Kathryn Maitland

Bio

Kathryn Maitland is a professor of paediatrics at Imperial College, London who is based full-time in East Africa, where she leads a research group whose major research portfolio includes severe malaria, bacterial sepsis and severe malnutrition in children and clinical trials in emergency care. Her team conducted the largest trial in critically children ever undertaken in Africa (FEAST trial) examining fluid resuscitation strategies in children with severe febrile illness, showing that fluid boluses increased mortality. She is currently conducting the TRACT trial which is investigating transfusion and other treatment strategies in 3900 African children severe life-threatening anaemia and will shortly start the COAST trial (Children Oxygenation Administration Strategies Trial) to examine the optimum oxygen saturation threshold for which oxygen should be targeted and how best to administer oxygen, by high flow or low flow, in 4200 severely ill African children. In recognition of her contribution to medical research and healthcare she was recently elected to Fellowship of the Academy of Medical Sciences.


Emergency Interventions in African Children: What Next?

Rationale for a controlled trial of oxygen to determine the threshold to target and mode of delivery in the African Children’s Oxygenation Administration Strategies Trial (COAST)
In Africa up to a quarter of children will visit a health facility in their final illness; many dying on the day of admission. Targeted emergency care may be a very cost-effective means of reducing child mortality, but has not been afforded a high enough priority. Moreover, the most basic treatments provided in the emergency room have never been subjected to evaluation in clinical trials, including in resource-rich settings. The controlled FEAST trial of fluids resuscitation demonstrated that guidelines, developed for the rest of the world, cannot be safely translated to Africa. Although oxygen is a basic element of hospital care, there are no relevant trials to guide which level of oxygen saturation or the best method of how to administer it (low flow or high flow) improves outcome. In practice many children in low-income countries do not receive oxygen, despite being recommended, owing to the lack of its availability due to the high cost, or supplies that are unpredictable (erratic delivery of cylinders and/or electricity) Outcomes of children in sub-Saharan Africa with pneumonia, remains poor with an in-hospital mortality 9-10% (for those with oxygen saturations between 80% and 92%) and 26-30% case fatality for those with oxygen saturations <80%. The Children’s Oxygenation Administration Strategies Trial (COAST) will start in 2017 in 3 countries and will enrol 4,200 children (aged 2m to 12y) with presumptive pneumonia and hypoxaemia (defined as SpO2<92%). The key questions COAST will establish are whether liberal oxygenation for SaO2≥80% will decrease mortality compared with a strategy that includes permissive hypoxia (usual care); and whether use of high flow oxygen delivery will decrease mortality (at 48 hours and up to 28 days) compared with low flow oxygen delivery (usual care).

Should we Transfuse the Sick Child in Africa?

The ongoing TRACT (transfusion) trial incorporating 4 randomisations in factorial design tackles a major cause of hospital admission, severe anaemia in 3900 African Children

In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. The TRansfusion and TReatment of severe Anaemia in African Children: (TRACT ISRCTN84086586) is a 3x2x2 factorial controlled trial involving 3954 children (aged 2m to 12y) with severe anaemia (haemoglobin <6g/dl). The trial has been designed to address the poor outcomes following SA in children in sub-Saharan Africa, which is associated with high rates of in-hospital mortality (9-10%), 6-month case fatality (12%) and relapse or re-hospitalisation (6%) indicating that the current recommendations and/or management strategies are not working in practice. Hospitalised children will be enrolled at 4 centres in 2 countries (Malawi, Uganda) and followed for 6 months. TRACT trial is designed to answer 4 simple questions. Q1 and 2: which children should receive a transfusion (since current guidelines recommend transfusions only in children with a Hb <4g/dl (or <6g/dl if accompanied by complications)); and how volume to transfuse in each transfusion event?. Q3 and 4: Since the major factors related to poor longer term outcome are micronutrient deficiencies and sepsis would post-discharge multi-vitamin multi-mineral supplementation versus routine care (folate and iron) for 3 months and/or cotrimoxazole prophylaxis for 3 months versus no prophylaxis improve outcome and prevent relapse. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons.
If confirmed by the trial, a cheap and widely available ‘bundle’ of effective interventions could lead to, if widely implemented, substantial reductions in mortality in African children hospitalised with severe anaemia every year. The trial started in Sept 2014 and currently 2700 children have been enrolled. We expect the trial results to be available in 2017.


In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. The TRansfusion and TReatment of severe Anaemia in African Children: (TRACT ISRCTN84086586) is a 3x2x2 factorial controlled trial involving 3954 children (aged 2m to 12y) with severe anaemia (haemoglobin <6g/dl). The trial has been designed to address the poor outcomes following SA in children in sub-Saharan Africa, which is associated with high rates of in-hospital mortality (9-10%), 6-month case fatality (12%) and relapse or re-hospitalisation (6%) indicating that the current recommendations and/or management strategies are not working in practice. Hospitalised children will be enrolled at 4 centres in 2 countries (Malawi, Uganda) and followed for 6 months. TRACT trial is designed to answer 4 simple questions. Q1 and 2: which children should receive a transfusion (since current guidelines recommend transfusions only in children with a Hb <4g/dl (or <6g/dl if accompanied by complications)); and how volume to transfuse in each transfusion event?. Q3 and 4: Since the major factors related to poor longer term outcome are micronutrient deficiencies and sepsis would post-discharge multi-vitamin multi-mineral supplementation versus routine care (folate and iron) for 3 months and/or cotrimoxazole prophylaxis for 3 months versus no prophylaxis improve outcome and prevent relapse. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons.
If confirmed by the trial, a cheap and widely available ‘bundle’ of effective interventions could lead to, if widely implemented, substantial reductions in mortality in African children hospitalised with severe anaemia every year. The trial started in Sept 2014 and currently 2700 children have been enrolled. We expect the trial results to be available in 2017.



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