Pouring salt on troubled waters

The case for isotonic parenteral maintenance solution Intravenous fluid and electrolyte therapy for acutely ill children has been a cornerstone of medical practice for well over 50 years. The scientific methodology behind fluid regimens generated much debate in the early 1950s following the pioneering work of Darrow, Talbot, Gamble and others who recognised the important relation between caloric expenditure and requirements for water.1–3 Caloric expenditure was originally calculated according to body surface area, which at the bedside required either tables or nomograms.1 In 1957 Holliday and Segar simplified this approach, relating energy expenditure to one of three weight based categories ( 20 kg).4 Electrolyte requirements were also calculated on a weight basis, producing an “ideal”, hypotonic solution comprising 0.2% saline in 5% dextrose water (0.18% saline in 4% dextrose in the United Kingdom). This simple regime was subsequently adopted on a global scale and is recommended in current paediatric and medical textbooks. Advances in our understanding of water and electrolyte handling in health and disease have called into question the validity of the Holliday and Segar approach. Specifically, many authors have reported how hypotonic maintenance fluid may result in iatrogenic hyponatraemia in hospitalised patients, often with devastating consequences.5–10 In this article we re-evaluate each of the concepts on which this traditional regime is based (energy expenditure, and water and electrolytes requirements) and use this to make the case for an alternative, namely isotonic fluid. ### Energy expenditure Talbot originally estimated basal metabolic rate in children based on water loss.11 Crawford extended this concept, by presenting total energy requirements (basal metabolic rate plus growth and activity) using this data in relation to body surface area (fig 1). Holliday and Segar further advanced this by indexing energy expenditure to body weight rather than surface area, …