Malaria treatment guidelines, paediatrics

What's New

Dose of primaquine has been corrected.

Malaria is the tropical disease most commonly imported into the UK. Three quarters of reported malaria cases are caused by Plasmodium falciparum, capable of invading a high proportion of red blood cells and rapidly leading to severe or life‐threatening multi‐organ disease. Most non‐falciparum malaria cases are caused by Plasmodium vivax, a few are caused by Plasmodium ovule, malariae and the more recently discovered knowlesi. Infections cause by mixed malarial organisms, commonly involve P.falciparum and carry the risk of  severe malaria.

Malaria is more commonly seen in children than in adults, probably because susceptible UK‐born children accompany their overseas‐born parents on visits to endemic areas.

Suspect malaria in a patient with fever and recent travel to a malaria‐endemic area.
http://travelhealthpro.org.uk  

P.falciparum infections usually present in first few months after exposure. P.vivax P.ovale can present after six months and presentation may be delayed for years. 

Presentation

Uncomplicated malaria:

Non‐specific symptoms - fever, lethargy, malaise, nausea, abdominal pain, vomiting and diarrhoea. Often no distinct fever pattern. Patient may also have hepatosplenomegaly.

Severe malaria: 

  • Respiratory distress
  • Hypoglycaemia
  • Cerebral malaria: reduced GCS, seizures, altered respiration
Investigation
  • Malaria antigen tests & thick and thin blood films (‘malaria parasite’ order on Trakcare covers both)
    The haematology laboratory will need to call the haematologist to examine the films to confirm results of antigen testing and provide an estimate of parasitaemia.

If initial tests are negative arrange to repeat after 12, 24 and 48hrs if child remains unwell  and no clear focus of infection evident. 

  • Blood gas including glucose
  • Full Blood Count. Thrombocytopenia is highly suggestive of malaria
  • LFT's, U&E's, blood glucose and clotting studies
  • G6PD screen (required prior to primaquine in case of P.vivax)
Indicators of severe or complicated malaria
  • Impaired consciousness or seizures
  • Respiratory distress or acidosis (pH less than 7.3)
  • Hypoglycaemia (blood glucose less than 2.2mmol/l)
  • Severe anaemia (haemoglobin less than 8g/dl)
  • Prostration
  • Parasitaemia greater than 2% (red blood cells parasitized)
Management
  • Admit all patients for a minimum 24 hours under the ID team.
  • Perform four hourly observations and blood sugar monitoring.
  • If the patient has features of severe malaria consider admission to PICU. 
  • Repeat thick films for parasitaemia after 12‐24 hours or sooner if there is clinical deterioration.
Treatment

Un‐complicated malaria: 

Oral Artemether with lumefantrine (Riamet®), kept in ward 5C QEUH 

  • Above 35 kg, 4 tablets then 4 tablets at 8, 24, 36, 48 and 60 hours 
  • 25 ‐ 35 kg 3 tablets then 3 tablets at 8, 24, 36, 48 and 60 hours
  • 15 ‐ 24 kg 2 tablets then 2 tablets at 8, 24, 36, 48 and 60 hours
  • 5 ‐ 14 kg 1 tablet then 1 tablet at 8, 24, 36, 48 and 60 hours

To increase absorption give with food or a milky drink. Tablets may be crushed immediately prior to administration. 

Use with caution in patients with severe renal impairment, electrolyte disturbance e.g. hypokalaemia or hypomagnesemia, concomitant drugs that prolong the QT interval. Monitor ECG and electrolytes.

Contraindicated in patients with history of arrhythmia, bradycardia, congestive heart failure accompanied by left ventricular ejection fraction, family history of QT interval prolongation. Avoid in patients with acute porphyria. 

If oral artemether with lumefantrine is unavailable, use oral atavoquone with proguanil hydrochloride (Malarone®)

Oral atavoquone with proguanil hydrochloride Malarone®

Dose:

  • Over 40 kg 4 'standard' tablets daily for 3 days
  • 31-40 kg 3 'standard' tablets daily for 3 days
  • 21-30 kg 2 'standard' tablets daily for 3 days
  • 11-20 kg 1 'standard' tablet daily for 3 days
  • 9-10 kg 3 'paediatric' tablets daily for 3 days
  • 5-8 kg 2 'paediatric' tablets daily for 3 days

To increase absorption give with food or a milky drink. Tablets may be crushed immediately prior to administration. 

Severe or complicated malaria: 

IV Artesunate (Malacef® Artesun®), kept in ward 5C QEUH

Artesunate has few side effects and there is no need to adjust for renal impairment or to monitor for cardiac toxicity. It does not promote hypoglycaemia. The dosing regimen is:

  • 20kg and above: 2.4mg/kg IV injection at 0, 12 and 24 hours then daily
  • Less than 20kg: 3mg/kg IV injection at 0, 12 and 24 hours then daily 

After 24 hours of IV treatment can switch to oral Artemether with lumefantrine (Riamet®). Give full treatment course as detailed above.

For information about dilution, reconstitution and administration of artesunate, please access the IV monograph via Medusa: http://medusa.wales.nhs.uk/IVGuideDisplay.asp 


IV artesunate is kept in ward 5C QEUH. As it is an unlicensed medication, please complete required paperwork (kept with medication) when removing supply. 

If artesunate is unavailable use IV quinine. 

IV quinine:

Dose:

  • Loading dose 20mg/kg (max 1.4g) infused over 4 hourse.
  • Maintenance dose: 10mg/kg (max 700mg) every 8 hours for the first 48 hours or until patient can swallow).
  • Frequency of dosing should be reduced to 12 hourly if intravenous quinine continues for more than 48 h.
  • Parenteral quinine therapy should be continued until the patient can take oral therapy when quinine sulphate 10mg/kg (max 700mg) should be given three times a day to complete five or seven days of quinine in total.
  • Quinine should always be given with a second drug either clindamycin 7‐13mg/kg/dose every 8 or doxycycline 200mg once daily if over 12 years of age. Give orally for a total of 7 days from when the patient can swallow. 

For information about dilution, reconstitution and administration of IV quinine, please access the IV monograph via Medusa: http://medusa.wales.nhs.uk/IVGuideDisplay.asp 

Do not give quinine if a previous dose of quinine or mefloquine has been given in the previous 12 hours. Dose reduction is required for children with severe renal and/or hepatic impairment (see BNF for Children).

Monitor blood sugar levels 4 hourly as both quinine and malaria can cause hypoglycaemia.

Use with caution in patients with cardiac disease - monitor ECG during administration. Care in patients with G6PD deficiency. 

Contraindicated in patients with haemoglobinuria, myasthenia gravis, optic neuritis and tinnitus. 

Discharge and follow-up

Patient may be discharged when they show clinical improvement, have falling parasitaemia (less than 2%) and stable blood parameters.

For follow up, FBC and malaria film should be arranged after 2 weeks if the patient has been treated with an anti‐malarial.

If P.vivax or P.ovale, treat to eradicate parasite in hepatocytes with primaquine (500micrograms/kg/day for 14 days) UNLESS the patient is less than 6 months of age or has G6PD deficiency (risk of haemolysis).

Advise parents/carers:

  • to re‐present if patient has fever in the following 3 months.
  • to use anti‐malarial prophylaxis if future travel to malaria‐endemic area. (GP, travel clinic)
References

Lalloo DG et al. UK malaria treatment guidelines. J infect. 2016 Jun;72(6):63549

World Health Organisation. WHO guidelines for the treatment of malaria (3rd ed). WHO; 2015

Editorial Information

Last reviewed: 15 November 2018

Next review: 30 November 2020

Author(s): Ysobel Gourlay

Approved By: Antimicrobial Utilisation Committee