How new IV maintenance fluid recommendations change decades of practice

­The American Academy of Pediatrics (AAP) Subcommittee on Fluid and Electrolyte Therapy issued a new guideline on intravenous (IV) maintenance fluid therapy last year that was a departure from 6 decades of practice. The rationale behind those changes was discussed in depth at the 2019 AAP National Conference in New Orleans, Louisiana, at a session presented on October 27, 2019  and repeated on October 28, 2019.

Leonard Feld, MD, PhD, MMM, CPE, FAAP, clinical professor of pediatrics at the Herbert Wertheim College of Medicine at Florida International University in Miami and chair of the AAP subcommittee, led a session titled, “Water and Salt: New AAP Clinical Practice Guideline for the Maintenance of Intravenous Fluids in Children,” to discuss the 2018 “Clinical Practice Guideline: Maintenance Intravenous Fluids in Children.”

The clinical practice guideline was published in Pediatrics in December 2018, and the recommendation was for patients aged 28 days to 18 years in need of maintenance IV fluids to receive isotonic solutions with appropriate potassium chloride and dextrose. This recommendation has the potential to significantly reduce the risk of developing hyponatremia, according to the guideline. This is a change from 60 years of practice in favor of hypotonic fluids in these populations.

“Our objective, as stated in the article, was to provide an evidence-based approach for patients who are hospitalized and in need of IV maintenance fluids,” Feld says. “This was a very methodical approach to arrive at the recommendation, and I think it’s important to point out the guideline does not address deficit fluid therapy, or the rate at which fluids need to be delivered. We are not proposing the amount of potassium or the potassium concentration in IV fluids. We are not addressing treatments for various electrolyte abnormalities. We are also not recommending how frequently biochemical monitoring is performed.”

The recommendation was based on randomized clinical trials and took into account study biases. Feld says the recommendation is important, but recognizes the limitations of the guidance. “The recommendation to use the isotonic fluids for maintenance therapy does not mean there are no indications for administering hypotonic fluids, or that isotonic fluids will be safe in all children,” he says, noting that clinical decision-making is key in all cases. “We need to emphasize that it doesn’t apply to all children such as those with high-risk disorders such as congenital heart disease, cancer, etc...”

The committee was made up a vast spectrum of specialties, Feld says, including nephrologists, epidemiologists, hospital medicine physicians, critical care physicians, surgeons, anesthesiologists, family medicine physicians, and emergency physicians.

“Each clinician has to appropriately assess the child to decide if they need maintenance IV fluids, or if they have conditions or disease states where other fluids choices may be appropriate,” he says, adding that consultations with other specialties may be a part of the decision-making process.

Feld says he welcomed discussion about the guideline at the conference.

“This is not the end, but it opens further discussion for a continued investigation,” Feld says. “I think any guideline you publish should have a meaningful discussion. It helps achieve the understanding of how the decision was reached.”