In recent years, there has been a fear of inducing complications like hypernatremia, volume overload, edema and hypertension with use of isotonic saline. all fluids should be calculated as maintenance + deficit correction + ongoing losses maintenance fluid requirements are calculated using the 4,2,1 rule (4ml/kg/hr for the first 10kg, 2ml/kg/hr for the second 10kg, and 1ml/kg/hr after that, with a maximum of 100ml/hr maintenance). Isotonic fluids have been recommended since 2003 as a maintenance IVF in hospitalized children to prevent these complications. This results in a range of mild to severe hyponatremia, in extreme cases manifesting as hyponatremic encephalopathy. In acutely ill states, excess secretion of arginine vasopressin retains free water and can exacerbate hyponatremia associated with administration of hypotonic fluids. Hypotonic maintenance IVF has been traditionally used in children based on theoretical calculations by Holliday and Segar in 1950s which yielded a fluid composition of 3 mEq/dL of sodium and 2 mEq/dL of potassium. Parenteral nutrition is preferred for any neonate needing IV fluids >5 days. For neonates greater than 32 weeks and 1500g requiring short term intravenous (IV) therapy, the preferred fluid type is glucose 10 in the first 24-48 hours of life, followed by fluids that contain sodium and potassium. Finally, for occasional patients with significant pre-existing hyperkalemia or metabolic acidosis, fluid choice may be extremely important. When leveraged over the high number of patients receiving fluid, even small differences in efficacy can be important (e.g. Tonicity or osmotic pressure exerted by the IVF on the semipermeable cell wall membrane is determined by the electrolyte concentration the major contributor being sodium. Whenever possible, the enteral route should be used. However, fluid therapy is an extremely common intervention. There has been an ongoing debate on the tonicity of IVF for maintenance requirements over the past few decades. An ideal IVF should match the daily fluid volume requirements and should contain electrolytes in appropriate concentrations to replenish ongoing loss and daily needs. Maintenance intravenous fluid (IVF) is a common and essential part of treatment in hospitalized children to maintain hydration in those in whom enteral fluid intake is not possible.
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