Practice Guidelines

Maintenance Intravenous Fluids in Children: AAP Provides Recommendation


Am Fam Physician. 2019 Aug 15;100(4):251.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Maintenance IV fluids provided to acutely ill children should be isotonic to prevent hyponatremia.

• Dextrose and potassium chloride can be added to isotonic maintenance fluids without risk of injury from hypertonicity.

From the AFP Editors

Maintenance intravenous (IV) fluids are a common element of the care of acutely ill children. Hypotonic maintenance fluids have long been a clinical standard for children, although this practice is not evidence based. The American Academy of Pediatrics (AAP) has created an evidence-based guideline recommending the use of isotonic fluids for patients 28 days to 18 years of age to reduce the risk of developing hyponatremia.


The standard administration of hypotonic maintenance IV fluid in children has been based on an article from 1957 that recommends weight-based fluid and glucose for maintenance (Pediatrics. 1957;19(5):823–332). Electrolyte recommendations were based on levels in human and cow's milk. Recent evidence has shown that hypotonic maintenance fluid administration significantly increases the risk of hyponatremia. The most common electrolyte complication in hospitalized patients is hyponatremia, affecting approximately 15% to 30% of hospitalized children and adults.

Commonly used hypotonic commercial solutions, 0.2% sodium chloride (NaCl) and 0.45% NaCl, have sodium concentrations of 34 mEq per L and 77 mEq per L, respectively. The sodium concentration in isotonic solutions is closer to plasma levels (134 to 144 mEq per L), with 0.9% NaCl having a concentration of 154 mEq per L.


The AAP recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children; this recommendation significantly reduces the risk of hyponatremia without increasing other risks, including hypernatremia and acidosis. The recommendation is rated as strong and is based on well-designed randomized controlled trials and systematic reviews. The number needed

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at



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