Safety of Saline 0.18% Normal Saline

• After reviewing all available data on this issue, the CHM concluded that the use of 0.18% saline/4% glucose should be contraindicated in all but a limited number of children treated by experts in paediatric specialist settings, such as renal, cardiac, liver, high dependency, and intensive care units.
• Intravenous 0.18% saline/4% glucose infusion is now contraindicated in children except when initiated and maintained under expert medical supervision in paediatric specialist settings – such as renal, liver, cardiac, high dependency and intensive care units
• Remove 0.18% saline/4% glucose intravenous infusions from stock and general use in areas that treat children and ensure that suitable alternatives are available (in line with local guidelines). Restrict availability of 0.18% saline/4% glucose intravenous infusions to critical care and specialist wards
• If hypotonic intravenous fluids do need to be prescribed to children (according to the strict conditions above), the child’s individual clinical needs and possibility of increased anti-diuretic hormone secretion should be taken into account - fluid balance, plasma and urinary electrolyte concentrations must be carefully monitored during treatment.
• Acute symptomatic hyponatraemic encephalopathy is a medical emergency. Healthcare professionals should be aware and promptly recognize the signs and symptoms of hyponatraemia (headache, nausea, seizures, lethargy, coma, cerebral oedema) in children receiving hypotonic intravenous fluids.

Practices

• All evidences and practices are based on combination with Dextrose 5%
• In special feeding considerations for infants weighing < 1.5 kg at birth
• Very low-birth-weight infants may need a 10% glucose solution. Add 10 ml of 50% glucose to every 90 ml of 4.3% glucose + 0.18% normal saline, or use 10% glucose in water solution.
• Most paediatricians outside the UK use hypotonic maintenance solutions. Within the UK, where the National Patient Safety Agency (NPSA) issued a guideline in 2008 stating the risks of using too hypotonic solutions such as sodium 0.18%, a significant number of doctors still prescribe hypotonic solutions (Davies). The guideline however, does state that the majority of children may be safely administered sodium chloride 0.45% with glucose

Alternative

• Reduced volume isotonic fluid results in fewer episodes of hyponatremia than hypotonic fluid in sick children during the first 48 hours of intravenous fluid therapy

References:

1. MHRA UK PUBLIC ASSESSMENT REPORT
2. Intravenous 0.18% saline/4% glucose solution (‘hypotonic saline’): do not use in children except in specialist settings under expert supervision. October 2012
3. http://www.ncbi.nlm.nih.gov/books/NBK154443/
4. Safety and efficacy of isotonic (0.9%) vs. hypotonic (0.18%) saline as maintenance intravenous fluids in children: A randomized controlled trial. December 2014, Volume 51, Issue 12, pp 969-974
5. http://e-safe-anaesthesia.org/sessions/16_06/d/ANAE_Session/425/tab_587.html 
6. Should isotonic infusion solutions routinely be used in hospitalised paediatric patients? http://bestbets.org/bets/bet.php?id=2263