Malaria treatment guidelines, paediatrics

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

• 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)

• 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 80g/l)
• Prostration
• Parasitaemia greater than 2% (red blood cells parasitized)

• 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.

Un‐complicated malaria: 

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

• 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®

• 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 RHC A& E and ward 5C QEUH (Unlicensed medicine, please complete the accompanying paperwork when removing a supply)

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

• Artesunate has few side effects and there is no need to adjust for renal or hepatic impairment.
• Monitor for hypersensitivity reactions.
• Risk of haemolysis – follow-up at 2weeks post treatment.
• Monitoring for cardiac toxicity is not required.
• Artesunate does not promote hypoglycaemia.
• See Medusa IV monograph for reconstitution, dilution and administration information (username: ggcstaff Password: ivguide)
• Once reconstituted, the solution must be used within ONE hour

If artesunate is unavailable use IV quinine. 

IV quinine:

*WHO

• Administer IV doses as an infusion over 4 hours
  See Medusa IV Monograph for reconstitution, dilution and administration information (Username: ggcstaff  Password: ivguide)
• OMIT loading dose if quinine or mefloquine given in the previous 12 hours
• Dose adjustment in renal/hepatic impairment – see BNF for Children
• Monitor blood sugar levels minimum every 4 hours during quinine therapy
• Obtain baseline ECG & electrolytes. ECG monitoring throughout the infusion in high risk patients (e.g cardiac disease, conduction abnormality on baseline ECG)
• Use with caution in G6PD deficiency – monitor for signs of acute haemolytic anaemia
• Contraindicated in patients with haemoglobinuria, myasthenia gravis, optic neuritis and tinnitus.
• Parenteral quinine therapy should be continued until the patient can take oral therapy. Oral quinine sulphate 10mg/kg (max 600mg) should be given three times a day to complete a total of 7 days.
• Quinine should always be given with a second drug either clindamycin 7‐ 13mg/kg/dose every 8 hours (max 450mg) 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.

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. 
For patient receiving IV artesunate additional follow-up at 4-6 weeks may be required.

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)