We thank you for your comments. The American Academy of Pediatrics Subcommittee on Fluid and Electrolyte Therapy has spent >2 years of hard work on this guideline.

We agree with Drs Segar and Brophy that appropriate fluid volumes for pediatric patients who are hospitalized are both important and understudied. In the guideline, we did not specifically address the volume of intravenous fluids (IVFs) because there was insufficient literature for us to do so. In the guideline, we also specifically excluded both fluid overload and polyuric states in which IVF volumes would need to be either restricted or liberalized, respectively. In our review of the literature, authors of 2 studies1  directly compared different rates of fluid administration, and no differences in hyponatremia were observed. It appears that fluid type is more important than fluid rate for the outcome of hyponatremia; however, more research needs to be done.

We concur that the amount of sodium infused in maintenance IVFs is higher than usual dietary requirements. However, this is also true of IVFs with 0.33% or 0.45% saline. The amount of sodium and water delivered to an infant or child receiving isotonic maintenance fluids is proportionally the same as that of an adult when expressed in relation to body surface area. Our literature review, as noted in the guideline, did not reveal hypernatremia or volume overload from isotonic fluid administration. Neither hypernatremia nor volume overload would be expected, however, because normal-functioning kidneys can generate free water by excreting a hypertonic urine, and this is a common occurrence in the ambulatory setting.2 

As described in our limitations of the recommendation, the use of isotonic fluids when maintenance IVFs are required does not mean that there are no indications for administering hypotonic fluids or that isotonic fluids will be safe in all patients. The clinical assessment of each patient is necessary to determine the appropriate parenteral or enteral prescription, with specific attention to volume administered, type of solution, and biochemical monitoring.

The practice guideline published is not the end but the start of the conversation. We need to do more work, ask more questions, educate each other, and get more answers about this issue. We need to be more thoughtful about each of our patients and avoid reflexive practice.

1
Feld
LG
,
Neuspiel
DR
,
Foster
BA
, et al
;
Subcommittee on Fluid and Electrolyte Therapy
.
Clinical practice guideline: maintenance intravenous fluids in children
.
Pediatrics
.
2018
;
142
(
6
):
e20183083
2
Moritz
ML
.
Urine sodium composition in ambulatory healthy children: hypotonic or isotonic?
Pediatr Nephrol
.
2008
;
23
(
6
):
955
957

Competing Interests

CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.