Get to know the 4 2 1 fluid rule

The Upkeep Fluid Calculator (MIVF Calculator) makes use of the Holliday-Segar methodology and the 4 2 1 fluid rule to find out youngsters’s every day and hourly fluid wants. Along with realizing these pediatric upkeep fluids, you too can calculate the suitable dimension of pediatric fluid bolus to provide in instances of want.

How one can use the pediatric upkeep fluid calculator?

  1. Decide when you ought to use the upkeep fluid calculator, because the components used right here has its limitations. You shouldn’t use it for newborns beneath 14 days, because it overestimates the required fluids. Additionally, the components shouldn’t be appropriate for kids beneath 3 kilograms. The calculator will warn you about that.
  2. Enter the kid’s weight. Think about using the perfect physique weight and very best weight calculator in overweight sufferers.
  3. You’ll get three outcomes. The primary is every day upkeep fluids, fluids wanted for your complete day, to be administered inside 24 hours.
  4. On the following line, you will notice the fluid move price. It tells you how briskly the intravenous infusion ought to be.
  5. The final line tells you concerning the quantity of the pediatric fluid bolus. 

Holliday-Segar Technique and 4-2-1 Rule

The components utilized in our IVFM calculator is an previous and well-established methodology, named for its builders, pediatricians Malcolm Holliday and William Segar.

The idea that permits this components to work is {that a} fastened quantity of fluid is required for each kilogram per day. Modifying this precept, known as the 4-2-1 rule, offers you the same reply, however per hour.

Are you utilizing imperial items? Don’t fear! Constructed-in weight converter.

Please word that in overweight sufferers it’s best to think about using the perfect physique weight. One of the simplest ways to observe a toddler’s weight and weight-to-height ratio is to see how they carry out throughout percentile ranges. 

How one can use the MIVF calculator – sensible instance

Let’s give an instance to make all the pieces clear. How a lot fluid would a 14 kg youngster want?

  1. For twenty-four hours – Holliday-Segar methodology
    first 10 kg * 100 ml/kg/24h + subsequent 4 kg * 50 ml/kg/24h = 1200 ml/24h
  2. For one hour – 4-2-1 rule
    first 10 kg * 4 ml /kg/24h + subsequent 4 kg * 2 ml/kg/24h = 48 ml/24h

The reply: the quantity of every day pediatric upkeep fluids is 1200 ml, and the hourly demand is 48 ml.

Pediatric fluid bolus

The time period “bolus” means an intravenous dose of a drug that’s given comparatively rapidly and fairly often straight from the hand. A bolus is usually utilized in acute states when there’s a want for the drug to succeed in the specified website (eg, the guts in case of resuscitation) and act as rapidly as attainable.

A bolus of fluid is given to quickly fill the vascular mattress and is given primarily within the presence of hypovolemic shock.

In youngsters, the quantity of fluid given as a bolus could be calculated utilizing the components:

fluid bolus = weight (kg) * 20 ml

with an higher restrict of 1000 ml = 1 litre.

This quantity ought to be administered as rapidly as attainable, since shock is a straight life-threatening situation.


One of many important aims of upkeep parenteral fluid remedy is to offer water to cowl physiological losses (insensible loss + urine loss). In a research revealed in 1957 within the Journal Pediatrics, Malcolm Holliday and William Segar developed a easy scheme that may very well be simply remembered to calculate upkeep water wants for hospitalized sufferers.

Assimilating the physiology identified at the moment, they noticed that “there was a DIRECT LINEAR relationship between Physiological Water Wants (insensible losses + urinary losses) and Energetic Metabolism”. In different phrases, “the common water wants, expressed in milliliters, are equal to power expenditure in energy (beneath regular resting situations, 1 ml of water is required to metabolize 1 kcal)”. It was discovered that the connection between Weight and Power 

Expenditure is NONLINEAR. Based mostly on their knowledge and assumptions, Holliday and Segar constructed a curve that plotted caloric power wants versus weight. This curve may very well be seen composed of three linear sections that coincided roughly with the next weight sections: 0 to 10 kg, 10 to twenty kg and 20 to 70 kg.

Considered this fashion, the authors concluded that 100 mL/kg/day for weights as much as 10 kg, an extra 50 mL/kg/day for every kilogram from 11 to twenty kg, and an extra 20 mL/kg/day for every kilogram above 20 kilos In anesthetic follow, this components has been additional simplified, with the hourly requirement often called the “4-2-1 rule” (4 ml/kg/h for the primary 10 kg of weight, 2 ml/kg/ h for the primary 10 kg). subsequent 10 kg and 1 mL/kg/hr for every kilogram thereafter.

 Quantity Calculations

  • All fluids ought to be calculated as upkeep + deficit correction + ongoing losses (
  • upkeep Fluid necessities of 1ml/kg/hr thereafter, with a most upkeep of 100ml/hr). See the RCH IV Fluid CPG and Upkeep Fluid Calculator.
  • Correctors could be calculated in keeping with the RCH pointers for gastroenteritis. Make certain IVs if RCH CPG, not Fluid nasogastric charges

Sorts and Choices

All pediatric IV fluids at BHS are based mostly on and adjust to the Requirements for Pediatric Fluids: NSW Well being (2nd Version).

A superb IV fluid sorts and volumes evaluate article is offered: McNab JPCH 2016.

Premixed IV fluid luggage ought to be utilized in nearly all circumstances for pediatric sufferers at BHS. 

word that there’s rising proof for the usage of Plasma-Lyte 148 in upkeep and alternative fluids, though this shouldn’t be but supported as commonplace follow.

hyponatremic fluids similar to 0.225%, 0.22%, or 0.18% NaCal (1/5) Needs to be prevented until in session with a consulting pediatrician (apart from neonates as famous above).

dextrose to be addedAll newborns ought to obtain 10% dextrose and all different youngsters ought to obtain 5% dextrose (plus components) always, until in any other case specified by the Pediatric Unit.

  • Pediatric sufferers fasting for the working room and different conditions nonetheless require dextrose.

Fluid Boluses

  • All fluid boluses for quantity ought to be administered with regular saline (0.9% NaCl), even in
  • . used for correction of hypoglycaemia
  • Colloids ought to be prevented for fluid boluses in youngsters
  • Aggressive fluid boluses, even in sepsis, could cause hurt and ought to be carried out with warning
    • IV fluid resuscitation remedy, Lengthy JPCH 2016

Enteral Fluids

  • Please word that nasogastric fluids are delivered at completely different charges and we use various kinds of fluids.
    • NGT fluid charges could be calculated utilizing RCH gastroenteritis CPG
    • NGT fluids for rehydration/hydration are ORS or breast milk/synthetic components.
    • By no means give fluids intravenously
  • by a nasogastric tube. to all enteral fluid orders (apart from IV fluid chart)