Fluid choice in pediatric diabetic ketoacidosis: a Systematic Review and Meta-Analysis

Why clinicians should know about it

• Picked for Pediatrics and Child Health (paper of the day, 6 November 2026): Paediatric DKA fluid comparison directly informs acute management

Abstract

UNLABELLED: Early fluid resuscitation is critical in pediatric diabetic ketoacidosis (DKA). While 0.9% saline is the standard of care, its high chloride content may cause hyperchloremic acidosis. Balanced electrolyte solutions (BES) have been proposed as alternatives to accelerate metabolic recovery, justifying an updated pediatric-specific analysis. This study aims to evaluate the efficacy and safety of BES compared with 0.9% saline in pediatric DKA. A systematic review and meta-analysis was conducted in accordance with Cochrane guidelines, searching PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) and observational studies comparing BES with 0.9% saline in pediatric DKA. Pooled analysis was performed using random-effects models, with 95% CI. Eight studies comprising 47,840 participants were included. Among RCTs, no significant difference was found in time to DKA resolution (n = 292; MD 2.27 h; 95% CI - 0.58 to 5.11; I2 = 4.4%) or hospital length of stay (n = 225; MD 0.11 days; 95% CI - 0.75 to 0.97; I2 = 45.1%). Pediatric Intensive Care Unit length of stay (n = 242; MD - 1.18 h) also did not differ significantly. The risks of cerebral edema (n = 176; RR 1.82; 95% CI 0.06 to 58.80) and acute kidney injury (n = 243; RR 1.39; 95% CI 0.67 to 2.87) did not differ between groups. CONCLUSION: In this study, BES showed no significant difference in clinical outcomes compared with 0.9% saline in pediatric DKA. However, additional high-quality studies are needed to strengthen the evidence base. Current evidence is insufficient to demonstrate superiority, inferiority or comparative safety of either fluid strategy. TRIAL REGISTRATION: This systematic review was registered in PROSPERO (CRD420261320121). WHAT IS KNOWN: • Early fluid resuscitation is critical in pediatric diabetic ketoacidosis (DKA), with 0.9% saline being the traditional standard of care. • High chloride content in 0.9% saline may cause hyperchloremic acidosis, leading to interest in balanced electrolyte solutions (BES) as alternatives. WHAT IS NEW: • This meta-analysis with pediatric patients found no significant difference between BES and 0.9% saline in the time of DKA resolution, hospital/Pediatric Intensive Care Unit stay, or complications like cerebral edema. • Future high-quality randomized controlled trials (RCTs) are needed to refine pediatric fluid management protocols in DKA and investigate potential biochemical benefits.

Abstract as published, via PubMed.