ORIGINAL ARTICLE

Hypotonic versus isotonic saline in hospitalised children: a systematic review

K Choong¹, M E Kho², K Menon³, D Bohn⁴

¹ Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
² Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
³ Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Canada
⁴ Department of Critical Care Medicine, The Hospital for Sick Children, Toronto and The Departments of Anaesthesia and Paediatrics, University of Toronto, Canada

Correspondence to:
Dr K Choong
Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada; choongk{at}mcmaster.ca

Background: The traditional recommendations which suggest that hypotonic intravenous (IV) maintenance fluids are the solutions of choice in paediatric patients have not been rigorously tested in clinical trials, and may not be appropriate for all children.

Aims: To systematically review the evidence from studies evaluating the safety of administering hypotonic versus isotonic IV maintenance fluids in hospitalised children.

Methods: Data sources: Medline (1966–2006), Embase (1980–2006), the Cochrane Library, abstract proceedings, personal files, and reference lists. Studies that compared hypotonic to isotonic maintenance solutions in children were selected. Case reports and studies in neonates or patients with a pre-existing history of hyponatraemia were excluded.

Results: Six studies met the selection criteria. A meta-analysis combining these studies showed that hypotonic solutions significantly increased the risk of developing acute hyponatraemia (OR 17.22; 95% CI 8.67 to 34.2), and resulted in greater patient morbidity.

Conclusions: The current practice of prescribing IV maintenance fluids in children is based on limited clinical experimental evidence from poorly and differently designed studies, where bias could possibly raise doubt about the results. They do not provide evidence for optimal fluid and electrolyte homoeostasis in hospitalised children. This systematic review indicates potential harm with hypotonic solutions in children, which can be anticipated and avoided with isotonic solutions. No single fluid rate or composition is ideal for all children. However, isotonic or near-isotonic solutions may be more physiological, and therefore a safer choice in the acute phase of illness and perioperative period.

Abbreviations: CI, confidence interval; ECF, extracellular fluid; IV, intravenous; PNa, plasma sodium; RCT, randomised controlled trial; WMD, weighted mean difference

Keywords: intravenous fluids; hypotonic; isotonic; hyponatraemia

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