In the linked systematic review (doi:10.1136/bmj.c4416), Akech and colleagues assessed studies that compared the use of isotonic crystalloids and colloids for fluid resuscitation in children with severe infection and shock. All of the studies were carried out in resource poor settings.1 This is an important topic because early fluid resuscitation is a mainstay of treatment for septic shock, which has a high mortality in children worldwide.2 3

One study carried out in the United States assessed mortality and functional morbidity in 5000 children who were referred to five children’s hospitals after being received in the emergency department of a community hospital.4 Shock was defined by the presence of prolonged capillary refill (>2 seconds) or hypotension, or both. The results showed that although 40% of children who were referred had shock, this was recognised as such in only 7%, and the remainder were mistakenly referred for “respiratory distress.” Outcomes were better in patients who presented at earlier stages of haemodynamic instability, and mortality was halved when these haemodynamic abnormalities were reversed in the emergency setting. Use …