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• ARGUMENT ON APPROPRIATE CHOICE OF MAINTENANCE FLUID COMES A FULL CIRCLE
  Davendralingam Sinniah
  Published on: 22 March 2016
• Should 0.9% saline be used for maintenance fluids in hospitalised children?
  Graham C. Smith
  Published on: 22 March 2016

• Published on: 22 March 2016

  ARGUMENT ON APPROPRIATE CHOICE OF MAINTENANCE FLUID COMES A FULL CIRCLE

  • Davendralingam Sinniah, Professor

  I read with great interest the arguments whether 0.9% saline with 5% dextrose would be a more appropriate choice than 0.45% saline with 5% dextrose for maintenance fluids in hospitalized children. In 1975, WHO and the United Nations Children's Fund (UNICEF) decided to promote a single ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80, base 30, and glucose 111 (2%) for use among diverse populations....

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  I read with great interest the arguments whether 0.9% saline with 5% dextrose would be a more appropriate choice than 0.45% saline with 5% dextrose for maintenance fluids in hospitalized children. In 1975, WHO and the United Nations Children's Fund (UNICEF) decided to promote a single ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80, base 30, and glucose 111 (2%) for use among diverse populations. This composition enabled a single solution to be used for treatment of diarrhoea caused by different infectious agents and associated with varying degrees of electrolyte loss. WHO-ORS has been demonstrated during >25 years of use to be safe and effective at rehydration and maintenance for children and adults with all types of infectious diarrhea.1 However, more recent multiple controlled trials summarized in a meta-analysis by Hahn et al has supported adoption of a lower osmolarity ORS with proportionally reduced concentrations of sodium and glucose.2 Lower osmolarity ORS was associated with less vomiting, less stool output, and reduced need for unscheduled intravenous infusions compared with standard ORS among infants and children with non-cholera diarrhoea. In cholera infection, there was no clinical difference between subjects treated with the lower osmolarity solution and those treated with the standard solution, apart from an increased incidence of asymptomatic hyponatremia.3 On the basis of these findings, UNICEF and WHO convened a technical meeting of experts on oral rehydration at New York that recommended a reduced osmolarity solution for global use.4 In May 2002, WHO announced a new ORS formulation consistent with these recommendations, with 75 mEq/L sodium, 75 mmol/L glucose, and total osmolarity of 245 mOsm/L.5 The newer WHO-ORS was also recommended for use in treating adults and children with cholera. The need for unscheduled supplemental IV therapy in children given this solution was reduced by 33%. In a combined analysis of this study and studies with other reduced osmolar-ity ORS solutions (osmolarity 210-268 mOsm/l, sodium 50-75 mEq/l) stool output was also reduced by about 20% and the incidence of vomiting by about 30%. The 245 mOsm/l solution also appeared safe and at least as effective as standard ORS for use in children with cholera. It would now appear that the earlier argument on WHO-ORS has come a full circle with JA Morgan's article that presents current evidence that strongly favours the use of isotonic fluids (0.9% saline with 5% dextrose) as standard for intravenous maintenance fluid prescription in children, and 0.45% saline with 5% dextrose and other similar hypotonic solutions should be reserved for specific cases and used on a case-by-case basis.6 The one thing that is universally agreed is that the use of 0.18% saline is not recommended as standard maintenance fluid either by WHO or by Morgan.

  References

  1. Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy. Morbidity and Mortality Weekly Report. Recommendations and Reports November 21, 2003 / Vol. 52 / No. RR-16

  2. Hahn S, Kim Y, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review. BMJ 2001; 323: 81-5.

  3. Alam NH, Majumder RN, Fuchs GJ. Efficacy and safety of oral rehydration solution with reduced osmolarity in adults with cholera: a randomised double-blind clinical trial. CHOICE Study Group. Lancet 1999; 354:296-9.

  4. World Health Organization. Reduced osmolarity oral rehydration salts (ORS) formulation. New York, NY: UNICEF House, 2001. Available at http://www.who.int/child-adolescent- health/New_Publications/NEWS/Expert_consultation.htm.

  5. World Health Organization. Oral rehydration salts (ORS): a new reduced osmolarity formulation. Geneva, Switzerland: World Health Organization, 2002.

  6. Jessie Anne Morgan. Question 2: Should 0.9% saline be used for maintenance fluids in hospitalised children? Arch Dis Child 2015; 100:715- 717 doi:10.1136/archdischild-2015-308821

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Should 0.9% saline be used for maintenance fluids in hospitalised children?

  • Graham C. Smith, Consultant Paediatric Nephrologist

  I just have a simple question for Dr Morgan in relation to her Archimedes article entitled "Should 0.9% saline be used for maintenance fluids in hospitalised children?"[1]. Is she telling me that the recommended maintenance sodium intake for a 10kg child who would normally be prescribed 1000 mls/day of fluid based on 100 mls/kg/day, is 150 mmol or 15 mmol/kg/day. This is far in excess of the recommended NaCl intake of 2g...

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  I just have a simple question for Dr Morgan in relation to her Archimedes article entitled "Should 0.9% saline be used for maintenance fluids in hospitalised children?"[1]. Is she telling me that the recommended maintenance sodium intake for a 10kg child who would normally be prescribed 1000 mls/day of fluid based on 100 mls/kg/day, is 150 mmol or 15 mmol/kg/day. This is far in excess of the recommended NaCl intake of 2g per day for a child aged 1-3 years which equates to 34 mmol/day [2]. I suggest that more thought should be given to the prescribing of maintenance fluids rather than blindly giving 0.9% saline. The recommendations to only give 0.9% saline are based on misunderstandings of salt and water handling and are just trying to cover up poor training in fluid and electrolyte prescribing. I would refer readers to a review written by Dr Malcolm Coulthard for this journal back in 2008 following a decision by the National Patient Safety Agency to recommend a switch in the standard paediatric intravenous maintenance fluid from 0.18% to 0.45% saline to prevent children from developing serious hyponatraemia.

  REFERENCES 1. Morgan JA. Should 0.9% saline be used for maintenance fluids in hospitalised children?" Arch Dis Child doi:10.1136/adc.2015.308821 2. NHS Choices. Salt: the facts. NHS Choices. Your Health, your choices. Available from http://www.nhs.uk/livewell/goodfood/pages/salt.aspx (accessed 22 May 2015) 3. Coulthard MG. Will changing maintenance intravenous fluid from 0.18% to 0.45% saline do more harm than good? Arch Dis Child 2008;93:335-340.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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