A paper published today in the British Medical Journal calls on the World Health Organisation to update their guidelines urgently on how to treat African children in shock. A group of researchers and paediatricians have warned that the World Health Organisation’s failure to update their guidelines is costing children’s lives.
Fluid bolus resuscitation (giving a lot of fluids rapidly through a vein) is commonly used as an emergency treatment for children in shock. The only randomised controlled trial to look at whether fluid boluses were beneficial for children was the FEAST trial, which was published in 2011 in the New England Journal of Medicine. The FEAST trial was a large trial of over 3,000 children in 3 African countries. It found that fluid bolus resuscitation actually increased deaths among children in shock due to severe infections. A subsequent systematic review of all the evidence on fluid resuscitation has backed up the FEAST trial findings.
Despite the findings of the FEAST trial, the World Health Organisation guidelines continue to recommend fluid bolus resuscitation for children in septic shock. In May 2013 they published a new edition of their guidelines, without any change to the recommendation. These guidelines are important as many countries in Africa adopt them.
The World Health Organisation’s failure to update their guidelines could be leading to thousands of unnecessary deaths of children in Africa. Shock due to severe infections is a big problem in Africa, with probably millions of children admitted to hospital because of it each year. If the World Health Organisation’s guidelines are followed, for every million children admitted with shock then 1,800 would die unnecessarily, due to fluid bolus resuscitation. In practice, fluid boluses are used for many more children than the small subgroup included in the World Health Organisation’s definition of shock. This could mean that around 30,000 children are dying unnecessarily for every million admitted to hospital with shock.
The guidelines for Africa need to be reassessed urgently, based on the best available evidence. The longer it takes to revise the guidelines, the more children will die unnecessarily.