Author:
Kai Knudsen
Updated:
4 September, 2025
Fluid therapy is a cornerstone of treatment for critically ill children in intensive care. Children differ physiologically from adults by having a higher proportion of body water, a faster turnover, and a different regulation of fluid balance. These factors make them particularly vulnerable to both dehydration and fluid overload, which can have serious consequences for circulation, respiration, and metabolism.
Fluid Therapy for Children
The goal of fluid therapy in pediatric intensive care is to maintain stable hemodynamics, ensure adequate tissue perfusion, and support vital organ function. Assessment of fluid requirements and treatment demands a careful balance between clinical experience, continuous monitoring, and an understanding of the child’s underlying condition. This chapter outlines the principles of fluid therapy in pediatric intensive care, focusing on physiological considerations, practical strategies, and common pitfalls.
- Albumin 5% is standard for volume requirements
- Ringer’s Acetate works in most situations
- Blood, platelets, etc., based on need
- All fluids can be given in boluses of 10 ml/kg over 1-4 hours
- If urgent, it is easiest to give volume directly with a syringe (quickly for small children < 10 kg)
- Hgb limits are debated for heart-healthy children but should cope with Hgb 8-9 g/dL
Basic Fluid Requirements (Use the 4/2/1 Rule)
- 0 – 10 kg → 4 ml/kg/hour
- 10 – 20 kg → 40 ml/hour + 2 ml/kg/hour for weight > 10 kg
- > 20 kg → 60 ml/hour + 1 ml/kg/hour for weight > 20 kg
Clinical signs of dehydration in Children
| Symptoms / signs | Mild | Moderate | Severe |
|---|---|---|---|
| Weight loss | < 5 % | 5–10 % | > 10 % |
| Deficit (ml/kg) | < 50 | 50–100 | > 100 |
| General condition | Thirsty and worried | Thirsty, anxious or lethargic, halonated | Very sluggish to comatose, cold, gray, cyanotic |
| Mucous membranes | Normal, moisty | Dry | Very dry |
| Skin turgor | Normal | Reduced | Pronounced impaired |
| Fontanelle | Normal | Sunken | Very sunken |
| Pulse | Normal | Tachycardia | Tachycardia, weak pulse |
| Capillary refill | < 2 sec | Slow > 2 sec | Very slow |
| Blood pressure (systolic) | Normal | Normal / low | Low |
| Breathing | Normal | Deep | Deep and fast |
| Diuresis (urinary output) | < 2 ml/kg/h | < 1 ml/kg/h | < 0,5 ml/kg/h |
| NOTE! Higher dehydration can be used without all the characters being met. In hyperosmolar conditions with dehydration, the symptoms may appear different. Drops in blood pressure will often be late and are ominous. | |||
The child's total fluid needs
Fluid requirements per kg of body weight (Holliday-Segar)
| Weight (kg) | Quantity per day |
|---|---|
| Children born before w.37 and during the neonatal period | See PM for patients at Neonatal |
| < 5 kg | 150 ml/kg |
| 5 -10 kg | 100 ml/kg |
| 11 - 20 kg | 1000 ml + 50 ml for every kg over 10 kg |
| > 20 | 1500 ml + 20 ml for every kg over 20 kg |
Intraoperative Fluid Requirements (Ringer’s Acetate = Standard)
- Children < 10 kg: 10 ml/kg/hour for the first 1-2 hours
- Children > 10 kg: 3 – 5 ml/kg/hour for the first 1-2 hours
- Then 1-2 ml/kg/hour + measured/estimated losses
- Third space loss: 1-10 ml/kg/hour depending on the type of surgery
If Fluid Boluses Are Needed
- Ringer’s Acetate: 5 – 10 – 20 ml/kg
- Albumin 5% 5 – 10 – 20 ml/kg
- Blood products: 5 – 10 – 20 ml/kg
Recommendations for Children During Massive Bleeding
- Red blood cell concentrate 10 ml/kg in repeated doses
- Plasma 10–20 ml/kg
- Platelet concentrate 5–10 ml/kg
- Cryoprecipitate 5 ml/kg
- Fibrinogen concentrate 30 mg/kg
- Tranexamic acid 10–15 mg/kg
- Recombinant factor VIIa 90 μg/kg
Glucose Administration Intraoperatively
- Glucose 10% + 40 Na/20 K
- 3 ml/kg/h → monitor based on blood glucose levels!
- Indications
- Children < 1 week if ongoing glucose infusion preoperatively
- Metabolic disorders
- Growth-restricted newborns
Postoperative Fluid Requirements
- Give 75% of the 4/2/1 rule on the first postoperative day (due to elevated ADH)
- Ringer’s Acetate
- Glucose 10% + 120 Na/20 K (Reduce electrolytes for children < 6 months)
Electrolyte content in losses of various body fluids in mmoll
| Body fluid | Na (mmol/l) | K (mmol/l) | Cl (mmol/l) | HCO3 (mmol/l) | H (mmol/l) |
|---|---|---|---|---|---|
| Stomach (Gastric content) | 20–60 | 14 | 140 | 60–80 | |
| Bile | 145 | 5 | 105 | 30 | |
| Diarrhea / colostomy losses | 30–140 | 30–70 | 20–80 | ||
| Losses from the ileum at high flows | 100–140 | 4–5 | 75–125 | 0–30 | |
| Losses from the ileum at low flows | 50–100 | 4–5 | 25–75 | 0–30 | |
| Drainage or fistula from the pancreas | 125–138 | 8 | 56 | 85 | |
| Losses from the jejunum | 140 | 5 | 135 | 8 | |
| Polyuria | Varies | Varies | |||
| Ref: Neilson J, O’Neill F, Dawoud D, Crean P, Guideline Development G. Intravenous fluids in children and young people: summary of NICE guidance. BMJ (Clinical research ed). 2015;351:h6388 | |||||
Total intravenous fluid supply to be assumed during the first days of life
| Age | Volume |
|---|---|
| Day of life 1 | 60–70 ml/kg/day |
| Day of life 2 | 70–80 ml/kg/day |
| Day of life 3 | 80–100 ml/kg/day |
| From four days old | 100 ml/kg/day |
Estimated fluid needs for intravenous maintenance treatment of children and adolescents
| Weight | Daily fluid needs(ml/24 h) | Fluid demand per hour (ml/h) |
|---|---|---|
| < 10 kg | 100 ml/kg/24 hours | 4 ml/kg/h |
| 10–20 kg | 1,000 ml + (50 ml/kg/24 h for each kg more than 10 kg) | 40 ml/h + (2 ml/kg/h for each kg more than 10 kg) |
| > 20 kg | 1 500 ml + (20 ml/kg/24 tim för varje kg över 20 kg*) | 60 ml/tim + (1 ml/kg/tim för varje kg över 20 kg)* |
| * Girls rarely need more than 2,000 ml / day and boys rarely need more than 2,500 ml / day as maintenance treatment even at weights exceeding 45 and 70 kg respectively. | ||
Preoperative supply of maintenance fluid volume
| Patient weight | Volume requirement according to Holliday and Segar/day | Example basal supply (ml/day) | Preoperative maintenance fluid (ml/day) |
|---|---|---|---|
| ≤ 10 kg | 100 ml/kg | 8 kg 8 × 100 = 800 | 800 × 0,8 = 640 |
| 10–20 kg | 1,000 ml + 50 ml/kg for every kg over 10 kg | 15 kg 1 000 + 5 × 50 = 1 250 | 1 250 × 0,8 = 1 000 |
| ≥ 20 kg | 1,500 ml + 20 ml/kg for every kg over 20 kg | 25 kg 1 500 + 5 × 20 = 1 600 | 1 600 × 0,8 = 1 280 |
Peroperative fluid requirement
| Patient weight | Basic volume requirement | After 1-2 hours | Add for 3rd room loss: |
|---|---|---|---|
| ≤ 10 kg | 10 ml/kg first 1-2 hours | 1-2 ml/kg/h + measured/estimated losses | 1-10 ml/kg/h depending on type of surgery |
| 10–20 kg | 3-5 ml/kg first 1-2 hours | 1-2 ml/kg/h + measured/estimated losses | 1-2 ml/kg/h + measured/estimated losses |
| ≥ 20 kg | 3-5 ml/kg first 1-2 hours | 1-2 ml/kg/h + measured/estimated losses | 1-2 ml/kg/h + measured/estimated losses |
Volume of postoperative maintenance fluid
| Patient weight | Basal volume requirement, /day | Example basal supply (ml/day) | After postoperative reduction (ml/day) |
|---|---|---|---|
| ≤ 10 kg | 100 ml/kg | 8 kg 8 × 100 = 800 | 800 × 0,7 = 560 |
| 10–20 kg | 1,000 ml + 50 ml/kg for every kg over 10 kg | 15 kg 1 000 + 5 × 50 = 1 250 | 1 250 × 0,7 = 875 |
| ≥ 20 kg | 1,500 ml + 20 ml/kg for every kg over 20 kg | 25 kg 1 500 + 5 x 20 = 1 600 | 1 600 × 0,7 = 1 120 |
Bleeding
Blood Volume: 70-90 ml/kg
Bleeding is replaced according to the percentage of blood volume lost
- 5-10 % Ringer’s Acetate
- > 10 % + Albumin 5%
- > 20 % + Blood
- > 50 % + Plasma
Massive Bleeding:
- Guide by thromboelastogram!
- Without thromboelastogram:
- Administer Blood/Plasma/Platelets in the ratio: 1:1:0.5
In Case of Coagulation Disorder
- + Platelets 5-10 ml/kg
- + Fibrinogen 30-70 mg/kg
- + Cyklokapron 15 mg/kg
Note
- Temperature > 36.5°C
- pH > 7.2
- Monitor s-Ca
- Hgb > 9 g/dL
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