We read with interest the article by Armon et al who undertook a
cross-sectional study of 99 children to determine the types and volumes of
intravenous fluids given to children in hospital in the UK, estimate the
prevalence of abnormal serum sodium and potassium levels, and evaluate the
use of local clinical guidelines (1). In the methods of the article
authors wrote that ‘’Patients on neonatal intensive care units were
excluded.’ whereas in results of the article the authors wrote that
‘’ninety nine children were receiving intravenous fluids and were a median
age of 3.6 years (range 7 days to 16 years)’’. Then, this is a
contradiction.
There is a significant tubular nephropathy and/or glomerular dysfunction
in the children treated with chemotherapy (2). The alterations of the
water-electrolyte balance are among the commonest early complications of
treatment in children with acute lymphoblastic leukaemia. In their study,
Benitez et al found that hyponatraemia in 4 cases, hypokalemia in 9,
hypomagnesaemia in 9, hypocalcaemia in 11, hypophosphataemia in 9,
hypouricemia in 3 and hyperuricaemia in 3 others (3). However, in their
study, Armon et al included the patients receiving chemotherapy in 5%.
Hyponatremia and hypokalemia may be due to the other causes in those
patients without intravenous hypotonic solutions administration. On the
other hand, on admission the authors did not give patients’
sodium/potassium values, renal function, and different diagnosis.
However, at our department of pediatrics, we used to use ¼ SF (1:3
proportion; 1 part of Sodium chloride 0.9% plus 3 part of glucose 5%) for
patients with aged between 1 month and 1 year, 1/3 SF (1:2 proportion;1
part of Sodium chloride 0.9% plus 2 part of glucose 5%) for patients after
1 year old. We calculate a formulae for maintenance fluid therapy (1500
ml/m2/day) in children according to body surface calculation [(4xbody
weight (kg)+7]/[90+ body weight (kg)]. We have added 1.0-2.0 mEq/kg/24h of
potassium based on estimates of dietary requirements. However, we have not
experienced significantly hyponatremia and/or hypokalemia.
Neville at al. demonstrated in a prospective randomized study of IV fluid
solutions in children with gastroenteritis that isotonic saline protected
against the development of hyponatremia without causing hypernatremia,
when compared to hypotonic fluids. Isotonic solutions have been found to
be safe, as hyponatremic children retain sodium, while normonatremic
children excrete sodium appropriately (4).
In our opinion, electrolyte imbalances and thus morbidity are preventable
if IV fluid is tailored to the individual, and a physiologically based
fluid therapy approach is adopted. The safest empirical choice is
therefore an isotonic solution. Hypotonic solutions should only be
considered if the goal is to achieve a positive free-water balance. The
minimum volume of maintenance fluid required to maintain hemodynamics
should be infused. All patients receiving IV fluids should be monitored
closely with a minimum of daily weights, strict fluid balances,
biochemical and clinical parameters. Water and solute intake can thus be
adjusted accordingly. These parameters should be often routinely monitored
in the critically ill child.
References
1. Armon K, Riordan A, Playfor S, Millman G, Khader A; Paediatric Research
Society. Hyponatraemia and hypokalaemia during intravenous fluid
administration. Arch Dis Child. 2008;93(4):285-287.
2. Phillips RS, Tyerman K, Al-Kassim MI, Picton S. A systematic review of
the accuracy and utility of early markers of Ifosfamide-induced proximal
tubulopathy in survivors of childhood cancers. Pediatr Hematol Oncol.
2008;25(2):107-113.
3. Benítez H, Arreguín L, Velásquez L, Bernaldez R, Juan L, Farfán J, Díaz
S, Gaona A, Martínez MC. Electrolytic changes in children with acute
lymphoblastic leukemia during remission induction. Sangre (Barc).
1995;40(3):213-217.
4. Neville K, Verge C, O'Meara M, Walker J. High antidiuretic hormone
levels and hyponatremia in children with gastroenteritis. Pediatrics.
2005;116:1401-1407.
We read with interest the article by Armon et al who undertook a cross-sectional study of 99 children to determine the types and volumes of intravenous fluids given to children in hospital in the UK, estimate the prevalence of abnormal serum sodium and potassium levels, and evaluate the use of local clinical guidelines (1). In the methods of the article authors wrote that ‘’Patients on neonatal intensive care units were excluded.’ whereas in results of the article the authors wrote that ‘’ninety nine children were receiving intravenous fluids and were a median age of 3.6 years (range 7 days to 16 years)’’. Then, this is a contradiction. There is a significant tubular nephropathy and/or glomerular dysfunction in the children treated with chemotherapy (2). The alterations of the water-electrolyte balance are among the commonest early complications of treatment in children with acute lymphoblastic leukaemia. In their study, Benitez et al found that hyponatraemia in 4 cases, hypokalemia in 9, hypomagnesaemia in 9, hypocalcaemia in 11, hypophosphataemia in 9, hypouricemia in 3 and hyperuricaemia in 3 others (3). However, in their study, Armon et al included the patients receiving chemotherapy in 5%. Hyponatremia and hypokalemia may be due to the other causes in those patients without intravenous hypotonic solutions administration. On the other hand, on admission the authors did not give patients’ sodium/potassium values, renal function, and different diagnosis. However, at our department of pediatrics, we used to use ¼ SF (1:3 proportion; 1 part of Sodium chloride 0.9% plus 3 part of glucose 5%) for patients with aged between 1 month and 1 year, 1/3 SF (1:2 proportion;1 part of Sodium chloride 0.9% plus 2 part of glucose 5%) for patients after 1 year old. We calculate a formulae for maintenance fluid therapy (1500 ml/m2/day) in children according to body surface calculation [(4xbody weight (kg)+7]/[90+ body weight (kg)]. We have added 1.0-2.0 mEq/kg/24h of potassium based on estimates of dietary requirements. However, we have not experienced significantly hyponatremia and/or hypokalemia. Neville at al. demonstrated in a prospective randomized study of IV fluid solutions in children with gastroenteritis that isotonic saline protected against the development of hyponatremia without causing hypernatremia, when compared to hypotonic fluids. Isotonic solutions have been found to be safe, as hyponatremic children retain sodium, while normonatremic children excrete sodium appropriately (4). In our opinion, electrolyte imbalances and thus morbidity are preventable if IV fluid is tailored to the individual, and a physiologically based fluid therapy approach is adopted. The safest empirical choice is therefore an isotonic solution. Hypotonic solutions should only be considered if the goal is to achieve a positive free-water balance. The minimum volume of maintenance fluid required to maintain hemodynamics should be infused. All patients receiving IV fluids should be monitored closely with a minimum of daily weights, strict fluid balances, biochemical and clinical parameters. Water and solute intake can thus be adjusted accordingly. These parameters should be often routinely monitored in the critically ill child. References 1. Armon K, Riordan A, Playfor S, Millman G, Khader A; Paediatric Research Society. Hyponatraemia and hypokalaemia during intravenous fluid administration. Arch Dis Child. 2008;93(4):285-287. 2. Phillips RS, Tyerman K, Al-Kassim MI, Picton S. A systematic review of the accuracy and utility of early markers of Ifosfamide-induced proximal tubulopathy in survivors of childhood cancers. Pediatr Hematol Oncol. 2008;25(2):107-113. 3. Benítez H, Arreguín L, Velásquez L, Bernaldez R, Juan L, Farfán J, Díaz S, Gaona A, Martínez MC. Electrolytic changes in children with acute lymphoblastic leukemia during remission induction. Sangre (Barc). 1995;40(3):213-217. 4. Neville K, Verge C, O'Meara M, Walker J. High antidiuretic hormone levels and hyponatremia in children with gastroenteritis. Pediatrics. 2005;116:1401-1407.