Objective:

To evaluate the efficacy and safety of balanced crystalloids versus 0.9% saline for fluid resuscitation in children with diabetic ketoacidosis (DKA).

Approach:

• Literature Search: Five databases were searched from inception to 27 April 2026 for randomized controlled trials (RCTs) comparing fluid resuscitation strategies in pediatric DKA.
• Outcomes: Primary outcomes included 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.
• Statistical Analysis: Random-effects models were used for analysis, with risk of bias assessed using the Cochrane RoB 2 tool and certainty of evidence evaluated using GRADE.

Key Findings:

• Balanced crystalloids were associated with a modest decrease in time to DKA resolution (MD: −1.60 h, 95% CI: −3.07 to −0.13).
• Insufficient evidence 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).
• Balanced crystalloids were linked to 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).

Interpretation:

Modest benefits in biochemical outcomes were associated with balanced crystalloids, but the small evidence base and low certainty of evidence limit conclusions on clinically important outcomes.

Limitations:

• Small number of included studies (five RCTs) with a total of 320 patients, which limits the generalizability of the findings.
• Low certainty of evidence regarding the effects on clinically significant outcomes, which affects the reliability of the conclusions drawn.

Conclusion:

Current evidence is insufficient to support a transition from normal saline to balanced crystalloids as the initial fluid in pediatric DKA. Further large, multicenter RCTs are needed.

Sources:

• Systematic Review Registration