Balanced crystalloids vs. 0.9% saline in pediatric diabetic ketoacidosis: a systematic review and meta-analysis of...

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.

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.

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).

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.

https://www.crd.york.ac.uk/PROSPERO/view/CRD420261387598, identifier CRD420261387598.