Comprehensive Clinical Care for Infants and Children with Ebola Virus Disease

  • Indi TrehanEmail author
  • Peter Matthew George
  • Charles W. Callahan
Part of the Global Maternal and Child Health book series (GMCH)


The 2013–2015 West African Ebola outbreak was by far the largest outbreak the world has ever faced. Ebola Treatment Units were set up throughout the three affected countries to care for suspected and confirmed cases of Ebola; among the most challenging patients cared for were children, who despite the best care available often had mortality rates far higher than healthy young adults. In addition to Liberia and Guinea, Sierra Leone also suffered immensely during the outbreak. Here we present the key elements for the care of children, grounded in the principles of pediatric critical care, balanced by our own experiences in Sierra Leone in 2014–2015, and informed by the peer-reviewed medical literature. These guidelines will need to be updated as further evidence and technologies become available should they be needed to care for children again in a future ETU, but they demonstrate the complexities and difficulties in providing theoretically simple yet practically complex care under austere conditions.


Antibiotics Children Infants Critical care Clinical care Diagnosis Ebola Fluids Nutrition Pediatrics Treatment West African Ebola epidemic Ebola treatment units Ebola virus disease Clinical recommendations 


  1. Ansumana, R., Jacobsen, K. H., Sahr, F., Idris, M., Bangura, H., Boie-Jalloh, M., et al. (2015). Ebola in Freetown area, Sierra Leone--A case study of 581 patients. New England Journal of Medicine, 372(6), 587–588. Scholar
  2. Baez, F., Perez, J., & Reed, G. (2015). Meet Cuban Ebola fighters: Interview with Felix Baez and Jorge Perez. MEDICC Review, 17(1), 6–10.PubMedGoogle Scholar
  3. Bower, H., Johnson, S., Bangura, M. S., Kamara, A. J., Kamara, O., Mansaray, S. H., et al. (2016). Exposure-specific and age-specific attack rates for Ebola virus disease in Ebola-affected households, Sierra Leone. Emerging Infectious Diseases, 22(8), 1403–1411. Scholar
  4. Broadhurst, M. J., Brooks, T. J., & Pollock, N. R. (2016). Diagnosis of Ebola virus disease: Past, present, and future. Clinical Microbiology Reviews, 29(4), 773–793. Scholar
  5. Chertow, D. S., Kleine, C., Edwards, J. K., Scaini, R., Giuliani, R., & Sprecher, A. (2014). Ebola virus disease in West Africa--Clinical manifestations and management. New England Journal of Medicine, 371(22), 2054–2057. Scholar
  6. Chertow, D. S., Uyeki, T. M., & DuPont, H. L. (2015). Loperamide therapy for voluminous diarrhea in Ebola virus disease. Journal of Infectious Diseases, 211(7), 1036–1037. Scholar
  7. Cournac, J. M., Karkowski, L., Bordes, J., Aletti, M., Duron, S., Janvier, F., et al. (2016). Rhabdomyolysis in Ebola virus disease. Results of an observational study in a treatment center in Guinea. Clinical Infectious Diseases, 62(1), 19–23. Scholar
  8. Damkjaer, M., Rudolf, F., Mishra, S., Young, A., & Storgaard, M. (2017). Clinical features and outcome of Ebola Virus disease in pediatric patients: A retrospective case series. Journal of Pediatrics, 182(3), 378–381.e371. Scholar
  9. DeBiasi, R. L., Song, X., Cato, K., Floyd, T., Talley, L., Gorman, K., et al. (2016). Preparedness, evaluation, and care of pediatric patients under investigation for Ebola virus disease: Experience from a pediatric designated care facility. Journal of the Pediatric Infectious Diseases Society, 5(1), 68–75. Scholar
  10. Delamou, A., Ayadi, A. M., Sidibe, S., Delvaux, T., Camara, B. S., Sandouno, S. D., et al. (2017). Effect of Ebola virus disease on maternal and child health services in Guinea: A retrospective observational cohort study. Lancet Global Health, 5(4), e448–e457. Scholar
  11. Dhillon, R. S., Srikrishna, D., Garry, R. F., & Chowell, G. (2015). Ebola control: Rapid diagnostic testing. Lancet Infectious Diseases, 15(2), 147–148. Scholar
  12. Dornemann, J., Burzio, C., Ronsse, A., Sprecher, A., De Clerck, H., Van Herp, M., et al. (2017). First newborn baby to receive experimental therapies survives Ebola virus disease. Journal of Infectious Diseases.
  13. Eriksson, C. O., Uyeki, T. M., Christian, M. D., King, M. A., Braner, D. A., Kanter, R. K., et al. (2015). Care of the child with Ebola virus disease. Pediatric Critical Care Medicine, 16(2), 97–103. Scholar
  14. Farmer, P. (2015). The secret to curing West Africa from Ebola is no secret at all. Retrieved November 5, 2017, from
  15. Fitzgerald, F., Awonuga, W., Shah, T., & Youkee, D. (2016a). Ebola response in Sierra Leone: The impact on children. Journal of Infection, 72(Suppl), S6–S12. Scholar
  16. Fitzgerald, F., Naveed, A., Wing, K., Gbessay, M., Ross, J. C., Checchi, F., et al. (2016b). Ebola virus disease in children, Sierra Leone, 2014-2015. Emerging Infectious Diseases, 22(10), 1769–1777. Scholar
  17. Fitzgerald, F., Wing, K., Naveed, A., Gbessay, M., Ross, J. C., Checchi, F., et al. (2017a). Risk in the “Red Zone”: Outcomes for children admitted to Ebola holding units in Sierra Leone without Ebola virus disease. Clinical Infectious Diseases. Scholar
  18. Fitzgerald, F., Wing, K., Naveed, A., Gbessay, M., Ross, J. C. G., Checchi, F., et al. (2017b). Refining the paediatric Ebola case definition: A study of children in Sierra Leone with suspected Ebola virus disease. Lancet, 389, S19. Scholar
  19. Fowler, R. A., Fletcher, T., Fischer II, W. A., Lamontagne, F., Jacob, S., Brett-Major, D., et al. (2014). Caring for critically ill patients with ebola virus disease. Perspectives from West Africa. American Journal of Respiratory and Critical Care Medicine, 190(7), 733–737. Scholar
  20. Frieden, T. (2015). Eight ways Ebola threatens the children of West Africa. Retrieved October 23, 2017, from
  21. Gignoux, E., Azman, A. S., de Smet, M., Azuma, P., Massaquoi, M., Job, D., et al. (2016). Effect of artesunate-amodiaquine on mortality related to Ebola virus disease. New England Journal of Medicine, 374(1), 23–32. Scholar
  22. Glynn, J. R. (2015). Age-specific incidence of Ebola virus disease. Lancet, 386(9992), 432. Scholar
  23. Guerrant, R. L., Oria, R. B., Moore, S. R., Oria, M. O., & Lima, A. A. (2008). Malnutrition as an enteric infectious disease with long-term effects on child development. Nutrition Reviews, 66(9), 487–505. Scholar
  24. Hartley, M. A., Young, A., Tran, A. M., Okoni-Williams, H. H., Suma, M., Mancuso, B., et al. (2017). Predicting Ebola severity: A clinical prioritization score for Ebola virus disease. PLoS Neglected Tropical Diseases, 11(2), e0005265. Scholar
  25. Hermans, V., Zachariah, R., Woldeyohannes, D., Saffa, G., Kamara, D., Ortuno-Gutierrez, N., et al. (2017). Offering general pediatric care during the hard times of the 2014 Ebola outbreak: Looking back at how many came and how well they fared at a Medecins Sans Frontieres referral hospital in rural Sierra Leone. BMC Pediatrics, 17(1), 34. Scholar
  26. Iannotti, L. L., Trehan, I., Clitheroe, K. L., & Manary, M. J. (2015). Diagnosis and treatment of severely malnourished children with diarrhoea. Journal of Paediatrics and Child Health, 51(4), 387–395. Scholar
  27. Katona, P., & Katona-Apte, J. (2008). The interaction between nutrition and infection. Clinical Infectious Diseases, 46(10), 1582–1588. Scholar
  28. Kreuels, B., Wichmann, D., Emmerich, P., Schmidt-Chanasit, J., de Heer, G., Kluge, S., et al. (2014). A case of severe Ebola virus infection complicated by Gram-negative septicemia. New England Journal of Medicine, 371(25), 2394–2401. Scholar
  29. Lado, M., Walker, N. F., Baker, P., Haroon, S., Brown, C. S., Youkee, D., et al. (2015). Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: A retrospective cohort study. Lancet Infectious Diseases, 15(9), 1024–1033. Scholar
  30. Lamontagne, F., Clement, C., Fletcher, T., Jacob, S. T., Fischer II, W. A., & Fowler, R. A. (2014). Doing today’s work superbly well--Treating Ebola with current tools. New England Journal of Medicine, 371(17), 1565–1566. Scholar
  31. Lazzerini, M., & Wanzira, H. (2016). Oral zinc for treating diarrhoea in children. Cochrane Database of Systematic Reviews, (12), CD005436.
  32. Liddell, A. M., Davey Jr., R. T., Mehta, A. K., Varkey, J. B., Kraft, C. S., Tseggay, G. K., et al. (2015). Characteristics and clinical management of a cluster of 3 patients eith Ebola virus disease, including the first domestically acquired cases in the United States. Annals of Internal Medicine, 163(2), 81–90. Scholar
  33. Lyon, G. M., Mehta, A. K., Varkey, J. B., Brantly, K., Plyler, L., McElroy, A. K., et al. (2014). Clinical care of two patients with Ebola virus disease in the United States. New England Journal of Medicine, 371(25), 2402–2409. Scholar
  34. MacDermott, N. E., De, S., & Herberg, J. A. (2016). Viral haemorrhagic fever in children. Archives of Disease in Childhood, 101(5), 461–468. Scholar
  35. Maitland, K., Kiguli, S., Opoka, R. O., Engoru, C., Olupot-Olupot, P., Akech, S. O., et al. (2011). Mortality after fluid bolus in African children with severe infection. New England Journal of Medicine, 364(26), 2483–2495. Scholar
  36. McElroy, A. K., Erickson, B. R., Flietstra, T. D., Rollin, P. E., Nichol, S. T., Towner, J. S., et al. (2014). Biomarker correlates of survival in pediatric patients with Ebola virus disease. Emerging Infectious Diseases, 20(10), 1683–1690. Scholar
  37. Mendoza, E. J., Qiu, X., & Kobinger, G. P. (2016). Progression of Ebola therapeutics during the 2014-2015 Outbreak. Trends in Molecular Medicine, 22(2), 164–173. Scholar
  38. Mobula, L. M. (2014). Courage is not the absence of fear: Responding to the Ebola outbreak in Liberia. Global Health: Science and Practice, 2(4), 487–489. Scholar
  39. Nebehay, S. (2015). High rates of child deaths from Ebola, special care needed: WHO. Retrieved March 25, 2017, from
  40. Nelson, J. M., Griese, S. E., Goodman, A. B., & Peacock, G. (2016). Live neonates born to mothers with Ebola virus disease: A review of the literature. Journal of Perinatology, 36(6), 411–414. Scholar
  41. Nosten, F., & White, N. J. (2007). Artemisinin-based combination treatment of falciparum malaria. American Journal of Tropical Medicine and Hygiene, 77(6 Suppl), 181–192.CrossRefGoogle Scholar
  42. Palich, R., Gala, J. L., Petitjean, F., Shepherd, S., Peyrouset, O., Abdoul, B. M., et al. (2016). A 6-Year-old child with severe Ebola virus disease: Laboratory-guided clinical care in an Ebola treatment center in Guinea. PLoS Neglected Tropical Diseases, 10(3), e0004393. Scholar
  43. Paterson, M. L., & Callahan, C. W. (2015). The use of intraosseous fluid resuscitation in a pediatric patient with Ebola virus disease. Journal of Emergency Medicine, 49(6), 962–964. Scholar
  44. Peacock, G., Uyeki, T. M., & Rasmussen, S. A. (2014). Ebola virus disease and children: What pediatric health care professionals need to know. JAMA Pediatrics, 168(12), 1087–1088. Scholar
  45. Prevail II Writing Group. (2016). A randomized, controlled trial of ZMapp for Ebola virus infection. New England Journal of Medicine, 375(15), 1448–1456. Scholar
  46. Rosenke, K., Adjemian, J., Munster, V. J., Marzi, A., Falzarano, D., Onyango, C. O., et al. (2016). Plasmodium parasitemia associated with increased survival in Ebola virus-infected patients. Clinical Infectious Diseases, 63(8), 1026–1033. Scholar
  47. Rouhani, S., Meloney, L., Ahn, R., Nelson, B. D., & Burke, T. F. (2011). Alternative rehydration methods: A systematic review and lessons for resource-limited care. Pediatrics, 127(3), e748–e757. Scholar
  48. Schibler, M., Vetter, P., Cherpillod, P., Petty, T. J., Cordey, S., Vieille, G., et al. (2015). Clinical features and viral kinetics in a rapidly cured patient with Ebola virus disease: A case report. Lancet Infectious Diseases, 15(9), 1034–1040. Scholar
  49. Schieffelin, J. S., Shaffer, J. G., Goba, A., Gbakie, M., Gire, S. K., Colubri, A., et al. (2014). Clinical illness and outcomes in patients with Ebola in Sierra Leone. New England Journal of Medicine, 371(22), 2092–2100. Scholar
  50. Scrimshaw, N. S. (2003). Historical concepts of interactions, synergism and antagonism between nutrition and infection. Journal of Nutrition, 133(1), 316S–321S.CrossRefGoogle Scholar
  51. Scrimshaw, N. S., Taylor, C. E., & Gordon, J. E. (1968). Interactions of nutrition and infection. Monograph Series of the World Health Organization, 57, 3–329.Google Scholar
  52. Shah, S., Price, D., Bukham, G., Shah, S., & Wroe, E. (2011). The partners in health manual of ultrasound for resource-limited settings. Boston: Partners In Health.Google Scholar
  53. Shah, T., Greig, J., van der Plas, L. M., Achar, J., Caleo, G., Squire, J. S., et al. (2016). 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 Global Health, 4(7), e495–e501. Scholar
  54. Sissoko, D., Keita, M., Diallo, B., Aliabadi, N., Fitter, D. L., Dahl, B. A., et al. (2017). Ebola virus persistence in breast milk after no reported illness: A Likely source of virus transmission from mother to child. Clinical Infectious Diseases.
  55. Smit, M. A., Michelow, I. C., Glavis-Bloom, J., Wolfman, V., & Levine, A. C. (2017). Characteristics and outcomes of pediatric patients with Ebola virus disease admitted to treatment units in Liberia and Sierra Leone: A retrospective cohort study. Clinical Infectious Diseases, 64(3), 243–249. Scholar
  56. Spandorfer, P. R. (2011). Subcutaneous rehydration: Updating a traditional technique. Pediatric Emergency Care, 27(3), 230–236. Scholar
  57. Sprecher, A. G., Caluwaerts, A., Draper, M., Feldmann, H., Frey, C. P., Funk, R. H., et al. (2015). Personal protective equipment for filovirus epidemics: A call for better evidence. Journal of Infectious Diseases, 212(Suppl 2), S98–S100. Scholar
  58. Takahashi, S., Metcalf, C. J., Ferrari, M. J., Moss, W. J., Truelove, S. A., Tatem, A. J., et al. (2015). Reduced vaccination and the risk of measles and other childhood infections post-Ebola. Science, 347(6227), 1240–1242. Scholar
  59. Tang, A. M., Dong, K., Deitchler, M., Chung, M., Maalouf-Manasseh, Z., Tumilowicz, A., et al. (2013). Use of cutoffs for mid-upper arm circumference (muac) as an indicator or predictor of nutritional and health-related outcomes in adolescents and adults: A systematic review. Washington, DC: FHI 360/FANTA.Google Scholar
  60. Tomasik, E., Ziolkowska, E., Kolodziej, M., & Szajewska, H. (2016). Systematic review with meta-analysis: Ondansetron for vomiting in children with acute gastroenteritis. Alimentary Pharmacology and Therapeutics, 44(5), 438–446. Scholar
  61. Trehan, I., & Manary, M. J. (2015). Management of severe acute malnutrition in low-income and middle-income countries. Archives of Disease in Childhood, 100(3), 283–287. Scholar
  62. Trehan, I., Goldbach, H. S., LaGrone, L. N., Meuli, G. J., Wang, R. J., Maleta, K. M., et al. (2013). Antibiotics as part of the management of severe acute malnutrition. New England Journal of Medicine, 368(5), 425–435. Scholar
  63. Trehan, I., Kelly, T., Marsh, R. H., George, P. M., & Callahan, C. W. (2016). Moving towards a more aggressive and comprehensive model of care for children with Ebola. Journal of Pediatrics, 170(28–33), e21–e27. Scholar
  64. UNICEF. (2014). Guidelines for a revised implementation of integrated community case management of childhood illnesses (ICCM) during the Ebola outbreak. New York: UNICEF.Google Scholar
  65. Uyeki, T. M., Mehta, A. K., Davey Jr., R. T., Liddell, A. M., Wolf, T., Vetter, P., et al. (2016). Clinical management of Ebola virus disease in the United States and Europe. New England Journal of Medicine, 374(7), 636–646. Scholar
  66. Walker, P. G., White, M. T., Griffin, J. T., Reynolds, A., Ferguson, N. M., & Ghani, A. C. (2015). Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: A modelling analysis. Lancet Infectious Diseases, 15(7), 825–832. Scholar
  67. WHO Ebola Response Team. (2015). Ebola virus disease among children in West Africa. New England Journal of Medicine, 372(13), 1274–1277. Scholar
  68. WHO/UNICEF/WFP. (2014). Interim guideline: Nutritional care of children and adults with Ebola virus disease in treatment centres. Geneva: World Health Organization.Google Scholar
  69. Wolf, T., Kann, G., Becker, S., Stephan, C., Brodt, H. R., de Leuw, P., et al. (2015). Severe Ebola virus disease with vascular leakage and multiorgan failure: Treatment of a patient in intensive care. Lancet, 385(9976), 1428–1435. Scholar
  70. World Health Organization. (1999). Management of severe malnutrition: A manual for physicians and other senior health workers. Geneva: World Health Organization.Google Scholar
  71. World Health Organization. (2014a). Interim infection prevention and control guidance for care of patients with suspected or confirmed filovirus haemorrhagic fever in health-care settings, with focus on Ebola. Geneva: World Health Organization.Google Scholar
  72. World Health Organization. (2014b). Interim list of WHO essential medicines necessary to treat Ebola cases based on existing guidelines. Geneva: World Health Organization.Google Scholar
  73. World Health Organization. (2015). Manual for the care and management of patients in Ebola Care Units/Community Care Centres: Interim emergency guidance. Geneva: World Health Organization.Google Scholar
  74. World Health Organization. (2016a). Clinical management of patients with viral haemorrhagic fever: A pocket guide for front line health workers. Geneva: World Health Organization.Google Scholar
  75. World Health Organization. (2016b). Interim guidance: Clinical care for survivors of Ebola virus disease. Geneva: World Health Organization.Google Scholar
  76. World Health Organization. (2016c). Personal protective equipment for use in a filovirus disease outbreak: Rapid advice guideline. Geneva: World Health Organization.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Indi Trehan
    • 1
    • 2
    Email author
  • Peter Matthew George
    • 3
    • 4
  • Charles W. Callahan
    • 5
  1. 1.Lao Friends Hospital for ChildrenLuang PrabangLao People’s Democratic Republic
  2. 2.Washington University in St. LouisSt. LouisUSA
  3. 3.Sierra Leone Ministry of HealthPort LokoSierra Leone
  4. 4.University of Sierra LeoneFreetownSierra Leone
  5. 5.University of MarylandBaltimoreUSA

Personalised recommendations