THE MAINTENANCE NEED FOR WATER IN PARENTERAL

FLUID THERAPY
By Malcolm A. Holliday, M.D., and William E. Segar, M.D.
Department of Pediatrics, Indiana University Medical Center

O NE OF THE MAJOR objectives of parent per kilogram from a simple formula relat
eral fluid therapy is provision of ing calories per kilogram to age.
water to meet physiologic losses. These The following scheme was devised to
losses, tile insensible and urinary losses, permit an estimate of total expenditure of
have 1)eehl extensively studied and defined energy from weight alone using a relation
for iiifants and adults. It is established from ship between weight and expenditure of
these studies that both insensible loss of energy that may be easily remembered
water and urinary water loss roughly paral (Fig. 1). The lower line in Figure 1 defines
id energy metabolism and do not parallel basal caloric expenditure at the various
body mass (weight). Therefore, any values weight levels and the upper line defines
which are applicable to all ages must be estimated caloric expenditure for normal
derived from some function of energy activity.' The line in between indicates the
metabolism. calculated expenditure of energy for hos
Initially, and to a large extent even today, pitalized patients. It is calculated from the
needs for water have been determined on simple equations illustrated below the graph
the basis of weight in infants and on the and is necessarily arbitrary. Tile course of
basis of total amounts in adults. Although tile calculated line for infants implies that
tilis serves well for infants and adults, the hospitalized infants are more active and
hapless individual between these two more nearly approach normal expenditure
groups receives, at best, a rough estimate than is the case with adults. Hospitalized
of his requirement for water. children and adults are assumed to have an
Darrow and Pratt' have referred water energy expenditure roughly midway be
needs directly to energy expenditure, com tween basal and normal levels. Using this
puted from a set of tables2 utilizing 100 system, expenditure of energy ranges from
calories as a I)asis of reference. This latter 100 to 3000 calories. Table I illustrates the
figure is well chosen since it is equivalent weight comparable to each of these 100-
to 1 kg in the infallt and ready transfer of calorieincrements.
familiarIlumbers is possible.However, the Since losses of water are a function of
necessity for using a table and for making expenditure of energy, needs for water
computations has probably served as a must he computed from some function of
barrier to its widespread acceptance. energy metabolism. In Table II require
Crawford and his associates3 have re ments for water at various weights are com
ferred needs for water, and a variety of pared using the different systems referred
drug dosages as well, to a unit of surface to previously. Close agreement of needs for
area (S.A.) since surface area closely paral water as determined by the various
lels basal energy metabolism. In this sys methods is apparent. There is one excep
tem surface area is computed from a height tion which merits comment. In computing
weight nomogram. needs for water per unit of surface area,
Wallace4 has recently devised a scheme the values in the 6 to 15 kg range are sig
for computing requirement for calories nificantly less than the others calculated in

(Submitted July 12, accepted October 5, 1956.)

Aided by a grant from the Riley Memorial Association.
ADDRESS:(W.E.S.) 1100West MichiganStreet, Indianapolis
7,Indiana.
823

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 824 HOLLIDAY
WATER IN PARENTERAL FLUID THERAPY

COMPARISON OF ENERGY EXPENDITURE IN BASAL AND IDEAL STATE

3000

2500

C
0
@ 2000

0
1500
U

1000

500

30 40
WEIGHT kg.

Fic. 1. The upper and lower lines were plotted from data of Talhot.3 \Veights at the 50th
percentile level were selected for converting calories at various ages to calories related to weight.
The computed line was derived from the following equations:
1. 0-10 kg100cal/kg.
2. 10-20 kgbOO cal + 50 cal/kg for each kg over 10 kg.
3. 20 kg and upi500 cal + 20 cal/kg for each kg over 20 kg.

that range, a finding related to the fact cordingly, a figure comparable to the others
that energy expenditure, either basal or would be obtained if this adjustment is
total, is higher per unit of surface area for made.
the child of intermediate weight than for It may be appropriate to examine the
the small infant or for the adult. An in two major components of loss of water,
crease of about 50% in needs for water per urinary and insensible, in terms of their
unit of surface area for this group would relation to these systems.
make them comparable to the other groups.
With this exception, the four systems give INSENSIBLE WATER LOSS
similar results. With respect to insensible loss of water,
The higher figure in the adult range com Newburgh and Johnston6 and Levine and
puted from the system of Darrow and Pratt Wheatley7 have demonstrated that, for au
results from the use of a constant percentage ages, insensible loss of water in tile resting
of basal metabolism as an estimate of activ state in a comfortable environment is a
ity. As noted by Darrow and Pratt, a lower constant function of basal energy expendi
percentage would more probably describe ture. The figures average 45 ml of water
the actual activity of hospitalized adults. Ac expended for each 100 cal of energy. At

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 ARTICLES 825

TABLE I this level 23% of the total expenditure of

EXPENDITURE OF ENERGY AND ITS RELATION energy is dissipated by insensible loss of
TO WEIGhT water. With increased activity, adults con
tinued to dissipate 25% of their total expen
Expendi- JVeiglil Expendi- Ji'eight diture of heat by insensible loss of water; but
lure of of lure at of
Energy Ilody Energy Body
with increased activity, infants showed a
(cat) (I.@g) (cal) (kg) marked increase in insensible loss of water
per 100 cal of total expenditure. The in
1001160020()1700@3()():i18004(8)4190().50(15@.?00()6006210()7(8)7@0()80()8@30()9009@40()100()102501)111)01226007.5120014270()80130(
25 sensible loss of water rose from 45 to 90
30
ml/100 cal. Under these conditions 50% of
35
40 the total expenditure of energy is dissipated
45 (average a(lUlt I)y insensible loss of water.7
female) In hospitalized patients, insensible loss
50
of water was estimated by Heeley and
55
60
Talbot8 to be 930 mum2 for all ages corn
65 pared to 750 mi/rn2 for adults in the basal
70 (average adult state as reported by Newburgh and associ
male) ates.9 Heeley and Talbot further showed
that insensible loss of water per unit of stir
face area was greatest in infancy and dim
inished with age. By recalculating these
data, using the reported weights of tile sub
jects, to express insensible loss of water in
I'lie
figure of 200()cal may he arbitrarily assigned to
the average female adult. Although this correlates with a
terms of estimated expenditure of energy,
weight less tihan the average for adult females, it takes an average of 50 ml/100 cal/day is ob
into ihC(t@)Uhlt
the lower metabolic rate per unit weight of tamed.
females uS @@ell
ItS the smaller weight of females in coIn Comparing the above data in terms of
parisun to males. A suggested average for adult males
surface area for tile various age groups to
is 251)0 ciml. Significant deviation in size could dictate
ap@)ropria te (le%'iIlt10115from t his figure. the average for the entire group, the per

l'ABLEII
NEEDS FOR WATER IN RESPE('T TO WEIGHT (oMPI'TED FROM \ARIOI'S SYSTEMS
(nil/24 hr)

JVeig/it
Sfet/wd of
Estimation S kg 6 kg JO kg 15 kg 20 kg So kg 6() kg

2300S.A.t
Cal. 3(K) 60() 1000 1250 1500 1700
255t)Cal.4-@
(Crawford et a!.') 300 450 660 900 1200 1500
3000Cal4(l)arrow el a'.') 240 600 975 1291) 1530 1950
24004(Wallace4) 300 600 1000 1360 1640 2100

text.t
Xeeds for water estimated to be 100 ml/l00 (alsee

forthat
Nee(lS for water estimated to be 1500 1111/11,2
for each weight computed and assuming 50th percentile height
weight.4*
ofTalhot.5
Needs for water estimated to be 120 iiil/100 cal as given by the author. l'asal calories fronl the table

increaseover
Activity assumed to be 30%, specific dynamic action 1.5%, an(l growth 5%. This results in a 50%
likely.)Needs
basal rate. (For adults a total increase of 30% is more
follows:cal/kg
for water estimated to be 100 1111/100cal as given by the author. (aloneiieed estithiated as
100 (SXage in years). Total calories tlieii equal weightXcalculated calories per kilogram.

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826 HOLLIDAY
WATER IN PARENTERAL FLUID THERAPY

TABLE III
RELATION OF INSENSIBLE Loss OF WATER TO SURFACE AREA AND TO ESTIMATED
CALORIc EXPENDITURE FOR VARIOUS AGE Gaou@s

Per (en!Deriation of Each Age

Group from Mean fr All Agest
Age Groups mi/rn2 m1/1(X) ca@
mi/rn' rni/lOO cal

yr1150591241183
03
yr95049102Ithi816
8
yr@m)0457390All
ages93050

* Data of Ileeley and Talbot8 recalculated from weight, estimated caloric expenditure and observed insensible loss.

t Mean for all ages taken as 100% and mean for each age group expressed as per cent of this figure.

centage deviation of each of the various age these limits by the intake of water. In dis
groups from the over-all average may be ease states requiring parenteral fluid ther
calculated. Repeating the same calculation apy the limits of concentration may be con
using the data expressed in terms of 100 siderably narrowed. In addition, the intake
cal of estimated expenditure, a similar but of water is no longer controlled by the
less marked influence of growth is demon patient in response to his own stimuli and,
strated (Table III). Using surface area as finally, administration of drugs as well as
the standard reference, infants have a 24% other stimuli may influence factors control
increase over the group average. Using esti ling excretion of water, i.e., secretion of
mated expenditure of energy as the stand antidiuretic hormone, independent of water
ard reference, the increase is 18%. Similarly, intake. Accordingly, a definition of the
values for adults by the first system are 25% average solute load during parenteral fluid
below average for the group and by the therapy, along with some knowledge of
second are 10% below. Therefore, 50 rnl/100 its range, is essential in ascertaining the
cal/day represents a figure that approxi volume of water needed. It is furthermore
mates insensible loss of water for all ages. desirable to consider those factors which
This figure agrees well with previously re might influence excretion of water other
ported estimates.1 than intake of water and load of solutes.
Such considerations would assist in ascer
URINARYWATERLOSS taining the safest concentration range and
The problem of urinary water loss is the factors which may dictate exception to
best considered in terms of total excretion the average figure for water needs.
of solutes. The excretion of water is largely A theoretic approach to the problem of
a function of the amount of solute requir requirements for water, in terms of excre
ing excretion and of the factors which con tion of solutes, during parenteral fluid ther
trol the concentration at which the solute apy has been applied by Gamble et a/IC and
is to be excreted. Talbot et ai.12 using data obtained from
These factors have been discussed in adults receiving glucose. In Table IV rates of
detail by Gamble,@Welt, and Talbot. excretion of solutes are illustrated for in
Under usual conditions, solute concentra fants receiving glucose and water.1' Two
tions may be varied from a low of 75 infants were shifted from a cow's milk feed
mOsm/l to a high of 1200 rnOsm/l so that ing to the glucose and water feeding for a
each milliosrnol may be excreted in as much 5-day period. Later glucose and water were
as 13.5 ml of water or as little as 0.8 ml, and administered to these infants for 10 days.
the concentration is determined within The data depict the average excretion of

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 ARTICLES 827

TABLE IV tion of solutes of infants and adults receiv

AVERAGE I)AILY EXCRETION OF SOLUTES ing glucose and water. Days 2 to 5 simu
ON %ARIOUS REGIMENS late the circumstances of parenteral fluid
therapy with respect to energy metabolism.
. of The average figure for this period is 15
@Suhjeels. RegimenDay
cal/dayInfantsGlucose124.2InfantsGlucose2514.5IhifalitsGlucose61010.3AdultsGlucoseAdjusted*12.5Infanthuman
StudymOsm/100
mOsm/100 cal/day. Normally, in paren
teral fluid therapy, extra electrolyte is in
eluded which will provide an excess of
from 3 to 7 mEq of cation per 100 cal per
day. This leads to an addition of 6 to 14
.0Infant(ow's milkAdjusted11
.0AdultAverage milkAdjusted41
mOsm/100 cal/day to the total excretion
diet of solutes. Using the mean of these figures,
(1200 mOsm/day)Adjusted48.0 10 mOsm/100 cal/day, the total daily excre
tion of solutes then averages 25 mOsm/100
* Observation ma(le when (hiet had been constant so
cal (15 mOsm/100 cal from energy metab
that excretion of solutes was relatively constant.
olism + 10 mOsm/100 cal extra electrolyte).
solutes for the first day while receiving From Table IV the minimal excretion of
glucose and water and the average excre solutes that would be encountered is 10
tion of soiutes during the second to fifth mOsm/100 cal/day. Maximum excretion of
days. In the two experiments extended to solutes would be 40 mOsm/100 cal/day in
10 days, the daily excretion of solute for days instances of rational parenteral fluid therapy
6 to 10 is presented and illustrates a gradual except wilere clinical evidence indicates
decline in excretion of solutes. Days 2 to higher excretion, e.g., diabetes mellitus.
5 are selected as most representative of the In circumstances encountered in most
rate of excretion of solutes during paren instances of parenteral fluid therapy, gb
teral fluid therapy. Days 6 to 10 appear to merular filtration rate is not greatly reduced
represent the irreducible minimum. The and rate of excretion of solutes is not
figures compare well with the data of greatly increased. In these circumstances
Gamble and Butler in which excretion of the limit of dilution with maximum water
solutes for an adult, receiving only glucose loading is approximately 75 mOsm/l, rep
and water, was measured, when the latter resenting a fourfold dilution from the con
was also expressed in terms of mOsm/ centration of solutes in glomerular filtrate,
100 cal/day. The adult was estimated to 300 mOsm/l. If the minimum solute load,
have a caloric expenditure of 2500 cal. 10 mOsm, is excreted at only a twofold
It is of interest to note that infants re dilution, 150 mOsm/l, 66.7 ml of urine
ceiving human milk had a solute excretion (10/150 X 1000 = 66.7 ml) would be re
of the same magnitude. Figures for excre quired. This would seem to represent an
tion of solutes are also given for infants attainable minimum for concentration of
receiving a standard cow's milk feeding. solutes of most patients.
These illustrate the greater solute excre Conversely, except with solute diuresis of
tion that results from the high protein and unusual degree, solutes may be concen
electrolyte intake of cow's milk. If the aver trated in the urine of normal subjects to
age diet of the adult results in the excre 1200 mOsm/l, a fourfold concentration of
tion of 1200 mOsm/day, the excretion of glomerular filtrate.
solutes expressed per 100 cal per day (48 Taking a twofold concentration, 600
mOsm) approximates that of the infant mOsm/l, as the maximum safe concentra
receiving cow's milk (41 mOsm). tion to expect of patients receiving paren
The figures of greater importance in this teral fluid therapy, the maximum solute load
table, however, refer to the average excre of 40 mOsm/100 cal/day excreted at this

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828 HOLLIDAY
WATER IN PARENTERAL FLUID THERAPY

concentration would require 66.7 ml (40/ To test this concept, the concentration of
600 X 1000 = 66.7). The minimum solute solutes in the urine was determined in in
load excreted at 150 mOsm/l requires the fants, children and adults who had been
same volume of water as the maximum receiving pareiiter@t1 fluid therapy for at
solute load excreted at 600 mOsm/l. This least 12 hours. The subjects were OIl vari
of course derives from the fact that the high ous hospital services and tileir intake of
concentration of solutes is four times the fluid was dictated by the individual ser@'
low and the maximum solute load is four ice. A random, untimed specimen of urine
times the minimum. The average solute was obtained. Urine was collected and Pre
load, 25 mOsm/l excreted in 66.7 ml of served with thymol. Concentration of
water would be excreted at a concentra soluteswas determined in a Fiske osmome
tion of 375 mOsrn/l (25/66.7 X 1000 = 375 ter and concentration of creatinine1w the
mOsm/l). Providing 66.7 ml of water for method of Folin and \Vu.1@
renal excretion for patients receiving par The data, with respect to concentration
enteral fluid therapy permits the predicted of solutes, are represented in Figure 2 in
solute loads of 10 to 40 mOsm/100 cal/day the form of a frequency distribution. This
to be excreted between the concentrations figure is subdivided into three categories
of 150 and 600 mOsm/l, and the average arbitrarily defined, as indicated, to repre
solute load of 25 mOsm/100 cal/day to be sent values pertaining to infants, children
excrete(I at a concentration of 375 mOsm/l. and adults. Concentrations of solutes were

FREQUENCYDISTRIBUTIONOF SOLUTE CONCENTRATIONSFOR

PATIENTS RECEIVING PARENTAL FLUID THERAPY
TOO MUCH WATER NORMAL,'
RANGE TOO LiTTLE WATER

20

I 15

I
I 10

C
C

C
0
<100 100.-iSO 150-300 300-000 000-1000 >1000
SOLUTE CONCENTRATION - mOs/L

LOW NORMAL EIGH NO. INFANTS.... <1000 CAL. (0- 10 kg.)

47 15
20 61 2$
25 [@JCRILDRzN.1oo0-20ooCAL.(10-4skg.)

...2_ ._!_ .1. _-!- @ADULTS >2000CAL.(>45kg.)

ii 42 8 61

Fic.. 2.

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 ARTICLES 829

within the normal

range in the urine of quite well with the theoretic calculations
seven of the eight adults. Concentrations concerning excretion of solutes. The validity
in 4 of the 25 children were low, and only of such calculations is admittedly doubtful,
one was high. Tile concentrations in 13 of for excretion of creatinine from hour to
the 28 infants were outside the normalhour and from infant to infant is constant
range. The (leviations from normalcould only within broad limits. Furthermore,
arise either from erroneous sampling due excretion of creatinine has not been oh
to variability in rate of administration of served tinder the circumstances of paren
fluid, from solute excretions outside the teral fluid therapy. In spite of these limita
estimated limits, or from improper adminis tions, we infer from the data that excretion
tration of water. A sampling error of this of solutes falls roughly within the theoreti
type is least likely to occur in the infants cally determined limits. If this is the case,
in whom therapy was generally provided it is then necessary to conclude that admin
at a constant rate over the 24-hour period. istration of water was improper in a signifi
Since the deviations were greatest in in cant number of infants.
fants, efforts were made to estimate the In the case of children and adults, a
quantity of solutes excreted during a 24- similar calculation to determine the rate of
hour period, thus providing a means of excretion of solutes was not possible since
comparing the theoretically estimated excretion of creatinine in the child and
values for excretion of solutes to observed adult varies even more than it does in the
values. From a measurement of the daily infant, at least in relation to weight or any
excretion of creatinine, the expected daily function of energy metabolism predicted
excretion of solutes was computed. A from weight.17
sample calculation is illustrated in Table V. The data does imply that the amount of
Tile daily excretion of creatinine was deter fluid actually given the individuals studied
mined in unpublished observations on in did not consistently permit excretion of
fants receiving either glucose or human solutes within a safe concentration range
milk and found to he 10.7 mg/kg/day.'@ as it imposed demands on dilution and con
This figure agrees well with the figure of centration of solutes which might well ex
Marples and Levine' for infants receiv ceed individual capability.
ing diets low in protein (11.6 mg/kg/day). As excretion of water is a slow, continuing
The rate of excretion of solutes computed process, the desirability of regulating the
in this manner averaged 19.5 mOsm/kg/ rate of administration of fluids in order
(lay. In the present system, this would be that large loads of water are not given in
19.5 mOsm/100 cal/day since, for the in short periods of time should be mentioned.
fants included, an infant weighing 1 kg An example might serve to illustrate this
expends 100 cal. A range of 9.9 to 39 mOsm/ point. An infant weighing 3 kg is assumed
100 cal/day was observed. This coincides to have a total daily need for water of

TABLE V
AN EXAMPLE ILLUSTRATING METHOD OF CALCULATION OF TOTAL I)AILY ExrhiETIoN (IF SOLITES

l)aily excretion of creatinine= 10.7 mg/kg/day (assumedsee text)

Concentration of solutes = 550 mOsm/l (by determination)
Concentration of creatinine = 301 mg/l (by (letermiflation)
Coiic, solute 550 .
- @-@---= = 1.82 niOsm/mg creatinine excreted
( one. creatinine 301
Solute cxcretiohh= 10.7 tug creatinine/kg/dayX 1.82 mOsm/rng creatinine= 19.5 mOsm/kg/day
1 kg in this range= 100 calories
Solute excretion = 19.5 mOsm/100 cal/day

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830 HOLLIDAY
WATER IN PARENTERAL FLUID THERAPY

300 ml (100 ml/100 cal) and a total daily 116.7 ml/100 cal/day. It is fair to assume
excretion of solutes of 75 mOsm (25 mOsm/ that the water of oxidation will provide
100 cal). The rate of excretion of solutes nearly 16.7 ml. The balance, 100 ml/100
would then be about 3 mOsm/hr. At maxi cal/day, must be provided parenterally.
mal urinary dilution (75 mOsm/l) the maxi Fortuitously then, average needs for water
mal rate of excretion of water would be 40 expressed in milliliters equals estimated
ml/hr (13.3 mI/mOsm). Should half the daily energy expenditure in calories.
need for water, 150 ml, be given in a 1-hour
period, the excretion could then be but MAINTENANCE ELECTROLYTENEEDS
40 ml. The insensible loss of water in that With respect to maintenance needs for
hour would account for an additional 6 ml. electrolyte, less precise data are available,
The balance, 104 ml, would be retained. and figures considerably in excess of the
The total quantity of water in the body is minimum requirements are readily handled.
estimated to be 1800 ml (60% of the body This fact is apparent in comparing the
weight). The addition of 104 ml of water electrolyte intake of infants receiving
would represent a dilution of body fluid of human milk and cow's milk. The intake of
nearly 6% and would result in a drop of electrolytes in relation to the intake of
approximately 8 mEq in the concentration calories for babies receiving each type of
of sodium in the serum. Such an abrupt milk is indicated in Table VI. Also pre
decrease in concentration of sodium is suffi sented are the figures recommended by
cient to produce symptoms. Furthermore, Darrow' for infants and adults, and by
under stimulus for maximal excretion of Welt for adults, recalculated in terms of
water the administered water would be 100 cal. Close agreement of the various sys
excreted in a 4-hour period and, unless this tems is evident. It is also apparent that
were taken into account, a period of rela these values fall between the intakes pro
tive water deficit would then ensue. vided by human milk and cow's milk and
Daily administration of water is then should therefore be acceptable as main
best provided continuously, but certainly tenance needs for electrolyte.
it should be provided over a period of at
least 12 hours. This is especially true in the TABLE VI
infant. The significant number of infants INTAKE OF ELECTROLYTES PROVIDED PER ESTIMATED
excreting urine at concentrations less than 100 CALORIES ON VARIOUS REGIMENS
100 mOsm/l indicates that the above con
siderations are often ignored. Excessive cal/dayNa(IKHuman
RegimenmEq/100
amounts of glucose and water are fre
quently given to maintainan infusion.
The inherent danger of such practices is milk*1.01.22.0Cow'srnilk3.54.56.0Recommendedt3.02.02.0Recommended
evident from the foregoing consideration.
Equally apparent is the fact that insuffi
(Darrow)3.02.03.0Recommended
cient amounts of water were provided in adult**3.03.01 .0
6 of the 28 infants, and a fairly extreme de
gree of concentration of solutes in the urine * Computed assuming an intake of 150 @@l/100 cal/

resulted. Such circumstances, obviously, day which provides 100 cal.

t May be added to glucose and water using 3 tnt of
may lead to production of significant def
molar sodium lactate and I ml of 2
molar potassium
icits of water and to dehydration. chloride for each 100 ml of maintenance fluid.
In summary, the losses of water of an ** Adult values from Welt.0 Administration of 500

individual consist of the insensible loss and ml ofnormalsaline

perdayprovides
75mEq ofsodium
and chloride total. Potassium administration of 30
the urinary loss, stool losses being negligi
mEq/day is recommended. The figures Ier 100 cal are
ble. From the considerations given here, calculated assuming adult calorie expenditure to be 2500
the average figure for total loss of water is cal/day.

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 ARTICLES 831

CONCLUSION weight more than 10; over 20 kg the caloric

In presenting a simple and arbitrary expenditure is 1500 cal plus 20 cal/kg for
scheme for computing calories from weight, each kilogram more than 20.
it is recognized that significant deviations Maintenance requirements for water de
from this relation exist. Excessive obesity, pend upon insensible loss of water and
the declining metabolism of the aged, and renal loss. An allowance of 50 ml/100 cal/
the increased metabolism of patients with day will replace insensible loss of water,
infection, all may require modifications of and 66.7 ml/100 cal/day will replace the
the scheme. Infants during the first 10 days average renal loss so that the total require
of life, have a metabolic rate 20 to 30@ less ment is 116.7 ml/100 cal/day. As water of
than tilat cited here. As with any method, oxidation will supply approximately 16.7
an understanding of the limitations of and ml/100 cal/day, the remaining 100 ml/100
exceptions to the system are required. Even cal/day must be supplied to meet the re
more essential is the clinical judgment to maining water losses of patients on par
modify the system as circumstances dictate. enteral fluid therapy. Possible exceptions
With respect to the general applicability to this figure are discussed.
of the average figures for water intake per Maintenance requirements of sodium,
100 calories, it is evident that specific clini chloride and potassium are 3.0, 2.0 and 2.0
cal situations dictate alterations. Hyperven mEq/100 cal/day, respectively.
tilation may double the insensible losses of ACKNOWLEDGMENT
water, and glycosuria or excessive excre
tion of nitrogen may double renal losses The authors wish to express their appre
of water. Obviously, in anuria losses of ciation to Arlene H. Lukenbill, R. Marie
water are decreased and administered fluids Valencia, Ph.D., and Anna May Durrell for
should replace only the insensible loss of technical assistance in this study.
water plus the measured volume of urine REFERENCES
excreted. Simple observations of the clini
1. Darrow, D. C., and Pratt, E. L.: Fluid
cal status may dictate a modification from
therapy; relation to tissue composition
the average values of this or any other sys and expenditure of water and electro
tem. Finally, it should be emphasized that lvte; Council on Food and Nutrition.
these figures provide only maintenance J.A.M.A., 143:365, 1950.
needs for water. It is beyond the scope of 2. Pickering, D. E., and Winters, R. W.:
this paper to consider repair of deficits or Fluid and electrolyte
management in
children. Ped. Clin. North America, p.
replacement of continuing abnormal losses 873, Nov. 1954.
of water. These must be considered sep 3. Crawford, J. D., Terry, M. E., and Rourke,
arately and must be added to the needs for G. M.: Simplification of drug dosage
maintenance. calculation by application of the surface
area principle. PEDIAmIcs, 5:783, 1950.
SUMMARY 4. Wallace, W. M.: Quantitative requirements
of infant and child for water and elec
It is generally agreed that the mainte trolyte under varying conditions. Am. J.
nance requirements for water of individuals Clin. Path., 23:1133, 1953.
5. Talbot, F. B.: Basal metabolism in chil
is determined by their caloric expenditure.
dren, in Brennemann's Practice of Pedi
By means of the following formulae, the atrics. Hagerstown, Prior, 1949, chap.
caloric expenditure of hospitalized patients 22.
can be determined from weight alone. For 6. Ne@vburgh, L. H., and Johnston, M. W.:
weights ranging from 0 to 10 kg, the caloric Insensible loss of water. Phvsiol. Rev.,
22:1, 1942.
expenditure is 100 cal/kg/day; from 10 to
7. Levine, S. Z., and Wheatley, M. A.:
20 kg the caloric expenditure is 1000 cal Respiratory metabolism in infancy and
plus 50 cal/kg for each kilogram of body in childhood; daily heat production of

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832 HOLLIDAY
WATER IN PARENTERAL FLUID THERAPY

infants, predictions based on insensible SUMMARIO IN INTERLINGUA

loss of weight compared with direct
measurements. Am. J. Dis. Child., 51: Le Requirimentos de Mantenentia de
1300, 1936. Aqua in Patientes sub Therapia
8. Heelev, A. M., and Talbot, N. B. : Insensi
ble water losses per day by hospitalized
a Fluido Parenteral
infants and children. Am. J. Dis. Child., Es acceptate in general que le requirimentos
90:251, 1955. de mantenentia de aqua es determinate per be
9. Newburgh, L. H., Wiley, F. H., and expension caloric del individuo. Per medio del
Lashmet, F. H.: Method for the de sequente svstema, ii es possibile determinar le
termination of heat production over long expension caloric de patientes hospitalisate
periods of time. J. Clin. Investigation, super le base de solmente br pesos. Pro pesos
10:703, 1931.
ab 0 a 10 kg, be expension caloric es 100 cal
10. Gamble, J. L.: Physiologic information
gained from studies on life raft ration. per kg per die; ab 10 a 20 kg, be expension
Harvey Lect., 42:247, 1947. caloric es 1000 cal plus 50 cal per kg pro omne
11. Welt, L. G.: Clinical Disorder of Hydration kg de peso corporee supra 10 kg; supra 20 kg,
and Acid-base Equilibrium. Boston, le expension caloric es 1500 cal plus 2() cab per
Little, 1955. kg pro omne kg de peso corporee supra 20 kg.
12. Talbot, N. B., Crawford, J. D., and Butler, Le resultatos obtenite per iste methodo de cal
A. M.: Medical progress; homeostatic culation es ben de accordo CODbe recornmenda
limits to safe parenteral fluid therapy. tiones de alteros que es basate super s@stemas
New Englind J. Med., 248:1100, 1953. plus complexe.
13. Gamble, J. L., Wallace, W. M., Metcoff, Le requirimentos de mantenentia de aqua de
J., and Hollidav,M.A.:Observations
on pende del insensibile perdita de aqua e del
electrolyte, nitrogen and solute excretion
in infants receiving cow's milk, breast perdita renal de aqua. Un margine de 50 ml
milk or glucose solution. Unpublished per 100 cal per die suffice a reimpbaciar le in
data. sensibile perdita de aqua, e 66,7 ml per 100
14. Gamble, J. L., and Butler, A. M.: Meas cal per die reimplacia be perdita renal medie
urement of renal water requirement. Tr. de aqua. Ergo le total requirimento de aqua es
A. Am. Physicians, 58:157, 1944. 116,7 ml per 100 cal per die. Proque aqua de
15. Folin, 0., and Wu, H.: System of blood oxvdation provide circa 16,7 ml per 100 cal
analysis. J. Biol. Chem., 38:81, 1919. per die, be remanente 100 ml per 100 cal per
16. Marples, E., and Levine, S. Z.: Creatinuria die debe esser administrate pro coperir le
of infancy and childhood; normal varia remanente perditas de aqua in patientes Sul)
tion; creatine tolerance tests and effect
therapia a fluido parenteral. Deviationes pos
of amino-acetic acid in normal infants.
Am. J. Dis. Child., 51:30, 1936. sibile ab iste vabores es discutite.
17. Beard, H. H.: Creatine and Creatinine Le requirimentos de mantenentia de natrium,
Metabolism. Brooklyn, Chem. Pub. Co., chlorido, e kalium es 3,0, 2,0, e 2,0 mEq per
1943. 100 cal per die, respectivemente.

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THE MAINTENANCE NEED FOR WATER IN PARENTERAL FLUID THERAPY
Malcolm A. Holliday and William E. Segar
Pediatrics 1957;19;823
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1957 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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THE MAINTENANCE NEED FOR WATER IN PARENTERAL FLUID THERAPY
Malcolm A. Holliday and William E. Segar
Pediatrics 1957;19;823

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/19/5/823

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1957 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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