updated by Piper Wenzel, BS April 2024

See also: Tonsillectomy and Adenoidectomy; Maximum allowable blood loss

GENERAL CONSIDERATIONS​

1. Pediatric patients have weight-based minimum fluid intake requirements. In patients who have had tonsillectomies or other procedures affecting their ability to swallow, their daily fluid requirements should be calculated prior to discharge to determine if they will be able to stay adequately hydrated with PO intake once they are no longer receiving IV fluids.
2. The Holliday-Segar Method provides a formula for calculating fluid requirements (Holliday-Segar 1957) - contemporary articles support continued use of this method with modifications based on overall health of the child with individualized rates of IV fluids "accounting for enteral fluid intake, IV medication fluids, and fluid loss (Alexander 2022) .
3. Clinicians should be aware of clinical signs of dehydration and respond appropriately.

SIGNS OF DEHYDRATION

1. Table 1 (Santillanes 2018, Alexander 2022, Cellucci 2023) 

   Dehydration	Mild	Moderate	Severe
   Fluid loss	Child: 3% (30 cc/kg)	Child: 6% (60 cc/kg)	Child: 9% (90 cc/kg)
   	Infant: 5% (50 cc/kg)	Infant: 10% (100 cc/kg)	Infant: 15% (150 cc/kg)
   Skin turgor	Normal	Tenting	None
   Skin moisture	Normal	Dry	Clammy
   Lips	Moist	Dry	Parched
   Eyes	Normal	Deep set	Sunken
   Tears	Present	Reduced	Absent
   Fontanelle	Flat	Soft	Sunken
   Mood	Consolable	Irritable	Obtunded
   Pulse	Regular	Mildly increased	Tachycardic
   Urine Output	Normal	Decreased	Anuric

HOLLIDAY-SEGAR METHOD

1. Daily fluid requirements (Holliday and Segar 1957)
   1. 100 cc/kg for 1st 10 kg of the patient's weight
   2. 50 cc/kg for the 2nd 10 kg of the patient's weight
   3. 20 cc/kg for the remaining weight
2. Fluid requirements per hour: Daily fluid requirements are divided into approximate hourly rates which gives the "4-2-1" formula often used to calculate hourly infusion rates of IV fluids (Zieg 2024).
   1. 100 cc/kg/24 hours= 4 cc/kg/hour for the 1st 10 kg of the patient's weight
   2. 50 cc/kg/24 hours= 2 cc/kg/hour for the 2nd 10 kg of the patient's weight
   3. 20 cc/kg/24 hours= 1 cc/kg/hour for the remaining weight
3. Example: A 35 kg child minimum hourly fluid intake would be: (4x10) + (2x10) + (1x15) = 75 cc/hour
4. Table 2. QUICK REFERENCE FOR MINIMUM FLUID REQUIREMENTS (based on 4-2-1 formula above from Zieg 2024)

   Weight	Minimum fluid intake per hour	Minimum fluid intake per 8 hour shift
   1 kg	4 cc/hour	32 cc/shift
   2 kg	8 cc/hour	64 cc/shift
   3 kg	12 cc/hour	96 cc/shift
   4 kg	16 cc/hour	128 cc/shift
   5 kg	20 cc/hour	160 cc/shift
   6 kg	24 cc/hour	192 cc/shift
   7 kg	28 cc/hour	224 cc/shift
   8 kg	32 cc/hour	256 cc/shift
   9 kg	36 cc/hour	288 cc/shift
   10 kg	40 cc/hour	320 cc/shift
   11 kg	42 cc/hour	336 cc/shift
   12 kg	44 cc/hour	352 cc/shift
   13 kg	46 cc/hour	368 cc/shift
   14 kg	48 cc/hour	384 cc/shift
   15 kg	50 cc/hour	400 cc/shift
   16 kg	52 cc/hour	416 cc/shift
   17 kg	54 cc/hour	432 cc/shift
   18 kg	56 cc/hour	448 cc/shift
   19 kg	58 cc/hour	464 cc/shift
   20 kg	60 cc/hour	480 cc/shift
   25 kg	65 cc/hour	520 cc/shift
   30 kg	70 cc/hour	560 cc/shift

REFERENCES

Flint et al. General Considerations in Pediatric Otolaryngology. Fluids and fluid management. Cummings Otolaryngology: Head and Neck Surgery, 5th ed. Chapter 180.

Holliday MA, Segar, WE. The maintenance need for water in parenteral fluid therapy. Journal of Pediatrics. 1957 (19) 823-832.

Alexander E, Weatherhead J, Creo A, Hanna C, Steien DB. Fluid management in hospitalized pediatric patients. Nutr Clin Pract. 2022 Oct;37(5):1033-1049. doi: 10.1002/ncp.10876. Epub 2022 Jun 24. PMID: 35748381.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018 May;36(2):259-273. doi: 10.1016/j.emc.2017.12.004. Epub 2018 Feb 10. PMID: 29622321.

Zieg J, Narla D, Gonsorcikova L, Raina R. Fluid management in children with volume depletion. Pediatr Nephrol. 2024 Feb;39(2):423-434. doi: 10.1007/s00467-023-06080-z. Epub 2023 Jul 14. PMID: 37452205.

Cellucci MF. (2023, April). Dehydration in Children. Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/dehydration-and-flu...