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Moving Towards a More Aggressive and Comprehensive Model of Care for Children with Ebola

2016; Elsevier BV; Volume: 170; Linguagem: Inglês

10.1016/j.jpeds.2015.11.054

1097-6833

Indi Trehan, Tracy Kelly, Regan H. Marsh, Peter George, Charles W. Callahan,

Ethics and Legal Issues in Pediatric Healthcare

Ebola is a devastating illness for children, particularly those under 5 years of age.1Baez F. Perez J. Reed G. Meet Cuban Ebola fighters: interview with Felix Baez and Jorge Perez. A MEDICC Review exclusive.MEDICC Rev. 2015; 17: 6-10PubMed Google Scholar, 2World Health OrganizationSierra Leone Ministry of HealthClinical management of patients in the Ebola treatment centres and other care centres in Sierra Leone - modified from “Clinical management of patients with viral haemorrhagic fever: A pocket guide for the front-line health worker”. World Health Organization, Geneva2014Google Scholar, 3Frieden T. Eight ways Ebola threatens the children of West Africa. [updated January 16, 2015] Fox News. http://fxn.ws/1G6fSnZ. Accessed December 18, 2015.Google Scholar Although children are proportionally less affected than adults during outbreaks of Ebola, including in the current West Africa outbreak,4McElroy A.K. Erickson B.R. Flietstra T.D. Rollin P.E. Nichol S.T. Towner J.S. et al.Biomarker correlates of survival in pediatric patients with Ebola virus disease.Emerg Infect Dis. 2014; 20: 1683-1690Crossref PubMed Scopus (66) Google Scholar it remains a major threat to child health in the affected nations and a neglected area of investigation and discussion.5Nebehay S. High rates of child deaths from Ebola, special care needed: WHO. [updated February 6, 2015]. Reuters. http://reut.rs/1D5rmbR. Accessed December 18, 2015.Google Scholar The threat is not only for those infected with Ebola, but for all children in the affected region because of the tremendous impact of this outbreak on national health care systems.6Peacock G. Uyeki T.M. Rasmussen S.A. Ebola virus disease and children: what pediatric health care professionals need to know.JAMA Pediatr. 2014; 168: 1087-1088Crossref PubMed Scopus (26) Google Scholar In addition to what appears to be a different immunologic response to Ebola in children,7W. H. O. Ebola Response TeamEbola virus disease among children in West Africa.N Engl J Med. 2015; 372: 1274-1277Crossref Scopus (93) Google Scholar the uniquely challenging bedside care of suspect and infected children plays a significant role in the increased morbidity and mortality in this age group. Little information has been published on efforts to care for children in Ebola treatment units (ETUs). We present a report of our experience caring for children at what was the largest ETU in Port Loko, Sierra Leone, and a discussion of our protocols for caring for children with Ebola, with the hope of stimulating an international dialogue regarding the care of children with this disease. These protocols represent the culmination of the accumulated experience and knowledge of our ETU health care staff. Although, admittedly, they reflect some shared insights from staff at other ETUs, the majority stem from the published literature with adaptations of standard pediatric therapy. The protocols represent the care we aspired to provide to each child at the time our ETU closed in March 2015 and serve as a starting point for future ETU providers and policymakers for the next Ebola epidemic. Because of resource limitations, a rigorous evidence-based demonstration of efficacy for all of these recommended interventions remains to be done. Thus, the protocols are well rooted in solid, biological rationale and clinical experience but as yet lack ideal empirical support. The Maforki ETU was a 106-bed facility opened in October 2014 in a former Red Cross Vocational School (Figure; available at www.jpeds.com). The unit was operated by the Sierra Leone Ministry of Health and manned by national staff, international staff through Partners In Health, and members of the Cuban Medical Brigade.1Baez F. Perez J. Reed G. Meet Cuban Ebola fighters: interview with Felix Baez and Jorge Perez. A MEDICC Review exclusive.MEDICC Rev. 2015; 17: 6-10PubMed Google Scholar The ETU was divided into a holding ward for suspected cases that were pending Ebola virus reverse-transcription polymerase chain reaction (RT-PCR) confirmation of infection and a treatment ward for confirmed Ebola cases.2World Health OrganizationSierra Leone Ministry of HealthClinical management of patients in the Ebola treatment centres and other care centres in Sierra Leone - modified from “Clinical management of patients with viral haemorrhagic fever: A pocket guide for the front-line health worker”. World Health Organization, Geneva2014Google Scholar The turnaround time for Ebola RT-PCR and malaria testing was typically 24-72 hours as venous blood samples were sent to an off-site laboratory. Point-of-care glucose and I-STAT (Abbott Laboratories, Abbott Park, Illinois) measurements (including sodium, potassium, chloride, carbon dioxide, anion gap, ionized calcium, glucose, blood urea nitrogen, creatinine, hematocrit, and hemoglobin) became available after the unit was in operation and were used as clinically indicated. Suspected cases were separated into those with “wet” symptoms of hemorrhage, vomiting, and/or diarrhea, and those who were still “dry” and without such symptoms. Children represented one-tenth to one-third of the patient census at any given time. Between November 1, 2014, and March 17, 2015, 910 patients were admitted to the Maforki ETU with suspected or laboratory-confirmed Ebola, 908 of whom had ages recorded. Of these 908 admissions, 261 (28.7%) were children under 18 years of age. Eighty-seven (9.6%) were less than 5 years of age, 117 (12.9%) were 5-12 years old, and 57 (6.3%) were 13-17 years of age. Because Maforki was a holding unit before the treatment center component was added, diagnostic and outcome data are missing for patients in the first months of the unit's operation, making it impossible to determine the specific pediatric case fatality rate (CFR). The published CFR of 75%-80% in children in this and previous epidemics, particularly those under 5 years of age, is consistent with the Maforki ETU experience.3Frieden T. Eight ways Ebola threatens the children of West Africa. [updated January 16, 2015] Fox News. http://fxn.ws/1G6fSnZ. Accessed December 18, 2015.Google Scholar, 4McElroy A.K. Erickson B.R. Flietstra T.D. Rollin P.E. Nichol S.T. Towner J.S. et al.Biomarker correlates of survival in pediatric patients with Ebola virus disease.Emerg Infect Dis. 2014; 20: 1683-1690Crossref PubMed Scopus (66) Google Scholar, 5Nebehay S. High rates of child deaths from Ebola, special care needed: WHO. [updated February 6, 2015]. Reuters. http://reut.rs/1D5rmbR. Accessed December 18, 2015.Google Scholar, 6Peacock G. Uyeki T.M. Rasmussen S.A. Ebola virus disease and children: what pediatric health care professionals need to know.JAMA Pediatr. 2014; 168: 1087-1088Crossref PubMed Scopus (26) Google Scholar, 7W. H. O. Ebola Response TeamEbola virus disease among children in West Africa.N Engl J Med. 2015; 372: 1274-1277Crossref Scopus (93) Google Scholar In December 2014, the ETU at the Hastings Police Training School near Freetown, Sierra Leone, reported an overall CFR of 31.5% among 581 patients, significantly lower than what had been reported previously by other centers.8Ansumana R. Jacobsen K.H. Sahr F. Idris M. Bangura H. Boie-Jalloh M. et al.Ebola in Freetown area, Sierra Leone—a case study of 581 patients.N Engl J Med. 2015; 372: 587-588Crossref PubMed Scopus (90) Google Scholar The decrease in mortality was attributed to an aggressive regimen of intravenous (IV) fluids, antibiotics, anti-inflammatory, and nutritional agents. Age-specific mortality rates were not included in their report, so it is impossible to know how well the protocol performed for children. Their protocol influenced the World Health Organization recommendations (modified for Sierra Leone) for the care of patients with Ebola,2World Health OrganizationSierra Leone Ministry of HealthClinical management of patients in the Ebola treatment centres and other care centres in Sierra Leone - modified from “Clinical management of patients with viral haemorrhagic fever: A pocket guide for the front-line health worker”. World Health Organization, Geneva2014Google Scholar and served as a foundation for the development of similar aggressive protocols for the care of pediatric and adult patients at Maforki. The Maforki medical protocols assume a range of pediatric experience among practitioners and address the particular challenges in the care of children. The protocols recognize the need for the continuous accompaniment of children to ensure they receive fluids, nutrition, and medications, as well as psychological support. They also stress the critical recognition of chronic malnutrition in children presenting for care and the importance of modified fluid and nutrition protocols for malnourished children.9Iannotti L.L. Trehan I. Clitheroe K.L. Manary M.J. Diagnosis and treatment of severely malnourished children with diarrhoea.J Paediatr Child Health. 2015; 51: 387-395PubMed Google Scholar At Maforki, children were initially integrated with adults in the suspect and confirmed wards of the ETU. Recognizing their need for specialized care, after about 2 months children were separated into their own wards within the suspect and confirmed units. The pediatric wards were stocked with supplies and equipment specific to children's needs (eg, diapers, nutritional products, small-gauge IV needles, toys). Parents and their children suspected of having Ebola were placed together in the pediatric suspect ward. As soon as Ebola was confirmed by RT-PCR in either parent or child, discordant dyads were separated. Similarly, as soon as Ebola was ruled out in 1 person, the 2 were separated and that individual discharged. Mothers were asked to stop breastfeeding on admission to reduce the risk of viral transmission. This required extensive time and reinforcement of alternative feeding methods. Because parents often were unavailable to attend to their children, additional environmental adaptations were made for the safety of unattended children, who also presented unique challenges to the unit's infection prevention and control protocols (eg, leaving their beds, exploring medical supplies, etc.).10World Health OrganizationInterim infection prevention and control guidance for care of patients with suspected or confirmed filovirus haemorrhagic fever in health-care settings, with focus on Ebola. World Health Organization, Geneva2014Google Scholar The Table summarizes key elements of the medical treatment protocols with full details given in Appendix 1 (available at www.jpeds.com). Given the severe gastrointestinal fluid losses found in almost all patients with Ebola, significant emphasis was placed on fluid and electrolyte resuscitation. In addition to the liberal use of oral rehydration solution (ideally flavored to improve intake), emphasis was placed on early and aggressive parenteral fluid resuscitation, even among those who appeared well-hydrated initially (except for children confirmed or suspected to have malaria or malnutrition, because of the risk of fluid overload11Maitland K. Kiguli S. Opoka R.O. Engoru C. Olupot-Olupot P. Akech S.O. et al.Mortality after fluid bolus in African children with severe infection.N Engl J Med. 2011; 364: 2483-2495Crossref PubMed Scopus (1090) Google Scholar). It was believed that IV access would be easiest to obtain at the time of admission before further fluid losses made finding vascular access difficult. After much consideration and recognition of the risks to both providers and patients, a second IV line was added to the protocol for “wet” patients with active vomiting and/or diarrhea. Pressure bags to increase the rate of fluid administration were also used. In the approximately 10% of children in whom IV access could not be obtained, intraosseous (IO)12Paterson M.L. Callahan C.W. The use of intraosseous fluid resuscitation in a pediatric patient with Ebola virus disease.J Emerg Med. 2015; 49: 962-964Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar and occasionally subcutaneous routes (Appendix 2; available at www.jpeds.com) were used for fluid resuscitation.13Rouhani S. Meloney L. Ahn R. Nelson B.D. Burke T.F. Alternative rehydration methods: a systematic review and lessons for resource-limited care.Pediatrics. 2011; 127: e748-e757Crossref PubMed Google Scholar The fluid of choice was lactated Ringer solution, ideally supplemented with glucose, potassium, and magnesium, as guided by clinical status and bedside I-STAT monitoring.TableKey elements of Maforki pediatric treatment protocolsInitial assessments Temperature Weight Mid-upper arm circumference Blood pressure Assessment of hydration statusOral rehydration solution IV/IO fluidsBolus of lactated ringers with 5% dextroseReassessments of hydration status and repetition of half bolusesPotassium and magnesium supplementation for those with diarrhea Nutritional supplementationF-100 or ready-to-use therapeutic food or BP-100 biscuits AntimalarialsIV/IM artesunate dailyComplete course with oral artesunate-combination therapy AntibioticsIV/IM ceftriaxone dailyAdd metronidazole for selected cases ZincOral zinc daily Vitamin KOral or intramuscular dose on admissionConsideration of additional doses for those with active bleeding OndansetronAs needed for nausea and vomiting LoperamideAs needed for nonbloody diarrhea in confirmed patients with Ebola Open table in a new tab Just prior to the unit's closure, a portable bedside ultrasound machine became available. The instrument was used as an aid to IV line placement, for visualizing the inferior vena cava and descending aorta to assess hydration status, to assess the lungs and pleura for signs of effusion or pneumonia or pulmonary edema, and to assess for the presence of ascites as a late sign of fluid overload. Because of its late arrival, use was relatively limited, and it is unclear how much ultrasonography could have ultimately helped overcome the limitations imposed by personal protective equipment (PPE) in performing physical examinations and procedures. Medications were used to decrease the amount of gastrointestinal losses including antiemetics such as ondansetron (IV and by mouth). Recognizing the controversy around its use, and after careful consideration of risks and benefits, loperamide was introduced to decrease diarrheal fluid losses. Its use was limited to patients with RT-PCR-confirmed Ebola and nonbloody diarrhea14Chertow D.S. Uyeki T.M. DuPont H.L. Loperamide therapy for voluminous diarrhea in Ebola virus disease.J Infect Dis. 2015; 211: 1036-1037Crossref PubMed Scopus (18) Google Scholar because of the risk of toxicity in those with bacterial diarrhea. Loperamide was used successfully in a number of children without any observed adverse effects. Micronutrient supplementation included empiric oral zinc for all patients based on the emerging consensus that this decreases the severity and duration of diarrhea in children due to other infections.15Galvao T.F. Thees M.F. Pontes R.F. Silva M.T. Pereira M.G. Zinc supplementation for treating diarrhea in children: a systematic review and meta-analysis.Rev Panam Salud Publica. 2013; 33: 370-377Crossref PubMed Scopus (17) Google Scholar Vitamin K was also provided at admission for all patients based on the suspicion that the elevated serum hepatic transaminases seen in early reports of severe Ebola also may have16Lyon G.M. Mehta A.K. Varkey J.B. Brantly K. Plyler L. McElroy A.K. et al.Clinical care of two patients with Ebola virus disease in the United States.N Engl J Med. 2014; 371: 2402-2409Crossref PubMed Scopus (284) Google Scholar reflected decreased synthetic function and/or increased consumption of coagulation factors. These factors could contribute to prolonged prothrombin time, an assumption borne out to some degree in subsequent clinical reports.17Liddell A.M. Davey Jr., R.T. Mehta A.K. Varkey J.B. Kraft C.S. Tseggay G.K. et al.Characteristics and clinical management of a cluster of 3 patients with Ebola virus disease, including the first domestically acquired cases in the United States.Ann Intern Med. 2015; 163: 81-90Crossref PubMed Scopus (95) Google Scholar Empiric antibacterial therapy with ceftriaxone was included due to the high risk of severe bacterial infections (particularly because of Salmonella and pneumococcus) that could mimic the clinical picture of Ebola and given our limited diagnostic ability to differentiate between Ebola and bacterial sepsis. The concern for bacteremia, particularly attributable to gram-negative bacilli from gut translocation complicating Ebola also was believed to be high enough to warrant presumptive therapy.18Kreuels B. Wichmann D. Emmerich P. Schmidt-Chanasit J. de Heer G. Kluge S. et al.A case of severe Ebola virus infection complicated by Gram-negative septicemia.N Engl J Med. 2014; 371: 2394-2401Crossref PubMed Scopus (237) Google Scholar Other antibiotics such as ciprofloxacin, cefdinir, or amoxicillin/clavulanate were used if an oral option was required. Initially, all patients received metronidazole as had been standard at Hastings.8Ansumana R. Jacobsen K.H. Sahr F. Idris M. Bangura H. Boie-Jalloh M. et al.Ebola in Freetown area, Sierra Leone—a case study of 581 patients.N Engl J Med. 2015; 372: 587-588Crossref PubMed Scopus (90) Google Scholar After we observed that a large number of patients had a significant increase in abdominal pain and nausea, its empiric use was limited to those with severe or bloody diarrhea. Similarly, endemic Plasmodium falciparum malaria was frequently found to mimic the clinical presentation of Ebola in children. Thus, all children received antimalarial therapy, begun on admission as IV artesunate, followed by a complete course of artemisinin-combination therapy (ACT). The laboratory available to us was off-site and used a commercial malaria rapid diagnostic test. Results generally were available 24-72 hours after admission. Given the limited ability and timeliness in diagnosing malaria, we elected to complete the full course of ACT even for patients with negative rapid diagnostic test results. Malaria potentially contracted in the unit and the theoretical benefit of a period of posttreatment prophylaxis that might extend some 10 days after completing ACT were additional rationales for the full course of ACT.19Nosten F. White N.J. Artemisinin-based combination treatment of falciparum malaria.Am J Trop Med Hyg. 2007; 77: 181-192Crossref PubMed Scopus (457) Google Scholar After recognizing continued significant mortality in children, nutritional care evolved to take a high priority. The World Health Organization Ebola nutrition recommendations20WHO/UNICEF/WFPInterim guideline: nutritional care of children and adults with Ebola virus disease in treatment centres. World Health Organization, Geneva2014Google Scholar were adapted to make liberal use of F-100 and ready-to-use therapeutic food (Appendix 3; available at www.jpeds.com). Brief nutritional assessments were made on admission using mid-upper arm circumference and weight when scales became available. Children with moderate acute malnutrition who were suspected or confirmed to have Ebola were considered to have “complicated moderate acute malnutrition ” and treated according to standard outpatient therapeutic feeding protocols for severe acute malnutrition.21Trehan I. Manary M.J. Management of severe acute malnutrition in low-income and middle-income countries.Arch Dis Child. 2015; 100: 283-287Crossref PubMed Scopus (12) Google Scholar Even with pediatric-specific equipment, assessments, and protocol-guided treatments, the greatest limitation to effective pediatric care remained the intermittent presence of staff at the bedside because of the challenges of working in PPE under extremely hot and humid conditions. The current forms of PPE limit staff time with patients to 1- to 2-hour intervals, 2 or 3 times in an 8- to 12-hour shift, a challenge that must be rationally addressed in the future if patient care is to be optimized.22Sprecher A.G. Caluwaerts A. Draper M. Feldmann H. Frey C.P. Funk R.H. et al.Personal protective equipment for filovirus epidemics: a call for better evidence.J Infect Dis. 2015; 212: S98-S100Crossref PubMed Scopus (33) Google Scholar This limitation made it particularly difficult to maintain parenteral access; resuscitation was interrupted and lines disconnected for safety when staff left the bedside. Components of Western treatment were adapted in an effort to move toward optimal care and improved mortality for critically ill children with Ebola.23Chertow D.S. Kleine C. Edwards J.K. Scaini R. Giuliani R. Sprecher A. Ebola virus disease in West Africa—clinical manifestations and management.N Engl J Med. 2014; 371: 2054-2057Crossref PubMed Scopus (266) Google Scholar, 24Fowler R.A. Fletcher T. Fischer II, W.A. Lamontagne F. Jacob S. Brett-Major D. et al.Caring for critically ill patients with Ebola virus disease. Perspectives from West Africa.Am J Respir Crit Care Med. 2014; 190: 733-737Crossref PubMed Scopus (174) Google Scholar, 25Lamontagne F. Clement C. Fletcher T. Jacob S.T. Fischer II, W.A. Fowler R.A. Doing today's work superbly well—treating Ebola with current tools.N Engl J Med. 2014; 371: 1565-1566Crossref PubMed Scopus (76) Google Scholar, 26Farmer P. The secret to curing West Africa from Ebola is no secret at all. [updated January 16, 2015]. The Washington Post. http://wapo.st/14IXlAZ. Accessed December 18, 2015.Google Scholar, 27Eriksson C.O. Uyeki T.M. Christian M.D. King M.A. Braner D.A. Kanter R.K. et al.Care of the child with Ebola virus disease.Pediatr Crit Care Med. 2015; 16: 97-103Crossref PubMed Scopus (14) Google Scholar Further improvements in the care environment may depend on better staffing models and climate-controlled ETUs in order to maximize staff accompaniment. In addition to the limitations of current care models, other factors likely also contribute to the high mortality of children with Ebola, particularly those less than 5 years of age. Children have a shorter incubation period and a more rapid progression to death, perhaps as a result of a higher viral inoculum relative to body weight.7W. H. O. Ebola Response TeamEbola virus disease among children in West Africa.N Engl J Med. 2015; 372: 1274-1277Crossref Scopus (93) Google Scholar The diagnosis of Ebola in the pediatric population may be delayed, as symptoms can mimic other common illnesses (eg, malaria, measles, and gastroenteritis). Children with Ebola are often brought for care later in the course of their disease, often after a period of underfeeding and its consequent immune deprivation, because their parents are ill or deceased. There remain a number of opportunities for further improvements in the care of children with Ebola. What is presented here is only the final iteration of our protocols that evolved over time based on accumulated experience and published literature. Interventions to improve the ability for providers to spend more time at the bedside, attempting to approach the level of attention and care children receive in traditional hospital settings or critical care units, has fundamental importance. Caring for patients in the hot and humid tropics is challenging to begin with and of course the addition of hot and stifling PPE makes this even more difficult. Lighter PPE and environmental cooling measures such as air conditioning would allow for longer and more focused periods of bedside care. Given that such changes are likely too expensive and logistically challenging at the present time and given present resources, some limitations on performing a thorough physical examination while wearing PPE might be overcome through technological innovations such as digital stethoscopes28McNeil DG Jr. In treating Ebola, even using a stethoscope becomes a challenge. [updated February 8, 2015]. http://nyti.ms/1IweznG. Accessed December 18, 2015.Google Scholar and remote monitoring of vital signs.29Steinhubl S.R. Marriott M.P. Wegerich S.W. Remote sensing of vital signs: a wearable, wireless “band-aid” sensor with personalized analytics for improved Ebola patient care and worker safety.Glob Health Sci Pract. 2015; 3: 516-519Crossref PubMed Scopus (15) Google Scholar From a patient monitoring standpoint, an essential improvement in care would be more accurate methods for assessing and improving hydration status in this infection that predominantly manifests as a severe gastroenteritis.30Freedman S.B. Vandermeer B. Milne A. Hartling L. Pediatric Emergency Research Canada Gastroenteritis Study GroupDiagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis.J Pediatr. 2015; 166: 908-916.e1-6Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar The most simple and essential aspect of assessing hydration status would be an accurate method to quantify intake and output, which proved remarkably challenging without a round-the-clock bedside presence. The use of adult Ebola survivors as caretakers who could spend long periods at the bedside without PPE should be considered, both for the sake of accompaniment but also as aides to ensure that each child's intake and output would be captured accurately. Frequent blood pressure monitoring and consistently obtained daily weights would be helpful as well, but these require careful consideration of the infection control implications. Better methods to consistently maintain IV access for fluid resuscitation in children are also needed; consideration should be given to obtaining early central venous access, as has been successfully demonstrated in adults.31Rees P.S. Lamb L.E. Nicholson-Roberts T.C. Ardley C.N. Bailey M.S. Hinsley D.E. et al.Safety and feasibility of a strategy of early central venous catheter insertion in a deployed UK military Ebola virus disease treatment unit.Intensive Care Med. 2015; 41: 735-743Crossref PubMed Scopus (22) Google Scholar It should also be feasible to make better use of point-of-care testing (eg, lactate, blood gases, glucose) to individualize each child's fluid and electrolyte resuscitation. An even more ambitious goal would be to develop an infrastructure for safe blood transfusions as part of goal-directed therapy for septic patients. We believe that even in the absence of marked infrastructure improvements such as climate-controlled ETUs or innovations such as lighter PPE, an early emphasis on appropriate and thorough training of both local and expatriate staff, as well as aggressive intervention and monitoring with already available technologies will lead to significant decreases in mortality. More comprehensive nutritional care for pediatric patients also should be provided. Although our protocols aimed for nutritional care at all hours, we were still unable to have a clinician or survivor caregiver at the bedside at all times. Given the severe nausea and vomiting in children with Ebola as well as each child's unique development and behaviors including sleep/wake cycle and interest in activities, it was impossible to predict exactly when each child would be hungry. Thus, it should be the goal to have caregivers at the bedside with food or formula available at all times. Psychosocial support also should be available on the child's schedule as much as possible, conceivably as an adaptation of the Child Life services available in children's hospitals. Given the relatively nonspecific case definition for suspect Ebola cases,2World Health OrganizationSierra Leone Ministry of HealthClinical management of patients in the Ebola treatment centres and other care centres in Sierra Leone - modified from “Clinical management of patients with viral haemorrhagic fever: A pocket guide for the front-line health worker”. World Health Organization, Geneva2014Google Scholar, 32Lado M. Walker N.F. Baker P. Haroon S. Brown C.S. Youkee D. et al.Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective cohort study.Lancet Infect Dis. 2015; 15: 1024-1033Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar at least one-half of the children we cared for did not have Ebola. Diagnostic capabilities were limited, so most children were treated with empiric antibiotics and antimalarials. A more refined care regimen would risk-stratify those children most likely to have Ebola based on algorithms incorporating clinical and historical criteria,33Levine A.C. Shetty P.P. Burbach R. Cheemalapati S. Glavis-Bloom J. Wiskel T. et al.Derivation and internal validation of the Ebola prediction score for risk stratification of patients with suspected Ebola virus disease.Ann Emerg Med. 2015; 66: 285-293.e1Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar potentially isolating highest-risk patients (as identified by these algorithms) in their own “suspect” wards while testing is conducted. In infants and children where there is difficulty in obtaining blood samples, capillary samples could be used initially as an alternative, although it should be remembered that they would not be perfectly sensitive.34Strecker T. Palyi B. Ellerbrok H. Jonckheere S. de Clerck H. Bore J.A. et al.Field evaluation of capillary blood samples as a collection specimen for the rapid diagnosis of Ebola virus infection during an outbreak emergency.Clin Infect Dis. 2015; 61: 669-675Crossref PubMed Scopus (25) Google Scholar Future diagnostic regimens should incorporate rapid Ebola tests,35Broadhurst M.J. Kelly J.D. Miller A. Semper A. Bailey D. Groppelli E. et al.ReEBOV Antigen Rapid Test kit for point-of-care and laboratory-based testing for Ebola virus disease: a field validation study.Lancet. 2015; 386: 867-874Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar specific testing for common childhood illnesses,36O'Shea M.K. Clay K.A. Craig D.G. Matthews S.W. Kao R.L. Fletcher T.E. et al.Diagnosis of febrile illnesses other than Ebola virus disease at an Ebola treatment unit in Sierra Leone.Clin Infect Dis. 2015; 61: 795-798Crossref PubMed Scopus (35) Google Scholar including rapid malaria and HIV tests, and rapid multiplex polymerase chain reaction-based bacterial and viral stool studies. All of these would of course require more sophisticated and complete laboratory facilities and isolation procedures. But as Ebola becomes a routine element of patient assessment and medical care in this region, the accurate diagnosis of common childhood diseases that mimic Ebola will become even more essential. The disruption of routine primary care during the epidemic has led to significant delays in routine, critical vaccinations.37Takahashi S. Metcalf C.J. Ferrari M.J. Moss W.J. Truelove S.A. Tatem A.J. et al.Reduced vaccination and the risk of measles and other childhood infections post-Ebola.Science. 2015; 347: 1240-1242Crossref PubMed Scopus (134) Google Scholar Catch-up immunizations should be provided to children admitted to an ETU while they are a “captive audience” in the health care system. Finally, as children recover from Ebola, psychosocial support for re-integration back into their community should be formalized, including preparing their families for the continued physical and psychological challenges they are likely to face. If available, physical and occupational therapy could even be introduced while children are convalescing in the ETU prior to discharge. In the future, frequent reassessment of the effectiveness of each new intervention and a flexibility to adapt to unpredictable problems and unanticipated consequences will be essential. Given the continued high mortality rate of children with Ebola, we should not remain satisfied with our current protocols. It is clear that with optimal care many of these children do not have to die.24Fowler R.A. Fletcher T. Fischer II, W.A. Lamontagne F. Jacob S. Brett-Major D. et al.Caring for critically ill patients with Ebola virus disease. Perspectives from West Africa.Am J Respir Crit Care Med. 2014; 190: 733-737Crossref PubMed Scopus (174) Google Scholar The care of children with suspected or confirmed Ebola in West Africa is extremely challenging, and current models of intermittent care driven by the limitations inherent to PPE leaves room for significant opportunities for improvement. Nevertheless, despite these handicaps, a methodical and aggressive approach to patient care is possible. More work is needed to understand how underlying social and nutritional vulnerability may contribute to high mortality rates, and more effort is needed to provide age-appropriate supportive and critical care for hospitalized children.