Intravenous Fluid Bolus Resuscitation Increases Mortality Risk in Malawian Children with Cerebral Malaria

The Fluid Expansion as Supportive Therapy (FEAST) clinical trial determined that African children with impaired perfusion receiving bolus intravenous (IV) fluids had increased mortality compared to children with impaired perfusion not receiving bolus IV fluids. Malaria was common in FEAST enrollees, but no stratified analysis for children with cerebral malaria (CM), a common cause of febrile coma in Africa, was reported. We investigated whether bolus fluid expansion changed mortality risk in children with CM. To evaluate this association, we performed a propensity score matched retrospective cohort study with data collected from 1,674 children with CM admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi from 2000 to 2018. After matching of participants by covariate balancing propensity score weighting, children who received an IV fluid bolus had increased mortality risk (odds ratio [OR]: 1.92; 95% CI: 1.36-2.71) compared with those who did not. When stratified by admission systolic blood pressure (SBP), children with an SBP greater than 100 mm Hg receiving bolus fluids had increased mortality (OR: 3.15; 95% CI: 1.81-5.48) compared with those not receiving bolus fluids. In children with an SBP ≤100 mm Hg at admission, receiving bolus IV fluids did not change mortality (OR: 1.44; 95% CI: 0.91-2.26). Bolus IV fluids are an ineffective therapeutic intervention in children with CM and are harmful in those with normal or elevated admission SBPs. Our results confirm the lack of efficacy and potential harm of IV bolus fluid administration in Malawian children with CM.