Skip to main content
SpringerLink
Log in

Isotonic versus hypotonic saline solution for maintenance intravenous fluid therapy in children: a systematic review

  • Original Article
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Background

The administration of hypotonic saline solution for maintenance intravenous fluid (IVF) therapy has been the standard of care, but recent evidence has shown this treatment to be associated with hyponatremia-related complications. The aim of this systematic review was to determine which IVF, i.e., a hypotonic or an isotonic saline solution, poses less risk for the development of hyponatremia among hospitalized children who require maintenance IVF therapy.

Methods

Medline, Cochrane Library, LILACS, Current Controlled Trials, reference lists, and abstract proceedings were searched for randomized controlled trials (RCTs) comparing hypotonic and isotonic saline solutions for maintenance IVF therapy in hospitalized children. Two reviewers independently assessed all potentially relevant studies and subsequently extracted data and evaluated the methodological quality of the RCTs. Studies were then combined and analyzed using a random effects model.

Results

Eleven RCTs met the inclusion criteria. Our analysis of these 11 RCTs showed that among hospitalized children receiving maintenance IVF therapy, isotonic solutions significantly decreased the risk of developing hyponatremia [relative risk (RR) 0.50, 95 % confidence interval (CI) 0.40–0.62] without significantly increasing the risk for hypernatremia (RR 0.83, 95 % CI 0.41–1.67).

Conclusions

Current evidence does not support the standard practice of prescribing a hypotonic saline solution as maintenance IVF therapy to hospitalized children. Although there is no single IVF composition ideal for all children, an isotonic saline solution does appear to be the safer choice when maintenance IVF therapy is used in the general pediatric population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Moritz ML, Ayus JC (2011) Intravenous fluid management for the acutely ill child. Curr Opin Pediatr 23:186–193

    Article  CAS  PubMed  Google Scholar 

  2. Easley D, Tillman E (2013) Hospital-acquired hyponatremia in pediatric patients: a review of the literature. J Pediatr Pharmacol Ther 18:105–111

    PubMed Central  PubMed  Google Scholar 

  3. Moritz ML, Ayus JC (2005) Preventing neurological complications from dysnatremias in children. Pediatr Nephrol 20:1687–1700

    Article  PubMed  Google Scholar 

  4. Holliday MA, Segar WE (1957) The maintenance need for water in parenteral fluid therapy. Pediatrics 19:823–832

    CAS  PubMed  Google Scholar 

  5. Moritz ML, Ayus JC (2007) Hospital-acquired hyponatremia—why are hypotonic parenteral fluids still being used? Nat Clin Pract Nephrol 3:374–382

    Article  CAS  PubMed  Google Scholar 

  6. Freeman MA, Ayus JC, Moritz ML (2012) Maintenance intravenous fluid prescribing practices among pediatric residents. Acta Paediatr 101:465–468

    Article  Google Scholar 

  7. Choong K, Kho EM, Menon K, Bohn D (2006) Hypotonic versus isotonic saline in hospitalised children: a systematic review. Arch Dis Child 91:828–835

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  8. Beck CE (2007) Hypotonic versus isotonic maintenance intravenous fluid therapy in hospitalized children: a systematic review. Clin Pediatr 46:764–770

    Article  Google Scholar 

  9. Alves JTL, Troster EJ, de Oliveira CAC (2011) Isotonic saline solution as maintenance intravenous fluid therapy to prevent acquired hyponatremia in hospitalized children. J Pediatr (Rio J) 87:478–486

    Article  Google Scholar 

  10. Wang J, Xu E, Xiao Y (2014) Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis. Pediatrics 133:105–113

    Article  PubMed  Google Scholar 

  11. Foster BA, Tom D, Hill V (2014) Hypotonic versus isotonic fluids in hospitalized children: a systematic review and meta-analysis. J Pediatr 165:163–169

    Article  PubMed  Google Scholar 

  12. Choong K, Bohn D (2007) Maintenance parenteral fluids in the critically ill child. J Pediatr (Rio J) 83:S3–S10

    Article  Google Scholar 

  13. Higgins J, Green S, eds (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0. Available at: www.cochrane-handbook.org. Accessed March 2013

  14. Choong K, Arora S, Cheng J, Farrokhyar F, Reddy D, Thabane L, Walton JM (2011) Hypotonic versus isotonic maintenance fluids after surgery for children: a randomized controlled trial. Pediatrics 128:857–866

    Article  PubMed  Google Scholar 

  15. Neville KA, Sanderman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL (2010) Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomized study of fluid type versus fluid rate. J Pediatr 156:313–319

    Article  CAS  PubMed  Google Scholar 

  16. Coulthard MG, Long DA, Ullman AJ, Ware RS (2012) A randomised controlled trial of Hartmann’s solution versus half normal saline in postoperative paediatric spinal instrumentation and craniotomy patients. Arch Dis Child 97:491–496

    Article  PubMed  Google Scholar 

  17. Brazel PW, McPhee IB (1996) Inappropriate secretion of antidiuretic hormone in postoperative scoliosis patients: the role of fluid management. Spine 21:724–727

    Article  CAS  PubMed  Google Scholar 

  18. Montañana PA, Alapont M, Ocon AP, Lopez PO, Prats JL, Parreño JT (2008) The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: A randomized, controlled open study. Pediatr Crit Care Med 9:589–597

    Article  PubMed  Google Scholar 

  19. Kannan L, Lodha R, Vivekanandhan S, Bagga A, Kabra S, Kabra M (2010) Intravenous fluid regimen and hyponatremia among children: a randomized controlled trial. Pediatr Nephrol 25:2303–2309

    Article  PubMed  Google Scholar 

  20. Baron FA, Meregalli CN, Rombola VA, Bolasell C, Pigliapoco VE, Bartoletti SE, Debaisi GE (2013) Hypotonic versus isotonic intravenous maintenance fluids in critically ill pediatric patients: a randomized clinical trial. Arch Argent Pediatr 111:281–287

    Google Scholar 

  21. Saba TG, Fairbairn J, Houghton F, Laforte D, Foster BJ (2011) A randomized controlled trial of isotonic versus hypotonic maintenance intravenous fluids in hospitalized children. BMC Pediatr 11:82

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  22. Yung M, Keeley S (2009) Randomised controlled trial of intravenous maintenance fluids. J Paediatr Child Health 45:9–14

    Article  PubMed  Google Scholar 

  23. Rey C, Los-Arcos M, Hernandez A, Sanchez A, Diaz J, Lopez-Herce J (2011) Hypotonic versus isotonic maintenance fluids in critically ill children: a multicenter prospective randomized study. Acta Paediatr 100:1138–1143

    Article  PubMed  Google Scholar 

  24. Ang VD, Anacleto FE, Mantaring JB (2010) Effect of isotonic versus hypotonic parenteral fluids on the serum sodium levels of children admitted to a tertiary hospital: An open, randomized, controlled trial (A preliminary study). Pediatr Nephrol 25:9

    Google Scholar 

  25. Roberts KB (2001) Fluid and electrolytes: parenteral fluid therapy. Pediatr Rev 22:380–387

    CAS  PubMed  Google Scholar 

  26. Dagli G, Orhan ME, Kurt E (1997) The effects of different hydration fluids used in pediatric anesthesia on blood glucose, electrolytes, and cardiovascular stability. GATA Bulteni 39:146–152

    Google Scholar 

  27. Neville KA, Verge CF, Rosenberg AR, O’Meara MW, Walker JL (2006) Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study. Arch Dis Child 91:226–232

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  28. Moritz ML, Ayus JC (2010) New aspects in the pathogenesis, prevention and treatment of hyponatremic encephalopathy in children. Pediatr Nephrol 25:1225–1238

    Article  PubMed Central  PubMed  Google Scholar 

  29. Holliday MA (2005) Isotonic saline expands extracellular fluid and is inappropriate for maintenance therapy. Pediatrics 115:93

    Google Scholar 

  30. Hatherhill M (2014) Rubbing salt in the wound: the case against isotonic parenteral maintenance solution. Arch Dis Child 89:414–418

    Article  Google Scholar 

  31. Steele A, Gowrishankar M, Abrahamson S, Mazer CD, Feldman RD, Halperin ML (1997) Postoperative hyponatremia despite near isotonic saline infusion: a phenomenon of desalination. Ann Intern Med 126:20–25

    Article  CAS  PubMed  Google Scholar 

  32. Eulmesekian PG, Perez A, Minces PG, Bohn D (2010) Hospital-acquired hyponatremia in postoperative pediatric patients: prospective observational study. Pediatr Crit Care Med 11:479–483

    PubMed  Google Scholar 

  33. Taylor D, Durward A (2004) Pouring salt on troubled waters. Arch Dis Child 89:411–414

    Article  PubMed Central  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

We would like to thank Prof. Cynthia P. Cordero (Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila), for her assistance in doing the meta-analysis.

Author information

Authors and Affiliations

  1. Department of Pediatrics, University of the Philippines Manila–Philippine General Hospital, Manila, Philippines

    April P. Padua, Josep Ryan G. Macaraya, Leonila F. Dans & Francisco E. Anacleto Jr.

Authors
  1. April P. Padua
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Josep Ryan G. Macaraya
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Leonila F. Dans
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Francisco E. Anacleto Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to April P. Padua.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Padua, A.P., Macaraya, J.R.G., Dans, L.F. et al. Isotonic versus hypotonic saline solution for maintenance intravenous fluid therapy in children: a systematic review. Pediatr Nephrol 30, 1163–1172 (2015). https://doi.org/10.1007/s00467-014-3033-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-014-3033-y

Keywords

Search

Navigation