Intravenous Fluid Therapy in Term Neonates, Children and Young People in Hospital

Publication: 10/05/2017  --
Last review: 26/09/2017  
Next review: 01/05/2020  
Clinical Guideline
CURRENT 
ID: 5026 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Intravenous Fluid Therapy in Term Neonates, Children and Young People in Hospital

Summary of Guideline
Patient group where guideline applies
Assessment and Monitoring
Fluid resuscitation
Routine Maintenance
Replacement and Redistribution
Managing Hypernatraemia (Plasma Sodium >145mmol/L) that develops during IV fluid therapy
Managing Hyponatraemia (Plasma Sodium <135mmol/L) that DEVELOPS DURING IV fluid therapy
Available fluids within LTHT
Guideline for the preparation of 10% glucose with 0.45% sodium chloride intravenous fluid at ward level

Summary of Guideline

This guideline has been developed to standardise and optimise the prescription of intravenous fluid therapy in term neonates, children and young people within the Leeds Teaching Hospitals NHS Trust.

The guideline is based on the National Institute for Care and Health Excellence (NICE) Intravenous Fluid Therapy in Children and Young People in Hospital  guideline (NG 29) and NICE Quality Standard QS 131 Intravenous Fluid Therapy in Children and Young People in Hospital.

This guideline covers:

  1. Assessment and monitoring of intravenous fluid requirements
  2. Fluid resuscitation
  3. Routine Maintenance fluids
  4. Replacement fluids and redistribution
  5. Managing hyponatraemia that develops during intravenous fluid therapy
  6. Managing hypernatraemia that develops during intravenous fluid therapy

For more detailed guidance on intravenous therapy the reader should refer to the NICE guidance available at www.nice.org.uk

This guidance is applicable to patients aged 18 or under who are under the care of the Leeds Children’s Hospital.

Separate guidance is available here for adult patients

This guidance does not cover the administration of intravenous fluids to the following patients:

  • Pre term neonates
  • Patients with diabetes insipidus
  • Patients with diabetes including DKA
  • Suspected salt poisoning
  • Patients receiving hydration fluids as part of a chemotherapy regimen

This guideline is applicable to all other patient groups, however use with caution in patients with existing renal dysfunction. Seek specialist advice for patients at risk of tumour lysis syndrome.

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Patient group where guideline applies

All children requiring intravenous fluid therapy.

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Assessment and Monitoring

Assess and document the following on the Children’s Fluid Balance Chart or local monitoring documentation where this exists.

Intravenous fluids must be prescribed on the ‘Paediatric Intravenous Infusions Prescription Chart.

1. Weight

If possible weigh patient daily. Document actual or estimated daily body weight and any change from previous day. If an estimate was used, the actual weight should be measured as soon as clinically possible.

2. Fluid balance

Document the following on either the Children’s Fluid Balance Chart or local monitoring documentation;

  • fluid input, output and balance over the previous 24 hours
  • types and volumes of fluid input and output (urine, gastric and other) recorded hourly and with running totals
  • clinical assessment of hydration status in patient record
    • 12 hour fluid balance subtotal
    • 24 hour fluid balance totals
    • 12 hourly assessments of
      1. the fluid prescription
      2. current hydration status
      3. whether oral fluids can be started
  • urine and other outputs

3. Urea and electrolytes

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

Record the results of laboratory and point of care assessments including

  • full blood count
  • urea
  • creatinine
  • plasma electrolyte concentrations (chloride, sodium, potassium)
  • blood glucose
  • urinary electrolyte concentrations where appropriate

4. Glucose

Measure blood glucose when starting intravenous fluid therapy, then at least every 24 hours, or more frequently* if there is a risk of hypoglycaemia (*follow local specialty guidance if more frequent monitoring required).

Consider increased risk of hypoglycaemia in patients;

  • under 1 year of age
  • with sepsis
  • with liver failure
  • receiving concurrent administration of insulin
  • with a known metabolic condition
  • with diabetes mellitus
  • on a ketogenic diet
  • who have recently received parenteral nutrition
  • who had a period of fasting exceeding 5 hours

5. Prescription of intravenous fluids

Intravenous fluids must be prescribed on the Paediatric Intravenous Infusions Chart. Take account of any ongoing losses and calculations of fluid needs for routine maintenance, replacement, redistribution and resuscitation.

Algorithm 1 - Assessment and Monitoring

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Fluid resuscitation

Fluid resuscitation should be administered to patients diagnosed with severe clinical dehydration or hypovolaemic shock. Common clinical features are listed here.

Before prescribing, take into account pre-existing conditions (e.g. cardiac or renal disease). For guidance on fluid resuscitation in children with diabetic ketoacidosis, see DKA guideline.

Administer 10-20mL/kg bolus of 0.9% Sodium Chloride over 10 minutes or less.

Reassess patient after completion of intravenous fluid bolus and decide whether they need more fluids.

Seek expert advice from paediatric intensivist if more than 40mL/kg of intravenous fluid has been given and the patient is not improving. (note - this advice differs from NICE algorithm). 

Algorithm 2 - Fluid Resuscitation

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Routine Maintenance

1. Term neonates 0-28 days of age 

For term neonates, calculate fluid requirement according to their age:

Birth to Day 1 of life  

60mL/kg/day

Day 2 of life

80mL/kg/day

Day 3 of life

100mL/kg/day

Day 4 of life

120mL/kg/day

Day 5 to 28 of life

150mL/kg/day

On Day 1 of life, use 10% Glucose without added electrolytes.

In term neonates during the critical postnatal adaptation phase prior to physiological diuresis, use 10% Glucose with minimal sodium.

For all other term neonates, standard fluid is 0.45% Sodium Chloride with 10% Glucose (guidance to prepare 0.45% sodium chloride with 10% glucose).

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

If there is a risk of water retention due to non-osmotic anti-diuretic hormone (ADH) secretion, consider restricting fluids to 50-80% of routine maintenance. 

Reassess patient and calculate any subsequent intravenous fluid prescriptions based on plasma electrolyte concentration and blood glucose measurements.

2. Children aged 1 month - 16 years

For children and young people calculate routine maintenance IV fluid requirement based on body weight using Holliday Segar formula

For each kg of 0 - 10kg

100mL/kg/day

or

4mL/kg/hour

For each kg of 11 - 20kg

50mL/kg/day

or

2mL/kg/hour

For each kg above 20kg

20mL/kg/day

or

1mL/kg/hour

Example:

Patient weighing 23kg

0-10 kg = 100 x 10 = 1000mL
11-20 kg = 50 x 10 = 500mL
20-23kg = 20 x 3 = 60mL
Total daily fluid requirement = 1560mL per day

Usual maximum for males is 2500mL per 24 hours and for females it is 2000mL per 24 hours.

For patients with complex fluid needs or when the patient’s body weight is above the 91st centile, consider using body surface area to calculate fluid requirements. In this patient group, maintenance fluid requirement can be considered equivalent to the sum of insensible losses plus urine output. Insensible losses are equivalent to 300- 400mL/m2/day.

Use isotonic fluid as standard maintenance fluid. Recommended glucose concentration is 5 to 10% Glucose for patients up to 3 months of age and 5% Glucose for patients over 3 months of age.

Consider individual patient requirements before prescribing, for example patients with existing renal dysfunction or those who are fluid restricted.

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

If there is a risk of water retention due to non-osmotic anti diuretic hormone (ADH) secretion, consider restricting fluids to 50-80% of routine maintenance.  

Reassess patient and calculate any subsequent intravenous fluid prescriptions based on plasma electrolyte concentration and blood glucose measurements.

Algorithm 3 - Routine Maintenance

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Replacement and Redistribution

Adjust the intravenous fluid prescription to account for existing fluid and or electrolyte deficits or excesses, ongoing losses or abnormal distribution, for example tissue oedema in sepsis.

Routinely, 0.9% Sodium Chloride with 20mmol Potassium  in 1000mL is the preferred LCH fluid for initial replacement of on-going losses (for example from enteral feeding tubes, gastrostomies, colostomies or drains). Choice of replacement fluid should be reviewed based on clinical picture, fluid balance and monitoring of electrolytes.

Algorithm 4 - Replacement and redistribution

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Managing Hypernatraemia (Plasma Sodium >145mmol/L) that develops during IV fluid therapy

If plasma sodium exceeds 155mmol/L inform consultant or senior registrar (within 4 hours of abnormal result).

Assess patient’s hydration status and PAWS, review fluid prescription and fluid balance, including weight.

If no evidence of dehydration, consider changing intravenous fluid prescription to 0.45% Sodium Chloride +/- 5% Glucose (if <3 months old may need higher glucose concentration)

If patient is dehydrated, calculate percentage dehydration and replace deficit over 48 hours with 0.9% Sodium Chloride +/- 5% Glucose in addition to daily maintenance fluid requirement. If hypernatraemia worsens or is unchanged after replacing deficit, reassess patient and consider changing to 0.45% Sodium Chloride with 5% Glucose.

Measure plasma electrolyte concentrations every four to six hours (up to two hourly may be required in severe hypernatraemia) for the first 24 hours, and review need for further testing based on treatment response.

Neonates presenting in the first week of life with hypernatraemic dehydration secondary to failure of lactation should be rehydrated enterally using expressed breast milk or formula milk wherever possible.

The rate of fall of plasma sodium must not exceed 12mmol/L in a 24 hour period (maximum rate 1mmol/hour).Consider checking urine electrolytes and osmolality.

Algorithm 5 - Hypernatraemia

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Managing Hyponatraemia (Plasma Sodium <135mmol/L) that DEVELOPS DURING IV fluid therapy

This guidance relates to the management of hyponatraemia that DEVELOPS DURING intravenous fluid therapy. It is not appropriate for patients where underlying SIADH is suspected.

Note – LTHT guidance differs from NICE algorithm

1. Patients with symptomatic hyponatraemia
Symptoms associated with  acute hyponatraemia during intravenous fluid therapy can include;

headache
nausea and vomiting
confusion and disorientation
irritability
lethargy
reduced consciousness
convulsions
coma
apnoea

If symptomatic hyponatraemia occurs, seek immediate referral to PICU and renal consultant via patient’s responsible consultant.

In acute symptomatic hyponatraemia with neurological compromise initiate paediatric emergency call via 2222.

Following advice from intensivist, consider transfer to PICU for administration of hypertonic 2.7% Sodium Chloride bolus. Administration of hypertonic 2.7% Sodium Chloride must only occur under the direction of the consultant intensivist

Prescribing and administration guidance is available via Leeds Hospital Formulary monograph.

After hyponatraemia symptoms have resolved, ensure that the rate of correction of plasma sodium does not exceed 12mmol per 24 hours and a maximum rate of 1mmol per hour.

2. Patients with asymptomatic hyponatraemia

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

If child is prescribed a hypotonic fluid, change to 0.9% Sodium Chloride +/- 5% Glucose.

If hypervolaemic, restrict to 50-80% of routine maintenance fluid requirement. 

Review medicines, particularly diuretic use.

For asymptomatic patients with a plasma sodium level <125mmol/L, check plasma sodium levels every two hours. Inform patient’s consultant.

For children with asymptomatic hyponatraemia in the presence of significant ascites, discuss with patient’s consultant prior to correction of hyponatraemia. 

Algorithm 6 - Hyponatraemia

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Available fluids within LTHT

Hypotonic

Bag Size

Comments

5%Glucose

500mL

 

10%Glucose

500mL

 

0.45% Sodium Chloride with 5%Glucose

500mL

 

0.45% Sodium Chloride with 5% Glucose and 10mmol Potassium

500mL

Unlicensed medicine 

0.45% Sodium Chloride with 5% Glucose and 20mmol Potassium

500mL

Unlicensed medicine 

Isotonic

 

 

0.9% Sodium Chloride

500mL, 1L

 

0.9% Sodium Chloride with 5% Glucose

500mL, 1L

 

0.9% Sodium Chloride with 5% Glucose and 10mmol Potassium

500mL

Unlicensed medicine

0.9% Sodium Chloride with 5% Glucose and 20mmol Potassium 

500mL

Unlicensed medicine 

Sodium Chloride 0.9% with 20mmol Potassium

1L

 

Sodium Chloride 0.9% with 20mmol Potassium

500mL

 

Hartmanns solution

1L

 

Hypertonic

 

 

2.7% Sodium Chloride  
Available via PICU only on advice of intensivist

500mL

 

Guideline for the preparation of 0.9% Sodium Chloride with 10% Glucose intravenous fluid at ward level

Ready-made bags of this fluid are not commercially available. The aim of this guidance is to ensure that this fluid is safely prescribed and prepared at ward level.

(a) 0.9% Sodium Chloride with  10% Glucose in 500mL
This should be prescribed as Sodium Chloride 0.9% with  5% Glucose 500mL + 50mL 50% Glucose

To prepare, add 50mL of 50% Glucose to a 500mL bag of 0.9% Sodium Chloride with 5% Glucose and mix well.
The final solution will be 0.82% Sodium Chloride with 9% Glucose in 550mL which can be considered equivalent to 0.9% Sodium Chloride with 10% Glucose.

(b) 0.9% Sodium Chloride with 10% Glucose and  10mmol Potassium Chloride in 500mL
This should be prescribed as 0.9% Sodium Chloride with 5% Glucose 500mL with 10mmol Potassium Chloride + 50mL 50% Glucose

To prepare, add 50ml of 50% Glucose to a 500mL bag of 0.9% Sodium Chloride with 5% Glucose and 10mmol Potassium Chloride and mix well.
The final solution will be 0.82% Sodium Chloride with 9% Glucose and 10mmol Potassium Chloride in 550mL (= 9.1mmol potassium in 500mL).  This can be considered equivalent to 0.9% Sodium Chloride with 10% Glucose and 10mmol Potassium Chloride.

Further information is available on the Leeds Formulary

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Guideline for the preparation of 10% glucose + 0.45% sodium chloride intravenous solution at ward level

Ready-made bags of this fluid are not commercially available. The aim of this guidance is to ensure that this fluid is safely prescribed and prepared at ward level.

(a) 10% Glucose with 0.45% Sodium Chloride in 500mL

This should be prescribed as 5% Glucose 0.45% Sodium Chloride 500mL + 50mL 50% Glucose

To prepare add 50mL of 50% Glucose to a 500mL bag of 5% Glucose with 0.45% Sodium Chloride and mix well.
The final solution will be 10% Glucose with 0.41% Sodium Chloride in 550mL which can be considered equivalent to 10% Glucose with 0.45% Sodium Chloride

(b) 10% Glucose with 0.45% Sodium Chloride and 10mmol Potassium Chloride in 500mL

This should be prescribed as 5% Glucose 0.45% Sodium Chloride 500mL with 10mmol Potassium Chloride +  50mL 50% Glucose

To prepare add 50mL of 50% Glucose to a 500mL bag of 5% Glucose with 0.45% Sodium Chloride and 10mmol Potassium Chloride and mix well.
The final solution will be 10% Glucose with 0.41% Sodium Chloride and 10mmol Potassium Chloride in 550mL  (= 9.1mmol potassium in 500mL).  This can be considered equivalent to 10% Glucose with 0.45% Sodium Chloride and 10mmol Potassium Chloride.  

Algorithms for Intravenous Fluid Therapy in Children

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Provenance

Record: 5026
Objective:

Aims
To improve the use of intravenous fluid therapy in children and young people in hospital.
To ensure safe use of intravenous fluid therapy in children
To standardise the use of intravenous fluid therapy across the Leeds Children’s Hospital

Objectives
To provide evidence-based recommendations for the use of intravenous fluid therapy in children and young people in hospital.

Clinical condition:

Term neonates, children and young people receiving IV fluid therapy in hospital

Target patient group: Patients under the age of 16 requiring IV fluid therapy
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References  and Evidence levels:

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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