to the editor: I was surprised to see the unqualified recommendation to use 25 percent normal saline for intravenous maintenance fluids in hospitalized infants and children. Research has called into question the safety of hypotonic maintenance fluids in hospitalized children.^1–3 Death and neurologic damage have been associated with hospital-acquired hyponatremia in children receiving hypotonic maintenance solutions, and a meta-analysis finds a significantly higher rate of the development of acute hyponatremia (odds ratio, 17.22; 95% confidence interval, 8.67 to 34.2).¹ The authors of this meta-analysis question the safety of hypotonic maintenance fluids in children because of the risk of iatrogenic hyponatremia and hyponatremic encephalopathy. The literature has not established that isotonic maintenance fluids are safer than hypotonic maintenance solution, but it is important to acknowledge research that questions the longstanding practice of using hypotonic maintenance fluids in children.

editor's note: This letter was sent to the authors of “Diagnosis and Management of Dehydration in Children,” who declined to reply.