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New Maintenance Fluid Guidelines Gaining Traction in Hospitals

April 30, 2020

 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 hospital-acquired hyponatremia and its associated morbidities and mortalities. The literature shows approximately a 15% to 30% rate of hyponatremia in hospitalized children and adults. 

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 on the committee that established the guidelines, which in part reflect a clinical practice change that Dr. Moritz has pioneered and studied for the past 15 years: namely, the use of isotonic fluids over those of a hypotonic concentration.

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

“Hypotonic fluids have, unfortunately, been the standard of care in pediatrics for more than 50 years, primarily based on tradition and not evidence. 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% to less than 5%,” says Dr. Moritz. 

Survey to Assess Isotonic Fluid Use

Now that the new clinical guidelines have been in place for nearly 18 months, are they being implemented by physicians and hospitals?

To find out, Dr. Moritz and colleagues Alan M. Hall, MD, from the University of Kentucky College of Medicine, and Juan Carlos Ayus, MD, from the University of California Irvine School of Medicine, surveyed pediatric hospitalists across the United States. The results of their research were published in January in the journal Frontiers in Pediatrics.2

The anonymous and voluntary survey was distributed to physicians who are part of the American Academy of Pediatrics Section on Hospital Medicine. Responses from 402 individuals were elicited from the survey request, which equates to a 10.1% response rate. The broad conclusion of the survey showed that pediatric hospitalists are choosing to follow the new fluid guidelines.

Survey responses indicated that for patient populations age 1 year to 18 years, 87.8% of surveyed physicians were using the recommended isotonic fluids for their hospitalized patients. For patients age 28 days to 1 year, the usage rate was 66.3%. For those younger than 28 days, 10.6% of physicians indicated the use of isotonic fluids. It should be noted that the new fluid guidelines specifically exclude neonates younger than 28 days or who are in the NICU from receiving isotonic fluids.

The guidelines recommend the use of isotonic fluids; based on this survey, pediatric hospitalists are following the guidelines for patients outside of the neonatal period.

Learn more about the Pediatric Division of Nephrology at UPMC Children's Hospital of Pittsburgh.


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.

2. Hall AM, Ayus JC, Moritz ML. How Salty Are Your Fluids? Pediatric Maintenance IV Fluid Prescribing Practices Among Hospitalists. Front Pediatr. 2020; 7: 549. E pub ahead of print.