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Evevident
Original paper
2011NEJMPediatrics

FEAST

Mortality after fluid bolus in African children with severe infection

RCTPediatric sepsis

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Overview

In resource-limited African hospitals, fluid boluses increased mortality in children with severe infection and impaired perfusion.

Clinical takeaway

FEAST is the major cautionary trial against indiscriminate fluid boluses in pediatric sepsis, especially where ICU ventilation and vasoactive support are limited.

Key result

48-hour mortality was higher with fluid boluses (10.5% albumin, 10.6% saline) than no bolus (7.3%).

Practice impact

Fluid resuscitation must be context-specific; pediatric sepsis boluses are not universally benign.

Evidence

Study design

Randomized controlled trial (stopped early for harm).

Enrollment

3,141

Follow-up

48 hours (primary); mortality also assessed at 4 weeks.

Geography

Kenya, Uganda, Tanzania

Clinical question

Do fluid boluses improve survival in children with severe infection and impaired perfusion in resource-limited settings?

Population

  • Children with severe febrile illness and impaired perfusion in East African hospitals, without routine ICU-level support.

Intervention

Albumin 5% bolus or 0.9% saline bolus.

Comparator

No bolus (maintenance fluids only).

Primary outcome

48-hour mortality.

Fluid boluses increased 48-hour mortality in severely ill African children with impaired perfusion, prompting early termination for harm.

Relative risk (any bolus vs no bolus) / 1.45 / CI 95% CI 1.13-1.86 / p=0.003

Key results

  • 48-hour mortality: 10.5% (albumin bolus), 10.6% (saline bolus), and 7.3% (no bolus).
  • Any bolus vs no bolus: relative risk 1.45 (95% CI 1.13-1.86; p=0.003).
  • Excess deaths were largely from cardiovascular collapse rather than fluid overload or neurologic events.
  • Albumin and saline boluses produced similar harm.

Harms

  • Both albumin and saline boluses increased mortality compared with no bolus.
  • Excess deaths were attributed mainly to cardiovascular collapse.

Clinical Use

When to cite

  • When considering fluid boluses in pediatric severe infection, especially in settings where intensive rescue support is limited.

Practice impact

  • Fluid resuscitation must be context-specific; pediatric sepsis boluses are not universally benign.

Applicability

  • Most applicable to children with severe febrile illness and impaired perfusion in resource-limited settings without routine mechanical ventilation or vasopressors.

Limitations

  • Resource-limited setting without routine mechanical ventilation or vasopressors; results may not extend to well-resourced ICUs.
  • The main randomization excluded children with severe hypotension (who received boluses in a separate stratum).
  • High malaria and anemia prevalence may influence the fluid response.

Common misinterpretations

  • FEAST does not prove fluid boluses are harmful in every setting; it highlights danger where escalation support is unavailable.
  • The harm signal was consistent for both crystalloid (saline) and colloid (albumin).

Citation

Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-2495. doi:10.1056/NEJMoa1101549

Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa.