FEAST or famine
The dangers of dehydration are well recognized. What about over-hydration? Too much fluid can kill as surely as too little.
The FEAST (Fluid Expansion As Supportive Therapy) Study reported in the New England Journal of Medicine in 2011 changed the conventional thinking on how to hydrate a sick child.
Over 3000 seriously ill African children with fever and poor blood circulation were treated with different intravenous fluid regimes on arrival at hospital.
The 48-hour mortality was 3.3% higher in children treated with a larger fluid volume. This might not seem like much but 3.3% of the half of the 3000 children who received the extra fluids equals 50 children! The children died due to cardiac collapse 2 to 11 hours after treatment with the higher volume of intravenous fluids.
The children admitted with malaria at the MSF hospital in Kenema already have a stressed heart when they arrive. The parasite breaks down red blood cells which clump up and narrow the coronary arteries. These young children are susceptible to over-hydration. Choosing the right fluid therapy is important. The right amount is not too much, but just enough. Figuring this out in a sick infant or toddler in a new hospital with new staff and with limited laboratory and monitoring equipment is a real challenge. For the ICU and ER teams, this will take time, practice, and a good understanding of the treatment and monitoring principles. This will be one of my major goals. I’ve already started to introduce the principles in my bedside teaching. I will introduce some formal teaching for the national doctors and nurses in the weeks ahead. The goal is to reduce avoidable mortality due to over-hydration.