What is the treatment for a 4-year-old male with severe malaria, presenting with vomiting, lethargy, semiconsciousness, tachycardia, tachypnea, and fever?

From the Guidelines

The treatment for a 4-year-old male with severe malaria requires immediate intravenous antimalarial therapy with artesunate at 2.4 mg/kg per dose given at 0,12,24, and 48 hours, as recommended by the most recent and highest quality study 1.

Key Considerations

• If artesunate is unavailable, intravenous quinine (loading dose of 20 mg/kg followed by 10 mg/kg every 8 hours) or artemether (3.2 mg/kg loading dose followed by 1.6 mg/kg daily) can be used, as suggested by older studies 1.
• Supportive care is essential, including management of fluids to prevent both dehydration and fluid overload, correction of hypoglycemia with IV glucose if needed, antipyretics for fever (acetaminophen 15 mg/kg every 6 hours), anticonvulsants if seizures occur, and blood transfusion if hemoglobin falls below 5 g/dL, as outlined in various guidelines 1.
• Close monitoring of vital signs, neurological status, blood glucose, and hemoglobin levels should be performed every 4-6 hours, as emphasized in the management of severe malaria 1.
• After the child can tolerate oral medication, complete the treatment with a full course of artemisinin-based combination therapy (ACT) such as artemether-lumefantrine for 3 days, as recommended by the most recent study 1.

Additional Measures

• Restrictive fluid management should be adopted to avoid pulmonary or cerebral edema, as suggested by the most recent study 1.
• Acute kidney injury may benefit from a reno-protective effect of acetaminophen (1 g 6-hourly for 72 hours), as demonstrated in a small open-label trial 1.
• Antibiotics should be started if a concomitant bacterial infection is suspected and should be continued only if blood cultures are positive, as recommended by the guidelines 1.
• Exchange blood transfusion is no longer indicated in severe malaria with the availability of artesunate, as stated in the most recent study 1.

From the Research

Treatment for Severe Malaria

The treatment for a 4-year-old male with severe malaria, presenting with vomiting, lethargy, semiconsciousness, tachycardia, tachypnea, and fever, involves the use of intravenous artesunate or quinine.

• Intravenous artesunate is more rapidly acting than intravenous quinine in terms of parasite clearance, is safer, and is simpler to administer 2.
• A study comparing intravenous artesunate and quinine for the treatment of severe falciparum malaria found that mortality in artesunate recipients was 15% compared with 22% in quinine recipients, an absolute reduction of 34.7% 2.
• Another study in Ugandan children with severe malaria found that intravenous artesunate plus artemisinin-based combination therapy (ACT) was effective in treating the disease, with a median time to parasite clearance of 2 days 3.

Administration and Monitoring

• Intravenous artesunate should be administered as a bolus at 0,12, and 24 hours, and then daily, with oral medication substituted when possible to complete treatment 2.
• Patients should be monitored for adverse events, such as hypoglycaemia, which is more common with quinine treatment 2.
• Extended follow-up of at least 30 days, including controls of haematological parameters, is recommended after artesunate treatment to detect potential post-treatment haemolysis 4.

Pre-Referral Treatment

• In remote areas where appropriate care is not immediately available, pre-referral rectal artesunate may be considered, although the evidence for its effectiveness is limited and flawed 5.
• The World Health Organization (WHO) endorses rectal artesunate as a pre-referral treatment for severe malaria, but its use should be carefully evaluated and monitored 5.