What is the recommended treatment for pediatric patients diagnosed with malaria?

Management and Diagnosis of Pediatric Malaria

Intravenous quinine (20 mg/kg loading dose followed by 10 mg/kg every 8 hours) is the recommended first-line treatment for severe malaria in children, while artemisinin-based combination therapy is preferred for uncomplicated malaria. 1

Diagnosis

Clinical Presentation

Malaria in children often presents with non-specific symptoms that can mimic other common childhood illnesses. Key clinical features include:

• Fever (the cardinal symptom)
• Irritability
• Poor feeding
• Vomiting
• Lethargy
• Seizures (particularly in cerebral malaria)
• Respiratory distress
• Pallor (due to anemia)

Diagnostic Tests

• Thick and thin blood films: Gold standard for diagnosis 2
• Rapid Diagnostic Tests (RDTs): Useful but may have false negatives with low parasitemia 2
• Laboratory investigations: Complete blood count, renal function, liver function, blood glucose, and arterial blood gases 2

Risk Stratification

High Risk (Severe Malaria)

Patients with any of the following require urgent treatment:

• Depressed conscious level (any degree)
• Active seizures or history of multiple convulsions
• Respiratory distress or irregular breathing
• Hypoxia (oxygen saturations <95%)
• Evidence of shock (systolic BP <80 mmHg or <70 mmHg if <1 year)
• Hypoglycemia (<3 mmol/l)
• Metabolic acidosis (base deficit >8 mmol/l)
• Severe anemia (hemoglobin <7 g/dL) 1, 2

Intermediate Risk

Patients requiring high dependency care:

• Hemoglobin <100 g/l
• History of convulsions during current illness
• Hyperparasitemia >5%
• Visible jaundice
• P. falciparum in a child with sickle cell disease 1

Low Risk

Patients requiring admission for parenteral medication:

• Vomiting
• Unable to take or comply with oral medication 1

Treatment Approach

Severe Malaria

1. Initial Resuscitation:

   • Secure airway, breathing, and circulation
   • Administer high-flow oxygen if respiratory distress
   • Check blood glucose and treat hypoglycemia if present
   • Establish IV access and take blood samples 1

2. Antimalarial Treatment:

   • First-line: Intravenous quinine dihydrochloride
     • Loading dose: 20 mg/kg diluted in 20-40 ml, infused over 4 hours
     • Maintenance: 10 mg/kg IV every 8 hours
     • Continue for 7 days or until oral therapy is tolerated 1

3. Management of Complications:

   • Seizures: Follow APLS protocol

     • Lorazepam 0.1 mg/kg IV/IO
     • If seizures persist: Paraldehyde 0.4 mg/kg rectally
     • Refractory seizures: Phenytoin 18 mg/kg IV or phenobarbital 15-20 mg/kg IV 1

   • Shock:

     • Bolus of 20 ml/kg of colloid or 0.9% saline
     • For children in coma with shock: 20 ml/kg of 4.5% albumin preferred
     • Reassess and repeat if necessary (up to 40 ml/kg) 1

Uncomplicated Malaria

For children able to tolerate oral medication, recommended treatments include:

1. Artemether with lumefantrine (Riamet/Coartem):

   • Dosing based on weight:
     • 5-<15 kg: 1 tablet
     • 15-<25 kg: 2 tablets
     • 25-<35 kg: 3 tablets
     • ≥35 kg: 4 tablets
   • Given at 0,8,24,36,48, and 60 hours 1

2. Proguanil with atovaquone (Malarone):

   • Daily for 3 days based on weight:
     • 5-8 kg: 2 pediatric tablets (25 mg)
     • 9-10 kg: 3 pediatric tablets
     • 11-20 kg: 1 adult tablet (100 mg)
     • 21-30 kg: 2 adult tablets
     • 31-40 kg: 3 adult tablets 1

3. Mefloquine (Lariam):

   • 15 mg base/kg followed by 10 mg/kg 8-24 hours later 1

Important Considerations

1. Avoid oral quinine in children: Oral quinine is unpalatable and should never be prescribed for young children due to poor compliance 1

2. Monitor for adverse effects:

   • With atovaquone-proguanil: Vomiting (10%), diarrhea (6%), and pruritus (6%) are common adverse effects in pediatric patients 3
   • Transaminase elevations may occur and can persist for up to 4 weeks following treatment 3

3. Special populations:

   • Infants: Have distinct pharmacokinetic parameters including larger volumes of distribution and higher clearance rates, potentially increasing risk of treatment failure 4
   • Children with sickle cell disease: Consider as intermediate risk even with uncomplicated P. falciparum infection 1

4. Follow-up:

   • Patients who remain symptomatic after 48-72 hours of treatment should be reassessed and considered for alternative therapy 1
   • Monitor for bacterial co-infections, which are common in children with malaria 2

Prevention

For high-risk groups in endemic areas (children <5 years, especially those with malnutrition or anemia), chemoprophylaxis should be considered during high transmission seasons 1.

By following this structured approach to diagnosis and management, the mortality and morbidity associated with pediatric malaria can be significantly reduced.