Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Principles and protocols for intravenous fluid therapy

1.1.1 For guidance on the principles and protocols for intravenous (IV) fluid therapy, see the principles and protocols for intravenous fluid therapy section in intravenous fluid therapy in adults (NICE guideline CG174; recommendations 1.1.1, 1.1.2, 1.1.3, 1.1.5, 1.1.6, 1.1.7 and 1.1.8 apply to all ages).

1.1.2 Offer IV fluid therapy as part of a protocol (see algorithms for IV fluid therapy in children and young people in hospital):

  • Assess fluid and electrolyte needs following algorithm 1: Assessment and monitoring.

  • If term neonates, children and young people need IV fluids for fluid resuscitation, follow algorithm 2: Fluid resuscitation.

  • If term neonates, children and young people need IV fluids for routine maintenance, follow algorithm 3: Routine maintenance.

  • If term neonates, children and young people need IV fluids to address existing deficits or excesses, ongoing abnormal losses or abnormal fluid distribution, follow algorithm 4: Replacement and redistribution.

  • If hypernatraemia develops, follow algorithm 5: Managing hypernatraemia that develops during IV fluid therapy.

  • If hyponatraemia develops, follow algorithm 6: Managing hyponatraemia that develops during IV fluid therapy.

1.2 Assessment and monitoring

1.2.1 Use body weight to calculate IV fluid and electrolyte needs for term neonates, children and young people.

1.2.2 Consider using body surface area to calculate IV fluid and electrolyte needs if accurate calculation of insensible losses is important (for example, if the weight is above the 91st centile, or with acute kidney injury, known chronic kidney disease or cancer).

1.2.3 In term neonates, children and young people who are receiving IV fluids, assess and document the following:

  • Actual or estimated daily body weight. Record the weight from the current day, the previous day, and the difference between the two. If an estimate was used, the actual weight should be measured as soon as clinically possible.

  • Fluid input, output and balance over the previous 24 hours.

  • Any special instructions for prescribing, including relevant history.

  • An assessment of the fluid status.

  • The results of laboratory and point‑of‑care assessments, including:

    • full blood count

    • urea

    • creatinine

    • plasma electrolyte concentrations (including chloride, sodium and potassium; see recommendation 1.2.4)

    • blood glucose (see recommendation 1.2.5)

    • urinary electrolyte concentrations.

  • Details of any ongoing losses (see recommendation 1.5.1 and the diagram of ongoing losses).

  • Calculations of fluid needs for routine maintenance, replacement, redistribution and resuscitation.

  • The fluid and electrolyte prescription (in ml per hour), with clear signatures, dates and times.

  • Types and volumes of fluid input and output (urine, gastric and other), recorded hourly and with running totals.

  • 12-hourly fluid balance subtotals.

  • 24-hourly fluid balance totals.

  • 12-hourly reassessments of:

    • the fluid prescription

    • current hydration status

    • whether oral fluids can be started

    • urine and other outputs.

1.2.4 Measure plasma electrolyte concentrations using laboratory tests when starting IV fluids, and then at least every 24 hours or more frequently if there are electrolyte disturbances.

1.2.5 Measure blood glucose when starting IV fluids, and then at least every 24 hours or more frequently if there is a risk of hypoglycaemia.

1.2.6 Consider point-of-care testing for measuring plasma electrolyte concentrations and blood glucose in time‑critical situations when IV fluids are needed (for example, during emergency situations and in A&E, theatre and critical care).

1.2.7 Diagnose clinical dehydration and hypovolaemic shock using the clinical features listed in table 1, but be aware that it can be difficult to identify the clinical features in term neonates.

Table 1 Clinical features of dehydration and hypovolaemic shock

No clinically detectable dehydration

Clinical dehydration

Hypovolaemic shock

Alert and responsive

Red flag

Altered responsiveness (for example, irritable, lethargic)

Decreased level of consciousness

Appears well

Red flag

Appears to be unwell or deteriorating

Eyes not sunken

Red flag

Sunken eyes

Moist mucous membranes (except after a drink)

Dry mucous membranes (except for 'mouth breather')

Normal blood pressure

Normal blood pressure

Hypotension (decompensated shock)

Normal breathing pattern

Red flag

Tachypnoea

Tachypnoea

Normal capillary refill time

Normal capillary refill time

Prolonged capillary refill time

Normal heart rate

Red flag

Tachycardia

Tachycardia

Normal peripheral pulses

Normal peripheral pulses

Weak peripheral pulses

Normal skin turgor

Red flag

Reduced skin turgor

Normal urine output

Decreased urine output

Skin colour unchanged

Skin colour unchanged

Pale or mottled skin

Warm extremities

Warm extremities

Cold extremities

Notes:

Within the category of 'clinical dehydration' there is a spectrum of severity indicated by increasingly numerous and more pronounced clinical features. For hypovolaemic shock, 1 or more of the clinical features listed would be expected to be present. Dashes (–) indicate that these features do not specifically indicate hypovolaemic shock. This table has been adapted from the assessing dehydration and shock section in diarrhoea and vomiting in children (NICE guideline CG84).

1.3 Fluid resuscitation

1.3.1 If children and young people need IV fluid resuscitation, use glucose‑free crystalloids[3] that contain sodium in the range 131–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre‑existing conditions (for example, cardiac disease or kidney disease), as smaller fluid volumes may be needed.

1.3.2 If term neonates need IV fluid resuscitation, use glucose‑free crystalloids[3] that contain sodium in the range 131–154 mmol/litre, with a bolus of 10–20 ml/kg over less than 10 minutes.

1.3.3 Do not use tetrastarch for fluid resuscitation.

1.3.4 For guidance on using IV fluids for fluid resuscitation in children and young people with diabetic ketoacidosis, see the diabetic ketoacidosis section in diabetes (type 1 and type 2) in children and young people (NICE guideline NG18).

1.3.5 Reassess term neonates, children and young people after completion of the IV fluid bolus, and decide whether they need more fluids.

1.3.6 Seek expert advice (for example, from the paediatric intensive care team) if 40–60 ml/kg of IV fluid or more is needed as part of the initial fluid resuscitation.

1.4 Routine maintenance

1.4.1 Calculate routine maintenance IV fluid rates for children and young people using the Holliday–Segar formula (100 ml/kg/day for the first 10 kg of weight, 50 ml/kg/day for the next 10 kg and 20 ml/kg/day for the weight over 20 kg). Be aware that over a 24‑hour period, males rarely need more than 2500 ml and females rarely need more than 2000 ml of fluids.

1.4.2 Calculate routine maintenance IV fluid rates for term neonates according to their age, using the following as a guide:

  • From 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.

1.4.3 If children and young people need IV fluids for routine maintenance, initially use isotonic crystalloids[4] that contain sodium in the range 131–154 mmol/litre.

1.4.4 Measure plasma electrolyte concentrations and blood glucose when starting IV fluids for routine maintenance (except before most elective surgery), and at least every 24 hours thereafter.

1.4.5 Be aware that plasma electrolyte concentrations and blood glucose are not routinely measured before elective surgery unless there is a need to do so, based on the child's medical condition or the type of surgery.

1.4.6 Base any subsequent IV fluid prescriptions on the plasma electrolyte concentrations and blood glucose measurements.

1.4.7 If term neonates need IV fluids for routine maintenance, initially use isotonic crystalloids[4] that contain sodium in the range 131–154 mmol/litre with 5–10% glucose.

1.4.8 For term neonates in critical postnatal adaptation phase (for example, term neonates with respiratory distress syndrome, meconium aspiration, hypoxic ischaemic encephalopathy), give no or minimal sodium until postnatal diuresis with weight loss occurs. 

1.4.9 If there is a risk of water retention associated with non‑osmotic antidiuretic hormone (ADH) secretion, consider either:

  • restricting fluids to 50–80% of routine maintenance needs or

  • reducing fluids, calculated on the basis of insensible losses within the range 300–400 ml/m2/24 hours plus urinary output.

1.4.10 When using body surface area to calculate IV fluid needs for routine maintenance (see recommendation 1.2.2), estimate insensible losses within the range 300–400 ml/m2/24 hours plus urinary output.

1.5 Replacement and redistribution

1.5.1 If term neonates, children and young people need IV fluids for replacement or redistribution, adjust the IV fluid prescription (in addition to maintenance needs) to account for existing fluid and/or electrolyte deficits or excesses, ongoing losses (see the diagram of ongoing losses) or abnormal distribution, for example, tissue oedema seen in sepsis.

1.5.2 Consider isotonic crystalloids[4] that contain sodium in the range 131–154 mmol/litre for redistribution.

1.5.3 Use 0.9% sodium chloride containing potassium to replace ongoing losses (see the diagram of ongoing losses).

1.5.4 Base any subsequent fluid prescriptions on the plasma electrolyte concentrations and blood glucose measurements.

1.6 Managing hypernatraemia that develops during intravenous fluid therapy

1.6.1 If hypernatraemia develops in term neonates, children and young people, review the fluid status and take action as follows:

  • If there is no evidence of dehydration and an isotonic fluid is being used, consider changing to a hypotonic fluid (for example, 0.45% sodium chloride with glucose)[5].

  • If dehydration is diagnosed, calculate the water deficit and replace it over 48 hours, initially with 0.9% sodium chloride.

  • If the fluid status is uncertain, measure urine sodium and osmolality.

  • If hypernatraemia worsens or is unchanged after replacing the deficit, review the fluid type and consider changing to a hypotonic solution (for example, 0.45% sodium chloride with glucose).

1.6.2 When correcting hypernatraemia, ensure that the rate of fall of plasma sodium does not exceed 12 mmol/litre in a 24‑hour period.

1.6.3 Measure plasma electrolyte concentrations every 4–6 hours for the first 24 hours, and after this base the frequency of further plasma electrolyte measurements on the treatment response.

1.7 Managing hyponatraemia that develops during intravenous fluid therapy

1.7.1 If asymptomatic hyponatraemia develops in term neonates, children and young people, review the fluid status and take action as follows:

  • If a child is prescribed a hypotonic fluid, change to an isotonic fluid (for example, 0.9% sodium chloride).

  • Restrict maintenance IV fluids in children and young people who are hypervolaemic or at risk of hypervolaemia (for example, if there is a risk of increased ADH secretion) by either:

    • restricting maintenance fluids to 50–80% of routine maintenance needs or

    • reducing fluids, calculated on the basis of insensible losses within the range 300–400 ml/m2/24 hours plus urinary output.

1.7.2 Be aware that the following symptoms are associated with acute hyponatraemia during IV fluid therapy:

  • Headache.

  • Nausea and vomiting.

  • Confusion and disorientation.

  • Irritability.

  • Lethargy.

  • Reduced consciousness.

  • Convulsions.

  • Coma.

  • Apnoea.

1.7.3 If acute symptomatic hyponatraemia develops in term neonates, children and young people, review the fluid status, seek immediate expert advice (for example, from the paediatric intensive care team) and consider taking action as follows:

  • Use a bolus of 2 ml/kg (maximum 100 ml) of 2.7% sodium chloride over 10–15 minutes.

  • Use a further bolus of 2 ml/kg (maximum 100 ml) of 2.7% sodium chloride over the next 10–15 minutes if symptoms are still present after the initial bolus.

  • If symptoms are still present after the second bolus, check the plasma sodium level and consider a third bolus of 2 ml/kg (maximum 100 ml) of 2.7% sodium chloride over 10–15 minutes.

  • Measure the plasma sodium concentration at least hourly.

  • As symptoms resolve, decrease the frequency of plasma sodium measurements based on the response to treatment.

1.7.4 Do not manage acute hyponatraemic encephalopathy using fluid restriction alone.

1.7.5 After hyponatraemia symptoms have resolved, ensure that the rate of increase of plasma sodium does not exceed 12 mmol/litre in a 24‑hour period.

1.8 Training and education

1.8.1 For guidance on training and education for healthcare professionals involved in prescribing and delivering IV fluid therapy, see the training and education section in intravenous fluid therapy in adults (NICE guideline CG174).

Algorithms for IV fluid therapy in children and young people in hospital

Download a PDF here containing all 6 algorithms.

Algorithms for IV fluid therapy
Algorithms for IV fluid therapy
Algorithms for IV fluid therapy
Algorithms for IV fluid therapy