What is the treatment for a 2-year-old boy with Plasmodium vivax (PV) malaria and pneumonia, weighing 12 kilograms?

Treatment for 2-Year-Old Boy with P. vivax Malaria and Pneumonia (12kg)

The optimal treatment for this 2-year-old boy with P. vivax malaria and pneumonia weighing 12kg should include both antimalarial therapy with chloroquine phosphate and antibiotic therapy with amoxicillin. 1, 2

Antimalarial Treatment

For P. vivax Malaria:

• First dose: Chloroquine phosphate 120mg base (10mg base/kg) orally
• Second dose: 60mg base (5mg base/kg) orally at 6 hours after first dose
• Third dose: 60mg base (5mg base/kg) orally at 24 hours after first dose
• Fourth dose: 60mg base (5mg base/kg) orally at 36 hours after first dose
• Total dose: 300mg base (25mg base/kg) over 3 days 2

Antibiotic Treatment

For Pneumonia:

• Amoxicillin: 600mg daily (50mg/kg/day) divided into two doses for 5 days 1
  • 300mg orally every 12 hours

Supportive Care

1. Hydration: Maintain adequate fluid intake

   • Oral rehydration solution if able to drink
   • Consider IV fluids (5% dextrose with 1/2 normal saline) if unable to tolerate oral intake

2. Antipyretics:

   • Paracetamol (acetaminophen) 180mg (15mg/kg) orally every 6 hours as needed for fever

3. Monitoring:

   • Daily clinical assessment until resolution of symptoms
   • Monitor vital signs every 4-6 hours
   • Check for signs of respiratory distress
   • Monitor for anemia, which can be a complication of both malaria and pneumonia 1, 3

Special Considerations

Assessment for Severe Disease:

• Evaluate for severe anemia, which can cause rapid breathing and mimic pneumonia symptoms 1
• Check for pallor in palms, nail beds, and conjunctivae if laboratory assessment is unavailable
• Any child with severe anemia should be referred to hospital for assessment 1

Warning Signs Requiring Hospital Referral:

• Inability to drink or breastfeed
• Persistent vomiting
• Convulsions
• Lethargy or unconsciousness
• Respiratory distress (chest indrawing, stridor, cyanosis)
• Oxygen saturation <90% if available
• Failure to respond to treatment within 48 hours 1

Important Clinical Pearls

1. Both treatments must be given concurrently: When a child has clinical features of pneumonia and malaria cannot be excluded, both recommended first-line therapies should be prescribed 1

2. Avoid erythromycin as a second-line agent if mefloquine or halofantrine are prescribed for malaria due to increased risk of arrhythmia 1

3. Monitor for complications: P. vivax can cause severe disease including pulmonary complications and thrombocytopenia 4, 3, 5

4. Follow-up: The child should be reassessed after 48 hours of treatment to ensure clinical improvement 1, 6

5. Primaquine consideration: For complete treatment of P. vivax, primaquine may be needed to eliminate liver hypnozoites, but this requires G6PD testing first and is typically administered after the initial chloroquine therapy 1, 2

This treatment approach addresses both infectious processes simultaneously, which is essential for reducing morbidity and mortality in this vulnerable pediatric patient.