MALARIA IN CHILDREN

Malaria parasites are usually transmitted by the bite of an infected female anopheles mosquito. Plasmodium falciparum is the commonest type in in sub-Saharan Africa and is associated with significant morbidity and mortality. The other species are:
P. malariae, P. vivax and P. ovale.

UNCOMPLICATED MALARIA

Classically, malaria presents with paroxysms of fever, chills, rigors, and sweating. Other features include:

  • Malaise
  • Headache
  • Myalgia
  • Joint pains
  • Refusal to feed
  • Nausea
  • Vomiting
  • Abdominal discomfort
  • Diarrhoea

SEVERE AND COMPLICATED MALARIA

This presents with a combination of most of the above plus one or more of the following:

  • Severe anaemia (Hb <5g/dl)
  • Lethargy or altered unconsciousness or coma
  • Generalized convulsions
  • Jaundice
  • Hypoglycaemia (blood sugar <2.2mmol/L)
  • Respiratory distress, pulmonary oedema
  • Acidosis
  • Disseminated intravascular coagulopathy – DIC (spontaneous bleeding)
  • Malaria haemoglobinuria (Coca-cola coloured urine)
  • Oliguria
  • Shock
  • Fluid electrolyte imbalance

Diagnosis of Malaria

CHILDREN UNDER 5 YEARS OLD

  • In high malaria endemic areas, any child with fever or history of fever should be presumptively classified and treated as malaria. The use of parasitological diagnosis is not a prerequisite for treatment.
  • In low malaria endemic areas, any child with fever or history of fever in the absence of measles, running nose, or any other identifiable cause of fever should be presumptively classified and treated as having malaria. The use of
    parasitological diagnosis is recommended where possible.

OLDER CHILDREN OVER 5 YEARS OF AGE

  • In all patients 5 years and above with fever or history of fever, the use of parasitological diagnosis is recommended.
  • At health facilities where malaria diagnostics (microscopy or RDT) are not available, patient with fever or history of fever in whom the health worker strongly suspects malaria and has eliminated other possible causes of fever,
    should be presumptively classified and treated as malaria.

ADDITIONAL INVESTIGATIONS IN PATIENTS WITH SEVERE AND COMPLICATED MALARIA

  • Thick blood smear for malaria parasites (several slides may need to be done)
  • Thin blood smear for parasite count (parasitaemia >5%) species identification and RBC morphology
  • Full blood count
  • Blood sugar
  • Serum bilirubin
  • Urea and electrolytes, creatinine
  • Urinalysis and microscopy
  • Lumbar puncture in unconscious patients
  • Blood culture
  • A negative slide does not necessarily rule out malaria. Where cerebral malaria is suspected appropriate therapy must be instituted promptly. On the other hand, a positive blood smear may be coincidental – up to 30% of the
    population in high endemic malaria parts of the country have parasitaemia without features of malaria.

Treatment of Uncomplicated Malaria

FIRST LINE TREATMENT FOR ALL AGE GROUPS

The recommended first line treatment for uncomplicated malaria is artemether-lumefantrine currently available as a co-formulated tablet containing 20mg of Artemether and 120mg of lumefantrine. This is administered as a 6- dose regimen given over 3 days.

Dosing schedule for artemether-lumefantrine
Body weight No. of tablets recommended at approximate timing (hours) of dosing
(each tablet contains 20mg A and 120mg L)
0 h 8 h 24 h 36 h 48 h 60 h
5–14kg (<3 yr) 1 1 1 1 1 1
15–24kg (4–8 yr) 2 2 2 2 2 2
25–34kg (9–14 yr) 3 3 3 3 3 3
>34kg (>14 yr) 4 4 4 4 4 4

The regimen can be expressed more simply for ease of use at the programme level as follows: the second dose on the first day should be given anytime between 8 and 12 hours after the first dose. Dosage on the second and third days is twice a day (morning and evening).

  • Malaria patients with HIV/AIDS should be managed according to the same regimen above.
  • In children below 5kg (under 2 months of age), malaria is not a common cause of fever. Evaluation of other causes should be undertaken. Where malaria is diagnosed, the recommended treatment
    is oral quinine.

COUNSELLING AND FOLLOW UP

For all patients the following counselling messages should be provided:

  • Explain dosing schedule: Use probing questions to confirm patient’s understanding.
  • Emphasize that all 6 doses must be taken over 3 days even if patient feels better after few doses.
  • Directly observe the first treatment dose.
  • Repeated the dose if vomiting occurs within 30 minutes after drug administration.
  • Advise that artemether-lumefantrine should preferably be taken with a meal.
  • Advise patients to return immediately to the nearest health facility if their condition deteriorates at any time, or if symptoms have not resolved after 3 days.

SUPPORTIVE TREATMENT

  • Fever management: In cases of hyperpyrexia (temp >39.5oC) administer an antipyretic. The recommended options are paracetamol or ibuprofen.
  • Encourage adequate fluids and nutrition: Caregivers should be encouraged to give extra fluids and where applicable to continue breastfeeding. Feeds and fluid should be administered as small quantities in frequent intervals,
    especially when the child is still very sick.

TREATMENT FAILURE

Treatment failure can be defined as a failure to achieve the desired therapeutic response after the initiation of therapy. Treatment failure is not synonymous with drug resistance.

  • Treatment failure may result from poor adherence to treatment, unusual pharmacokinetic properties in that individual, or drug resistance.
  • Treatment failure could also arise because of a wrong diagnosis and thus initiating the wrong treatment. In evaluating a patient with treatment failure, it is important to determine from the patient’s history whether they vomited previous
    treatment or did not complete a full treatment course.

Treatment failures should be suspected if patient deteriorates clinically at any time or if symptoms persists 3–14 days after initiating drug therapy in accordance with the recommended treatment regimen.

Development of symptoms 14 days after initiation of therapy where there has been prior clearance of symptoms should be considered as a new infection and be treated with the first line drug.

Remember that not all fevers are due to malaria. A fever that does not respond to adequate antimalarials may be due to other causes.

For second line treatment and treatment of severe malaria, visit Malaria in adults.