The following information is for guidance only; the user is responsible for ensuring accuracy of the information below.

1. Maintenance Fluid Requirements - Holliday-Segar Method (4-2-1 Rule)

Weight	Daily Requirement	Hourly Rate
0–10 kg	100 mL/kg/day	4 mL/kg/hr
10–20 kg	1000 mL + 50 mL/kg over 10 kg	40 mL/hr + 2 mL/kg/hr
>20 kg	1500 mL + 20 mL/kg over 20 kg	60 mL/hr + 1 mL/kg/hr
Maximum	Usually not >2400 mL/day	100 mL/hr

Fluid Composition

Traditional:

• D5 0.45% NaCl + 20 mEq KCl/L
• D5 0.2% NaCl for neonates and young infants (risk of hypernatremia with higher Na)

Modern Recommendations:

• Isotonic fluids (e.g., D5 0.9% NaCl or D5 0.45% NaCl) are now recommended for most hospitalized children to reduce hyponatremia risk.

2. Fluid Deficit Replacement

Estimate dehydration based on clinical signs:

Severity	Weight Loss	Volume to Replace
Mild	3–5%	30–50 mL/kg
Moderate	6–9%	60–90 mL/kg
Severe	≥10%	≥100 mL/kg

General Approach

1. Initial bolus for moderate/severe dehydration or shock:

• 20 mL/kg of isotonic fluid (NS or LR) over 15–30 min
• Repeat as needed up to 60 mL/kg

2. Deficit replacement (after initial resuscitation):

• Administer over 24–48 hours
• Give 50% in first 8 hours, remainder over next 16–24 hours

3. Ongoing Losses

Loss Type	Replacement Strategy	Recommended Fluid
General	Replace mL-for-mL based on output	Match composition to loss
Gastric losses	Volume replacement	NS + KCl
Diarrhea	Volume replacement	D5 0.45% NaCl + KCl
CSF/Urine losses	Volume replacement	NS or similar isotonic fluid

4. Special Considerations

Condition	Special Management
Neonates (<1 month)	Immature kidneys, avoid excessive sodium or fluid overload
DKA	Use NS initially; no fluid bolus unless in shock; replace deficit slowly over 48 hours
Burns	Use Parkland formula (4 mL × kg × %TBSA) with half in first 8 hours
CNS pathologies/SIADH risk	Avoid hypotonic fluids; consider fluid restriction or hypertonic saline

5. Monitoring Parameters

Essential Monitoring

• Weight (daily)
• Strict input/output monitoring
• Urine output goal: >1 mL/kg/hr
• Serum electrolytes (Na, K, glucose, bicarbonate)
• Signs of overhydration: Edema, hypertension, pulmonary findings

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📚 References

1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823–832.
2. Moritz ML, Ayus JC. Maintenance intravenous fluids in acutely ill children: a paradigm shift. Pediatrics. 2003;111(2):227–230.
3. American Academy of Pediatrics. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018;142(6):e20183083.
4. Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM. Nelson Textbook of Pediatrics, 21st ed. Elsevier; 2020.
5. World Health Organization. Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses. 2nd ed. 2013.
   https://apps.who.int/iris/handle/10665/81170
6. International Society for Pediatric and Adolescent Diabetes (ISPAD). DKA Guidelines. ISPAD Clinical Practice Consensus Guidelines 2022.
   https://www.ispad.org/page/ISPADGuidelines2022
7. National Institute for Health and Care Excellence (NICE). Intravenous fluid therapy in children and young people in hospital (NG29). 2020.
   https://www.nice.org.uk/guidance/ng29
8. American Burn Association. Advanced Burn Life Support (ABLS) Provider Manual. 2020.

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