In 2003, Michael Moritz, an MD, and his fellowship mentor, Juan Carlos Ayus, rocked the parenteral nutrition boat with a paper in Pediatrics. They presented evidence against the use of hypotonic IV solution (fluid with less sodium than a patient’s plasma)—a practice that had been entrenched in pediatric hospital care for 50 years. They argued that the solution could cause hyponatremia, or low sodium levels, and eventually neurological problems and death. Today, Moritz says, “over 20 prospective studies in over 2,000 children” have proven him right—that isotonic fluid, with sodium concentration matching patient plasma, is appropriate for most patients.

Moritz, now clinical director of pediatric nephrology at Children’s Hospital of Pittsburgh of UPMC and professor of pediatrics, published an October review article in the New England Journal of Medicine about the physiological principles of IV fluid selection. “Changing fluid practice is a simple and safe measure which can be taken to improve patient safety and will save lives,” he says.

What made you realize that a change in IV solution administration was needed?

Dr. Ayus and I observed that almost all hospitalized patients were at risk for hyponatremia from elevated hormone levels that prohibit the kidneys from releasing water. With that, I wanted to know why hypotonic IV solution became standard of care. There was really no data to support the practice—it was based on the sodium concentration of breast milk and cow’s milk.

What tactics did you take to manage the controversy?

We were convinced that we were right, but we also realized that many physicians did not have a good understanding of renal physiology and sodium and water metabolism. Physicians were fearful that isotonic fluids would cause fluid overload and hypernatremia. We thought, if we repeat our message and explain it in very clear terms, eventually it would catch on. We wrote letters to the editor, commentaries, and reviews correcting misconceptions and misinformation on the topic. Fortunately, this sparked a renewed interest in the topic, and investigators around the world began conducting studies and verifying our concept. Now, societies are developing consensus guidelines on fluid therapy in children and adults, when before there were none. These society recommendations will be critical in changing worldwide practice.