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Article Reviews and Commentary

Prevention of Hospital-Acquired Hyponatremia: A Case for Using Isotonic Saline.
Moritz, Ayus. Pediatrics 2003;111;2217-230

Reducing Errors in Fluid Therapy Management
Holliday, Segar Pediatrics 2033; 111: 424-425

Moritz and Ayus advocate the use of 0.9% NaCl for use as maintenance parenteral fluid for children. This recommendation is based on their report of 50 cases of neurologic morbidity and 26 deaths seen in the past 10 years whose case, they claim, is hospital-acquired hyponatremia resulting from the use of hypotonic parenteral fluids. The paper reviews situations when SIADH occurs without an osmotic stimulus, including the postoperative period. The authors report that > 50% of the morbidity and mortality reported hyponatremia occurred in the post-operative period, many in children who were receiving hypotonic fluids.

Holliday and Segar, in their editorial on the paper by Moritz and Ayus, comment that many of the cases reported resulted from "egregious errors in management, not from conventional therapy." These authors cast a much wider net with their recommendations. They point out that hypernatremia and inadequate ECF expansion in the setting of dehydration are also dangerous clinical situations to be avoided. The authors mention recent recommendations for rapid ECF expansion when dehydration is present The earlier recommendations for fluid administration based upon caloric expenditure still are applicable for maintenance fluid administration but not for ECF expansion.

Commentary
Thomas J. Mancuso, MD, FAAP

The editorial very nicely summarizes current thinking about parenteral fluid administration in pediatrics. I agree with the position taken by the editorial authors and completely disagree with the Moritz and Ayus who advocate the abandonment of hypotonic fluid for maintenance pediatric IV therapy. Many of the cases of hyponatremia cited in the Moritz paper are indeed due to inappropriate fluid management not the use of hypotonic fluid. In addition, the risks of hypernatremia are real and the incidence of this complication would very likely increase if routine fluid administration were with isotonic fluids.

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