Conservative Fluid Management in Pediatric DKA May Reduce Adverse Events, Study
Pakistan: A meta-analysis of 10 randomized controlled trials suggests that smaller initial fluid boluses and avoiding prolonged 0.9% saline rehydration may improve safety in children with diabetic ketoacidosis (DKA). Larger boluses were associated with potentially greater risks, while prolonged saline use may increase adverse events such as hypoglycemia. The findings, published in the Journal of the Endocrine Society, support a more conservative, individualized approach to fluid management in pediatric DKA.
DKA is a serious and potentially life-threatening complication of type 1 diabetes that requires rapid correction of dehydration, circulatory compromise and metabolic disturbances. Although intravenous fluids are a cornerstone of treatment, uncertainty remains over the ideal volume, composition and tonicity of fluids, particularly because of concerns about cerebral complications and electrolyte abnormalities.
To examine the available evidence, Ridwa Alam, Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan, and colleagues conducted a systematic review and meta-analysis of randomized controlled trials assessing different fluid strategies in children with DKA. The researchers searched PubMed, CINAHL, Cochrane, Scopus, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform without imposing date restrictions.
The analysis included 10 randomized controlled trials involving 2,291 children. Study quality was evaluated using the Cochrane Risk of Bias 2 tool, while the certainty of evidence was assessed using the GRADE framework.
Key findings included:
- Children receiving an initial 20 mL/kg fluid bolus followed by exclusive 0.9% saline rehydration had a potentially higher risk of adverse events than those receiving a 10 mL/kg bolus (RR 1.11).
- However, among children treated exclusively with 0.9% saline, the 20 mL/kg bolus was associated with a lower risk of hypoglycemia compared with 10 mL/kg (RR 0.78).
- When used for 48–72 hours of rehydration, 0.9% saline was associated with a higher risk of hypoglycemia compared with 0.45% saline (RR 1.35).
- Prolonged 0.9% saline administration was also linked to more adverse events, with the risk increasing over both 48–72 hours and periods exceeding 36 hours.
The researchers cautioned that the findings should be interpreted carefully, as most outcomes were supported by moderate- to low-quality evidence. Differences in healthcare systems, patient characteristics, and outcome definitions across studies also limited the generalizability and direct comparison of results.
Despite these limitations, the review supports a more cautious approach to fluid therapy, including smaller initial boluses and the use of balanced crystalloids or hypotonic saline when clinically appropriate. The authors called for high-quality studies, particularly in low-resource settings, to assess strategies such as balanced crystalloids and the two-bag system.
Evidence remains limited for children with DKA and shock, leaving uncertainty about the safest fluid strategy in this high-risk group. The researchers recommended multicenter randomized trials to better define fluid requirements and develop treatment protocols adaptable to different healthcare settings.
Reference:
Alam, R., Memon, F., Haryani, A., Ishaq, A., Idrees, H., Amjad, F., Lang, E., Soofi, S. B., & Ariff, S. (2026). Fluid regimens for diabetic ketoacidosis in children and adolescents: Systematic review and meta-analysis. Journal of the Endocrine Society, 10(8). https://doi.org/10.1210/jendso/bvag148
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