Large global study confirms similar outcomes for common pediatric sepsis fluids

Sepsis is one of the most serious emergencies in pediatric medicine. It can move quickly, cause organ failure and put a child’s life at immediate risk. For clinicians, they must stabilize the child’s blood pressure, protect organs and begin treatment as soon as it is recognized. One of the first decisions is also one of the most common: Which IV fluid should be used for resuscitation?

For years, pediatric emergency teams have relied on two standard options: balanced crystalloids, such as lactated Ringer’s – a sterile fluid used to replace water and electrolytes in the body – and traditional 0.9% saline. Both are inexpensive, widely available and used every day in hospitals around the world. But up until recently, it was unclear whether one offered better protection against kidney injury, complications or death for children with suspected septic shock.

Now, a major international study with senior author Nathan Kuppermann, MD, MPH, executive vice president and chief academic officer at Children’s National Hospital and director of the Children’s National Research Institute, proves that  both are equally safe and effective for children with suspected septic shock. The findings from the PRoMPT BOLUS trial, published in The New England Journal of Medicine and presented at the 2026 Pediatric Academic Societies Meeting, help answer a long-standing question in pediatric emergency and critical care medicine and give clinicians confidence to move quickly with whichever fluid is most readily available.

Dive deeper

More than 18,000 children in the United States are hospitalized with sepsis each year. Despite major advances in care, about 1 in 10 children with sepsis or septic shock still face the risk of death. Researchers wanted to understand whether the type of fluid used during those first critical hours could improve outcomes.

In adults, earlier studies suggested balanced fluids might reduce complications compared with normal saline. However, pediatric-specific evidence was limited, and answering the question required something difficult to achieve in children’s research – getting thousands of patients enrolled into a clinical trial across multiple institutions and countries.

What this means

“This trial demonstrates the power of large collaborative research networks to answer important clinical questions for children,” said Dr. Kuppermann. “By enrolling thousands of patients across multiple countries, we were able to provide the kind of evidence clinicians need to guide care for children with suspected septic shock – definitive and generalizable.”

Led by first authors Fran Balamuth, MD, PhD, of Children’s Hospital of Philadelphia and Scott L. Weiss, MD, of Nemours Children’s Hospital, the study relied on the Pediatric Emergency Care Applied Research Network (PECARN), the first and largest federally funded pediatric emergency care research network in the U.S., along with partner research networks Pediatric Emergency Research Canada (PERC) in Canada, Pediatric Research in Emergency Departments International Collaborative (PREDICT) in Australia and New Zealand and a separate site in Costa Rica. In total, all sites enrolled more than 9,000 pediatric patients across 47 emergency departments in five countries.

How it worked

Children in the trial received either balanced fluid or 0.9% saline during treatment for suspected septic shock. Researchers focused on Major Adverse Kidney Events within 30 days, known as MAKE30. This includes death, the need for kidney replacement therapy or ongoing kidney dysfunction.

MAKE30 occurred in 3.4% of patients who received balanced fluids and 3.0% of those treated with saline. Hospital-free days, mortality and overall safety outcomes were also similar between the two groups. Researchers did see some biochemical differences, including higher chloride levels in the saline group and higher lactate levels in the balanced fluid group, but those differences did not lead to better or worse outcomes for patients. Both fluids worked.

Why this matters

Sometimes the most important breakthrough in medicine is not finding a new treatment. It is proving that the care already being delivered is the right one. Rather than forcing clinicians to choose between two competing standards, the PRoMPT BOLUS trial confirms that either fluid is an appropriate choice. That means doctors can focus less on debating which bag to use and more on what matters most: starting treatment quickly. This may be even more important in low-resourced countries that do not have access to multiple types of intravenous fluid.

For hospitals around the world, especially in resource-limited settings, that kind of evidence is powerful. It removes uncertainty, supports faster decision-making and reinforces that excellent care does not always require a more complicated answer. For families facing sepsis in their children and the teams fighting for those children in the emergency department, that clarity can make all the difference.

Read the full study “Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock” in the New England Journal of Medicine here.