1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303(3):235–241. [PubMed] [Google Scholar] Show 2. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA. 2010;303(3):242–249. [PubMed] [Google Scholar] 3. Barlow SE. and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164–S192. [PubMed] [Google Scholar] 4. Centers for Disease Control and Prevention. Defining childhood overweight and obesity. 2010 www.cdc.gov/obesity/childhood/defining.html. Accessed November 19. [Google Scholar] 5. Wurtz R, Itokazu G, Rodvold K. Antimicrobial dosing in obese patients. Clin Infect Dis. 1997;25(1):112–118. [PubMed] [Google Scholar] 6. Cheymol G. Effects of obesity on pharmacokinetics: implications for drug therapy. Clin Pharmacokinet. 2000;39(3):215–231. [PubMed] [Google Scholar] 7. Koshida R, Nakashima E, Taniguchi N, et al. Prediction of the distribution volumes of cefazolin and tobramycin in obese children based on physiological pharmacokinetic concepts. Pharm Res. 1989;6(6):486–491. [PubMed] [Google Scholar] 8. Ritzmo C, Soderhall S, Karlen J, et al. Pharmacokinetics of doxorubicin and etoposide in a morbidly obese pediatric patient. Pediatr Hematol Oncol. 2007;24(6):437–445. [PubMed] [Google Scholar] 9. Hijiya N, Panetta JC, Zhou Y, et al. Body mass index does not influence pharmacokinetics or outcomes of treatment of children with acute lymphoblastic leukemia. Blood. 2006;108(13):3997–4002. [PMC free article] [PubMed] [Google Scholar] 10. Twite MD, Rashid A, Zuk J, Friesen RH. Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training programs. Pediatr Crit Care Med. 2004;5(6):521–532. [PubMed] [Google Scholar] 11. Schwartz AE, Matteo RS, Ornstein E, et al. Pharmacokinetics of sufentanil in obese patients. Anesth Analg. 1991;73(6):790–793. [PubMed] [Google Scholar] 12. Katz R, Kelly HW. Pharmacokinetics of continuous infusions of fentanyl in critically ill children. Crit Care Med. 1993;21(7):995–1000. [PubMed] [Google Scholar] 13. Katz R, Kelly HW, Hsi A. Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion. Crit Care Med. 1994;22(5):763–767. [PubMed] [Google Scholar] 14. Carr RR, Ensom MHH. Drug disposition and therapy in adolescence: the effects of puberty. J Pediatr Pharmacol Ther. 2003;8(2):86–96. [PMC free article] [PubMed] [Google Scholar] 15. BMI percentile calculator for child and teen metric version. Centers for Disease Control; 2010. http://apps.nccd.cdc.gov/dnpabmi/. Accessed November 19. [Google Scholar] 16. Pollack MM, Patel KM, Ruttimann UE. PRISM. III: an updated pediatric risk of mortality score. Crit Care Med. 1996;24(5):743–752. [PubMed] [Google Scholar] 17. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 16th ed. Hudson, OH: Lexi-Comp, Inc;; 2009. [Google Scholar] 18. Mirski MA, Lewin JJ. Sedation and pain management in acute neurological disease. Semin Neurol. 2008;28(5):611–630. [PubMed] [Google Scholar] 19. Darnell CM, Thompson J, Stromberg D, et al. Effect of low-dose naloxone infusion on fentanyl requirements in critically ill children. Pediatrics. 2008;121(5):e1363–e1371. [PubMed] [Google Scholar] 20. STATA for Windows version 10.1. College Station, TX: StataCorp; 2009. [Google Scholar] 21. Shibutani K, Inchiosa MA, Jr, Sawada K, Bairamian M. Accuracy of pharmacokinetic models for predicting plasma fentanyl concentrations in lean and obese surgical patients: derivation of dosing weight (“pharmacokinetic mass”) Anesthesiology. 2004;101(3):603–613. [PubMed] [Google Scholar] 22. Shibutani K, Inchiosa MA, Jr, Sawada K, Bairamian M. Pharmacokinetic mass of fentanyl for postoperative analgesia in lean and obese patients. Br J Anaesth. 2005;95(3):377–383. [PubMed] [Google Scholar] 23. Miller JL, Johnson PN, Harrison DL, Hagemann TM. Evaluation of antimicrobial and analgesic dosing errors in overweight children. Ann Pharmacother. 2010;44(1):35–42. [PubMed] [Google Scholar] 24. Stucky ER. American Academy of Pediatrics Committee on Drugs and Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431–436. [PubMed] [Google Scholar] 25. Fentanyl. DRUGDEX® System [Internet database]. Version 2.0. Greenwood Village, CO: Thomson Healthcare; 2010. In. Updated 7 January 2011. http://thomsonreuters.com/products_services/healthcare/healthcare_products/a-z/drugdex_system/ Accessed November 14. [Google Scholar] This guideline is the basis of QS131. This guideline covers general principles for managing intravenous (IV) fluids for children and young people under 16 years, including assessing fluid and electrolyte status and prescribing IV fluid therapy. It applies to a range of conditions and different settings. It does not include recommendations relating to specific conditions. This guideline represents a major opportunity to improve patient safety for children and young people having IV fluid therapy in hospital. Who is it for?
The following recommendations have been identified as priorities for implementation. The full list of recommendations is in the recommendations section. Assessment and monitoring
Fluid resuscitation
Routine maintenance
Replacement and redistribution
Managing hyponatraemia that develops during intravenous fluid therapy
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. 1.1.1. For guidance on the principles and protocols for intravenous (IV) fluid therapy, see the principles and protocols for intravenous fluid therapy section in NICE’s guideline on intravenous fluid therapy in adults (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):
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:
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. 1.3.1. If children and young people need IV fluid resuscitation, use glucose-free crystalloids 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. Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information. 1.3.2.If term neonates need IV fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 131–154 mmol/litre, with a bolus of 10–20 ml/kg over less than 10 minutes. Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information. 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 of NICE’s guideline on diabetes (type 1 and type 2) in children and young people. 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. 1.4.1. 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 2,500 ml and females rarely need more than 2,000 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:
If children and young people need IV fluids for routine maintenance, initially use isotonic crystalloids that contain sodium in the range 131–154 mmol/litre. Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information. 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 aged 8 days or over need IV fluids for routine maintenance, initially use isotonic crystalloids that contain sodium in the range 131–154 mmol/litre with 5–10% glucose. For term neonates aged up to 7 days, use professional judgement, taking into account:
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:
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. 1.5.1. 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 that contain sodium in the range 131–154 mmol/litre for redistribution. Note that this is an off-label use for some intravenous fluid therapy preparations in some age groups. See prescribing medicines for more information. 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. 1.6.1. If hypernatraemia develops in term neonates, children and young people, review the fluid status and take action as follows:
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. 1.7.1. If asymptomatic hyponatraemia develops in term neonates, children and young people, review the fluid status and take action as follows:
Be aware that the following symptoms are associated with acute hyponatraemia during IV fluid therapy:
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:
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. Neonates, children and young people are defined as follows: neonates:infants aged 28 days and under (born at term; or born prematurely who have a corrected age of term or more) children:29 days to under 12 years young people:12 to under 16 years. Recommendation 1.4.7 In 2020 NICE checked whether the guideline needed updating and decided that it did not. When we consulted on this decision, concerns were raised about recommendation 1.4.7 on IV fluids for routine maintenance in term neonates. Specifically, that for term neonates in the first days of life, the sodium content may be too high and the glucose content too low. Evidence in this area was very limited when the guideline committee made the original recommendation in 2015, with no evidence at all in term neonates aged 0 to 48 hours. The committee therefore made a recommendation based on consensus. We found no further evidence in this area in 2020. After discussion with topic experts, the recommendation has been revised to reduce the potential for incorrect use of isotonic crystalloids in the youngest neonates. We may revisit this area if we become aware of any relevant new evidence in future. Return to recommendations This section highlights 3 areas of the IV fluid therapy in children and young people guideline that could have a big impact on practice and improve quality of care. We identified these with the help of stakeholders and guideline committee members (see the information on approaches to additional consultation in section 10.1 of the manual). The section also gives information on resources to help with implementation. See recommendation 1.2.3 (KPI). To ensure that children and young people receiving IV fluid therapy are prescribed the appropriate fluids, precise measurement of fluid and electrolyte status is essential. Measuring and documenting key components on an IV fluid balance and/or prescription chart enables clinical staff to monitor changes in patients’ fluid balance and helps to ensure the appropriate prescribing of fluids. The guideline specifies the minimum information needed on these charts, and provides clarity on when weight or body surface area is the most effective way to calculate routine maintenance needs. Currently there is no standard fluid balance and prescription chart in the NHS that is used to record fluid and electrolyte status. In addition, there is variation in what is recorded and documented on a patient’s chart between hospitals and between units within hospitals. This can make it difficult for clinicians to determine an accurate fluid balance for a patient when they are moving between hospitals and within hospital departments, and when there is more than 1 clinician involved in a patient’s care. Including all the recommended measurements on a chart may mean a change in practice. Using a chart that encompasses all of the aspects considered important in monitoring, prescribing and safely administering IV fluid therapy for children and young people may support implementation. What can clinicians and department managers do to help?
See recommendations 1.3.1 (KPI), 1.3.2 (KPI), 1.4.3 (KPI) and 1.4.7. Information for prescribers about the most appropriate intravenous fluid to use in specific circumstances can help ensure that the amount of fluid or electrolytes given restore and maintain fluid balance. The guideline specifies the use of glucose-free crystalloids that contain sodium in the range 131–154 mmol/litre for fluid resuscitation, and isotonic crystalloids that contain sodium in the range 131–154 mmol/litre, with and without glucose, for routine maintenance, but does not specify which isotonic fluid to use as there was a lack of evidence to recommend one isotonic crystalloid over another. There are a range of IV fluids available to most healthcare professionals, and some staff who prescribe IV fluids may not know the specific composition of the choices available to them. A table highlighting examples of commonly used IV fluid types and their compositions has been included in the guideline. What can clinicians and department managers do to help?
See recommendation 1.8.1. Ensuring education and training for all healthcare professionals involved in prescribing and delivering IV fluid therapy for children and young people is important for patient safety. Prescribers are not always aware of the most appropriate IV fluid to use in specific circumstances and as such, the amount of fluid or electrolytes provided can be either too high or too low to restore and maintain fluid and electrolyte balance. The assessment, prescription and administration of IV fluids in children and young people are complex responsibilities involving clinical and biochemical assessment and a good understanding of the principles of fluid physiology. Failures in education and training which contribute to poor fluid management include:
There is little formal training and education in IV fluid management to support correct prescribing. Accessible training and education for all clinicians responsible for fluid management can help ensure that morbidity and mortality is minimised. What can organisations and department managers do to help?
Further resources are available from NICE (including shared learning examples) that may help to support implementation.
Correct fluid and electrolyte balance is essential to maintain physiological function. Normally, children and young people get the fluid they need by drinking. Many children and young people admitted to hospital may be too ill to drink so may need intravenous (IV) fluid therapy to correct or maintain their fluid and electrolyte balance. Children and young people may need IV fluids to account for losses of red blood cells, plasma, water or electrolytes beyond the usual losses in urine, stools and sweat. These losses can come from burns, diarrhoea, vomiting or leakage of fluid into the interstitial space. In these cases the aim is to replace any depleted fluids and restore electrolyte balance. Conditions such as cardiac dysfunction, liver disease, inappropriate antidiuretic hormone secretion and nephrotic syndrome can result in an excess of fluids in the body, known as fluid overload. If this happens, the aim is to rebalance and redistribute fluids and ensure the correct levels of electrolytes. Whether IV fluid therapy is needed for fluid resuscitation, routine maintenance, replacement or redistribution, it is vital that the correct composition, volume and timing of IV fluid therapy is used. IV fluid types include colloids, crystalloids and combinations of fluids, and different types of fluids are appropriate for different situations (see the MHRA Drug Safety Alert for hydroxyethyl starch intravenous infusions). Errors in prescribing or administering IV fluids can result in inadequate or excessive provision, leading to hypovolaemia and poor organ perfusion, or hypervolaemia, oedema and heart failure. Failing to correct imbalances in electrolytes can lead to disturbances in intracellular or extracellular electrolyte balance, particularly in children and young people with reduced liver or kidney function. Failing to deliver correct fluids can therefore have a significant impact on morbidity and mortality. Surveys have shown that many staff who prescribe IV fluids know neither the likely fluid and electrolyte needs of individual patients, nor the specific composition of the many choices of IV fluids available to them. There is little formal training and education in IV fluid management to support correct prescribing. There is also a wide variation in the charts used to prescribe fluids and to record fluid and electrolyte status. Monitoring children and young people is often challenging: it may be difficult to assess urine output accurately, and blood tests can be painful, distressing and difficult to repeat. Assessment and monitoring is often suboptimal, and fluid and electrolyte status may not be recorded accurately. Changes in patients’ fluid needs may not be reassessed appropriately or at the correct intervals, which can lead to fluids being prescribed incorrectly. Clinical staff need to ensure that appropriate identification, treatment and monitoring of changes in fluid and electrolyte status is maintained and documented. There is a need for a standardised approach to assessing patients’ fluid and electrolyte status and prescribing IV fluid therapy in the NHS. This guidance represents a major opportunity to improve patient safety for children and young people having IV fluid therapy in hospital. The guideline committee has made the following recommendations for research. The committee’s full set of research recommendations is detailed in the full guideline. What is the incidence of complications during, and as a consequence of, IV fluid therapy in children and young people? Every day, children and young people are prescribed IV fluid therapy for a variety of reasons. However, there is little evidence on IV fluids in children and young people, and the limited evidence available is of very poor quality. Complications of IV fluid therapy can lead to mortality and significant morbidity for the patient. This, in turn, represents a cost burden for the NHS in terms of critical care admissions, prolonged inpatient stays or the potential need for long-term follow-up and care by medical and allied healthcare professionals. What is the most appropriate glucose concentration in IV fluids for children and young people of different ages? In recent years, the use of glucose-containing hypotonic IV fluids in children and young people has been questioned, because of the risk of hyponatraemia. Many children and young people are now prescribed non-glucose-containing isotonic IV fluids for maintenance. However, there are several groups of children and young people, in particular, neonates and some children in the perioperative period (for example, those who underwent prolonged fasting preoperatively, and those who had central blocks during anaesthesia), who may benefit from glucose-containing IV solutions to prevent hypoglycaemia. A blanket prescription of 5 or 10% glucose solution for all may result in hyperglycaemia in some children and young people. However, the use of IV fluids containing lower concentrations of glucose may be sufficient to prevent hypoglycaemia and also avoid unnecessary hyperglycaemia. This may have a clinical application across all age groups, including neonates. For children and young people receiving IV fluids, does the use of a standardised national fluid balance chart reduce the rate of complications arising as a result of prescription and/or administration errors? The National Confidential Enquiry into Perioperative Deaths reports in 1999 and 2009 identified problems in fluid management in patients in the UK. A lack of consistency in prescribing and recording IV fluids may contribute to this. A lack of familiarity of ‘mobile’ medical and nursing staff with fluid balance charts in different hospital settings may further increase the likelihood of prescription and administration errors. A prospective cohort of children and young people receiving IV fluids, prescribed and documented on a standardised national fluid balance chart, or a case–control study comparing the use of a standardised national fluid balance chart with non-standard ‘local’ fluid balance charts is needed to assess the clinical and cost effectiveness of using a standardised national fluid balance chart. Outcomes should include complications of IV fluid therapy (hypovolaemia, hypervolaemia, electrolyte abnormalities, neurological complications and hypoglycaemia) and incidence of prescription errors. If using a standardised national fluid balance chart resulted in better fluid prescription and clinical outcomes in children and young people, this could potentially lead to significant cost savings for the NHS. Does ensuring that all hospital healthcare professionals involved in prescribing and delivering IV fluids for children and young people are appropriately trained in the principles of fluid prescribing and IV fluid therapy-related complications lead to a reduction in IV fluid-related complications and associated healthcare costs? Assessing patients’ IV fluid needs, as well as prescribing and delivering IV fluids, are essential daily tasks on most paediatric wards. These are complex responsibilities that entail careful clinical assessment, good understanding of the physiology of fluid homeostasis both in health and disease, and appropriate supervision and training. There is currently no standard training provided for healthcare professionals working in the UK. Any teaching at both undergraduate and postgraduate level is currently delivered ad hoc, and in many cases may be limited. If fluid management in hospitalised children and young people is to improve, standardised training is likely to be needed. Any educational interventions made would need to be evaluated to assess whether practice had subsequently improved. You can see everything NICE says on this topic in the NICE Pathway on intravenous fluid therapy in hospital and NICE Pathway on sepsis. To find NICE guidance on related topics, including guidance in development, see our topic pages for medicines management, children and young people, hospital settings, acute and critical care, and trauma. For full details of the evidence and the guideline committee’s discussions, see the full guideline. You can also find information about how the guideline was developed, including details of the committee. NICE has produced tools and resources to help you put this guideline into practice. For general help and advice on putting NICE guidelines into practice, see resources to help you put guidance into practice. June 2020: We have reviewed the evidence and made a change to recommendation 1.4.7 to clarify the use of isotonic crystalloids for routine maintenance in term neonates. This recommendation is marked [amended 2020]. Your responsibility: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Created: December 9, 2015; Last Update: June 11, 2020. |