Ebola in Children: Clinical Differences, Mortality, and Care Challenges
Ebola affects children differently from adults — with distinct clinical presentations, variable mortality rates, and unique care challenges. This article examines the paediatric data from major outbreaks.
Children and Ebola: An Understudied Population
Despite children accounting for a significant proportion of cases in major Ebola outbreaks, paediatric Ebola disease has historically been understudied compared to adult disease. Children present distinctive challenges: their clinical presentation differs, their care needs differ, standard ETCs are designed for adults, and the emotional and ethical dimensions of managing critically ill children in outbreak settings are uniquely challenging.
Epidemiological Data: How Many Children Are Affected?
2014–2016 West Africa Epidemic
The largest dataset on paediatric Ebola comes from the West Africa epidemic:
- Children under 15 accounted for approximately 19–20% of all confirmed and probable cases
- Children under 5 (infants and toddlers) had the highest case fatality rates of any age group
- Adolescents (10–14 years) had lower CFRs than adults in some analyses
Across countries:
| Country | % Cases Under 15 | Paediatric CFR |
|---|---|---|
| Guinea | ~18% | ~71% |
| Sierra Leone | ~22% | ~63% |
| Liberia | ~18% | ~64% |
2018–2020 DRC Kivu Outbreak
- Children under 5 accounted for approximately 28% of all confirmed cases — notably higher than in West Africa
- CFR for children under 5 in Kivu: approximately 70–75% — higher than the overall outbreak average of 66%
The higher proportion of young children in DRC may reflect different transmission dynamics (household clustering in settings with high child-to-caregiver ratios) and different outbreak exposures.
How Does Ebola Present in Children?
Similarities to Adults
The core syndrome — fever, myalgia, weakness, nausea, vomiting, diarrhoea — occurs in children as in adults. The pathophysiology (endothelial injury, DIC, multi-organ failure) is the same.
Differences in Clinical Presentation
Infants and young children (0–5 years):
- Fever may be less reliably detectable (temperature instability)
- Haemorrhagic features (visible bleeding) are more common in young children than in adults — present in up to 50–60% in some case series
- Hiccups — a notable symptom of severe EVD — may be more frequently reported
- Rapid deterioration to shock more common due to smaller fluid reserves
- Seizures occur more frequently than in adults, possibly related to fever, hypoglycaemia, or direct neurological involvement
Adolescents (10–19 years):
- Clinical presentation more similar to adults
- In some outbreaks, adolescent girls had higher case counts, potentially related to caregiving roles
Key Complication: Dehydration
Children, particularly infants, have a much smaller total body fluid volume than adults. The profuse vomiting and diarrhoea of EVD leads to rapid, severe dehydration in children. Without rapid IV fluid replacement, hypovolemic shock can develop within hours.
In low-resource ETCs, obtaining IV access in a small, critically ill child — while maintaining full PPE — is technically very challenging. This contributes to higher paediatric CFRs.
Why Is Child Mortality Higher?
Several factors contribute to higher case fatality rates in young children:
1. Physiological Vulnerability
Smaller fluid reserves mean dehydration and shock develop faster. Less metabolic reserve. Immature immune responses.
2. Barriers to IV Access in Full PPE
Inserting an IV into a dehydrated infant while wearing two pairs of gloves, a gown, and a face shield is technically demanding. Even experienced paediatric nurses struggle in ETCs.
3. Separation From Caregivers
Standard ETC protocols severely limit family visitation to prevent transmission. For infants and young children, separation from parents causes distress that can complicate care and feeding. Children who refuse food or oral rehydration due to separation distress deteriorate faster.
4. Oral Rehydration Challenges
Oral rehydration solution (ORS) — the standard treatment for severe diarrhoea — requires a child to drink voluntarily and repeatedly. Severely ill, frightened children in an unfamiliar clinical environment are often unable to do this effectively.
5. Dosing Uncertainties
Dosing for experimental treatments (mAb114, Inmazeb, remdesivir) was developed primarily in adult patients. Paediatric dosing required adjustment — with limited pharmacokinetic data available in young children, particularly infants.
Paediatric ETCs and Care Adaptations
During the DRC Kivu outbreak, the Coalition for Epidemic Preparedness Innovations (CEPI) and partners supported development of paediatric-specific ETC protocols. Adaptations included:
- Parent or guardian co-admission: In some facilities, one caregiver could be admitted alongside the child (vaccinated first, if possible) to maintain normal feeding and comfort care
- Child-friendly spaces: Age-appropriate materials, familiar objects, and caregiving routines within the ETC
- IV access training: Intensive training for ETC nurses on paediatric IV access in full PPE
- Oral rehydration support: Dedicated staff and time for oral rehydration with children
- Paediatric nasogastric tube protocols: For fluid administration when oral intake insufficient
These adaptations improved care quality and likely outcomes, though controlled evidence is limited.
Treatment: What Is Known for Children
Supportive Care
The cornerstone of EVD management in children is aggressive, early supportive care:
- IV fluid resuscitation: Careful balancing of fluid administration with monitoring for fluid overload (different from adults — children are at risk of pulmonary oedema with aggressive resuscitation)
- Electrolyte replacement: Hypokalaemia (low potassium) and hyponatraemia common
- Anti-emetics: Reduce fluid and caloric losses from vomiting
- Antipyretics: Paracetamol (acetaminophen) — not aspirin or ibuprofen (impair platelet function)
Monoclonal Antibody Treatments in Children
Inmazeb (REGN-EB3) and Ebanga (mAb114) — the two FDA-approved Ebola treatments — have been used in children, including infants, under compassionate use and in outbreak settings. Small paediatric case series have been published.
The DRC Kivu PALM trial included paediatric patients, and analysis of outcomes in children who received mAb114 or REGN-EB3 versus ZMapp/remdesivir showed similar patterns to adults — substantially lower mortality with the approved agents.
Dosing approach: Weight-based dosing extrapolated from adult mg/kg data, with paediatric PK sampling where feasible.
Orphaned Children: A Long-term Burden
Ebola outbreaks create orphans on a large scale. In the West Africa epidemic, an estimated 16,000–17,000 children lost one or both parents to Ebola. These children faced:
- Social stigma and exclusion from communities
- Foster care or extended family care often under economic stress
- Psychological trauma from witnessing illness and death
- Disrupted education
- Potential sexual exploitation and abuse in vulnerable settings
The long-term wellbeing of outbreak-orphaned children requires specific programming that extends far beyond the outbreak declaration of end.
Looking Forward: Better Data, Better Outcomes
Key research priorities for paediatric EVD include:
- Larger paediatric-specific prospective cohorts to establish optimal fluid management protocols
- Age-stratified pharmacokinetic data for all approved treatments
- Evaluation of parent co-admission models in ETCs
- Psychological support protocols for children during and after ETC admission
Progress on these research fronts will directly translate to lives saved in future outbreaks.