A significant proportion of Egyptian pediatricians continue to use hypotonic fluids as their foremost choice of mIVFs for critically ill children. The utilization of 0.45% NaCl has become more prevalent than the previously favored 0.2% NaCl. This shift could be attributed to increasing recognition of the hyponatremia risk linked to 0.2% NaCl; nevertheless, it is imperative for them to acknowledge that the risk of hyponatremia still persists with the use of 0.45% NaCl.

In the context of neonates, however, 0.2% NaCl remains the predominant mIVFs choice. This trend could potentially be attributed to the limited data available for this specific age group. Furthermore, it is noteworthy that the recommendations from AAP-CPG have excluded the neonatal age group from their guidelines. However, an interesting observation has emerged indicating a growing adoption of less hypotonic fluids, such as 0.45% NaCl, and even isotonic solutions such as 0.9% NaCl, particularly in scenarios involving meningitis or traumatic brain injuries. This emerging preference can be explained by increased awareness of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) associated with neurological disorders or insults.

Our findings are congruent with several previously published surveys that have investigated the prescribing practices of mIVFs in pediatric settings. For example, Freeman et al. [6] demonstrated that pediatric residents in the United States of America (USA) prefer hypotonic fluids as the primary choice of mIVF, even in scenarios involving excessive ADH secretion. Similarly, Davies et al. [19] reported comparable results, revealing a preference for the use of hypotonic fluids, particularly among pediatric surgeons and anesthesiologists. Considering these insights, it becomes evident that the inclination towards hypotonic fluids persists within pediatric medical practice, underscoring the imperative for heightened awareness and enhanced education concerning the potential risks and considerations associated with varying fluid selections.

During the perioperative phase, Way et al. [15] shed light on the proclivity of anesthesiologists in the United Kingdom to favor hypotonic fluids. Similarly, in Australia, Keijzers et al. [16] demonstrated that hypotonic fluids remained the predominant choice, even in instances involving excessive ADH secretion.

Since the release of the AAP-CGP guidelines, limited surveys have explored the prescription practices of mIVFs, particularly within the realm of pediatrics. Hall et al. [17] conducted a survey illustrating that most surveyed pediatricians opt for isotonic fluids within the age group spanning from 28 days to 18 years. Remarkably, these practitioners were found to be adhering to the AAP-CGP recommendations. Furthermore, the use of hypotonic fluids continues among neonates, with 0.45% NaCl emerging as a more frequently employed option than the previously prevalent 0.2% NaCl.

An alarming observation arises from this study, indicating a notable upsurge in the utilization of isotonic fluids in scenarios where there is a heightened susceptibility to excess ADH secretion. This trend is particularly evident in cases of meningitis and TBI. One possible explanation for this trend is an increased awareness of the incidence of SIADH in such cases, especially those involving neurological insults.

Of particular significance is the statistically significant increase in the use of isotonic fluids across all age groups, including newborns, in cases of TBI. This phenomenon can be attributed to the influence of continuous medical education efforts. Through repeated explanations and the clear communication of management strategies, a heightened understanding of this topic has been cultivated. This includes a distinct emphasis on the risks associated with the administration of hypotonic fluids in cases of TBI.

Based on the findings, it is strongly recommended that further educational lectures be conducted on this subject across various clinical scenarios. These lectures should comprehensively address the existing evidence and newly formulated guidelines, thereby enhancing healthcare professionals’ understanding and guiding appropriate fluid management decisions.

In relation to balanced fluids, we observed a minimal utilization rate of ringer lactate in specific age categories (28 days to 1 year and 1–18 years) at 1% and 3.3% respectively, with no instances of its application in the neonatal age group. This trend might be attributed to the scarcity of available data concerning the use of balanced mIVFs in the pediatric population. Additionally, some existing data advocating for its use in adults could potentially account for these limited rates [20, 21].

Furthermore, when inquiring about the reasons behind non-adherence to the AAP-CPG among those who do not implement them, certain factors came to light. Notably, issues such as the unavailability of pre-made solutions, hospital policies, and recommendations from senior medical staff emerged as prominent causes. These findings underscore the need for heightened awareness and a systematic assessment of the accessibility of appropriate mIVFs. It is imperative that hospital guidelines on fluid management are routinely reviewed and updated. Moreover, the continuous education and upskilling of senior medical practitioners are crucial, given their substantial influence on the practices of junior colleagues. Regrettably, even well-informed junior medical personnel may struggle to implement optimal practices unless their senior counterparts are both persuaded and kept well-informed as well. Worth noting is the absence of analogous outcomes in previous research concerning the rationale behind deviations from the AAP guidelines.