By Professor Kathryn Maitland, Director of the IGHI Centre of African Research and Engagement.
First published by the Hippocratic Post on 22/8/16.
‘Back in 2011, my research team published the results of the largest trial of critically ill children ever undertaken in Africa (FEAST trial), a trial that examined fluid resuscitation strategies in children with severe febrile illnesses (including malaria and bacterial sepsis). Contrary to expectation, the trial showed that fluid boluses were associated with an increased mortality compared to no-bolus (control), the greatest effect was in children with the most severe forms of shock. We were delighted when the FEAST trial won the prestigious 2011 BMJ Research Paper of the Year award and expected that doctors around the world would sit up and take notice – and guidelines for management of children suffering from shock due to sepsis would change.
However, five years on, I have to say that I am disappointed that the WHO guidelines in resource-poor settings are still largely unaltered. Although the humanitarian aid charity Medicins sans Frontieres changed its own procedures within nine months of our results becoming public, the directing and coordinating agency for international health of the United Nations has so far left existing guidelines in place. This is despite the fact that we found that the intervention of rapidly administering fluids was actually harmful to children in our study which was robust and based on sound scientific evidence. One statistician said it was the most consistent he had ever seen.
What we found was the administering fluids did have an immediate effect of brining children round so they appeared to be better in the short term, but four or five hours later many of the children suffered a catastrophic vascular collapse, which often sent them into deeper shock. In low GDP countries, where there are few intensive care facilities to support children in this emergency, this deep shock can lead to death in many cases. Interestingly, this result may be masked in developed countries where children have better support after they are brought into hospital and can be given special drugs called inotropes to assist the recovery of the circulatory system. However, no research has been done to confirm or refute this.
The WHO guidelines committee looked at the evidence and decided to downplay our results. One of the problems was that the members of the committee themselves did not have sufficient expertise to review the evidence we presented and understand the context. I did write a very detailed response to their conclusion, but it was ignored.
So they retained the guideline to give very sick children a rapid infusion of fluids, but tempered it with the recommendation that children would also be given inotropes. But this just shows the lack of understanding of the committee of what actually happens in resource poor settings. Access to drugs can be limited and the logistics may not be in place to get them to where they are needed. Inotropes cannot just be popped under the tongue by a healthcare assistant. They need to given as a continuous infusion by a trained professional who may well not exist.
In my opinion, this lack of decisive action is costing tens of thousands of children their lives in Africa. It is very frustrating for people like me who are working in areas where it is having a dramatic negative impact. It is like trying to change the direction of a juggernaut which thunders on despite all the evidence that it is going the wrong way.
