Balanced crystalloids vs. 0.9% saline in pediatric diabetic ketoacidosis: a systematic review and meta-analysis of randomized controlled trials
In brief
Balanced crystalloids shorten pediatric DKA recovery by about 1½ hours
A meta-analysis of five randomized trials (320 children) found that using balanced solutions reduced the time to DKA resolution by roughly 1.6 hours compared with normal saline. While they also lowered rates of hypokalemia and hyperchloremia, there was no clear impact on new-onset kidney injury, and overall evidence remains low-certainty, so routine replacement of saline cannot yet be recommended.
- Journal
- Frontiers in pediatrics (Q2)
- Published
- 9 July 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Zeid Alkhairi, Charlie Kajo, Abdolaziz A Zadeh, Dawood Khaja, Mohammad Alqaryuti, Nada K Alsaleh, et al.
- PMID
- 42495261
- DOI
- 10.3389/fped.2026.1879829
Why clinicians should know about it
- Picked for Biochemistry (medical) (top studies of the week, 26 July 2026).
- Picked for Emergency Medicine (top studies of the week, 26 July 2026): Balanced crystalloids vs saline in pediatric DKA
Abstract
BACKGROUND: Fluid resuscitation is a cornerstone in the management of pediatric diabetic ketoacidosis (DKA). While 0.9% normal saline (NS) remains the conventional first-line fluid, concerns regarding its high chloride content and potential to induce hyperchloremic metabolic acidosis have led to increasing interest in balanced crystalloids. However, evidence comparing both strategies in pediatric populations remains limited and inconsistent. METHODS: Five databases were searched from inception to 27 April 2026. The primary outcomes were time to resolution of DKA and incidence of new-onset acute kidney injury (AKI). Secondary outcomes included hospital and PICU length of stay, electrolyte disturbances, and major complications. Random-effects models were used. Risk of bias was assessed using the Cochrane RoB 2 tool, and certainty of evidence was evaluated using GRADE. RESULTS: Five RCTs involving 320 patients were included. A modest but statistically significant decrease in the time to DKA resolution (MD: -1.60 h, 95% CI: -3.07 to -0.13) was associated with balanced crystalloids. Current evidence is insufficient to determine the effect of fluid choice on new-onset AKI due to substantial statistical uncertainty (RR: 0.55, 95% CI: 0.17-1.82; p = 0.325). No significant differences were observed in the other secondary outcomes; however, balanced crystalloids were associated with a lower incidence of hypokalemia (RR: 0.66, 95% CI: 0.46-0.93) and hyperchloremia (RR: 0.40, 95% CI: 0.21-0.78). CONCLUSION: Modest benefits in biochemical outcomes were associated with balanced crystalloids. However, due to the small evidence base and low certainty of evidence, it remains unclear if these advantages translate into improvements in clinically important outcomes, particularly rare complications such as cerebral edema and need for mechanical ventilation or inotropic support. Current evidence remains insufficient to support a transition from NS to balanced crystalloids as the initial fluid in pediatric DKA. Further large, multicenter RCTs are needed to better determine the clinical role of balanced crystalloids in this setting. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261387598, identifier CRD420261387598.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.