African trial questions emergency treatment of children in shock
27 May 2011
The research, funded by the Medical Research Council and published today in the 'New England Journal of Medicine', showed that giving children fluids slowly if they are sick and cannot drink is safer and more effective than rapid fluid resuscitation in aiding recovery. These findings challenge current WHO guidelines on how best to provide fluids to children in Africa with fever and shock caused by malaria, sepsis and other infections.
The two-year trial, known as FEAST (Fluid Expansion As Supportive Therapy), involved more than 3000 children in six hospitals across Tanzania, Uganda and Kenya. It examined the effectiveness of a long-standing treatment used across the world called fluid resuscitation. This treatment involves giving seriously ill children large volumes, or 'boluses', of intravenous fluids quickly through a drip in their first hour at hospital to try to reverse the deadly effects of shock.
The children on the trial were divided randomly into three equally sized groups. Two groups were given emergency boluses of either albumin or saline in the first hour of arriving in hospital. After the first hour, the children were then given fluids slowly, to replace the amounts a sick child should drink. The third group were given fluids slowly but no additional bolus treatment.
The trial results showed that children given fluids more slowly did better, with a 48-hour survival rate of 92.7 per cent, compared with 89.4 per cent of those children given boluses. Compared with giving children fluids slowly, fluid resuscitation caused three additional children to die out of every 100 treated.
The trial was stopped early because the independent committee overseeing safety saw that giving boluses was unsafe. However, all children who took part in FEAST had a higher than average chance of survival, in part due to extra training given to hospital staff to give emergency treatments, such as oxygen, and providing medicines for malaria and other infections.
Professor Kathryn Maitland, the Chief Investigator for FEAST, Imperial College London and KEMRI-Wellcome Trust Programme, said: "This is the first time anywhere in the world that fluid resuscitation has been evaluated for safety and effectiveness in such a large trial, even though it has been standard treatment for the last two decades in the United States, Europe and Australasia. The FEAST trial was set up with the hope that fluid resuscitation would help the many African children with malaria and septicaemia.
"Around one in ten children in Africa admitted to hospital with these deadly infections are in a state of shock. Although there are effective medicines for these illnesses, too often children arrive in hospital already very sick, with many children dying within hours of admission. Large-scale clinical trials of this nature carried out to the highest levels are crucial if we are to find new ways to keep children alive when they come into hospital. Disappointingly, across all parts of the trial we found that fluid resuscitation had no benefit – our only conclusion is that boluses are harmful when used for shock in the illnesses we studied."
Professor Sarah Kiguli, Chief Principal Investigator in Uganda, said: "The results have surprised me, particularly as I had seen some children getting better after being given large volumes of fluids. But more importantly the results went against the recommendations of the WHO and the normal practice in wealthy countries, and this surprised me greatly. Finding this out before we started to encourage the use of fluid resuscitation for children with severe infections and shock across Africa was incredibly important. It will save many lives in future."
The study authors agree that further research is needed in countries where fluid resuscitation is already standard practice, although the results in Africa may not be directly applicable to high-income countries. One reason for this is that sophisticated life support equipment is available in high-income countries and is available along with fluid resuscitation as part of a 'package of care'.
They stress the need to continue to use fluid resuscitation to treat diarrhoea and other conditions like burns and trauma, where children lose fluids. For these conditions, where fluid resuscitation will continue to be a vital life-saving treatment, they advise that current WHO recommendations should stay the same. Children with severe malnutrition were not included in the trial because fluids are not recommended as part of their treatment.
Image: A mother and her child in Kenya. Credit: Wellcome Photo Library, Wellcome Images.
Reference
Maitland K et al. Mortality after fluid bolus in African children with severe infections. New Engl J Med 2011 [epub ahead of print]
