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American Academy of Pediatrics Releases New Clinical Guidelines on IV Fluid Use in Children

February 26, 2019

New Guidelines Will Help Prevent Cases of Hyponatremia

In November 2018, the American Academy of Pediatrics (AAP) published the first-ever clinical practice guidelines in the United States for the use of intravenous maintenance fluids in children. The new, evidence-based guidelines are meant, in part, to reduce or prevent as many cases as possible of hyponatremia and its often severe morbidities and mortalities. The literature shows approximately a 15 to 30 percent rate of hyponatremia in children and adults who are hospitalized.

Michael L. Moritz, MD, FAAP, clinical director and director of dialysis in the Division of Pediatric Nephrology at UPMC Children’s Hospital of Pittsburgh, was the senior author in the committee that established the guidelines, which in part reflect a clinical practice change Dr. Moritz has pioneered and studied for the past 15 years: namely, the use of isotonic fluids over those of a hypotonic concentration.

“Hypotonic fluids have, unfortunately, been the standard of care in pediatrics for more than 50 years, primarily based on tradition and not on science. I introduced the concept of avoiding hypotonic fluids and using isotonic fluids to prevent hyponatremia about 15 years ago. Since then, numerous studies in thousands of children have demonstrated that isotonic fluids decrease the incidence of hyponatremia from greater than 20 percent to less than 5 percent,” says Dr. Moritz.

Action Recommended for Physicians

The “Key Action Statement” from the new guidelines, “Recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia.”1

Perspectives and Additional Details

“There has never been a clinical practice guideline in the United States for the use of intravenous fluids in children; physician practice heretofore has primarily relied upon tradition. Tradition is not a good substitute for evidence-based science. These new guidelines from the AAP for the administration of intravenous maintenance fluids now specifically recommend isotonic fluids and caution against using hypotonic fluids due to the risk they present for developing hyponatremia,” says Dr. Moritz.

Excluded from the new guidelines are “patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, severe burns, and neonates who are younger than 28 days old or in the NICU.”1

“The AAPs new clinical practice guide-lines apply to most of the approximately two million children and adolescents ages 1 month to 18 years who are admitted to the hospital every year. The new guidelines apply to all pediatric patients who may need intravenous fluids in the emergency department, around the time of surgery, or after being admitted to the hospital,” says Dr. Moritz.

Webinar Discussion on New Guidelines

The American Academy of Pediatrics Pediatric Care Online™ hosted a webinar discussion on the new guidelines on January 16. During the webinar Dr. Moritz, along with Leonard G. Feld, MD, PhD, MMM, FAAP from Nicklaus Children’s Health System, and Matthew D. Garber, MD, FHM, FAAP from Wolfson Children’s Hospital, discussed the objectives, methods, and implications of the new IV fluid guidelines. 

References and Further Reading

The full text of the new guidelines can be found in the journal Pediatrics. 1 Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018; 142(6): e20183083. Epub ahead of print.