Evidence needs to be shown in paediatrics

Editorial by McClelland

EDITOR—We are concerned that the Cochrane Injuries Group's meta-analysis regarding administration of albumin1 may alter the practice of resuscitating hypovolaemic hypotensive children, infants, and neonates. Although we are affiliated to the Institute of Child Health, we want to emphasise that this article does not reflect our own clinical practice, and at present we believe that it provides no compelling evidence to change our practice.

We reviewed the 32 articles in the three groups. We identified only one paediatric study (So et al) in the hypovolaemia group, in which 63 preterm infants received albumin for hypotension. In the burns group there is only one paediatric study (n=70), in which albumin was given to maintain arbitrary serum concentrations (Greenhalgh et al). Finally, in the hypoproteinaemic group there are two studies of 64 neonates that addressed several hypotheses, including whether albumin was detrimental to respiratory status (Greenough et al) and was beneficial in weight gain (Kanarek et al). In a third study (n=27) that assessed the use of bicarbonate in acidotic neonates only the control groups of 5% dextrose and albumin were compared (Bland et al).

We are now faced with concerns from parents about the “killer fluid,” and our junior staff are confused about the appropriate fluid to use for resuscitation of critically ill children. Have we been put into a legally indefensible position by this report from the Cochrane Injuries Group?

We continue to use albumin for several reasons. To produce the same sustained increase in blood pressure as a 20 ml/kg bolus of albumin, up to five times as much volume of crystalloid would have to be given based on their relative oncotic pressures.2 This increased volume of crystalloid may lead to problems with fluid overload, hyperchloraemia in renal dysfunction, and pulmonary oedema. One leading …