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Precision fluid management in pediatric critical care: time for a paradigm shift

Pediatric Research (2025)Cite this article

Fluid management remains a cornerstone of pediatric critical care, yet practices continue to rely heavily on traditional weight-based formulas that fail to address the physiological complexities of critically ill children. Recent evidence demonstrates that both fluid overload and inadequate resuscitation contribute significantly to morbidity and mortality in pediatric intensive care units (PICUs).1 We argue that a paradigm shift toward precision fluid management is urgently needed.

The traditional Holliday-Segar method for maintenance fluids, developed over 60 years ago, was never intended for critically ill children with altered physiology.2 Despite mounting evidence linking cumulative fluid overload to adverse outcomes, implementation of precision approaches remains inconsistent. Alobaidi et al. demonstrated in their meta-analysis that fluid overload exceeding 10% is independently associated with increased mortality (OR: 4.33, 95% CI: 1.68–11.18) and prolonged mechanical ventilation in critically ill children.1

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References

  1. Alobaidi, R. et al. Association between fluid balance and outcomes in critically ill children: a systematic review and meta-analysis. JAMA Pediatr. 172, 257–268 (2018).

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  2. Holliday, M. A. & Segar, W. E. The maintenance need for water in parenteral fluid therapy. Pediatrics 19, 823–832 (1957).

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  3. Singh, Y. et al. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit. Care 24, 65 (2020).

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  4. Valentine, S. L. et al. Fluid balance in critically ill children with acute lung injury. Crit. Care Med. 40, 2883–2889 (2012).

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Authors and Affiliations

  1. Department of Pediatric Surgery, Weifang People’s Hospital, Weifang City, Shandong Province, China

    Yuxi Zhou & Wen Chen

Authors
  1. Yuxi Zhou
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  2. Wen Chen
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Contributions

Yuxi Zhou: designed the study, conducted all analyses, interpreted the findings, and authored the initial draft of the manuscript. Wen Chen: oversaw the overall research design and supervision, interpreted the findings, and conducted the final review and approval of the manuscript.

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Correspondence to Wen Chen.

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The authors declare no competing interests.

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Zhou, Y., Chen, W. Precision fluid management in pediatric critical care: time for a paradigm shift. Pediatr Res (2025). https://doi.org/10.1038/s41390-025-04281-w

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