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Analysis

WHO guidelines on fluid resuscitation in children: missing the FEAST data

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.f7003 (Published 14 January 2014) Cite this as: BMJ 2014;348:f7003
  1. Sarah Kiguli, consultant paediatrician1,
  2. Samuel O Akech, research fellow2,
  3. George Mtove, research fellow3,
  4. Robert O Opoka, consultant paediatrician1,
  5. Charles Engoru, consultant paediatrician4,
  6. Peter Olupot-Olupot, consultant paediatrician5,
  7. Richard Nyeko, consultant paediatrician6,
  8. Jennifer Evans, consultant paediatrician7,
  9. Jane Crawley, consultant paediatrician8,
  10. Natalie Prevatt, research fellow9,
  11. Hugh Reyburn, senior lecturer in clinical epidemiology10,
  12. Michael Levin, consultant paediatrician9,
  13. Elizabeth C George, statistician11,
  14. Annabelle South, policy, communications and research impact coordinator11,
  15. Abdel G Babiker, statistician11,
  16. Diana M Gibb, professor of epidemiology11,
  17. Kathryn Maitland, professor of tropical paediatric infectious disease9
  1. 1Department of Paediatrics, Mulago Hospital, Makerere University, Kampala, Uganda
  2. 2Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
  3. 3Department of Paediatrics, Joint Malaria Programme, Teule Hospital, Muheza, Tanzania
  4. 4Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, Uganda
  5. 5Department of Paediatrics, Mbale Regional Referral Hospital Pallisa Road, Mbale, Uganda
  6. 6Department of Paediatrics, St Mary’s Hospital, Lacor, Uganda
  7. 7Department of Paediatrics University Hospital of Wales Heath Park, Cardiff, UK
  8. 8Nuffield Department of Medicine, University of Oxford, Oxford, UK
  9. 9Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, London W2 1PG, UK
  10. 10Joint Malaria Programme, Moshi, Tanzania
  11. 11Medical Research Council Clinical Trials Unit, UCL, London, UK
  1. Correspondence to: K Maitland k.maitland{at}imperial.ac.uk

The 2013 World Health Organization guidelines continue to recommend rapid fluid resuscitation for children with shock despite evidence that this can be harmful. Sarah Kiguli and colleagues call for WHO to think again

RPBERTO SCHMIDT/AFP/GETTY IMAGES

The World Health Organization recommendations on management of common childhood illnesses affect the lives of millions of children admitted to hospital worldwide. Its latest guidelines,1 released in May 2013, continue to recommend rapid fluid resuscitation for septic shock, even though the only large controlled trial of this treatment (Fluid Expansion as a Supportive Treatment (FEAST) found that it increased the risk of death in African children.2 A subsequent systematic review of bolus resuscitation in children with shock resulting from severe infection also did not support its use.3 Failure to take this evidence into account is not consistent with WHO’s commitment to systematically and transparently assess evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) process when producing guidelines and could endanger the lives of children.

Evidence on fluid resuscitation

Rapid fluid resuscitation was recommended as a lifesaving treatment for shock on the basis of a GRADE systematic review that found weak evidence of benefit (largely expert opinion based on two paediatric case series at a single tertiary centre).4 It has become a key component of surviving sepsis campaigns in children and adults4 5 and is widely practised in well resourced settings. Fluid resuscitation is also being increasingly promoted in resource poor settings6 7 as part of the WHO endorsed emergency triage assessment and treatment training.8 This is despite systematic reviews9 and commentaries highlighting concerns that these recommendations are not based on research evidence.10

FEAST was published in 2011. It is the only randomised controlled trial comparing bolus fluid resuscitation with no bolus. The study was conducted in six African hospitals …

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