Inserting IVs into tiny veins, persuading sick children to eat, discerning the presence of other diseases, comforting children who are separated from their parents—the challenges of treating the youngest Ebola patients have proved medically difficult and emotionally brutal for Partners In Health clinicians and their colleagues in West Africa.
Although precise figures are hard to come by, reports suggest that children under 5 have dismal chances of surviving the virus.
Dr. Chuck Callahan, a pediatrician with more than three decades of experience, worked in Sierra Leone as part of PIH’s Ebola Response.
“These were the sickest children I have ever seen,” Callahan said. “In a bad year in my intensive care unit in the States, we’d have six or eight kids die out of hundreds of admissions. In the two months I was there, I think there were 23 deaths.”
Callahan is a pediatrics professor and retired U.S. Army colonel, and former director of Fort Belvoir Community Hospital in northern Virginia. He believes what makes young children vulnerable to dying from Ebola are the lack of round-the-clock nursing, malnutrition, and other underlying diseases. He and other PIH team members have created protocols to care for children with Ebola, which they hope to make available through publication in a medical journal.
The challenges begin with poverty-related health issues. The probability of survival for Sierra Leonean children was among the lowest in the world even before Ebola. According to World Bank figures, the likelihood that a child in the country would die before age 5 was 161 per 1,000 in 2013. By contrast, probability of death before age 5 in the United States was 7 per 1,000.
“The common causes of death for children in Sierra Leone are treatable conditions such as malaria, pneumonia, and diarrhea—all of which are significantly more dangerous when a child has malnutrition,” said Dr. Joia Mukherjee, PIH’s chief medical officer and a pediatrician. “These underlying conditions have made mortality very high among young children with Ebola.”
Some children who came to the unit had diseases such as malaria or pneumonia—sometimes instead of Ebola, sometimes in addition to it—and these were difficult to diagnose. The latter typically would be evaluated by listening to the lungs. But clinicians can’t use a stethoscope while wearing full-body personal protective equipment (PPE). In these cases, pediatric nurse practitioner Tracy Kelly said, they did their best to treat children based on visible symptoms and history from caregivers.
Challenges of care
Callahan worked at the 108-bed Maforki Ebola Treatment Unit in Port Loko in December and January. Port Loko is about 2.5 hours northeast of Freetown, the capital, in an area with a large number of Ebola cases. The ETU has admitted 788 patients—84 younger than 5.
As with adults, care for children begins with fluids. People who have Ebola lose liter upon liter of liquid through vomiting and diarrhea, making fluid replacement crucial. During Callahan’s stint, responders started putting IVs in children more regularly to resuscitate and rehydrate them. In some cases, they used intraosseous lines (inserted into the bone) if insertion into a vein wasn’t possible.
“The more aggressive use of hydration has certainly dropped mortality rates,” Mukherjee said.
Many more children younger than 5 with Ebola died at the Maforki ETU, compared with older children.
This might be related to differences in their immune systems, Callahan said. Younger children’s immune systems haven’t yet matured, and an attack from Ebola might be too much to handle. Younger children also are less likely to be able to eat and drink on their own, and they require more hands-on care.
Dr. Regan Marsh and Dr. Guy Giordano place an intravenous line in a 3-year-old boy the night of Jan. 9, 2015, at the Maforki Ebola Treatment Unit in Port Loko, Sierra Leone. IVs have become standard for all patients at the ETU. Clinicians later found that this boy had malaria and not Ebola, and he was transferred out of the ETU for care. (Photo: Rebecca E. Rollins/Partners In Health)
Malnutrition and breastfeeding
The high death rate among young children also might be related to malnutrition, Kelly said. Before heading to Port Loko, Kelly worked in Rwanda, Cambodia, and Indonesia, where she developed a keen interest in the issue.
According to Sierra Leone’s 2013 Demographic and Health Survey, 38 percent of children younger than 5 were stunted (having low height for their age)—18 percent severely. Stunting suggests chronic malnutrition. Children who are short for their age probably have received inadequate nutrition for quite some time. In the same year, 9 percent of children under 5 were categorized as wasted (having low weight for height). Wasting reveals acute malnutrition. Sixteen percent of Sierra Leonean children younger than 5 were underweight for their age, which can indicate both acute and chronic malnutrition.
Malnutrition is related to a number of factors. Most obvious is poverty: buying and even growing food requires resources. In addition, people living in poor countries often don’t have access to micronutrients such as zinc, vitamin A, vitamin D, and iron, Kelly said. Foods aren’t fortified with those elements as they often are in rich countries. And families do their best to feed their children, but diets often contain mostly staples, such as cassava and maize, and limited fresh fruits and vegetables.
Clinicians working with PIH have started to measure mid-upper arm circumference to determine whether children who arrive at the ETU are malnourished, Kelly said.
“We believe that very aggressive treatment of severe malnutrition has to be given at the same time as treatment for Ebola,” Mukherjee said. “PIH has experience in treating children with malnutrition in many countries, and what we see is that unless adequate calories are given every two to three hours, children will die. The timing and ‘dosing’ of food—whether therapeutic milk or nutrition-fortified peanut butter (ready-to-use therapeutic food, RUTF)—is critical to ensuring survival.”
Another major challenge is breastfeeding. Breastfeeding mothers often enter the ETU clutching their babies, and clinicians ask them to stop breastfeeding until results of Ebola tests for both are available. Close contact puts people at risk of becoming infected, and breast milk can contain Ebola virus.
“A 3-month-old child comes in with their mother … who’s also very sick, and we say right away ‘stop breastfeeding, no breastfeeding’—the infant doesn’t know how to feed by bottle or cup or spoon, and the mother is too sick to prepare the formula,” Kelly said. “If you’ve ever had an exclusively breastfed child and you’re introducing a new tool, it’s very difficult.”
Further problems arise when a child and mother come in and one is Ebola-positive and the other negative. Clinicians must separate the pair. If a mother is positive and a child is not, the child is taken to an observation center for 21 days, Ebola’s maximum incubation period. If the reverse is true, the child must be separated from his or her family and placed in the unit for treatment.
“Very often I had a sense that a child who was malnourished was not going to make it,” Kelly said. “And we know virtually all the children under 1 year of age were not going to make it, and all those children were breastfeeding.”
Dr. Regan Marsh cares for 9-year-old Mariatu while an adult Ebola survivor helps to feed and encourage the little girl Jan. 9, 2015, at Government Hospital in Port Loko, Sierra Leone. Mariatu, who suffers from extreme malnutrition, had been so close to death that PIH clinicians were preparing to call the burial team. Her condition was improving by the time this photo was taken. (Photo: Rebecca E. Rollins/Partners In Health)
Realities of the treatment unit
A child alone in an Ebola unit is extremely difficult to feed, Kelly said. Clinicians in PPE have to tend to as many patients as possible in about two hours, the maximum length of time it is safe to stay suited up. There is little time to sit and help a toddler eat. Adult patients or older children frequently help care for the small ones.
Kelly described a 9-month-old child she was treating. Clinicians put in an intraosseous line and placed the child carefully on a mattress on the floor with a makeshift railing, as there were no cribs or beds with railings. An older girl was receiving treatment in the next bed.
“Invariably, every time I came in, the 12-year-old girl was lying on the mattress cuddling the child, trying to provide a safe, secure environment,” Kelly said. “And those two were not related in any way. You can just imagine if that 9-month-old had died, what’s the impact on the 12-year-old girl? … There’s a whole psychological effect of what went on in the Ebola unit that I don’t think we’ve tapped into all that much.”
The 9-month-old and the 12-year-old survived.
Past outbreaks have been far smaller than the current epidemic, sickening a few dozen or a few hundred people rather than more than 23,000. Children typically account for only 20 percent of cases. This may help explain why there has not historically been a special focus on children in Ebola outbreaks, even though they are among the most vulnerable. If another epidemic occurs, Callahan said, responders should be prepared to take their specialized needs into consideration. That’s where published protocols come in.
The protocols Callahan and other clinicians have crafted call for antibiotics, vitamins, antimalarial drugs, fluids, and nutritious foods. They also include systematic screening for malnutrition and treatment when needed. The protocols offer adjusted treatment courses depending on symptoms and severity.
Continuous nursing care also might improve survival, he said. Callahan believes there’s a need for child-only Ebola treatment units with nurses tending to them 24 hours a day. This type of care is difficult because of staffing numbers and PPE-related limitations.
“Children with Ebola are very often critically ill, and effective critical care involves three components: critical care monitoring, critical care nursing, and critical care treatment,” he said. “Those are the three things that we have to plan on, and those are the three things that have not been consistently available to care for these children, in my assessment.”
Three-year-old Ibrahim survived Ebola but lost his sight as the virus ran its course. Ibrahim, who lost both parents to Ebola, is receiving treatment for malnutrition at Government Hospital in Port Loko, Sierra Leone. (Photo: Rebecca E. Rollins/Partners In Health)
Medical needs aside, caring for children with Ebola is gut-wrenching, Kelly and Callahan said. Clinicians have to avoid unnecessary physical contact with all patients, to protect themselves from the disease. Sick children often have other ideas.
“You really want to try to keep your physical distance if you can so you don’t risk contamination,” Kelly said. “Think of any 3-year-old child you know. They’re going to come up to you; they want to hug you.”
After watching a child suffer from Ebola, clinicians are heartened to see little ones overcome the disease. When survivors leave the Maforki ETU in Port Loko, they tie a ribbon to a survivors’ tree. The clinicians, still in protective gear, help send off the children.
But many children survive only to return to situations where malnutrition, uncertainty, and disease pose a constant threat. Although the efforts of West African clinicians, the Ministries of Health, the local people, and international teams have helped slow Ebola, primary health care concerns must be addressed to give the children and families that survive Ebola the opportunity to thrive.
“Many of them are going back to a community they don’t know well or they’re going to an orphanage, or maybe their mother or father died or brother and sister died,” Kelly said. “This very joyful celebration is very bittersweet … to realize that they still have a lot of difficulty in their next years of life, and though it is joyful that they have been discharged and they’re survivors, the journey is only just beginning.”
See more photos of PIH's response to Ebola.