Efficacy and Safety of Isotonic and Hypotonic Intravenous Maintenance Fluids in Hospitalised Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

Norfarahin Hasim,Mimi Azliha Abu Bakar,Md Asiful Islam

doi:10.3390/children8090785

Norfarahin Hasim, Mimi Azliha Abu Bakar + Show 1 more

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https://doi.org/10.3390/children8090785

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Abstract

Hyponatraemia is a known complication in hospitalised children receiving maintenance intravenous fluid. Several studies have been published to investigate the efficacy and safety of intravenous fluids in children. However, there is still an ongoing debate regarding the ideal solution to be used in the paediatric population. Therefore, the aim of this meta-analysis was to investigate the safety and efficacy of administering isotonic versus hypotonic intravenous maintenance fluid in hospitalised children. An extensive search was undertaken on PubMed, Web of Science, Scopus, ScienceDirect, Google Scholar and Cochrane Library on 28 December 2020. Only randomised controlled trials (RCTs) were included. We used the random-effects model for all analyses. Risk ratio (RR) and mean difference with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. The quality of each study was assessed using the Joanna Briggs Institute critical appraisal tool for RCTs. This study is registered with PROSPERO (CRD42021229067). Twenty-two RCTs with a total of 3795 participants were included. The studies encompassed surgical and medical patients admitted to intensive care unit as well as to general wards. We found that hypotonic fluid significantly increases the risk of hyponatremia at both ≤24 h (RR 0.34; 95% CI: 0.26–0.43, p < 0.00001) and >24 h (RR 0.48; 95% CI: 0.36–0.64, p < 0.00001). Isotonic fluid increases the risk of hypernatraemia at ≤24 h (RR 2.15; 95% CI: 1.24–3.73, p = 0.006). The prevalence of hyponatraemia was also higher in the hypotonic group at both ≤24 h (5.7% vs. 23.3%) and >24 h (6.0% vs. 26.3%). There was no statistically significant difference in the risk of developing adverse outcomes between the two groups. Mean serum and urine sodium as well as serum osmolality/osmolarity was lower in the hypotonic group. Isotonic solution is protective against the development of hyponatraemia while hypotonic solution increases the risk of hyponatraemia.

Highlights

The practice of prescribing hypotonic solution as maintenance intravenous fluid (IVF)in children was made popular more than six decades ago following the recommendation proposed by Holliday and Segar in 1957 [1]
Moritz and Ayus [3], in their 2003 review, highlighted the dangers of prescribing hypotonic fluid in children. They reported over 50 deaths and significant undesirable neurological outcomes linked to hypotonic fluid; they proposed that an isotonic solution would be a better choice as maintenance IVF in children
The duration of fluid therapy and the timing of outcome measurements varied between studies, ranging from less than 8 h to seven days after the start of the maintenance IVF

Summary

Introduction

In children was made popular more than six decades ago following the recommendation proposed by Holliday and Segar in 1957 [1] Their recommendations were derived based on the caloric expenditure of healthy children as well as the electrolyte composition of human and cow’s milk [1]. These days, this equates to a 0.2% sodium chloride in a 5% dextrose solution [2], which is markedly hypotonic in comparison to plasma tonicity. Moritz and Ayus [3], in their 2003 review, highlighted the dangers of prescribing hypotonic fluid in children They reported over 50 deaths and significant undesirable neurological outcomes linked to hypotonic fluid; they proposed that an isotonic solution would be a better choice as maintenance IVF in children

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