Improvements in treatment of children younger than age 5 years infected with Ebola virus

THE JOURNAL OF PEDIATRICS • www.jpeds.com Improvements in treatment of children younger than age 5 years infected with Ebola virus To the Editor: Ebola virus infection causes a severe hemorrhagic fever syndrome with a case-fatality rate up to 90%. Damkjær et al1 reported that the case-fatality rate of pediatric patients was 42%, with the majority of deaths occurring within 10 days of admission. Smit et al2 reported that the odds of death were 14.8fold greater if patients were younger than 5 years of age. Shah et al3 reported that the case fatality was greater in children aged younger than 2 years (76.5%) compared with those aged 2-5 years (45.6%). Rapidly developing cumulative dehydration and electrolyte disturbances may be the main reason2 the World Health Organization has pediatric clinical management guidelines and recommended oral rehydration solutions (ORS)4 for children, such as the Hartmann solution suggested by Damkjær et al.1 Considering, however, that children’s body surface area to volume ratio is greater than that of adults and that some children are malnourished,5 dosages of drugs may be underestimated if calculated based on body weight. For example, 1000 mL of initial ORS is suggested for the adult weighing approximately 50 kg. Then, 1000 mL/h (20 mL/kg/h) continuous ORS (for 2 hours) is recommended for the adult.4 For a child of 10 kg, 200 mL of initial ORS and 200 mL/h continuous ORS would be recommended; however, actually 290 mL of initial ORS and 290 mL/h (29 mL/kg/h) continuous ORS are required for a 10-kg child, if based on body surface area (0.45 m2 for 10 kg vs 1.55 m2 for 50 kg).6 To treat severe dehydration, the World Health Organization recommends 30 mL/kg Ringer lactate solution at the beginning and then 70 mL/kg or ORS by mouth.4 This amount calculated may meet the requirement. Nevertheless, 70 mL/kg ORS might be too much for the child younger than 5 years of age. Considering that large volumes of ORS may be not feasible for the children younger than 5 years of age, in-time intravenous infusion with an accurate dosage may be crucial for the survival.1 The differences between the dosages based on body weight vs body surface area are even larger for the neonate.6

LETTERS TO THE EDITOR

Moreover, pediatric dosages of other drugs (such as loperamide for diarrhea,7 artemether for malaria infections,8 and ondansetron/omeprazole for nausea1) also may be more appropriately based on body surface area. Shu Yuan, PhD Zhong-Wei Zhang, PhD College of Resources Sichuan Agricultural University Chengdu, China Zi-Lin Li, MD, PhD Department of Cardiovascular Surgery General Hospital of Lanzhou Military Region Lanzhou, China

References 1. Damkjær M, Rudolf F, Mishra S, Young A, Storgaard M. Clinical features and outcome of Ebola virus disease in pediatric patients: a retrospective case series. J Pediatr 2017;182:378-81.e1. 2. Smit MA, Michelow IC, Glavis-Bloom J, Wolfman V, Levine AC. Characteristics and outcomes of pediatric patients with Ebola virus disease admitted to treatment units in Liberia and Sierra Leone: a retrospective cohort study. Clin Infect Dis 2017;64:243-9. 3. Shah T, Greig J, van der Plas LM, Achar J, Caleo G, Squire JS, et al. Inpatient signs and symptoms and factors associated with death in children aged 5 years and younger admitted to two Ebola management centres in Sierra Leone, 2014: a retrospective cohort study. Lancet Glob Health 2016;4:e495501. 4. World Health Organization. Clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker. http:// www.who.int/csr/resources/publications/clinical-management-patients/ en/. Accessed October 6, 2014. 5. Chertow DS, Kleine C, Edwards JK, Scaini R, Giuliani R, Sprecher A. Ebola virus disease in West Africa—clinical manifestations and management. N Engl J Med 2014;371:2054-7. 6. Stucky ER, American Academy of Pediatrics Committee on Drugs, American Academy of Pediatrics Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics 2003;112:431-6. 7. Chertow DS, Uyeki TM, DuPont HL. Loperamide therapy for voluminous diarrhea in Ebola virus disease. J Infect Dis 2015;211:1036-7. 8. Gignoux E, Azman AS, de Smet M, Azuma P, Massaquoi M, Job D, et al. Effect of artesunate-amodiaquine on mortality related to Ebola virus disease. N Engl J Med 2016;374:23-32.

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