What is the treatment for a 10-year-old boy with high-grade fever, confirmed malaria (Plasmodium falciparum) infection, vomiting, hypoglycemia (Random Blood Sugar (RBS) 89), weakness, and anorexia?

From the Guidelines

For a 10-year-old boy with high-grade fever, confirmed malaria, vomiting, low blood sugar (RBS 89), weakness, and poor appetite, immediate treatment with intravenous artesunate is essential, as it is the recommended first-line treatment for severe malaria 1.

Treatment Approach

The treatment should prioritize addressing the severe malaria, managing symptoms, and preventing complications.

• Antimalarial Treatment: Intravenous artesunate should be administered for 3 doses, and once the patient is clinically improved, a switch to an artemisinin-based combination therapy (ACT) such as artemether-lumefantrine can be considered, with the administration of a full course of the chosen drug 1.
• Managing Hypoglycemia: Address the low blood sugar immediately with oral glucose solutions if the child can tolerate them, or consider IV dextrose if severe, as hypoglycemia is a common complication of severe malaria 1.
• Fever Management: Manage the fever with acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours).
• Anti-emetic: For vomiting, use an antiemetic like ondansetron (2-4 mg every 8 hours).
• Hydration: Ensure adequate hydration with oral rehydration solution or IV fluids if unable to tolerate oral intake.
• Monitoring: The child should be closely monitored in a healthcare setting due to the combination of high fever, vomiting, and hypoglycemia, which can indicate severe malaria requiring more intensive care.

Additional Considerations

• Secondary Bacterial Infection: Consider empiric broad-spectrum antibiotics such as ceftriaxone 100 mg/kg/day if a secondary bacterial infection is suspected 1.
• Coagulation Activation: Monitor for signs of coagulation activation, although bleeding is rare despite thrombocytopenia 1.

From the FDA Drug Label

Coartem is a prescription medicine used to treat uncomplicated malaria caused by the parasite Plasmodium falciparum (P. falciparum) in people 2 months of age and older who weigh at least 11 pounds (5 kg). A 3-day treatment schedule with a total of 6 doses is recommended as below: 5 kg to less than 15 kg bodyweight: One tablet as an initial dose, 1 tablet again after 8 hours, and then 1 tablet twice daily (morning and evening) for the following 2 days (total course of 6 tablets) 15 kg to less than 25 kg bodyweight: Two tablets as an initial dose, 2 tablets again after 8 hours, and then 2 tablets twice daily (morning and evening) for the following 2 days (total course of 12 tablets) 25 kg to less than 35 kg bodyweight: Three tablets as an initial dose, 3 tablets again after 8 hours, and then 3 tablets twice daily (morning and evening) for the following 2 days (total course of 18 tablets) 35 kg bodyweight and above: Four tablets as a single initial dose, 4 tablets again after 8 hours, and then 4 tablets twice daily (morning and evening) for the following 2 days (total course of 24 tablets).

For a 10-year-old boy with a high-grade fever, positive for malaria, vomiting, RBS 89, weakness, and no appetite, the treatment would depend on his weight.

• If the boy weighs between 5 kg to less than 15 kg, the dose is 1 tablet as an initial dose, 1 tablet again after 8 hours, and then 1 tablet twice daily for the following 2 days.
• If the boy weighs between 15 kg to less than 25 kg, the dose is 2 tablets as an initial dose, 2 tablets again after 8 hours, and then 2 tablets twice daily for the following 2 days.
• If the boy weighs between 25 kg to less than 35 kg, the dose is 3 tablets as an initial dose, 3 tablets again after 8 hours, and then 3 tablets twice daily for the following 2 days.
• If the boy weighs 35 kg or more, the dose is 4 tablets as a single initial dose, 4 tablets again after 8 hours, and then 4 tablets twice daily for the following 2 days. It is essential to take Coartem with food, as this improves the absorption of artemether and lumefantrine. If the patient is unable to swallow the tablets, they can be crushed and mixed with a small amount of water. In the event of vomiting within 1 to 2 hours after administration, a repeat dose should be taken 2.

From the Research

Treatment for Malaria

The treatment for a 10-year-old boy with high-grade fever, positive for malaria, vomiting, RBS 89, weakness, and no appetite can be guided by the following points:

• The use of artemisinin-based combination therapies, such as artemether + lumefantrine, is recommended for the treatment of uncomplicated malaria 3.
• The absorption of lumefantrine is dependent on the presence of food in the stomach, which can be difficult in cases of loss of appetite and nausea, but intake of about 1.5 g of fat seems sufficient for satisfactory absorption 3.
• For the treatment of severe malaria, intramuscular artemether has been compared to quinine and artesunate, with artemether appearing to be more effective than quinine in children and adults, but inferior to artesunate in adults 4.
• The World Health Organization recommends parenteral artesunate as the first-line treatment for severe malaria, but artemether is acceptable when artesunate is not available 4.

Management of Fever

In managing the fever associated with malaria, the following points are relevant:

• Fever is a normal physiological response to illness that facilitates and accelerates recovery, but it may also be a presenting symptom of more serious conditions requiring urgent medical care 5.
• It is essential to distinguish between a child with fever who is at high risk of serious illness and who requires specific treatment, hospitalization, or specialist care, and those at low risk who can be managed conservatively at home 5.

Anti-Malarial Combinations

The use of anti-malarial combinations, such as artemether + lumefantrine, is safe and efficacious for the treatment of uncomplicated malaria, but the emergence of artemisinin-resistant parasites in SE Asia means that there is a need to optimize drug dosing and investigate novel therapies 6.

• A study in Chad found that artesunate-amodiaquine and artemether-lumefantrine are highly efficacious for the treatment of uncomplicated falciparum malaria, with a high parasite clearance rate at day 3 and no known pfkelch13 mutations associated with artemisinin partial resistance 7.