Abstract:
Background: Although the African "Fluid Expansion as Supportive therapy" (FEAST)
trial showed fluid resuscitation was harmful in children with severe febrile illness
managed in resource-limited hospitals, the most recent evidence reviewed World Health
Organization (WHO) guidelines continue to recommend fluid boluses in children with
shock according to WHO criteria "WHO shock", arguing that the numbers included in
the FEAST trial were too small to provide reasonable certainty.
Methods: We re-analysed the FEAST trial results for all international definitions for
paediatric shock including hypotensive (or decompensated shock) and the WHO criteria.
In addition, we examined the clinical relevance of the WHO criteria to published and
unpublished observational studies reporting shock in resource-limited settings.
Results: We established that hypotension was rare in children with severe febrile illness
complicating only 29/3170 trial participants (0.9%). We confirmed that fluid boluses
were harmful irrespective of the definitions of shock including the very small number
with WHO shock (n = 65). In this subgroup 48% of bolus recipients died at 48 h
compared to 20% of the non-bolus control group, an increased absolute risk of 28%, but
translating to an increased relative risk of 240% (p = 0.07 (two-sided Fisher's exact test)).
Examining studies describing the prevalence of the stringent WHO shock criteria in
children presenting to hospital we found this was rare (~ 0.1%) and in these children
mortality was very high (41.5-100%).
Conclusions: The updated WHO guidelines continue to recommend boluses for a very
limited number of children presenting at hospital with the strict definition of WHO
shock. Nevertheless, the 3% increased mortality from boluses seen across FEAST trial
participants would also include this subgroup of children receiving boluses.
Recommendations aiming to differentiate WHO shock from other definitions will
invariably lead to "slippage" at the bedside, with the potential of exposing a wider group
of children to the harm of fluid-bolus therapy.