Viewpoint

Intravenous maintenance fluid therapy in acutely and

critically ill children: state of the evidence
David W Brossier, Isabelle Goyer, Sascha C A T Verbruggen, Corinne Jotterand Chaparro, Shancy Rooze, Luise V Marino, Luregn J Schlapbach,
Lyvonne N Tume, Frederic V Valla, on behalf of the European Society of Paediatric and Neonatal Intensive Care-IV-MFT group*

Intravenous maintenance fluid therapy (IV-MFT) is one of the most prescribed, yet one of the least studied, Lancet Child Adolesc Health 2024
interventions in paediatric acute and critical care settings. IV-MFT is not typically treated in the same way as drugs Published Online
with specific indications, contraindications, compositions, and associated adverse effects. In the last decade, societies January 12, 2024
https://doi.org/10.1016/
in both paediatric and adult medicine have issued evidence-based practice guidelines for the use of intravenous fluids
S2352-4642(23)00288-2
in clinical practice. The main objective of this Viewpoint is to summarise and compare the rationales on which these
*Collaborators listed in the
international expert guidelines were based and how these recommendations affect IV-MFT practices in paediatric appendix
acute and critical care. Although these guidelines recommend the use of isotonic fluids as a standard in IV-MFT, Paediatric Intensive Care Unit,
some discrepancies and uncertainties remain regarding the systematic use of balanced fluids, glucose and electrolyte Centre Hospitalier Universitaire,
requirements, and appropriate fluid volume. IV-MFT should be considered in the same way as any other prescription Caen, France (D W Brossier MD);
drug and none of the components of IV-MFT prescription should be overlooked (ie, choice of drug, dosing rate, Medical School, Université Caen
Normandie, Caen, France
duration of treatment, and de-escalation). Furthermore, most evidence that was used to inform the guidelines comes (D W Brossier); Centre
from high-income countries. Although some principles of IV-MFT are universal, the direct relevance to and feasibility Hospitalier Universitaire,
of implementing the guidelines in low-income and middle-income countries is uncertain. Université de Lille, ULR 2694—
METRICS: Évaluation des
technologies de santé et des
Introduction IV-MFT prescription, such as the indication, anion pratiques médicales, Lille,
Intravenous maintenance fluid therapy (IV-MFT) has balance, and the volume of infusate to be administered. France (D W Brossier);
been in use for almost 200 years1,2 and is considered Alongside the AAP recommendation, four other relevant Department of Pharmacy,
University Hospital of Caen,
a standard of care for a substantial number of international clinical guidelines regarding IV-MFT in
Caen, France (I Goyer PharmD);
hospitalised children.3 However, IV-MFT is not paediatric and adult populations were published or Paediatric Intensive Care Unit,
considered on par with other drugs used in daily medical updated between 2017 and 2022.4,6–8 These guidelines Department of Neonatal and
practice in terms of the prescribed doses and monitoring were issued by: the European Society of Paediatric and Paediatric Intensive Care,
Erasmus MC, Sophia Children’s
potential side-effects.4 Professional societies have only in Neonatal Intensive Care (ESPNIC);6 International Fluid
Hospital, Rotterdam,
the last decade developed evidence-based Academy (IFA);4 the UK National Institute for Health Netherlands
recommendations to guide the prescription of IV-MFT.4–8 and Care Excellence;8 and the Association of the (Prof S C A T Verbruggen MD);
Historically, IV-MFT was guided by the 1957 Holliday Scientific Medical Societies in Germany (AWMF), which Geneva School of Health
Sciences, HES-SO University of
and Segar approach,9 which evaluated the water is a continuum of the 2011 European consensus
Applied Sciences and Arts
requirement on the basis of the energy expenditure of statement on intraoperative fluids.7,11 These statements Western Switzerland, Geneva,
healthy children, with 1 mL of fluid provided for each Switzerland
kilocalorie expended. Furthermore, the suggested (Prof C Jotterand Chaparro RD);
Key messages Paediatric Intensive Care,
electrolyte concentrations and glucose content of Hôpital Universitaire des
IV-MFT were estimated to reflect the composition of • Intravenous maintenance fluid therapy (IV-MFT) is Enfants Reine Fabiola, Brussels,
human and cow’s milk.9 Holliday and Segar’s approach one of the most widely prescribed medications in Belgium (S Rooze MD);
was developed from studies of healthy children; however, University Hospital
hospitalised children. Southampton, National Health
by definition, hospitalised children are anything but • IV-MFT prescription was based on historical Service Foundation Trust,
healthy.5 IV-MFT practices are regularly reviewed, as recommendations but between 2017 and 2022 several Southampton, UK
they have been associated with several possibly severe scientific societies issued updated guidelines. (L V Marino RD); Department of
complications, such as hyponatremia, fluid overload, Intensive Care and
• IV-MFT prescription deserves as much consideration as Neonatology, and Children’s
and hyperchloremic acidosis.1,10 These adverse events are the prescription of any other drug in terms of choice of Research Centre, University
caused by inap­propriate fluid composition or infusion infusate solution, dosing, duration of treatment, and Children’s Hospital Zurich,
rates, especially in situations of non-osmotic stimulated timing of de-escalation. University of Zurich, Zurich,
antidiuretic hormone secretion or impairment of free Switzerland
• Isotonic fluids are considered the standard intravenous (Prof L J Schlapbach MD);
water and sodium excretion.5,10 In 2018, in light of fluids in paediatrics. Paediatric Intensive Care Unit
growing evidence for the deleterious effect of the • In cases when enteral hydration is insufficient or Alder Hey Children’s Hospital,
Holliday and Segar’s fluid composition recommendation, impossible, standard IV-MFT should consist of a volume-
Liverpool, UK
the American Academy of Pediatrics (AAP) issued an (Prof L N Tume RN); Faculty of
controlled isotonic (ideally balanced) fluid, providing Health Social Care and
evidence-based, strong recommendation regarding the tailored amounts of glucose and potassium. Medicine, Edge Hill University,
use of isotonic fluid as the standard in IV-MFT for • Implementation of these guidelines might be challenging, Ormskirk, UK (Prof L N Tume,
children aged from 28 days to 18 years.5 This AAP especially in countries where recommended infusate
F V Valla MD); Paediatric
Intensive Care, Hospices Civils
recommendation, although thorough, was not solutions are unavailable. de Lyon, Lyon, France (F V Valla)
exhaustive and neglected considerations relating to

www.thelancet.com/child-adolescent Published online January 12, 2024 https://doi.org/10.1016/S2352-4642(23)00288-2 1

 Viewpoint

Correspondence to:
Dr David W Brossier, Paediatric
Intensive Care Unit,Centre
Hospitalier Universitaire, Caen,
France 14000 CAEN, France
brossier-d@chu-caen.fr
See Online for appendix
all address different populations and questions regarding
IV-MFT (table). The main objective of this Viewpoint is
to summarise and compare the rationales on which
these international expert guidelines were based and
how they affect IV-MFT practices in paediatric acute and
critical care.
IV-MFT should be treated like any other drug
The IFA reiterated the importance of judicious fluid
administration in its 2020 executive summary on
intravenous fluid therapy in the perioperative and critical
care settings.4 To be used safely, IV-MFT must be
considered as a drug. As with any other drug prescription,

ESPNIC guidelines (2022)6
Territory Europe
Population and Acutely and critically ill children aged
settings from term newborns to 18 years
Indication IV-MFT when enteral or oral route No recommendation
cannot be considered (GRADE low-level
evidence*)
Tonicity, Systematic use of isotonic fluids
sodium (GRADE high-level evidence*)
content
Balanced fluids, Systematic use of balanced fluids in
chloride acutely ill children (GRADE high-level
content evidence*); and critically ill children
(GRADE moderate-level evidence*)
Glucose Provide glucose to prevent
content hypoglycaemia (GCP*) or
hyperglycaemia (GRADE moderate-
level evidence*)
Potassium An appropriate amount of potassium
content should be considered and added to
IV-MFT (GCP*)
Other Insufficient evidence to recommend
electrolytes routine supplementation of
magnesium, calcium, or
phosphate (GCP*)
Volume Use a restrictive strategy in case of: risk No recommendation; IV-MFT
of increased ESADH: 65–80% of HSF; risk should be restricted in case of
of oedematous states:† 50–60% of HSF
(GCP*); the total daily amount of
maintenance fluid therapy includes:
intravenous fluids, blood products (eg,
packed red blood cells and fresh frozen
plasma), all intravenous drugs, arterial
and venous line flush solutions, and all
enteral intakes (GRADE very low-level
evidence*); targeting zero to negative
fluid balance and avoidance of fluid
overload (GRADE very low-level
evidence*)
Duration Not mentioned
AAP guidelines (2018)5
USA
Hospitalised children in
surgical (postoperative) and
medical acute-care settings,
including critical care, and
general inpatient wards aged
from 28 days to 18 years
Systematic use of isotonic
fluids (GRADE high-level
evidence*)
No recommendation
Provide glucose
Provide potassium
No recommendation
oedematous states†
No recommendation
NICE guidelines (2015 AWMF guidelines7,11 IFA guidelines (2020)4
and 2020)8 European consensus (2011 and
2017)
UK Germany International
Hospitalised children Children in the perioperative Adults in the perioperative and
aged less than 16 years setting critical care setting
No recommendation IV-MFT not required in the IV-MFT when necessary; avoid
perioperative setting if: the length unnecessary administration
of preoperative and postoperative
fasting is short; procedure is less
than 1 h; and children are beyond
neonatal age with sufficient
enteral intake
Recommend isotonic Systematic use of isotonic fluids Sodium amount of about
fluids 1–1·5 mmol/kg per day; no
recommendation of systematic
use of isotonic fluids as IV-MFT
No recommendation Systematic use of balanced fluids Chloride amount of about
1 mmol/kg per day; balanced
fluids help avoid fluid-induced
metabolic acidosis and excessive
chloride load; no
recommendation on systematic
use as IV-MFT
No recommendation in Fluid glucose concentration Glucose amount of about
children of 1–2·5%; adjust to blood glucose 1–1·5 g/kg per day
concentrations in case of
prolonged surgery or in at-risk
patients to target
normoglycaemia
No recommendation Not directly mentioned; use of Potassium amount of about
balanced fluid containing 1 mmol/kg per day
4 mmol/L of potassium is
recommended
No recommendation Not directly mentioned; use of No recommendation
balanced fluid containing
2 mmol/L of calcium and
magnesium is recommended
Calculate routine MFT Initial infusion rate of 10 mL/kg/h; 25–30 mL/kg/day or 1 mL/kg/h;
using the HSF; use for intermediate or major including (or minus): enteral
a restrictive strategy in procedures, adjust background nutrition, parenteral nutrition,
case of risk of increased infusion to actual requirements and fluid creep; targeting zero to
ESADH; consider either: during the procedure slightly negative fluid balance
50–80% of HSF or
300–400 mL/m2 per day
plus urinary output
No recommendation The scope of the guidelines only Stop as soon as possible when
covers the perioperative setting patient is stable
(Table continues on next page)

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 Viewpoint

ESPNIC guidelines (2022)6
(Continued from previous page)
Monitoring Fluid balance (daily); weight (daily);
electrolytes (regular); blood glucose
concentration (daily)
Particularities Preterm neonates (less than 37 weeks
gestational age) and intraoperative
setting were not included; no focus on
specific conditions (ie, TBI, heart failure)
AAP guidelines (2018)5
Laboratory monitoring
(frequent if risk of electrolyte
abnormality or in case of
symptoms)
Patients with neurosurgical
disorders, cardiac disease,
hepatic disease, cancer, renal
dysfunction, diabetes insipidus,
voluminous watery diarrhoea,
or severe burns, and neonates
younger than 28 days or in the
NICU were excluded
NICE guidelines (2015 AWMF guidelines7,11 IFA guidelines (2020)4
and 2020)8 European consensus (2011 and
2017)
Fluid balance Regular clinical evaluation of Fluid balance (daily); electrolytes
(twice daily); fluid input hydration status; regular blood and urea (within 24 h); and
and output; weight gas analysis weight
(daily); electrolytes (at
least daily); blood
glucose concentration
(daily)
Addresses every type of Considers colloids as additional Addresses every type of fluid
fluid therapy: fluid when standard IV-MFT is not therapy (resuscitation,
resuscitation, sufficiently effective, which is maintenance, or replacement)
maintenance, or called volume therapy (similar to and specific clinical situations
replacement; provides fluid-resuscitation phase). (perioperative, trauma, or burns)
guidance for neonatal
IV-MFT

AAP=American Academy of Pediatrics. AWMF=Association of the Scientific Medical Societies in Germany. ESADH=endogenous secretion of antidiuretic hormone. ESPNIC=European Society of Paediatric and
Neonatal Intensive Care. GCP=good clinical practice. HSF=Holliday and Segar formula, defined as 100 mL/kg/day for the first 10 kg of weight, 1000 mL plus 50 mL/kg/day for the next 10 kg, and 1500 mL plus
20 mL/kg/day for more than 20 kg. IFA=International Fluid Academy. IV-MFT=intravenous maintenance fluid therapy. NICE=National Institute for Health and Care Excellence. NICU=neonatal intensive care unit.
TBI=traumatic brain injury.* Where guidelines indicated the GRADE level of evidence for the recommendation this has been included †Oedematous states are defined in the AAP guidelines as cardiac, kidney, or
liver failure, or nephrotic syndrome.

Table: Summary of the included intravenous maintenance fluid therapy guidelines

the IFA has developed the concept of the four Ds of fluid
therapy: drug, dose, duration, and de-escalation. IV-MFT
is possibly the most prescribed drug in the first 48 h of
hospitalisation in children. Yet, studies investigating
medication prescription practices in hospitalised children
with acute illnesses frequently do not take IV-MFT
prescriptions into consideration.12 IV-MFT has its own
indications, contraindications, specific compositions, and
associated adverse events that must all be carefully
considered. Maintenance fluid therapy is defined as the
prescription of water and electrolytes to replace
anticipated physiological losses in the following 24 h.6
Maintenance fluid therapy can be administered
intravenously, enterally, or through a combination of both
routes. The considerations for prescribing IV-MFT should
be different from those for prescribing a resuscitation
fluid to restore effective circulating volume, or
a replacement fluid to replace ongoing non-physiological
fluid losses.4 Electrolyte composition and glucose content
in IV-MFT must be considered, reassessed, and adapted
according to the patient’s characteristics, clinical
situation, and progression of their condition (figure). The
dose of IV-MFT and rate of infusion are also important.
Most prescribers, whether in acute or intensive care,
assess their patients’ total daily fluid volume requirements
on the basis of the Holliday and Segar formula (HSF).3
However, this practice has been widely criticised, as
determining a universal therapeutic intravenous fluid
dose that is suitable for all paediatric patients in all clinical
situations seems hazardous.6,8–10 Thus, individualisation
of IV-MFT with re-evaluation of duration and de-
escalation of volumes is important to minimise the risk of
adverse events, such as fluid overload or hyponatraemia.4
Indications for IV-MFT
There is no consensus on the medical indications for
starting IV-MFT,4,5,8 except during the perioperative
period.7 IV-MFT prescription is often left to the discretion
of the prescriber, who makes the decision on the basis of
their experience.4–6,8 Both NICE and AAP guidelines do
not provide any recommendations on the indications for
IV-MFT. In the context of paediatric acute care, IV-MFT is
often considered the only way to provide hydration,
especially when a child is critically ill.3 However, based on
a systematic review and meta-analysis of patient
outcomes, the latest recommendations on IV-MFT in
children who are acutely or critically ill are that oral or
enteral fluid intakes should be favoured, and IV-MFT
should be considered only if enteral intake is not possible
(figure).6 These recommendations are in accordance with
the ESPNIC guidelines on nutrition that recommend use
of the enteral route for providing hydration and nutrition
as soon as the child is haemodynamically stable with
adequate systemic perfusion.13 Nonetheless, evidence
remains insufficient to reach a consensus for all patients,6
except for very specific situations (eg, in bronchiolitis14,15 or
acute gastroenteritis16), where IV-MFT is associated with
higher costs, higher failure rates of intravenous access,
and no difference in adequate rehydration compared with
an enteral fluid strategy. In patients at risk of enteric
perfusion impairment, such as patients under therapeutic
hypothermia, receiving high-dose vasopressors or
inotropes, or after a high-risk gastro­intestinal surgery, use
of intravenous rather than the enteral route for fluid
administration is common.13,17–19 In low-income and
middle-income countries, use of the enteral route could
be preferred in the absence of a suitable alternative, for

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 Viewpoint
example in the absence of an appropriate intravenous
infusate solution.20 The use of an infusate solution that is
unsuitable for children (eg, hypotonic intravenous
solutions) could be more deleterious than an appropriate
enteral hydration strategy.20 Furthermore, once IV-MFT
has been started, the clinical indication for continuing
IV-MFT should be regularly re-evaluated.
Prescription of IV-MFT
Once the indication of IV-MFT has been identified, the
prescriber must order the type of fluid to infuse and its
volume or dose to be administered (figure).
Isotonic fluids
Historically, IV-MFTs used in children were hypotonic
fluids.9 Hypotonic fluids have a sodium concentration that
is lower than that of the plasma.10 The term tonicity
describes the effect of plasma on cells. Tonicity dictates
water movements across the semipermeable cellular
membrane; hypotonicity makes cells swell (due to cellular
water intake) and hypertonicity makes cells shrink (due to
cellular water loss). Tonicity of IV-MFT depends on the
sodium and potassium concentrations.10 Isotonic fluids
have a sodium concentration equivalent to the plasma
sodium concentration (135–144 mmol/L). In the last two
decades, evidence from randomised controlled trials and
meta-analyses showed that the use of isotonic fluids was
associated with a decreased risk of hyponatremia
compared with the use of any type of hypotonic fluid
(Na+ less than 130 mmol/L), or moderately hypotonic
fluids (Na+ 70–130 mmol/L).5,6,21–26 Based on these data, the
four discussed paediatric guidelines recommend the use
of isotonic fluid as standard IV-MFT in children.
Hyponatraemic episodes in hospitalised children can be
related to the administration of hypotonic IV-MFT in the
context of endogenous secretion of antidiuretic hormone.10
Children who are critically or acutely ill are affected by
free-water excretion impairment, triggered by volume-
dependent activation of both renin–angiotensin–
aldosterone and arginine–vasopressin systems, or
inappropriate volume-independent non-osmotic stimuli
of arginine–vasopressin release.10,27 The latter occurs very
frequently in children who are critically or acutely ill with
pain, nausea, stress, hypovolaemia, pulmonary disorders
(eg, pneumonia), CNS disorders (eg, meningitis), or with
some medications. These intertwined mechanisms can
result in symptomatic hyponatremia (eg, neurological
impairment, seizures, and cerebral oedema), and
subsequent admission to a paediatric intensive care
unit (PICU), which can adversely affect patient
outcomes.10,28 Thus, all paediatric guidelines recommend
the use of isotonic fluid as standard IV-MFT in children
(table).5–8 This recommendation has already been adopted
by many health-care workers in paediatric critical and
acute care units.3 Due to the absence of data and specific
physiopathological considerations, patients at risk of
major ongoing free-water losses associated with a risk of
4 www.thelancet.com/child-adolescent Published online January 12, 2024 https://doi.org/10.1016/S2352-4642(23)00288-2
hypernatraemic dehydration, such as renal concentrating
defects (eg, nephrogenic diabetes insipidus), and patients
with voluminous diarrhoea or severe burns were
considered out of the scope of most guidelines.5,6 However,
the NICE guidelines address the specific situations of
hypernatraemic dehydration and recommend the use of
isotonic fluid until urgent expert advice on fluid
management is obtained.8
Balanced intravenous fluids
In the last decade, there has been a growing interest in
the use of balanced crystalloids instead of the standard
unbalanced normal saline (NaCl 0·9%) for IV-MFT.3,29–31
Balanced crystalloids are characterised by partial
replacement of sodium chloride with another sodium-
containing organic anion. The chloride content is
reduced by the addition of other organic anions, such as
lactate, acetate, malate, gluconate, or citrate. With
a lower chloride concentration and an overall electrolyte
composition that is similar to that of plasma,
balanced solutes are theoretically less likely to
cause hyperchloraemia and associated metabolic hyper­
chloraemic acidosis.6,29 As a consequence of hyper­
chloraemia, the plasma strong ion difference, which is
the difference between the sum of the concentration of
strong cations and strong anions in plasma
([Na+ + K++ Ca²+ + Mg²+]–[Cl− + lactate + urate]), will
decrease according to the Stewart’s concept.32 A decrease
in strong ion difference produces an increase in free
hydrogen ion concentration and generates a state of
metabolic acidosis caused by hyperchloraemia.32
Furthermore, some of these organic anions can act as
buffers by being bicarbonate precursors (lactate and
acetate), and some have energy-providing properties, but
no clinical evidence favours the use of an organic anion
over other anions. Recognition is growing for the
importance of decreasing exogenous chloride load, as
hyperchloraemia at admission and during hospitalisation
has been associated with an increased risk of intensive
care complications, such as acute kidney injury, organ
dysfunction, and mortality.31,33–36 Two of the meta-analyses
published in the ESPNIC guidelines showed that the use
of balanced solution slightly decreases the length of
PICU and hospital stay, compared with the use of
normal saline. These two meta-analyses dedicated to the
effect of the use of balanced solutions on the length of
PICU and hospital stay included, respectively, 283 and
213 children with ketoacidosis, sepsis, or gastroenteritis
(mean difference –0·33 days; 95% CI –0·58 to –0·09,
p=0·007; mean difference –0·20 days; –0·33 to –0·08,
p=0·001).33–36 Based on these meta-analyses, balanced
fluids are recommended as a standard of care in the
paediatric acute care setting and should be favoured in
Figure: Prescribing IV-MFT5,6,8,9
HSF=Holliday and Segar’s formula. IV-MFT=intravenous maintenance fluid therapy
 Viewpoint

Does the patient require hydration? No

Yes

Could you consider oral or enteral hydration ? Hydration via oral or enteral liquids with or without
Yes
nutrition as appropriate

No For example (non-exhaustive):

• Haemodynamic instability with vasopressor requirement
• High-risk digestive surgery, abdominal trauma, or infection
Consider IV-MFT • Therapeutic hypothermia

Drug
Are there any precautions to be taken with isotonic intravenous Prescribe isotonic fluid or the specific IV fluid considered
fluids? Yes appropriate; seek expert advice on fluid management;
For example (non-exhaustive): closely monitor natraemia
• Severe watery diarrhoea with hypernatraemia
No • Renal concentrating defect
• Severe burns
Consider isotonic balanced intravenous fluids with or without
glucose to avoid hyperglycaemia and hypoglycaemia

Is there a need for other electrolytes? Prescribe the appropriate specific isotonic balanced
Yes intravenous fluid and add electrolytes

No
Dose
Evaluate the total daily amount of fluid using HSF:
• 3–10 kg: 100 mL/kg per day
• From 11–20 kg: 1000 mL plus 50 mL/kg per day for each kg
over 10 kg
• More than 20 kg: 1500 mL plus 20 mL/kg per day for each kg
over 20 kg (maximum 2000 mL per day)

Is there a risk of oedematous state? Yes Reduce total daily fluid volume to 50–60% of HSF
For example (non-exhaustive):
• Cardiac, kidney, or liver failure
• Nephrotic syndrome
No • Capillary leak
• Malnutrition

Is there a risk of endogenous secretion of antidiuretic hormone? Yes Reduce total daily fluid volume to 65–80% of HSF
For example: (non-exhaustive):
• Lower respiratory tract infections
No
• Other infections (eg, meningitis)
• Inflammatory diseases
• Postoperative state
Are there other fluid intakes to consider?
• I ntravenous drugs (continuous or intermittent administration)
• Blood products
• Arterial and venous line flushes
• Parenteral nutrition Remove those fluids from the total target daily goal
Yes
• Enteral intake (water, nutrition, drugs, flushes, etc) of fluid amount

No

Prescribe the appropriate IV-MFT (drug, dose, and rate)

Duration
Monitor at least daily: Target
• Bodyweight • Normal bodyweight
• Fluid intake and output • Fluid balance: neutral
• Fluid balance • Electrolyte plasma levels: normal range for age
• Electrolyte plasma levels • Normal blood glucose concentration:
• Blood glucose concentration 3·5–8·0 mmol/L

De-escalation
Consider at least daily:
• Adaptation of the infusion (drug, dose, and rate)
• Stopping or reducing the IV-MFT if oral or enteral hydration can
be initiated

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paediatric critical care (table; figure).6 The AWMF
perioperative guidelines also recommend the use of
balanced solutions,7 but the other three societies do not
address this issue (table).4,5,8
The amount of intravenous fluids
Once the type of fluid (the drug) is chosen, the total volume
and infusion rate (the dose) of IV-MFT should be
considered. There is currently no reliable way to predict
the daily maintenance fluid volume requirement for
children in both acute and critical care settings.6 In 2018,
the AAP guidelines considered this aspect out of the scope
of their review.5 Nevertheless, in their rationale, the AAP
highlighted that fluid volume should be restricted in some
patients who are at an increased risk of hyponatremia or
fluid overload when receiving fluid at a standard rate,
especially patients with congenital or acquired heart
disease, liver disease, or renal failure.5 The IFA and AWMF
proposed volume strategies for specific populations that
are difficult to extrapolate for all children in acute and
critical care settings (table).4,7 However, the HSF, which is
widely used as a standard in the paediatric setting,3 has
been shown to result in a lower natraemia compared with
a more restrictive strategy.6 This result was observed
regardless of the tonicity of the maintenance fluid used.
Thus, the ESPNIC and NICE guidelines recommended
reducing the total daily volume intake to 50–80% of the
volume calculated with the HSF for children at risk of
arginine-vasopressin secretion.6,8 In the ESPNIC
guidelines, there are differences in the recommendations
for patients at risk of arginine-vasopressin secretion
(65–80% of HSF) and patients at risk of oedematous states
(50–60% of HSF; figure).6 The evidence supporting these
recommendations remains scarce.6 However, this
restrictive IV-MFT strategy is common practice in
paediatric critical care.3 There are clear associations
between fluid overload in critically ill patients and poor
patient outcomes, such as worsening respiratory function,
acute kidney injury, extended PICU stay, and death.37
Excess intravenous fluid, especially when provided by
IV-MFT or fluid creep—defined as the sum of the volumes
administered to keep venous and arterial lines open,
volumes used as a vehicle for medication, and volumes of
concentrated electrolytes administered separately or with
other fluids—is linked to fluid overload and associated
with poor patient outcomes.6,38,39 Yet, a causative link
between fluid restriction strategies and reduction of fluid
overload remains to be shown.6 To prevent fluid creep and
reduce fluid intake in acutely and critically ill patients,
paediatric and adult guidelines recommend that all
administered fluids should be considered in the total daily
amount of fluid intake: intravenous fluids, blood products,
all intravenous and enteral medications (continuous
infusions, intermittent administrations, and drug flushes),
arterial and venous line flush solutions, and enteral
intake.4,6 Thus, the amount of IV-MFT prescribed should
consider the child’s estimated fluid needs, with a restrictive
6 www.thelancet.com/child-adolescent Published online January 12, 2024 https://doi.org/10.1016/S2352-4642(23)00288-2
strategy in mind considering what fluids the child is
already receiving. In addition, the ESPNIC, NICE, and IFA
guidelines recommend paying particular attention to
ongoing daily fluid balance and patient weight (table).4,6,8
Unanswered questions on IV-MFT practice
Similarly to the calculation of IV-MFT amounts, there is
no evidence on how to determine the correct amount of
glucose and other electrolytes that should be provided by
IV-MFT. Infants and younger children are at an increased
risk of developing hypoglycaemia and ketosis during
prolonged fasting because of their small glycogen stores.
Provision of glucose in IV-MFT is important to avoid
hypoglycaemia in these younger children.40 In the
perioperative setting, 1–2·5% glucose concentration in
IV-MFT is recommended.7 No clear consensus exists on
the optimal glucose concentrations in other settings. In
the PICU, critical illness hyperglycaemia might occur due
to stress-related metabolic shifts and insulin resistance.
These metabolic changes might lower the risk of
hypoglycaemia and reduce the need for highly
concentrated glucose fluids. In the general paediatric
setting, the use of glucose 5%, or even 10% for the
youngest children, is common.3 No clear age threshold
exists that would distinguish children requiring glucose
infusions from those who do not.3 In adults,
1–1·5 g/kg per day of glucose is recommended to limit
starvation ketosis.4 In children, sufficient amounts of
glucose should be provided, but not in excess, with regular
blood glucose monitoring to prevent hypoglycaemia or
hyperglycaemia.5,6,8 For electrolytes, only potassium is
subject to a specific recommendation.4–6 Depending on the
child’s clinical situation, potassium should be provided to
prevent hypokalaemia, with close monitoring of blood
potassium concentration.4–6 The ideal IV-MFT composition
of calcium, magnesium, phosphorus, vitamins, and other
micro­nutrients remains unknown (table).41
Guideline implementation and special
considerations in low-income countries and
middle-income countries
Questions remain regarding the implementation of the
IV-MFT guidelines, especially in low-income countries.
The authors of these guidelines were mostly health-care
professionals practising in high-income countries.4–8
Although some of the discussed guidelines have been
developed based on literature from low-income
countries, this literature remains scarce. Relevance and
feasibility of implementation of these guidelines in
such settings is also difficult to assess.6 The complexities
involved with caring for children in low-income settings,
the availability of appropriate intravenous infusate
solutions, and their cost (especially for balanced fluids)
have a strong negative effect on the applicability of these
guidelines in such settings.3,42 In addition, this negative
effect is somewhat reinforced by the differences with
patients from higher-income countries, who are less

prone to nutritional deficiencies and particular
infectious diseases, such as malaria.3,42 Yet, as many of
the principles are universal, some of the
recommendations are applicable in all health-care
settings, including: favouring of the enteral route of
fluid administration; use of a fluid-restriction strategy
in patients at risk of fluid overload; and use of isotonic
fluids as a standard. Ultimately, tailored guidelines
based on resource availability could be proposed. In this
context, paediatric critical care societies and inter­
national societies advocating for children’s health could
encourage WHO to develop normative guidance
dedicated to the specific topic of IV-MFT in children,
according to the resource availability of the setting and
context in which children are receiving medical care.43
This document should address the availability of
infusions and appropriate alternatives, supply chains,
and safety measures, such as equipment for correct
administration and monitoring of IV-MFT in infants
and young children. Several condition-specific guidance
documents have been issued by WHO and can be used
to complement IV-MFT recommendations to help
health-care workers prescribe fluid therapy in
emergency situations, such as shock, dehydration,
diarrhoea, and malnutrition.44–46
In addition, questions remain regarding the inter-
relations between recommendations. For instance, once
a definite restrictive strategy is used for the total amount of
fluid administered, would the composition of the
remaining IV-MFT be clinically relevant? Would the risks
of hyponatraemia and hyperchloraemic acidosis be
sufficiently mitigated by an effective fluid restriction
strategy?47 How can we best ensure adherence to a restrictive
strategy given the need for a dynamic and individualised
evaluation of fluid needs and balance? In relation to
balanced solutions, what is the best sodium organic anion
to provide in specific clinical scenarios? Who are the
children we expect could benefit the most from balanced
solutions? What are the adverse events associated with the
different anions and to what extent do we expect these to
manifest, with what amount of anion, in what specific
subpopulations of acutely ill children? In children who
require substantial amounts of IV-MFT, is the sodium load
associated with clinically significant adverse events?22,24,48,49
Research in IV-MFT: past, present, and future
directions
Since the beginning of the 21st century, the evidence
produced on IV-MFT mainly assessed the effects of
isotonic fluid administration.6,8,26 In the last 5 to 10 years
the paradigm of trials has shifted to the evaluation of
the effects of balanced fluids.6,29–31,50 Future studies and
randomised controlled trials, possibly using a platform
trial design, should assess the applicability of some of
these fluid interventions in specific subpopulations,
such as in patients with traumatic brain injury or heart,
kidney, or liver failure. In the meantime, the use of
www.thelancet.com/child-adolescent Published online January 12, 2024 https://doi.org/10.1016/S2352-4642(23)00288-2
Viewpoint
Search strategy and selection criteria
In developing this Viewpoint, we did a literature search on
June 4, 2023, on PubMed. The literature review was focused
on relevant guidelines regarding intravenous maintenance
fluid therapy in paediatric and adult acute and critical care
published in the last 10 years. The search terms were: “fluids,
maintenance”, ”balanced fluids”, “isotonic fluids”, and “fluid
therapy”. Literature regarding fluid bolus was considered out
of the scope of this Viewpoint.
a restrictive strategy and dynamic adjustment of fluid
volumes might become the new intervention of interest
for the general paediatric population in acute and
critical care. However, feasibility studies are required to
assess what fluid volume strategies to compare.51 Above
all, formulating a definite and consensus-based set of
core outcomes seems essential, since the results of
reviews and meta-analyses are heterogeneous and the
choice of evaluated outcomes is debatable.6,8,52 Finally,
observational studies should help to assess the inter-
relationship between recommendations.
Guidelines provide health-care professionals with
evidence-based advice that applies to most of their patients.
Following the guidelines lowers the risk of adverse events.
However, in the case of IV-MFT, the same rules might not
be applicable to every patient, particularly children who
require tailored medical care.8,53
Conclusions
IV-MFT is one of the most prescribed drugs in paediatric
acute and critical care settings, and yet one of the most
underregulated ones in day-to-day practice. The published
guidelines by American and European paediatric and
adult societies encourage us to review our daily practices
based on new evidence. We should give IV-MFT
prescriptions the same considerations as we give any
other drug prescription.
Contributors
DWB, LNT, and FVV conceptualised the Viewpoint and assumed
supervision of the core team. DWB and IG drafted the first version of
the manuscript. DWB, IG, and FVV contributed to the design of the
table and figure. SCATV, CJC, SR, LVM, and LJS provided feedback on
the manuscript. IG and LNT edited the manuscript. All authors
reviewed, edited, and approved the manuscript.
Declaration of interests
DWB and IG received honoraria for presentations from B. Braun.
SCATV received honoraria for presentations from Nutricia.
LVM received honoraria for presentations from Nutricia, Danone,
Abbott Laboratories, and Nestle. LNT received honoraria for
presentations from Nestle. FVV received honoraria for presentations
from Baxter, Nutricia, and Nestle Health Care. All other authors declare
no competing interests.
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