Holliday-Segar maintenance fluids

Category: Fluids and resuscitation
Version: v1.0.1
Reviewed: Reviewed 6 Sep 2026
Validation: Validation pending

Daily volume uses the 100-50-20 rule: 100 mL/kg for the first 10 kg, plus 50 mL/kg for each kg from 10 to 20 kg, plus 20 mL/kg for each kg above 20. The hourly rate uses the 4-2-1 rule, which applies 4, 2 and 1 mL/kg/h across those same three brackets. Its coefficients are the daily coefficients divided by 24 and rounded, so the hourly rate multiplied by 24 does not equal the daily volume, by design. A third output caps the hourly rate at 100 mL/h, the one figure every current guideline states identically (NICE, Leung 2021, RCH, Be-PIV). Under the 4-2-1 rule that cap binds at exactly 60 kg. The cap is a guideline overlay. Holliday and Segar’s function has no ceiling.

Weight is accepted from 4 to 150 kg, and below 4 kg the score refuses to compute. The 4 kg floor is this project’s own proxy and is stated as such: every guideline scope that excludes neonates is written in age (term, 28 days, one month), which a weight input cannot implement, and the populations overlap in weight. A 3.2 kg term neonate on day 2 needs roughly 70–80 mL/kg/day while a well 3.2 kg two-month-old needs 100. NICE’s separate neonatal day-of-life ladder, rising from 50–60 to 120–150 mL/kg/day over the first 28 days, is not implemented here. This is a ceiling, not a prescription. Current guidance recommends infusing less than the calculated volume in most hospitalised children: a two-thirds default (RCH), 65–80% for ADH risk or 50–60% for oedematous states (ESPNIC), and 50–80% (NICE). Count concurrent IV fluids, blood products, drug volumes and flushes, and enteral intake before prescribing. Restriction is not hyponatraemia prophylaxis; tonicity is what protects. Neville 2010 randomised tonicity and rate independently (2 × 2, n = 124) and found that hyponatraemia risk decreased by isotonic saline “but not fluid restriction”, and the AAP found that hypotonic-fluid risk persisted even at restricted rates. Give isotonic maintenance fluid with appropriate potassium chloride and dextrose (AAP 2018 statement 1A, evidence A; number needed to treat 7.5 to prevent one sodium below 135), preferably balanced (ESPNIC), avoiding lactate-buffered solutions in severe liver dysfunction. Check electrolytes and glucose at baseline and at least every 24 h. No daily cap is applied, because guidelines disagree (2000, 2400 and 2500 mL figures for the same question) and no evidence-based daily ceiling exists. The circulating 2400 traces to a citation error and is arithmetically 100 mL/h × 24. The formula over-estimates in illness. Measured energy expenditure in acutely ill children runs 50–60 kcal/kg/day against the formula’s assumed 100 for the first 10 kg, and accuracy falls further in fever, burns, tachypnoea, hypothermia, and altered-ADH states. The output excludes deficit and ongoing losses, which are added separately. For infants aged 1–3 months, prefer a dextrose-containing balanced solution with lower sodium chloride content and monitor electrolytes (Leung statement 5.4). Above about 60 kg, and in obesity, acute kidney injury, chronic kidney disease or cancer, switch to BSA-based or adult forms per NICE. Never prescribe above the calculated maintenance rate (Leung 6.1). The 1957 electrolyte figures (3 mEq sodium, 2 mEq potassium per 100 kcal) are per 100 kcal metabolised, not per kg. The volume rule stands; the 1957 composition is superseded. The burn-resuscitation calculator on this site deliberately reimplements this arithmetic from 0.5 kg, because refusing a burned neonate would withhold the resuscitation volume too. It discloses the scope limit instead of refusing.

References

Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823–832.Origin of the method. SECOND-HAND — every figure attributed to it arrives through the AAP 2018 guideline's direct citation, the AAP structured summary, and Chesney's 1998 commentary. The journal is Pediatrics, not Journal of Pediatrics, and the page range is 823–832; both errors circulate widely.PMID 13431307 DOI 10.1542/peds.19.5.823
Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018;142(6):e20183083.Isotonic key action statement 1A (28 days to 18 years, evidence A, strength strong; NNT 7.5 to prevent one Na<135, 27.8 for Na<130). Source of the measured 50–60 kcal/kg/day expenditure figure, of the 3 mEq Na / 2 mEq K per 100 kcal composition cited directly from the 1957 original, and of the finding that hypotonic-fluid hyponatraemia risk persisted even in rate-restricted patients. AAP explicitly declines to recommend a rate or a volume, so it must never be cited for one.DOI 10.1542/peds.2018-3083
Brossier DW, Tume LN, Briant AR, et al. ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children. Intensive Care Med. 2022;48(12):1691–1708.Restriction percentages (65–80% for ADH risk, 50–60% for oedematous states), the fluid-creep inclusion list, balanced-solution and lactate recommendations, and the PICO 5 counter-evidence. States no daily cap. Grades its own volume recommendations C, D and GCP — the weakest in the document.DOI 10.1007/s00134-022-06882-z
Brossier DW, Goyer I, Verbruggen SCAT, et al. Intravenous maintenance fluid therapy in acutely and critically ill children: state of the evidence. Lancet Child Adolesc Health. 2024;8(3):236–244.Source of the 2000 mL/day figure in the ESPNIC group's own prescribing box — the fourth and most conservative of the four circulating daily maxima. Renders the bottom weight band as 3–10 kg.DOI 10.1016/S2352-4642(23)00288-2
Leung LCK, So LY, Ng YK, et al. Initial intravenous fluid prescription in general paediatric in-patients aged >28 days and <18 years: consensus statements. Hong Kong Med J. 2021;27(4):276–286.Statement 6.1 (2 L/day girls, 2.5 L/day boys or 100 mL/hour, citing NICE; do not prescribe above the calculated maintenance rate), 6.2 restriction bands, 5.4 the 1–3 month fluid-type band, and the statement 6 conclusion that fluid TYPE matters more than fluid RATE for preventing hyponatraemia.DOI 10.12809/hkmj209010
NICE. Intravenous fluid therapy in children and young people in hospital. NG29. Published 9 December 2015, last updated 11 June 2020.Rec 1.4.1 (males rarely need more than 2500 mL and females more than 2000 mL over 24 h — an awareness note, not a cap — and 100 mL/hour), 1.4.2 the term-neonate day-of-life ladder (50–150 mL/kg/day), 1.4.4 monitoring, 1.4.9 the 50–80% restriction band, 1.4.10 the BSA insensible-loss form, and the 91st-centile trigger for switching to BSA.Source
Royal Children's Hospital Melbourne. Clinical Practice Guideline: Intravenous fluids. Updated January 2026.Source of the 60 kg upper anchor (where the band structure stops and the cap begins), the 100 mL/hour rate, the 3 kg table floor, the 1 month scope statement, and the two-thirds operational default for unwell children. Its guideline states 2400 mL/day without citation while its own fluids calculator page states 2500 — the contradiction is left visible rather than reconciled.Source
Chang AJ, York DJ, Chen W, Heidenreich KN, Shah MD. Maintenance Fluids for Late Preterm and Term Infants: Is it Time to Reconsider? Pediatr Open Sci. 2025;1(2).174 infants ≥34 weeks GA; serum sodium fell 0.07 mEq/L per mL/kg of positive fluid balance, and term infants fared WORSE than late preterm (31% vs 17% reaching Na ≤132; OR 2.22). The counterintuitive direction is the evidence against extrapolating paediatric bands downward on the assumption that bigger is safer.DOI 10.1542/pedsos.2024-000372
Amer BE, Abdelwahab OA, Abdelaziz A, et al. Efficacy and safety of isotonic versus hypotonic intravenous maintenance fluids in hospitalized children: an updated systematic review and meta-analysis of RCTs. Pediatr Nephrol. 2024;39(1):57–84.Isotonic fluid significantly increased hypernatraemia risk specifically in neonates (RR 3.74, 95% CI 1.42–9.85), a subgroup signal running opposite to the overall finding. Also the source of the ≤70% = restricted, 80–120% = maintenance definition.DOI 10.1007/s00467-023-06032-7
Friedman AL, Ray PE. Maintenance fluid therapy: what it is and what it is not. Pediatr Nephrol. 2008;23(5):677–680.Independent corroboration that the electrolyte figures rest on a per-100-kcal (per-100-mL-infused) basis, and that this is the detail routinely dropped when the method is restated per kilogram.DOI 10.1007/s00467-007-0610-3
Neville KA, et al. J Pediatr. 2010;156(2):313–319. (2 × 2 factorial randomised trial in 124 postoperative children: 0.9% versus 0.45% saline crossed with 100% versus 50% of the maintenance rate. Conclusion, verbatim in part: hyponatraemia risk was decreased by isotonic saline solution 'but not fluid restriction'.)The direct source for this score's restriction-is-not-prophylaxis rule, which otherwise rests only on the AAP's rate-restricted subgroup observation and Leung's reading of Cochrane. Its 2 × 2 crossing is what makes it decisive: it varies fluid TYPE and fluid RATE independently, which a single restriction arm cannot. NO TITLE IS CARRIED — the record for this trial reaches us without one, and a plausible-looking title is not invented to fill the field. It is also one of the three RCTs ESPNIC's PICO 5 pools, so it was already in this score's evidence base indirectly. No 2016-2026 trial repeated the design.PMID 19818450
University of Iowa Head and Neck Protocols — Pediatric Fluid Management. Secondary confirmation of the 4-2-1 hourly rule and the 35 kg → 75 mL/hr worked example.Used for the 35 kg worked example only. This page miscites the 1957 paper's journal, so it is not relied on for provenance.Source

Reproduction rights

Freely reproducible.Piecewise-linear arithmetic function of body weight; the coefficients (100/50/20, 4/2/1), the weight-bracket thresholds (10 kg, 20 kg) and the 100 mL/h guideline rate cap are facts and a mathematical formula, not copyrightable expression. No proprietary scale wording exists to reproduce — every element is a number in and a volume out — and all prose here is this project's own (holliday-segar.md IP status).

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Important. For use by qualified health professionals as an informational and educational aid. It supports clinical judgment and does not replace it. Verify every result independently before making a clinical decision. This is not a medical device.