Balanced crystalloids versus normal saline in pediatric septic shock or suspected septic shock requiring fluid resuscitation: a systematic review, and meta-analysis

The optimal choice of resuscitation fluid in pediatric children with septic shock or suspected septic shock requiring fluid resuscitation remains controversial. This systematic review and meta-analysis aimed to compare the efficacy and safety of balanced crystalloids (BCs) versus normal saline (NS) in pediatric patients with septic shock or suspected septic shock requiring fluid resuscitation and evaluate the certainty and sufficiency of current evidence. A systematic search of PubMed, Embase, Scopus, and ClinicalTrials.gov was performed from inception to 17 May, 2026. Randomized controlled trials comparing BCs with NS in pediatric septic shock or suspected septic shock requiring fluid resuscitation were included. Primary outcomes were in-hospital mortality and acute kidney injury (AKI). Secondary outcomes included 90-day mortality, renal replacement therapy (RRT), major adverse kidney events at 30 days (MAKE30), length of stay, mechanical ventilation, and electrolyte abnormalities. Random-effects meta-analysis, and GRADE assessment were performed. Five RCTs involving 9,343 pediatric patients with septic shock or suspected septic shock were included. BCs showed no significant differences compared with NS in in-hospital mortality (RR 1.00, 95% CI 0.82–1.22), AKI (RR 0.94, 95% CI 0.52–1.70), 90-day mortality, mechanical ventilation, MAKE30, or hospital and PICU length of stay. BCs significantly reduced hyperchloremia (RR 0.65, 95% CI 0.61–0.70) and showed a potentially important reduction in RRT in the primary analysis (RR 0.67, 95% CI 0.37–1.23), with the same point estimate in the DerSimonian–Laird sensitivity analysis (95% CI 0.48–0.92). Hypernatremia also showed a consistent numerical reduction (RR 0.59), although the primary Hartung–Knapp analysis was not statistically significant (95% CI 0.30–1.17). Current randomized evidence does not demonstrate a difference in mortality or conventionally defined AKI between BCs and NS, but these findings should not be interpreted as evidence of equivalence because clinically important benefit or harm cannot be excluded for several outcomes. BCs consistently reduced hyperchloremia and showed concordant, although not definitive, signals toward lower RRT and hypernatremia. In the absence of a demonstrated clinical advantage of NS, the totality of available physiological and clinical evidence supports a conditional preference for BCs for fluid resuscitation in pediatric septic shock or suspected septic shock, while recognizing that specific clinical circumstances may favor NS. Adequately powered RCTs are needed to clarify the effects of fluid composition on mortality, AKI, RRT, and other patient-important outcomes. Not Applicable.