2019 surveillance of intravenous fluid therapy in children and young people in hospital (NICE guideline NG29)
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NICE's surveillance team checked whether recommendations in intravenous fluid therapy in children and young people in hospital (NICE guideline NG29) remain up to date.
The surveillance process consisted of:
Feedback from topic experts via a questionnaire.
A search for new or updated Cochrane reviews.
Examining related NICE guidance and quality standards and NIHR signals.
A search for ongoing research.
Examining the NICE event tracker for relevant ongoing and published events.
Literature searches to identify relevant evidence.
Assessing the new evidence against current recommendations to determine whether or not to update sections of the guideline, or the whole guideline.
Consulting on the proposal with stakeholders, except if we propose to update and replace the whole guideline (this document).
For further details about the process and the possible update proposals that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
We searched for new evidence related to the whole guideline.
We found 23 studies in a search for randomised controlled trials and Cochrane reviews published between 22 December 2014 and 31 August 2019.
See the summary of evidence from surveillance for details of all evidence considered, and references.
We included randomised controlled trials of children and young people. Although the original guideline allowed evidence from adult populations, this was excluded from the surveillance review.
We considered the views of topic experts who were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the guideline.
We sent questionnaires to 9 topic experts and received 5 responses. The topic experts who provided feedback were: a consultant nurse in paediatric emergency medicine, an advanced paediatric nurse practitioner, a specialist clinical pharmacist, a consultant paediatric nephrologist and a consultant neonatologist.
Overall, 1 topic expert thought that the guideline should be updated and 4 thought that an update was not necessary. The issues that topic experts thought could be addressed in an update were: whether outcomes are worse with larger versus reduced fluid resuscitation bolus volumes; and whether there is a role for balanced crystalloids as they were being used more widely in practice. The surveillance review identified evidence in these areas, but it was decided not to update the guideline in these areas at this point in time. The rationale for the decision is explained in the previous section 'Reasons for the proposal'.
Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal is to not update the guideline, we are consulting with stakeholders.
See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.
During the surveillance review we identified variations in the information about fluids across recommendations, footnotes and the table of example fluids. Via NICE's field team, we queried with a paediatric clinical group whether this was an issue in practice. The group reassured us that they had no concerns about inconsistencies in the guideline.
We considered all other correspondence received since the guideline was published.
An enquiry to NICE raised concerns about the absence from NICE guideline NG29 recommendation 1.3.1 of a specific maximum resuscitation bolus volume for children and young people (whereas NICE guideline CG174 intravenous fluid therapy in adults in hospital gives a figure of 500 ml). This was discussed by the NG29 guideline committee during development of the original guideline. At the time, the committee felt that including a maximum value would not be consistent with clinical practice or with other guidance (such as Advanced Paediatric Life Support – a course run by the Advanced Life Support Group). Additionally, NG29 recommendation 1.3.1 is qualified by stating 'take into account pre-existing conditions as smaller fluid volumes may be needed', which allows healthcare professionals to reflect the needs of individual patients. Topic experts involved in the current surveillance review agreed that it was correct not to state a maximum bolus volume.
No equalities issues were identified during the surveillance process.
During surveillance of the guideline, we identified the following points in the guideline that should be amended:
Recommendation 1.1.1 cross-refers to the principles and protocols for intravenous fluid therapy section of NICE guideline CG174 intravenous fluid therapy in adults in hospital. However, the hyperlink goes to the introduction section of CG174; it will be changed to link to the principles and protocols for intravenous fluid therapy section of CG174.
The guideline currently has 3 footnotes related to unlicensed use in children and young people of the following intravenous fluids: glucose-free crystalloids; isotonic crystalloids with 5–10% glucose; and hypotonic solutions. These will be replaced by the following single footnote to ensure that all the many intravenous infusion solutions currently available in the UK are covered:
At the time of review ([Month] 2019), some intravenous fluid therapy preparations may not have a UK marketing authorisation for this indication in all ages of children and young people. Please refer to the individual summary of product characteristics for licensing information. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.
The table 'Intravenous fluid types for children and young people' has a footnote which links to the British national formulary for children. However, the link goes to www.bnf.org – it will be replaced with a link to the section of the BNFc website on fluids and electrolytes.
The section of the guideline 'Intravenous fluid therapy in children and young people in hospital implementation: getting started' has the following issues:
The first paragraph states: 'We identified these with the help of stakeholders and guideline committee members (see section 9.4 of the manual).' However, the manual has since been updated and the link now directs to the wrong section of the manual. This will be amended to link to section 10.1 of the manual (subsection 'Approaches to additional consultation').
In 'Recording fluid and electrolyte status to ensure appropriate prescribing', there is a link to the Department of Health, Social Services and Public Safety (DHSSPS) in Northern Ireland. However, this has now been renamed Department of Health and has a new URL. This will be amended.
In 'Raising awareness of training and education resources' there is a link to the NICE online learning tool. This link is broken and will be removed.
See the summary of evidence from surveillance for full details.
After considering all evidence and other intelligence and the impact on current recommendations, we decided that no update is necessary.