Intravenous fluid therapy in children and young people in hospital - NICE guideline

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.

Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in the recommendations section.

Assessment and monitoring

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.

Fluid resuscitation

  • If children and young people need IV fluid resuscitation, use glucose‑free crystalloids[1] 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.

  • If term neonates need IV fluid resuscitation, use glucose‑free crystalloids[1]that contain sodium in the range 131–154 mmol/litre, with a bolus of 10–20 ml/kg over less than 10 minutes.

Routine maintenance

  • If children and young people need IV fluids for routine maintenance, initially use isotonic crystalloids[2] that contain sodium in the range 131–154 mmol/litre.

  • 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.

  • 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.

Replacement and redistribution

  • Consider isotonic crystalloids[2] that contain sodium in the range 131–154 mmol/litre for redistribution.

Managing hyponatraemia that develops during intravenous fluid therapy

  • 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.

  • 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.

Related publications

Neilson J, O'Neill F, Dawoud D, Crean P. Intravenous fluids in children and young people: summary of NICE guidance. BMJ. 2015; 351

Dawoud D, Fenu E, Griffin EA, Wonderling D, Ritchie G, Crean P. Intravenous Fluids for Children: Cost and Threshold Analysis to Inform the National Institute for Health and Care Excellence (NICE) Clinical Guideline Recommendation. Value in Health. 19(7):A607