Rapid fluid boluses for children with severe illness

Friday, 09 May 2014

Systematic review confirms findings of 2011 FEAST study and the urgent need to revise global guidance

A new systematic review conducted by an international team of researchers* and published in BMJ Open Access in May 2014, finds high quality evidence that giving rapid fluid boluses to children with severe febrile illness and impaired circulation in low income settings increases their risk of death, and reiterates the urgent need to revise global guidance on treatment of sick children.  

Fluid boluses were first shown to be harmful in these children in a large study from East Africa published in 2011; the Fluid Expansion and Supportive Therapy Study (FEAST), but despite this they continue to be recommended in global guidance such as the Pocket Book of Hospital Care of Children from the World Health Organization (WHO). This slow pace of change led to written requests to the WHO from African paediatricians, and open criticism of the WHO in the BMJ of January 2014.

In the May review, the authors critically appraised the findings of the FEAST trial and searched for additional evidence on the effects of fluid boluses from both high and low income settings. The authors found that the evidence leading to global recommendations for fluid boluses had mainly been conducted in high-income settings where intensive care facilities were available, and was of very low quality and at high risk of bias. In contrast, the FEAST trial randomized over 3000 children with severe febrile illness and impaired circulation and provides high quality evidence that fluid boluses kill children.

This overwhelming evidence of harm, lead the Kenyan Ministry of Health to independently review their national guidance in April 2013 using rigorous guideline development procedures endorsed by the WHO and an early draft of this review. Similar changes are being considered in Malawi. This new analysis will increase the pressure on WHO to adopt the new evidence and update their guidelines on fluid resuscitation, as three years have gone by since the evidence from the trial has been made available to them.


*KEMRI – Wellcome Trust Research Programme in Kenya and the Nuffield Department of Medicine and Department of Paediatrics of the University of Oxford in the UK, supported by researchers from the Department of Paediatrics of the College of Medicine and Queen Elizabeth Central Hospital in Malawi and the International Public Health Department of the Liverpool School of Tropical Medicine.