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Editors: Sabella, Camille; Cunningham, Robert J.

Title: Cleveland Clinic Intensive Review of Pediatrics, The, 2nd Edition
Copyright 2006 Lippincott Williams & Wilkins
> Table of Contents > III - Pediatric Nephrology > 10 - Fluids and Electrolytes

10
Fluids and Electrolytes
Robert J. Cunningham III
The appropriate fluid and electrolyte therapy involves the understanding of a few basic principles that can be
applied systematically to calculate the requirements for an individual patient. The maintenance requirements for
water are based on the studies of the energy expenditures of hospitalized children performed by Holliday and Segar.
In these studies, the average energy expenditure was measured as a function of body weight. The requirement for
water was then calculated by assuming that the child was consuming 2 g of protein/kg per day. A second assumption
was that the products of protein metabolism were to be excreted in urine that was neither concentrated nor
dilutedthat is, urine with a specific gravity of 1.008 to 1.015. Given these two assumptions, the water requirement
is then 1 mL/calorie expended. A simplified graph of the data on energy expenditure described in the original work
of Holliday and Segar is shown in Fig. 10.1. By breaking the continuous line into three segments, it is possible to
approximate the daily fluid requirements. They are as follows:
n

100 mL/kg for the first 10 kg of body weight

50 mL/kg for the second 10 kg of body weight

20 mL/kg for each kg above 20 kg (at least until 80 kg is reached)

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Figure 10.1 Energy requirement as a function of body weight. This calculation allows an estimation of fluid
requirements and works out to 1 mL of fluid for each calorie expended. (Modified from Holliday MA, Segar WF.
The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:825.)

TABLE 10.1 MAINTENANCE ELECTROLYTE REQUIREMENTS

Easiest way to remember is 1 2 3

1.

mEq of potassium/kg/day

2.

mEq of sodium/kg/day

3.

mEq of chloride/kg/day

This is a simple method of estimating maintenance water requirements. The daily electrolyte requirements are
summarized in Table 10.1.
The fluid and electrolyte requirements of a 40-kg child are outlined in Tables 10.2 and 10.3. Note that in 0.2%
normal saline (NS) solution, the concentration of NaCl is 34 mEq/L, and if 20 mEq of KCl is added to each liter of
fluid, then a correct calculation of the water requirements automatically gives the correct complement of Na, K,
and Cl. This is why commercially available solutions contain 0.2% NSbecause they provide adequate concentrations
of electrolytes if the patient has no deficits and requires intravenous (IV) fluids to maintain homeostasis.
A situation that the pediatrician encounters more commonly is when the patient arrives with a history of
P.90
diarrhea and dehydration and requires not only maintenance IV fluids but also replenishment of a fluid and
electrolyte deficit that has resulted from vomiting and diarrhea. Physical findings that help in estimating the
severity of the deficit are shown in Fig. 10.2.

TABLE 10.2 MAINTENANCE CALCULATIONS FOR A 40-KG CHILD: FLUIDS

Water requirement

100 mL/kg/24 hour 10 kg = 1,000 mL

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plus

50 mL/kg/24 hour 10 kg = 500 mL

plus

20 mL/kg/24 hour 20 kg = 400 mL

Total water requirement = 1,900 mL

TABLE 10.3 MAINTENANCE CALCULATIONS FOR A 40-KG CHILD: ELECTROLYTES

Severity of deficit

K = 1 mEq/kg/24 hour 40 kg = 40 mEq

Na = 2 mEq/kg/24 hour 40 kg = 80 mEq

Cl = 3 mEq/kg/24 hour 40 kg = 120 mEq

Therefore, 2 L of 0.2% NS plus 20 mEq of KCl/L will approximate the requirements.

0.2% NaCl provides 34 mEq of Na/L.

Addition of 5% dextrose is recommended.

NS, normal saline.

Note that Fig. 10.2 gives an estimation of the percentage of dehydration. To translate this into how much fluid the
patient has lost, multiply the percentage loss with the body weight in kilograms. The result is the fluid deficit in
liters. For example, if you evaluate a 1-year-old child who appears dehydrated, and the best estimate from the
physical finding appears to be that he is 10% dehydrated and weighs 10 kg, then 0.10 (10%) 10 kg = 1 kg (or 1 L) of
fluid deficit. Remember, 1 L or 1,000 mL of water weighs 1 kg!
When a fluid prescription is calculated for an individual patient, the task should involve answering three questions:

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What is the deficit?

What is the maintenance fluid requirement?

What is the estimate of ongoing losses over the next 24 hours?

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If this approach is applied consistently, fluid and electrolyte calculations will cease to be perplexing and can become
routine. The major source of error when the approach is utilized is the estimation of ongoing losses. This is always a
guess, and although (it is hoped) a thoughtful one, like any projection into the future, it is subject to error.
Therefore, when a patient is treated with a fluid regimen and the response is not the expected one, always check to
determine if a source of continuing fluid loss is present that which you did not anticipate. Or conversely, did you
anticipate fluid losses that are not present?

Figure 10.2 Clinical signs as a function of the degree of dehydration. As pointed out in the text, these signs
depend on the intravascular and extracellular fluid volumes. BP, blood pressure.

In the review exercises, three cases are presented for which you are asked to estimate fluid deficits and calculate
replacement regimens.

SUGGESTED READINGS
Finberg L. Hypernatremic (hypertonic) dehydration in infants. N Engl J Med 1973;289:196.

Finberg L, Kravath R, Fleischman A. Water and electrolytes in pediatrics. Philadelphia, PA: WB Saunders, 1982.

Friedman AL. Pediatric hydration therapy: historical review and a new approach. Kidney Int 2005;67:380-388.

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Holliday MA, Segar WF. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:825.

Mathew OP, Jones AS, James E, et al. Neonatal renal failure: usefulness of diagnostic indices. Pediatrics
1980;65:57-60.

Roberts KB. Fluid and electrolytes: parenteral fluid therapy. Pediatr Rev 2001;22:380-386.

REVIEW EXERCISES
QUESTIONS
Case 1
A 1-year-old boy is brought to you with vomiting and diarrhea of 4 days duration. Initially, the mother gave him an
oral electrolyte maintenance solution (Pedialyte) every 3 to 4 hours, but for the last 24 hours the baby has been
vomiting all feeds. The mother does not know when he last urinated.
The infant appeared sleepy, and responded only disinterestedly when blood was drawn.
n

Temperature, 38C (100F); pulse, 142/minute; respiratory rate, 32/minute; weight, 10 kg.

Skin turgor was decreased with obvious tenting. Nail beds were pink with prompt capillary refill. Orbits were
squishy.

1. The estimated degree of dehydration is:

a) 3.5%
b) 5%
c) 10%
d) 15%
View Answer
2. Calculate the fluid requirements for the next 24 hours assuming his diarrhea persists and he loses an
additional 400 mL of fluids during the next 24 hours.
a) 1,200 mL
b) 1,600 mL
P.91
c) 2,100 mL
d) 2,400 mL
View Answer
3. Which of the following would represent the best choice for the initial fluid orders?
a) D5W (5% dextrose in water)/0.2% NS to run at 100 mL/hour. Add 20 mEq of KCl/L after urination.
b) D5W/0.45% NS to run at 150 mL/hour for the next 8 hours. Add 20 mEq of KCl/L after urination.

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c) D5W/0.45% NS to run at 150 mL/hour for the next 8 hours.

d) 9% NS to run at 150 mL/hour for the next 8 hours.
View Answer
4. Which of the following is most helpful in assessing the adequacy of the therapy?
a) Normalization of electrolytes
b) Patient's level of alertness, skin turgor, pulse rate, and blood urea nitrogen (BUN)
c) Presence of diarrhea, resumption of urine output, and decrease in irritability
d) Normal creatinine clearance, decrease in the white blood cell count and hemoglobin levels to normal
values, which were increased secondary to hemoconcentration
View Answer

Case 2
An 8-month-old infant is brought to the emergency department with a history of fever, diarrhea for 96 hours, and
vomiting for the past 24 hours. Beginning 4 days ago, fever and profuse diarrhea developed. He was switched to an
oral electrolyte maintenance solution (Pedialyte) but was getting no nutrition, so he was given boiled skim milk for
the next 48 hours. Yesterday, he became irritable and began vomiting all feeds.
The physical examination reveals a very irritable infant with a high-pitched scream when disturbed. Temperature,
38C (100F); pulse, 130/minute; blood pressure, 80/45 mm Hg. His fontanelle is flat but not sunken, his eyeballs
feel normal, and his skin has an odd silly putty or doughy feel.
5. The estimated degree of dehydration is:
a) 3.5%
b) 5%
c) 10%
d) 15%
View Answer
6. What would you predict the serum sodium to be in this patient at presentation?
a) 125 mEq/L
b) 135 mEq/L
c) 145 mEq/L
d) 155 mEq/L
The following electrolyte values were obtained:
l

Na = 156 mEq/L

K = 5.4 mEq/L

Cl = 123 mEq/L

HCO3 = 17 mEq/L

BUN = 36 mg/dL

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Creatinine = 1.2 mg/dL

Glucose = 126 mg/dL

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Calculate the serum osmolarity.

The formula for calculating the serum osmolarity is shown below along with the calculations for this
patient.
l

(2 [Na]) + 10 + ([BUN]/3) + ([Glucose]/18)

(2 156) + 10 + (36/3) + (126/18) = 341mOsm/L

In most cases, a reasonable estimate of osmolarity can be obtained by multiplying the value for the serum
sodium with 2 and adding 10. The glucose and BUN do not add much to the calculation when the levels are
in the normal range. Obviously, if one or the other is elevated, then it may make a significant contribution
to the serum osmolarity.

View Answer
7. Calculate the fluid requirements for the next 24 hours, assuming another 400 mL of diarrhea.
a) 2,000 mL
b) 2,400 mL
c) 3,000 mL
d) 3,500 mL
View Answer
8. What is the optimal fluid regimen?
a) D5W/0.45% NS to run at 150 mL/hour for 8 hours and at 100 mL/hour for the next 16 hours. Add 20 mEq of
KCl/L after patient urinates.
b) D5W/0.9% NS plus 20 mEq of KCl/L to run at 150 mL/hour for 8 hours and at 75 mL/hour thereafter.
c) D5W/0.3% NS plus 20 mEq of KCl/L to run at 70 mL/hour for 48 hours.
d) Run fluids as outlined in choice b and introduce oral feeds ad libitum at 24 hours.
After the first 18 hours of therapy, the following electrolyte values were obtained:
l

Na = 152 mEq/L

K = 5.4 mEq/L

Cl = 115 mEq/L

HCO3 = 22 mEq/L

BUN = 27 mg/dL

Creatinine = 0.8 mg/dL

Glucose = 378 mg/dL

View Answer
9. Your next step in the treatment should be:
a) Give 1 U of regular insulin/kg subcutaneously.

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b) Give 0.1 U/kg every hour IV until the blood sugar level is <200 mg/dL.
c) Remove dextrose from the IV fluids.
d) Continue current treatment and give insulin only if the blood sugar level is >500 mg/dL.
After 30 hours of treatment, the following electrolyte values were obtained:
l

Na = 148 mEq/L

K = 5.4 mEq/L

Cl = 112 mEq/L

HCO3 = 25 mEq/L

BUN = 23 mg/dL

Creatinine = 0.7 mg/dL

Glucose = 150 mg/dL

P.92

View Answer
10. Fifteen minutes later, the patient has a seizure. The most likely cause is:
a) Hypocalcemia
b) Hypoglycemia
c) Pyridoxine deficiency
d) Intracranial hemorrhage
View Answer

Summary of Hypernatremic Dehydration

Hypernatremic dehydration occurs when hypotonic fluid is lost (e.g., diarrhea) and replaced with a hypertonic fluid.
A source of hypertonic fluid can nearly always be identified, and boiled skim milk is an old, grandmother's remedy.
When hypertonic dehydration is suspected, initiate fluid resuscitation slowly, obtain the electrolyte determinations
as quickly as possible, and if the serum sodium is high, tailor the fluid resuscitation scheme over 48 hours. Watch for
both hyperglycemia and hypocalcemia. The critical variable is the time taken to correct the deficit, not the type of
fluids that you choose to administer. If you correct too quickly with a more hypertonic fluid (e.g., 0.9% NS), the
kidneys will excrete the additional sodium and conserve water, and the correction of the serum osmolarity will
proceed at nearly the same rate as if you had corrected with pure water. The only way to limit the rate of fall of the
serum sodium is to change the time frame over which you are making the correction.

Case 3
A 10-year-old developmentally delayed white girl was well until 4 days before admission, when she developed lowgrade fever. Because she did not appear to be very ill, these symptoms were treated only with aspirin. Her oral
intake of fluids was well maintained until 2 days before admission, when it decreased significantly, and she
subsequently began to refuse fluids. On the day before admission, her intake remained poor, and she passed green,
watery stools. Approximately 12 hours before admission, her temperature spiked to 41C (105F), and an
erythematous rash erupted on her face, trunk, and upper extremities. Close questioning revealed that she had
apparently not voided in the last 2 days.
Physical examination revealed a semicomatose child with a generalized rash. Her weight was 44 kg (surface area,

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1.15 m2); blood pressure, 70/50 supine and 50/0 sitting; pulse, 200/minute; respirations, 32/minute. Her mucous
membranes were parched, and her peripheral extremities were cold and moderately cyanotic. She had a whitish
tonsillar exudate and a beefy red tongue.
11. The estimated degree of dehydration is:
a) 3.5%
b) 5%
c) 10%
d) 15%
View Answer
12. The first step in therapy should be which of the following?
a) D5W/0.45% NS to run at 490 mL/hour for 8 hours.
b) D5W/0.45% NS plus 20 mEq of KCl/L to run at 490 mL/hour.
c) 0.9% NS, 900 mL to run over 20 minutes followed by D5W/0.45% NS plus 20 mEq of KCl to run at 500
mL/hour.
d) 0.9% NS, 900 mL to run over 30 minutes followed by D5W/0.45% NS to run at 500 mL/hour. Add 20 mEq of
KCl/L when the patient has urinated twice.
e) 0.9% NS, 900 mL to run over 20 minutes followed by D5W/0.45% NS to run at a rate of 200 mL/hour for 24
hours. Add 20 mEq of KCl/L when the patient has urinated twice.
After you have initiated therapy, the following laboratory values that were sent stat are given to you:
l

Na = 145 mEq/L

K = 3.3 mEq/L

Cl = 110 mEq/L

HCO3 = 10 mEq/L

BUN = 96 mg/dL

Creatinine = 6.7 mg/dL

Hemoglobin = 15.8 g/dL

Hematocrit = 50%

View Answer
13. Your next step is to:
a) Decrease the rate of fluid administration to insensible loss, remove KCl from the IV fluids, and give 1 mEq
of NaHCO3/kg.
b) Obtain a urinalysis and a urine specimen for measurement of the sodium and creatinine.
c) Decrease the IV fluid rate to two thirds of maintenance and correct the acidosis with a solution of
D5W/0.33% NS plus 50 mEq of NaHCO3/L.
d) Order renal ultrasonography and a urine culture and continue current IV administration of fluids. Urinalysis
shows the following values:

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Specific gravity = 1.027

Protein = 1+

Ketones = 3+

pH = 5.0

Na = 4 mEq/L

Creatinine = 450 mg/L

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View Answer
14. The data are most consistent with which of the following:
a) Chronic renal failure
b) Acute renal failure
P.93
c) Glomerulonephritis
d) Acute dehydration
View Answer

ANSWERS AND EXPLANATIONS

1. c.
My estimation of the degree of dehydration is 10%. The skin turgor is decreased with obvious tenting, which suggests
5% to 10% dehydration. The patient is listless and responds only when blood is drawn; this also suggests a level of
dehydration of approximately 10%. The fact that capillary refill is present and no comment is made that the
extremities are cold or that the pulse is not higher or thready, goes against 15% dehydration.
2. d.
My calculations are shown below:
l

Deficit: 10 kg 10% = 1 kg = 1,000 mL*

Maintenance: 10 kg 100 mL/kg = 1,000 mL

Losses ongoing (an estimate) = 400 mL

Total = 2,400 mL

3. b.
A good general approach is to replenish half of the estimated need for 24 hours in the first 8 hours. This helps to
eliminate the deficit more quickly. One choice that was not given and would be a very reasonable one would be to
restore the circulating blood volume quickly by first giving a bolus of 0.9% NS at 20 mL/kg over 20 minutes or as
quickly as the IV line will run. At levels of dehydration that compromise circulating blood volume, the first goal is to
normalize the intravascular volume and then proceed with normal fluid resuscitation. I do not include the bolus fluid
in my calculations and would give fluids as described in choice b following the 0.9% NS.
4. b.
The best way to assess fluid balance is by repeatedly examining the patient. Laboratory values are of little benefit in
the ongoing evaluation of fluid therapy.

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The second case is a slight variation of the first one, but with important implications for fluid therapy.
5. c.
6. d.
Although this patient does not appear as volumecontracted as the first one, there is a critical difference between
them. The second patient was given boiled skim milk as a fluid replacement solution. Boiling the milk removes the
water and thereby makes it soluterich. It is being used to replace losses secondary to diarrhea, in which the losses
are more water than solute. Because a low-solute loss is being replaced with a very high-solute solution, the patient
is at high risk for hypernatremia. Patients with hypertonic dehydration do not present the same clinical picture as
those with the more routine forms of dehydration that we are accustomed to evaluating. If you look at Fig. 10.2, the
signs of dehydration are the result of intravascular and extracellular fluid contraction. If we administer hypertonic
solutions into the extracellular space, the solute serves to draw fluid from the intracellular space to the
intravascular and extracellular compartments. Hence, the dehydration in hypertonic states is an intracellular
phenomenon, and the extracellular fluid volume is reasonably maintained. The hints that this patient was
hypertonic, aside from the history of being given boiled skim milk, are the high-pitched scream and extreme
irritability. The other characteristic is the silly putty or doughy feel to the skin, a characteristic of patients with
hypertonic dehydration. These clues should alert you to the fact that the patient may be hypertonic and therefore
more dehydrated than he first appears.
7. b.
The answer, as in the first case, is 2,400 mL. The percentage of dehydration, maintenance fluid requirement, and
ongoing losses are all identical to those of the first patient.
8. c.
This is where the second case differs significantly from the first. The method used to derive this answer was to
calculate the maintenance for the second 24 hours (1,000 mL), add it to the requirements for the first 24 hours
(2,400 mL), and divide the resultant sum by 48 hours so that the dehydration would be corrected slowly. Why should
we tarry with this one? The reason is that hypernatremia has developed in the patient during a period of 4 days, and
the normal response of the brain is to generate idiogenic osmoles from amino acids (lysine). This response serves
to keep the intracranial osmolarity identical to that of the serum, so that as the dehydration progresses, the brain
cells are protected from severe dehydration. Only a vascular barrier is present between the circulating blood and the
brain cells. If idiogenic osmoles were not formed, intracellular dehydration of the brain cells would be severe and
life-threatening. It takes 48 hours for these osmoles to develop, and it also takes time for them to be metabolized as
the osmolarity returns to normal. If fluids were administered quickly, the serum osmolarity would drop suddenly, a
net movement of water from the circulation into the brain would occur, and the result would be the development of
cerebral edema, seizures, and possibly death. Hence, in patients who are severely hypernatremic, correction should
proceed at a rate slow enough to give the brain cells time to metabolize the idiogenic osmoles. In this way, sudden
intracranial shifts of fluid are prevented!
P.94
Please note that the preceding discussion refers to patients in whom hypernatremia develops during days, not hours.
In a patient who has diabetes insipidus and in whom the serum sodium level rises from 140 mEq/L in the morning to
168 mEq/L in the evening, the sodium level may be corrected quickly; idiogenic osmoles have not developed because
the process takes time. A good general rule for the correction of hypernatremia or hyponatremia is not to attempt to
correct the abnormalities at a rate different from the rate at which the abnormalities were established.
9. c.
The best answer is to remove dextrose from the IV solutions. Again, a sudden drop in osmolarity is to be avoided;
therefore, the blood glucose should not drop suddenly either. Hyperglycemia is a frequent complication of
hypernatremic dehydration, and blood glucose levels should be followed up carefully.
10. a.

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The answer is hypocalcemia. This, too, is a complication of hypernatremic dehydration. Serum calcium
determinations should be followed up closely and calcium supplements given if hypocalcemia is developing.
11. d.
This patient is 15% dehydrated and in shock. Her blood pressure is down to 70/50 mm Hg, her pulse is 200/minute,
and she has poorly perfused extremities, evidenced by the fact that they are both cold and cyanotic.
12. d.
The infusion of 0.9% NS may have to be repeated more than once to re-establish the circulating vascular volume. You
would want to see improved perfusion, and evidence of this would be an increase in the blood pressure, a lower
pulse rate, and warmer extremities. A rate of 500 mL/hour seems high, but as shown from the calculations below, it
will replace approximately half of the deficit in 8 hours.
Approach to the fluid calculations:
l

Deficit (0.15 44 kg) = 6,600 mL

Maintenance = 1,980 mL/day = 8,580 mL/24 hour

Assuming no ongoing losses,

If intravascular volume is depleted, give 20 mL of 0.9% NS/kg over 20 minutes.
In most cases, you should calculate the total fluids for 1 day, then give half of the total in the first 8 hours.
13. b.
Do not assume a patient is in renal failure until hydration is normal and evidence of renal insufficiency is still
present. Volume contraction and severe dehydration can cause severe laboratory abnormalities. Choices a and c both
assume that this patient is in renal failure, and even if this proves to be the case, she needs adequate circulating
volume. She should be back to a normal state of hydration before the IV fluid administration is decreased. Choice d
is less likely than choice b to help you determine whether this patient is in acute renal failure.
14. d.
The fractional excretion of sodium is less than 1%, which indicates that the renal tubules are continuing to conserve
sodium, and therefore volume, in the face of dehydration. This is the desired response. Were the urine sodium
elevated, it would mean that the kidneys were no longer capable of conserving sodium, and this would be a
consequence of tubular damage. In general, when you see a urine sodium level of less than 10 mEq/L, you can
assume that the kidneys are conserving sodium well.
The method of calculating the fractional excretion of sodium is as follows:
l

FENa = ([UNa PCr]/[UCr PNa]) 100 = ([4 mEq/L 6.7 mg/dL]/[450 mg/dL 145mEq/L]) 100 = 0.0004 100 =
0.04%

Fractional excretion of sodium (FENa) below 1% indicates dehydration.

FENa above 1% indicates acute renal insufficiency.

Comment: The preceding scenario is a real one, and I chose it to demonstrate that even if a patient has severe
abnormalities and a very high creatinine level, this approach must be followed. The patient in this example received
8 L of IV fluids over 24 hours, and her serum creatinine was 1.2 mg/dL with a BUN of 35 mg/dL on the day after the
IV fluids had been administered. And yes, she did have streptococcal pharyngitis! Her pharynx was very inflamed,
and the pain was sufficiently intense that she did not take in any oral fluids for 2 to 3 days before she was seen. She
was given penicillin for this condition in addition to the IV hydration.

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