What are the recommended malaria prophylaxis options for children traveling to areas with chloroquine-resistant malaria?

Malaria Prophylaxis Options for Children in Chloroquine-Resistant Areas

For children traveling to areas with chloroquine-resistant malaria, atovaquone-proguanil is the recommended first-line prophylactic agent due to its excellent efficacy and safety profile, while mefloquine is an appropriate alternative for children weighing more than 15 kg when atovaquone-proguanil cannot be used. 1, 2

First-Line Options

• Atovaquone-proguanil (Malarone) is highly effective against drug-resistant strains of P. falciparum with 95-100% prophylactic efficacy 1
  • Dosage based on body weight for children ≥11 kg 1, 2
  • Only needs to be continued for 7 days after leaving the malaria-endemic area (unlike most other options which require 4 weeks) 1
  • Well-tolerated with fewer gastrointestinal adverse events compared to chloroquine-proguanil 2
  • Cannot be used in children weighing less than 11 kg 3

Alternative Options

• Mefloquine is effective for prophylaxis in chloroquine-resistant areas 4

  • Contraindicated in children weighing less than 15 kg 5
  • Weekly dosing (5 mg/kg) may improve compliance compared to daily regimens 6
  • Should be avoided in children with history of seizures, psychiatric disorders, or taking medications that may prolong cardiac conduction 5
  • Neuropsychiatric side effects (including nightmares, anxiety, sleep disturbances) occur in some children, typically with the first three doses 5
  • Consider disguising the bitter taste to increase adherence in children 3

• Doxycycline can be used as an alternative regimen 5

  • Contraindicated in children less than 8 years of age 5
  • Daily dosing required during travel and for 4 weeks after leaving the malarious area 5
  • Side effects include photosensitivity (minimize by avoiding sun exposure, using UVA-blocking sunscreens, and taking the drug in the evening) 5

Special Considerations

• For children <8 years who cannot take mefloquine or atovaquone-proguanil: Options are limited, and travel to high-risk areas should be reconsidered 5

• Medication administration tips:

  • Pediatric doses should be calculated carefully according to body weight 5
  • For chloroquine (when used): Pharmacists can prepare capsules with calculated pediatric doses; alternatively, mixing the powder in food or drink may facilitate administration 5
  • Store all antimalarial medications in child-proof containers out of children's reach as overdose can be fatal 5

• Compliance is essential: Most malaria cases in travelers occur in those who do not fully comply with prophylaxis regimens 5

Prevention Beyond Medication

• Apply insect repellents containing diethyltoluamide to exposed skin (follow manufacturer's recommendations for children) 5
• Use bed nets treated with permethrin, especially for young children 5
• Dress children in long-sleeved clothing and long trousers if outdoors after sunset 5
• Start prophylaxis 1-2 weeks before travel (except doxycycline which can begin 1-2 days before) 5

Monitoring and Follow-up

• Parents should be educated about malaria symptoms and the importance of seeking immediate medical attention if fever develops during or after travel 3
• Even with appropriate prophylaxis, breakthrough infections can occur; malaria should always be suspected if a child becomes ill after travel to an endemic area 3