Pediatric Shock in Low-Middle-Income Countries: Evidence-Based Strategies for Recognition, Resuscitation, and System-Level Adaptations

Pediatric shock remains a leading cause of preventable mortality in low-resource settings, where limited diagnostics, shortages of trained personnel, and constrained critical care infrastructure delay recognition and treatment. The purpose of this narrative is to review studies current evidence and frontline innovations to guide clinicians working in low-middle income countries (LMICs), with particular emphasis on LMIC-specific etiologies such as malaria, dengue, anemia, burns, heat and malnutrition. A comprehensive, non-systematic search of the literature from 1990 to 2025 was conducted regarding clinical practice guidelines and implementation studies related to emergency care delivery in LMICs. Searches were performed in PubMed, Google Scholar, and WHO IRIS and sources included the following: World Health Organization (WHO) guidelines, Surviving Sepsis Campaign pediatric recommendations, Global Burden of Disease (GBD) reports, relevant key trials, studies, and context-specific documents. Due to limited laboratory and invasive monitoring in low-resource settings, early detection of shock relies on clinical signs such as capillary refill time, pulse quality, and mental status. Recent studies focused on fluid resuscitation strategies, like those established in the African FEAST trial, revealed that early fluid resuscitation in children with shock may increase mortality when compared to children who did not receive fluid boluses. As a result, a cautious stepwise administration of crystalloids with frequent reassessment is the current, predominate fluid resuscitation strategy used in low-resource settings. When fluids alone fail, epinephrine or norepinephrine are preferred over dopamine as first-line vasoactive agents, with peripheral or intraosseous delivery and gravity-drip systems offering feasible alternatives to infusion pumps. Neonates require special consideration: Kangaroo Mother Care sharply reduces hypothermia, and routine glucose screening mitigates occult hypoglycemia. In the context of hemorrhagic shock, whole blood is used rather than its components due to chronic blood shortages, with tranexamic acid and improvised autotransfusion serving as adjuncts. Low-cost technologies, such as telemedicine, task-shifting protocols, solar-powered devices, and AI-assisted triage, demonstrate promising reductions in mortality when integrated into broader health system improvements. Together, these context-adapted approaches form a pragmatic roadmap for improving pediatric shock outcomes in resource-scarce settings. This review discusses the challenges of pediatric shock management in low-resource settings and outlines practical, evidence-based approaches to improve outcomes. We focus on (1) clinical recognition of shock without advanced diagnostics (2), acute resuscitation strategies, including fluid therapy, vasoactive support, and transfusion alternatives tailored to resource-limited environments, and (3) innovative interventions and research advances that hold promise for the future of pediatric emergency and critical care in LMICs. By synthesizing current evidence and expert recommendations, we aim to provide a framework for clinicians and health systems to strengthen the care of children with shock in settings where resources are constrained.