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Fluid infusions are given to children to treat cardiovascular compromise from shock in locations across the globe, where resources vary widely. The most common cause of cardiovascular compromise is septic shock. In low and middle income countries severe malnutrition complicates sepsis largely from malaria, pneumonia, and diarrheal diseases, leading to interesting treatment conundrums. The high mortality rate of about 40% in children with severe malnutrition and shock from diarrheal diseases results from the confluence of clinical factors, inequity, socio-economic and cultural context resulting in late presentation, increased vulnerability, and sub-optimal care [1]. Fluid resuscitation in this context is risky with little margin for error, where small deficits or excesses can lead to cardiovascular collapse or respiratory failure. Thus, the WHO recommends a cautious approach with frequent clinical monitoring. This recommendation is supported by weak evidence and accompanied by a suggestion that research is needed to determine optimal fluid management in children with severe malnutrition and shock [2]. In response to these uncertainties, Obonyo and colleagues investigated the cardiovascular response to two fluid infusion regimes (bolus and continuous infusion over 5 h) in severely malnourished children with hypovolemic shock due to diarrheal diseases with dehydration [3]. The authors concluded that the concern of compromised cardiac function and vulnerability to fluid overload in children with severe malnutrition and diarrheal diseases with dehydration is not supported by their findings. However, there was a high mortality rate at 48 h (36–44%) and 28 days (56–82%) [3]. The rationale for this study is partly based on the FEAST trial in which bolus fluid in febrile children in Africa resulted in worse outcomes [4]. However, the FEAST trial excluded children with dehydration from diarrheal diseases, few enrolled had septic shock, and almost 60% of the children suffered from malaria. The findings of the FEAST trial signals a cautious approach to fluid boluses in low resource settings, but the final chapter on fluid approaches in children with septic shock in any setting is not yet written. Septic shock is a complex pathophysiological derangement; its expression depends on microbial agent virulence, systemic inflammation, endothelial and microcirculation disruption, primary and secondary immune derangements, and coagulation and parenchymal tissue insults [5, 6]. Endothelial barrier dysfunction occurs early in septic shock and whether it is amplified in SM is unclear [7]. Mortality in children with diarrheal disease and septic shock is higher (67%) than in controls with dehydration (14%). Those with septic shock are also more likely to receive a blood transfusion and mechanical ventilation, therapies which may not be available in low and middle income countries [8]. Thus, the distinction between hypovolemic and septic shock has tremendous implications regarding treatment and outcomes because those in septic shock are more likely to need mechanical ventilation which may not be available [9]. Correspondence: nkissoon@cw.bc.ca Department of Pediatrics, BC Children’s Hospital, University of British Columbia, B245, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada Child & Family Research Institute (CFRI), Vancouver, British Columbia, Canada Full list of author information is available at the end of the article

Understanding fluid administration approaches in children with co-morbidities and septic shock