IV Maintenance Fluid Rate Calculator (Holliday-Segar 4-2-1 Rule)
The **Holliday-Segar 4-2-1 rule** (Pediatrics 1957) is the bedside estimate of maintenance fluid that every clinician, nurse and pharmacist still uses. Enter the patient weight in kg and the tool returns the **hourly rate** in mL/hr and **daily volume** in mL/day, with the 4 / 2 / 1 tier breakdown spelt out. **Mnemonic**: first 10 kg → 4 mL/kg/hr; next 10 kg (11–20) → 2 mL/kg/hr; each kg above 20 → 1 mL/kg/hr. NICE NG29 (2020) caps adult maintenance at 25–30 mL/kg/day, so the rule over-estimates above ~70 kg.
Weight must be a positive number (kg).
Hourly rate
60
mL/hr
Total daily volume
1,440
mL/day
4-2-1 tier breakdown
- First 10 kg × 4 mL/kg/hr 40 mL/hr
- Next 10 kg (11–20) × 2 mL/kg/hr 20 mL/hr
- Above 20 kg × 1 mL/kg/hr 0 mL/hr
Formula
Hourly rate (mL/hr) — the 4-2-1 form: first 10 kg → 4 mL/kg/hr next 10 kg (11–20 kg) → 2 mL/kg/hr each kg above 20 kg → 1 mL/kg/hr Daily volume (mL/day) — the 100-50-20 form (= hourly × 24): first 10 kg → 100 mL/kg/day next 10 kg (11–20 kg) → 50 mL/kg/day each kg above 20 kg → 20 mL/kg/day Worked example: 70 kg adult = 4×10 + 2×10 + 1×50 = 110 mL/hr ≈ 2 640 mL/day.
- · **Maintenance only — does NOT include deficit or ongoing losses.** The 4-2-1 rule covers normal metabolic requirement (insensible loss + urine + stool). It does not replace dehydration deficit, ongoing losses (vomiting, diarrhoea, surgical drains, burns) or glycogen needs. A complete IV plan = maintenance + deficit + ongoing losses, each computed and prescribed separately.
- · **Adult cap 25–30 mL/kg/day (NICE NG29, 2020)** — strict 4-2-1 over-estimates in large adults (an 80 kg adult would get 120 mL/hr → 2 880 mL/day, already above 30 mL/kg/day ≈ 2 400 mL/day). Most adult protocols cap maintenance at ~100 mL/hr or 25–30 mL/kg/day; anything more should trigger a fresh look at ongoing losses, diuretics, heart failure or risk of fluid overload.
- · **Not applicable to neonates (< ~3.5 kg).** Neonatal fluid and electrolyte physiology is different: day 1 ~60–80 mL/kg/day, increasing daily to ~150 mL/kg/day by day 5–7. Use a NICU-specific protocol (e.g. the WHO Pocket Book of Hospital Care for Children) rather than the 4-2-1 rule.
- · **4-2-1 vs 100-50-20 — a known ~4 % gap.** Strictly, hourly 4-2-1 × 24 is slightly below daily 100-50-20 (e.g. 15 kg: 50 mL/hr × 24 = 1 200 mL versus 100×10 + 50×5 = 1 250 mL). Holliday-Segar wrote the daily form; the hourly numbers are rounded from 4.17 / 2.08 / 0.83. The gap is clinically irrelevant — we use 4-2-1 because the night-shift nurse can remember it.
- · **Isotonic crystalloid is now the maintenance default.** NICE NG29 (2020) and the AAP (2018, Hyponatraemia avoidance guideline) both recommend 0.9 % NaCl or lactated Ringer’s as the maintenance solute, avoiding hypotonic fluids (e.g. 0.18 % NaCl in 5 % dextrose) that have been shown by multiple RCTs (PALISI, SPLIT) to cause iatrogenic hyponatraemia. Add ~1–2 mmol/kg/day K⁺ and a modest amount of glucose to prevent ketosis.
- · **References**: (1) Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. *Pediatrics* 1957; 19: 823-832. (2) NICE NG29 (2020) — Intravenous fluid therapy in adults in hospital. (3) AAP Clinical Practice Guideline (2018) — Maintenance Intravenous Fluids in Children. (4) WHO Pocket Book of Hospital Care for Children, 2nd ed. (2013). (5) Moritz ML, Ayus JC. *N Engl J Med* 2015; 373: 1350-1360 (iatrogenic hyponatraemia in hospital).
Frequently asked
Which is the “correct” version — 4-2-1 (hourly) or 100-50-20 (daily)?
**The original is 100-50-20 mL/kg/day (Holliday-Segar 1957)**; 4-2-1 mL/kg/hr is the bedside-friendly rounding (strictly divided by 24, the tier values would be 4.17 / 2.08 / 0.83). For example a 15 kg child: hourly form → 50 mL/hr × 24 = **1 200 mL/day**; daily form → 100×10 + 50×5 = **1 250 mL/day** — a ~4 % gap. **Practical advice**: (a) write inpatient orders in the 4-2-1 hourly form ("IV NS 50 mL/hr") because the infusion pump expects mL/hr; (b) use the 100-50-20 daily form for fluid balance and neonatal total volumes; (c) the two are clinically equivalent and the gap is far smaller than evaporation, intake and urinary output variability. This tool reports the hourly × 24 daily figure.
An 85 kg adult patient comes out at 125 mL/hr by 4-2-1 — is that too much?
**Usually yes, it is too much.** NICE NG29 (2020) recommends an adult maintenance ceiling of **25–30 mL/kg/day**, i.e. 85 kg should be capped at 2 125–2 550 mL/day (~88–106 mL/hr) rather than 125 mL/hr (= 3 000 mL/day = 35 mL/kg/day). **Why**: the 4-2-1 formula was derived by Holliday & Segar (1957) from paediatric metabolic rate; it *over-estimates* in adults ≥ 70 kg because metabolic rate per kg falls (BMR scales sublinearly with mass). **Practical handling**: (a) cap adult maintenance at ~100 mL/hr; (b) be careful with weight > 70 kg or with heart failure, kidney impairment or prolonged inpatient stays; (c) ongoing losses (vomiting, surgical drains, hyperventilation, burns) are addressed by *replacement* on top of maintenance, not by inflating the maintenance formula. The tool computes raw 4-2-1; apply the cap clinically.
Which IV solution should I run as maintenance?
**Current consensus: isotonic crystalloid.** NICE NG29 (2020) and the AAP 2018 maintenance-fluid guideline both recommend **0.9 % NaCl** or **lactated Ringer's**, with modest glucose to prevent ketosis and ~1–2 mmol/kg/day potassium. **Why not hypotonic fluids any more?** Multiple RCTs in the 1990s–2010s (PALISI 2003, Choong 2011, SPLIT 2018) showed that hypotonic maintenance fluids (0.18 % NaCl in 5 % dextrose, 0.45 % NaCl, etc.) substantially raise the risk of iatrogenic hyponatraemia, especially in hospitalised children whose ADH release is elevated ("sick child" physiology). **Special cases**: (a) D10W is acceptable in neonates to maintain glucose; (b) DKA has its own protocol; (c) severe liver, heart or kidney failure needs lower sodium; (d) resuscitation in shock or sepsis uses *resuscitation* boluses (20–30 mL/kg) — separate from maintenance.
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