When maintenance IV fluids are indicated (**Indicated:** NPO (nil per os) for surgery, medical fasting, or prolonged vomiting; unable to maintain oral intake; perioperative fluid support when oral route unavailable · **NOT for deficit replacement** — use dehydration card for gastroenteritis deficit/shock; **NOT for DKA** — use DKA card for ISPAD 48-h deficit+maintenance protocol (NICE NG29, AAP, ESPGHAN, WHO Pocket Book 2022, CPS))
Recommended fluid type — isotonic shift (Current guidelines favor **isotonic maintenance** — **0.9% NaCl** or **balanced crystalloids** (Plasma-Lyte, Hartmann's/Ringer lactate per local availability) over routine **hypotonic** solutions (e.g. D5 0.18% NaCl, 0.45% NaCl) — hypotonic maintenance associated with **iatrogenic hyponatremia** in hospitalized children (NICE NG29, AAP 2018, ESPGHAN, WHO, CPS))
Duration: 24 h · 100 + 50 + 20 mL/kg/day per weight bracket (calculator: mL/24h ≈ 100 × weight kg for ≤10 kg only) — 8 kg: 800 mL/24h · 15 kg: 1250 mL/24h · 25 kg: 1600 mL/24h; use tiered formula for >10 kg (Holliday-Segar, NICE NG29)
• **Holliday-Segar (24-h daily volume):** **100 mL/kg/day** for first **10 kg** + **50 mL/kg/day** for next **10 kg** + **20 mL/kg/day** for each kg **>20** — formula: maintenance mL/24h = **100×min(w,10) + 50×min(max(w−10,0),10) + 20×max(w−20,0)** · **Examples:** 8 kg → **800 mL/24 h** (33 mL/h); 15 kg → **1250 mL/24 h** (52 mL/h); 25 kg → **1600 mL/24 h** (67 mL/h) (Holliday-Segar 1957, NICE NG29, AAP, WHO).
• **4-2-1 rule (hourly infusion rate):** **4 mL/kg/h** for first **10 kg** + **2 mL/kg/h** for next **10 kg** + **1 mL/kg/h** for each kg **>20** — formula: rate mL/h = **4×min(w,10) + 2×min(max(w−10,0),10) + 1×max(w−20,0)** · **Examples:** 8 kg → **32 mL/h**; 15 kg → **50 mL/h**; 25 kg → **65 mL/h** — mathematically equivalent to Holliday-Segar ÷ 24 (Holliday-Segar, pediatric anesthesia/critical care teaching).
• **Isotonic fluid selection:** first-line **0.9% NaCl** or **balanced isotonic crystalloid** (Plasma-Lyte, Hartmann's/Ringer lactate) — avoids free-water excess from hypotonic maintenance; **avoid routine hypotonic maintenance** (D5 0.18% NaCl, 0.45% NaCl, D5 0.2% NaCl) as sole IV fluid in children — associated with hospital-acquired hyponatremia (NICE NG29 2015/2020 update principles, AAP 2018 Clinical Report, ESPGHAN, CPS).
• **When to add dextrose:** add **D5** (or D10 in neonates/infants) to **isotonic base** when NPO and at risk of hypoglycemia — typical indications: infants, prolonged NPO, neonates, malnutrition, endocrine/metabolic disease, on insulin or sulfonylureas; target glucose infusion rate (GIR) **4–8 mg/kg/min** in neonates/infants (adjust per local protocol); older children often tolerate isotonic saline alone for short NPO periods if euglycemic (PES 2015, WHO Pocket Book, AAP).
• **Calculator note:** weight-based tiers below use mL/kg encoding — **accurate for weight ≤10 kg**; for **>10 kg** use formulas and examples above (tiered Holliday-Segar/4-2-1), not simple weight × single mL/kg factor.
Enter weight on Kids to calculate doses
Plasma-Lyte or Hartmann's • i.v. • 4–4 mg/kg/dose • 1×/day
Duration: Continuous · Same Holliday-Segar/4-2-1 volumes — balanced isotonic crystalloids acceptable alternative to 0.9% NaCl for maintenance; may reduce hyperchloremic acidosis with prolonged infusion (NICE NG29, pediatric critical care evidence)
• Balanced crystalloids: acceptable first-line alternative to 0.9% NaCl for standard maintenance — use identical Holliday-Segar/4-2-1 volumes; consider in prolonged NPO or concern for hyperchloremia (NICE NG29, ESPGHAN principles).
• Oral/enteral offset: as soon as child tolerates oral fluids, reduce IV rate by volume consumed — prevents fluid overload; target early return to oral hydration when clinically appropriate (NICE NG29, WHO Pocket Book).
• Ongoing losses: maintenance card covers **euvolemic NPO** needs only — add replacement for vomiting, diarrhea, drains, or third-space losses per dehydration card or surgical protocols (10 mL/kg per significant stool/vomit as guide) (WHO, ESPGHAN).
• When maintenance is indicated: IV maintenance for **NPO** states (pre/post-operative, medical fasting, inability to drink), perioperative support when oral route unavailable, and bridging until enteral intake resumes — **not** for active dehydration deficit (use dehydration card) or DKA (use DKA card with ISPAD restrictions) (NICE NG29, AAP, WHO Pocket Book 2022, CPS).
• Hyponatremia risk with hypotonic fluids: routine hypotonic maintenance (D5 0.18% NaCl, 0.45% NaCl) delivers excess free water relative to sodium needs — hospitalized children, especially post-operative and with ADH elevation, are at risk of **iatrogenic hyponatremia** and neurologic complications; **isotonic maintenance** (0.9% NaCl or balanced crystalloid) is now recommended by NICE, AAP, and CPS over historical hypotonic regimens (NICE NG29, AAP 2018, CPS 2024).
• Monitoring electrolytes and glucose: check **Na+, K+, Cl−, urea, creatinine, glucose** at baseline and **q12–24 h** during continuous IV maintenance (more frequently in neonates, cardiac/renal disease, or clinical change); monitor **fluid balance**, weight, and urine output (goal ≥1 mL/kg/h when euvolemic); adjust K+ in fluids when urine output established and K+ <5.5 mmol/L (NICE NG29, AAP, WHO).
• When to reduce volume: see **reduced-maintenance variant** for SIADH, heart failure, renal impairment, cerebral edema risk, oliguria, or fluid overload signs — do not give full Holliday-Segar if clinical condition mandates restriction; reassess rate q4–6 h (NICE NG29, AAP, pediatric critical care).
• PICU/specialist consult: complex electrolyte disorders (Na+ <120 or >160 mmol/L), fluid-refractory shock, suspected SIADH with severe hyponatremia, congenital heart disease with Fontan physiology, renal failure requiring dialysis planning, neonatal surgical complexes, or inability to maintain euvolemia/euglycemia on ward-level care — early PICU/nephrology/endocrinology involvement (NICE NG29, AAP, CPS, WHO ETAT).
• NICE NG29 — Intravenous fluid therapy in children and young people in hospital (2015)
• AAP Clinical Report — Maintenance intravenous fluids in children (isotonic recommendation) (2018)
• Holliday MA, Segar WE — The maintenance need for water in parenteral fluid therapy (1957)
+ 3 more
• WHO — Pocket Book of Hospital Care for Children (IV fluids and maintenance) (2022)
• ESPGHAN / NASPGHAN — Fluid therapy principles in hospitalized children (2014)
• CPS — Parenteral fluid therapy and hyponatremia prevention in children (2024)
