (mL)
Worked example: fluid replacement
A child who weighs 12kg is 5% dehydrated. Calculate their total fluid requirement over 24 hours:
Fluid deficit = 5% dehydration x 12 x 10 = 600 mL
Maintenance = 1000mL (100 mL/kg for first 10 kg) + 100mL (50 mL/kg for last 2kg) = 1100
mL
Total fluid requirement = 1100 mL + 600 mL = 1700 mL/24 hours » 71 mL/hour
Resuscitation fluids
Glucose-free balanced crystalloids (e.g. Hartmann’s solution) are recommended as initial
resuscitation fluids.
Boluses of fluid are required if the patient is shocked or haemodynamically compromised.
The standard fluid for resuscitation is 0.9% sodium chloride with no additives via intravenous (IV)
or intraosseous (IO) access (if IV access is not possible) in a standard bolus of 10 mL/kg over <10
minutes.1
Exceptions to this rule in which smaller boluses may need to be used:
Neonatal period (<28 days of age)
Diabetic ketoacidosis
Septic shock
Trauma
Cardiac pathology (e.g. heart failure)
After the bolus has been administered, the volume status should be re-assessed (e.g. heart rate,
respiratory rate, capillary refill time). If the patient is still shocked urgent senior advice should be
sought.
If further fluid is required, the paediatric intensive care team should be contacted with consideration
of other measures (e.g. inotropic support).
For a shocked child, we assume 10% dehydration based on body weight. Therefore, to calculate the
total 24-hour fluid requirements we would use the following two formulae:
Fluid deficit (mL) = 10% dehydration x weight (kg) x 10
Total fluid requirement (mL) = maintenance fluids (mL) + fluid deficit (mL)
Worked example: resuscitation
A 4-year old boy who weighs 15kg is admitted with gastroenteritis. He is repeatedly vomiting oral
fluids. Clinically he displays signs of shock and is 10% dehydrated.
Calculate the initial IV fluids that should be administered. Then calculate the total fluid requirement
for replacement over the following 24-hour period.
Resuscitation fluids
Bolus = 10 mL/kg x 15 kg = 150 mL over <10 minutes
24-hour fluid requirement
Fluid deficit = 10% x 15kg x 10 = 1500 mL
Maintenance fluids = 1000 mL (first 10 kg) + 250 mL (last 5 kg) = 1250 mL
Total fluid requirement = 1500 + 1250 = 2750 mL/day » 115 mL/hour