Scrub typhus is a common cause of unexplained fever in children in northern India. Hemophagocytic lymphohistiocytosis can occasionally complicate scrub typhus in children.

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Intravenous fluid therapy forms the cornerstone of managing a hospitalized child with poor oral intake or contra-indication to feeding. However, the composition of intravenous maintenance fluids, which is designed to provide water and various electrolytes to replace the daily urinary and insensible losses in a child without adequate enteral delivery of fluids and electrolytes, has been a matter of concern and controversy for long. Hypotonic fluids became the standard of care more than a half century ago, when Holliday and Segar estimated fluid requirements of children based on physiologic principles and proposed a fluid-calorie estimation method [1]. However, over the years an improved understanding of the non-osmotic stimuli for ADH secretion [2] and reports of iatrogenic hyponatremia and neurological injury in hospitalized children with use of hypotonic fluids [3][4][5], have brought out the differences in fluid-electrolyte homeostasis and energy expenditure in sick children as compared to healthy, well -hydrated children studied by Holliday and Segar. These reports also raised questions about safety of hypotonic fluid administration to sick children. Two recent meta-analyses, which included data from nearly ten randomized controlled trials involving 893 children, found significant risk of hyponatremia with the use of hypotonic fluids. Foster et al. [6] reported an overall relative risk (RR) of 2.37 [95 % CIs, 1.72-3.26] whereas Wang et al. [7] reported a RR of 2.24 [95 % CIs, 1.52-3.31]for development of hyponatremia with use of hypotonic fluids. About two-third of children in above analyses were post-operative surgical patients and nearly half of the studies were ICU-based.To reduce the risk of hospital acquired hyponatremia, several authors have suggested use of isotonic maintenance fluids [4,5]. However, prospective controlled studies that evaluated isotonic maintenance fluid in sick children were not stratified by specific illnesses and were mostly limited to post-surgical settings [8-10]. The paper by Pemde et al. [11] in this issue of the journal assumes importance as it attempts to find the ideal maintenance fluid for children hospitalized with central nervous system (CNS) infections. It is a well designed trial, in which the authors randomized 92 children, aged 3 mo -5 y to three commonly prescribed fluid regimens in pediatrics; either 0.9 % saline, 0.45 % saline or 0.18 % saline at standard maintenance rates. They found 6.5-8.5 times higher risk of hyponatremia with the use of hypotonic saline within the first 24 h [11]. Appropriate masking of participants as well as investigators adds to the strength of the study design.However, the study by Pemde et al.[11] falls short on data that could have helped in improving our understanding of the issue. The authors should have provided details of input-output volumes, urinary sodium losses, and serum and urine osmolarity changes. To interpret the sodium changes in isolation would not be very different from 'the blind men and the elephant' tale. We do know tha...

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