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ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 1  |  Page : 16-18

Study of the serum sodium changes in children between 3 months and 5 years age receiving isotonic maintenance intravenous fluids


Department of Paediatrics, Father Muller Medical College and Hospital, Mangaluru, Karnataka, India

Date of Web Publication24-Jan-2018

Correspondence Address:
Dr. M D Jaidev
Department of Paediatrics, Father Muller Medical College and Hospital, Mangaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_53_17

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  Abstract 

Background: Isotonic fluid is now the accepted standard of practice as maintenance intravenous fluids. The use of hypotonic fluids has been associated with electrolyte imbalance which could potentially lead to morbidity and mortality. The aim of this prospective study was to assess whether the use of isotonic fluids causes significant changes in the serum sodium concentration and is associated with any related complications in the age group between 3 months and 5 years. Methods: Serum sodium was measured at 0, 12, 24, and 48 h of commencement of isotonic intravenous fluids. Results were analyzed separately for groups between 3–12 months and 13–60 months. Results: All the children in the study group had sodium levels within normal range before the commencement of intravenous fluids. There was no significant change in the mean sodium levels at 12, 24, and 48 h of commencement of intravenous fluids in the age groups between 3–12 months and 13–60 months. There were no complications noted with the use of isotonic intravenous fluids. Conclusion: Use of isotonic intravenous fluids in the age group between 3 months and 5 years is not associated with significant changes in the serum sodium concentrations or adverse events. Hence, isotonic intravenous fluid can be used safely for maintaining hydration in children.

Keywords: Electrolyte imbalance, hypotonic fluids, isotonic fluids, serum sodium


How to cite this article:
Maddukuri ES, Jaidev M D, Castelino DN, Khan HU, Hegde P. Study of the serum sodium changes in children between 3 months and 5 years age receiving isotonic maintenance intravenous fluids. Muller J Med Sci Res 2018;9:16-8

How to cite this URL:
Maddukuri ES, Jaidev M D, Castelino DN, Khan HU, Hegde P. Study of the serum sodium changes in children between 3 months and 5 years age receiving isotonic maintenance intravenous fluids. Muller J Med Sci Res [serial online] 2018 [cited 2018 Apr 21];9:16-8. Available from: http://www.mjmsr.net/text.asp?2018/9/1/16/223918


  Introduction Top


Fluid and electrolyte homeostasis plays an important role in the management of sick children. Hospitalized children are prone to have elevated antidiuretic hormone secretion.[1],[2] Use of hypotonic solution as maintenance intravenous fluids in such a scenario may result in electrolyte imbalance that could potentially lead to irreversible consequences including death. Randomized trials of intravenous fluid have suggested that the use of an isotonic fluid with a similar sodium concentration to plasma might reduce the risk of hyponatremia. Hence, the need for maintenance fluids to be isotonic.[3],[4] There is much hesitancy to use isotonic intravenous fluids among practitioners in children (especially below 5 years of age) possibly due to the concern about electrolyte imbalance (like hypernatremia) and associated complications because of scarcity of evidence. This prospective study was commenced to assess the impact of isotonic intravenous maintenance fluids on sodium homeostasis.


  Methods Top


This prospective observational study was done in a tertiary care hospital in children between 3 and 60 months of age during the period between March 2016 and February 2017. Initial serum sodium was measured before or within 4 h of starting intravenous fluids in all children included in the study. Isotonic fluid (5% dextrose normal saline) was continued for 48 h or until the patient required <50% of standard maintenance rate. Serum electrolytes were measured subsequently at 12, 24, and 48 h of commencement of intravenous fluids. Results were analyzed separately for age groups between 3–12 months and 13–60 months.

All children admitted during the study period in the age group between 3–60 months and requiring maintenance intravenous fluids as part of their management for a minimum of 12 h were included in the study. Excluded were children <3 months and >60 months of age, gastroenteritis on correction fluids, shock, plasma sodium concentration of lower than 130 mEq/L or higher than 150 mEq/L, diabetes insipidus, diabetic ketoacidosis, renal disease that needed dialysis, disorders causing excessive renal sodium excretion, liver disease, meningitis, and inborn errors of metabolism.

The study was approved by the Institutional Ethics Committee. All data were recorded in a predesigned data collection form. Data were analyzed using ANOVA for repeat values and t-test to look for electrolyte disturbances and complications.


  Results Top


Age distribution

Out of the 51 children included in the study, 61% (n = 31) were in the age group between 3 and 12 months and 39% (n = 20) were in age group between 13 and 60 months [Table 1].
Table 1: Age distribution

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Serum sodium before the commencement of intravenous fluids

The mean value of serum sodium before starting isotonic maintenance intravenous fluids was 138.13 in the age group between 3 and 12 months and 138.3 in the age group between 13 and 60 months, with P = 0.786 [Table 2].
Table 2: Mean serum sodium levels at 0, 12, 24, and 48 h of commencement of intravenous fluids

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Serum sodium at 12, 24, and 48 h of commencement of isotonic intravenous maintenance fluids

The mean serum sodium levels in the age groups between 3–12 months and 13–60 months at 0, 12, 24, and 48 h were within the normal ranges. The mean change in serum sodium was not statistically significant (P = 0.628 and 0.309, respectively) [Table 2].

Complications associated with isotonic maintenance intravenous fluids

The sodium concentration was within normal range throughout the study period and none of the children in our study developed adverse events (seizures, cerebral edema, and death) in both the age groups (between 3–12 months and 13–60 months).


  Discussion Top


This is one among the few studies done prospectively to assess the impact of prescribing isotonic intravenous maintenance fluids on serum sodium changes and other associated complications in the age group between 3 and 60 months (results were analyzed separately between 3–12 months and 13–60 months).

The results of our study showed that the mean-variance of serum sodium over 0, 12, 24, and 48 h is not statistically significant in the age groups between 3–12 months and 13–60 months. There were no associated adverse events or hypernatremia observed.

In a randomized controlled double-blind trial by McNab et al., 690 children (below 12 years of age) received isotonic intravenous maintenance fluids. The mean variance of sodium at 6, 24, 48, and 72 h was within the normal range (138.5, 139.7, 139, and 139.3, respectively) with no statistical significance (P = 0.29, 0.15, 0.13, and 0.21, respectively).[4] In another meta-analysis by McNab et al., 16 of the 437 patients receiving isotonic fluid and 17 of the 500 patients receiving hypotonic fluid developed hypernatremia (4% vs. 3%; relative risk: 1.2; 95% confidence interval [CI]: 0.7–2.4).[5] Colin V E Powell stated that such a broad CI observed makes it difficult to determine whether there is an increased risk of hypernatremia with the use of isotonic fluids.[6] Wang et al. in their meta-analysis involving 855 subjects showed that hypotonic intravenous fluids had a higher risk of developing hyponatremia (serum sodium <136 mmol/L, relative risk: 2.24, 95% CI: 1.52–3.31) and severe hyponatremia (serum sodium <130 mmol/L, relative risk: 5.29, 95% CI: 1.74–16.06) when compared to isotonic intravenous maintenance fluids. The fall in plasma sodium was greater in children who received hypotonic intravenous fluids (−3.49 mmol/L, 95% CI: −5.63–−1.35). There was no significant difference in the risk of hypernatremia (relative risk: 0.73, 95% CI: 0.22–2.48, and P = 0.62).[7] In a randomized controlled trial by Choong et al. (which included 258 children in the age group 6 months to 16 years), hypotonic intravenous maintenance fluids used significantly increased the risk of hyponatremia compared with isotonic intravenous fluids (40.8% vs. 22.7%; P = 0.004). Isotonic intravenous maintenance fluids did not increase the risk of hypernatremia and no adverse events were noted (relative risk: 1.30; P = 0.722).[8]

Although strict nil per oral (NPO) was not followed in our study, most of the children to begin with were kept NPO and as they improved symptomatically, oral fluids were commenced by the carers.

In our study, the limitations were the serum sodium levels could not be done for all children at 24 and 48 h as some of them did not require maintenance intravenous fluids, children were not strictly NPO throughout, and there was no control group to assess if the etiology of illness has any effect on serum sodium concentration.


  Conclusion Top


It is safe to prescribe isotonic intravenous maintenance fluids and is the recommended fluid of choice in the age group between 3 months and 5 years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shukla S, Basu S, Moritz ML. Use of hypotonic maintenance intravenous fluids and hospital-acquired hyponatremia remain common in children admitted to a general pediatric ward. Front Pediatr 2016;4:90.  Back to cited text no. 1
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2.
Edelson J, Orenstein E, Zaoutis L, Copelovitch L. Intravenous Fluid Management in the Pediatric Hospital Setting: Is Isotonic Fluid the Right Approach for all Patients? Current Treatment Options in Pediatrics 2015;1:90-9.  Back to cited text no. 2
    
3.
Friedman JN, Canadian Paediatric Society, Acute Care Committee. Risk of acute hyponatremia in hospitalized children and youth receiving maintenance intravenous fluids. Paediatr Child Health 2013;18:102-7.  Back to cited text no. 3
    
4.
McNab S, Duke T, South M, Babl FE, Lee KJ, Arnup SJ, et al. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): A randomised controlled double-blind trial. Lancet 2015;385:1190-7.  Back to cited text no. 4
[PUBMED]    
5.
McNab S, Ware RS, Neville KA, Choong K, Coulthard MG, Duke T, et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane database Syst Rev 2014;12(12).  Back to cited text no. 5
    
6.
Powell CV. Not enough salt in maintenance fluids! Arch Dis Child 2015;100:1013-5.  Back to cited text no. 6
    
7.
Wang J, Xu E, Xiao Y. Isotonic versus hypotonic maintenance IV fluids in hospitalized children: A meta-analysis. Pediatrics 2014;133:105-13.  Back to cited text no. 7
[PUBMED]    
8.
Choong K, Arora S, Cheng J, Farrokhyar F, Reddy D, Thabane L, et al. Hypotonic versus isotonic maintenance fluids after surgery for children: A randomized controlled trial. Pediatrics 2011;128:857-66.  Back to cited text no. 8
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