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There is ongoing debate regarding the optimal fluid therapy for treating diabetic ketoacidosis (DKA) in pediatric patients. This paper reviews the evidence comparing balanced fluids with normal saline (NS), examines the best fluid tonicity and the effects of rapid versus slow rehydration rates for the treatment of DKA, based on articles published since 2004. Weak evidence suggests that balanced solutions (Ringer's, Hartmann's) may be superior to NS in some areas, such as shorter time to DKA resolution. However, no significant differences were found between some balanced solutions and NS regarding most outcomes (acute kidney injury, hospital stay, or mortality). There are no significant differences in neurological complications or the speed of DKA resolution when comparing 0.45% saline to NS, although NS is associated with more frequent electrolyte disturbances, such as hyperchloremic metabolic acidosis. There is no strong evidence that rapid-rate rehydration DKA resolution or increases major complications, although it is linked to more hyperchloremic metabolic acidosis. Current evidence suggests that balanced solutions and 0.45% saline are not inferior to NS in pediatric DKA, but evidence is insufficient to recommend them over NS. There is no evidence that rapid-rate rehydration increases major complications. More studies are needed to provide further evidence.