What is the management of malaria in children?

Management of Malaria in Children

Manage malaria in children using a structured ABC approach with immediate risk stratification, followed by intravenous quinine (20 mg/kg loading dose over 4 hours) for severe cases and supportive care targeting respiratory failure, shock, and neurological complications as the primary life-threatening emergencies. 1

Initial Assessment and Risk Stratification

The management of malaria in children begins with rapid triage assessment focusing on airway, breathing, and circulation before confirming diagnosis, as most deaths occur within hours of admission due to unrecognized circulatory collapse or respiratory compromise. 1

High-Risk Features Requiring Urgent Intervention

Children with any of the following require immediate supportive treatment: 1

• Depressed conscious level (any degree) 1
• Active seizure activity or status epilepticus 1
• Respiratory compromise: irregular respirations, obstructed airway (pooling saliva/vomit), or hypoxia (oxygen saturations < 95%) 1
• Shock indicators: systolic BP < 80 mm Hg (< 70 mm Hg if < 1 year) OR two or more of: tachycardia, increased work of breathing, cool peripheries, capillary refill time ≥ 3 seconds 1
• Hypoglycemia < 3 mmol/l 1
• Metabolic acidosis (base deficit > 8 mmol/l) 1
• Severe hyperkalaemia (potassium > 5.5 mmol/l) 1

Intermediate-Risk Features

These children require high dependency care: 1

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

Emergency Management Algorithm

Step 1: Airway and Breathing

Immediately assess and secure airway, as irregular breathing or drooling indicates complex seizures with respiratory depression. 1

• Provide high-flow oxygen (10 L/min) if oxygen saturations < 95% 1
• Monitor for characteristic respiratory patterns of severe malaria 1
• Consider rapid sequence intubation if respiratory failure develops 1

Step 2: Circulation and Shock Management

Insert two large intravenous cannulae and assess for shock using pulse rate, capillary refill, temperature gradient, and blood pressure. 1

For children with shock: 1

• First bolus: 20 ml/kg of colloid or 0.9% saline (or 20 ml/kg of 4.5% albumin if child in coma) 1
• Observe closely for response/deterioration 1
• If no response: repeat 20 ml/kg bolus 1
• After 40 ml/kg with persistent shock: proceed to rapid sequence intubation and use central venous pressure monitoring to guide further fluid management 1

Critical caveat: Use cautious volume resuscitation in children presenting in coma due to risk of raised intracranial pressure. 1

Step 3: Neurological Assessment

After addressing airway, breathing, and circulation, assess conscious level and exclude: 1

• Ongoing seizures 1
• Hypoglycemia 1
• Shock 1

If neurological deterioration occurs despite correction of above, consider raised intracranial pressure. 1

Antimalarial Treatment

Severe Malaria

Initiate intravenous quinine dihydrochloride immediately after initial resuscitation, even if awaiting diagnostic confirmation when clinical suspicion is high. 1

• Loading dose: 20 mg/kg diluted in 20-40 ml, infused over 4 hours 1
• Emergency management should not be delayed while awaiting malaria diagnosis confirmation 1
• Specific antimalarial drugs can be deferred until resuscitation treatments are given and diagnosis confirmed, unless undue delay is likely 1

Uncomplicated Malaria

For children able to take oral medication: 1

• Admit and observe on oral treatment 1
• Never prescribe oral quinine (tablets or syrup) for young children, as it is unpalatable and compliance will be poor 1

Diagnostic Approach

Obtain thick and thin blood films from EDTA sample with direct laboratory liaison for urgent processing. 1

• Three negative thick blood films taken 12 hours apart generally exclude malaria 1
• Continue further films if clinical suspicion remains high 1
• Rapid diagnostic tests (e.g., OptiMAL assay) have advantages in children with low-density parasitemia or those who have taken prophylaxis 1

Monitoring and Supportive Care

Check blood glucose immediately and serially, as hypoglycemia is a common life-threatening complication. 1

Take blood for: 1

• Complete blood count 1
• Metabolic panel (assess acidosis, electrolytes, renal function) 1
• Blood glucose 1

Common Pitfalls to Avoid

Do not use experimental treatments such as exchange transfusion in initial management, as they distract from urgent, simple life-saving interventions. 1

Do not delay emergency management while awaiting diagnostic confirmation. 1

Do not miss impending circulatory collapse or respiratory compromise, which are the principal causes of death within hours of admission. 1

Do not overlook prolonged seizures as a cause of respiratory compromise. 1

Do not prescribe oral medications for children who are vomiting or unable to comply with oral medication. 1

Clinical Presentation Recognition

Consider malaria in any febrile child with travel history to endemic areas, even up to one year after exposure (particularly P. vivax, P. ovale, P. malariae). 1

Initial symptoms are non-specific: 1

• Fever, cough, headache, malaise, vomiting, diarrhea 1
• Splenomegaly, thrombocytopenia, anemia, mild jaundice may be absent in early stages 1

Urgent referral is mandatory for presumptive malaria diagnosis, as failure to expedite appropriate referral leads to life-threatening disease. 1