Malaria

Fevers in children are very commonly due to malaria (Malawi is a malaria endemic area, there are seasonal peaks, but it occurs all throughout the year). The most common species in Malawi is Plasmodium falciparum. The most common symptoms are fever, headache and malaise. There may be vomiting, diarrhoea, cough, anaemia or convulsions.

Malaria parasites can be tested by microscopy

!!! Always document if the child has received any previous treatment for malaria (when, which drug, how many doses, and the strength [in mg] of the doses). The malaria rapid diagnostic test (mRDT) most commonly used in Malawi is based on the parasite protein HRP2, and this protein persists in the blood long after effective treatment. As a result, the mRDT can stay positive for up to 28 days after a malaria episode. When possible, verify a positive mRDT with a blood smear for parasites.

Uncomplicated Malaria

• Fever and positive blood smear
• No evidence of altered conscious level, hypoglycaemia, severe anaemia, jaundice or respiratory difficulties.

Management

• No need to admit to hospital, some might profit from Short Stay (see below)
• First line treatment for uncomplicated malaria is lumefantrine-artemether (LA or Coartem)
  Dose: s. table - give dose twice daily for 3 days. Combined tablets of artemether 20 mg and lumefantrine 120 mg. Take with fatty food, like milk. If patient vomits out dose within 1-2 hours, give another dose

• Give paracetamol for fever (15 mg/kg per dose, max QID)
• Ensure tablets are swallowed and not vomited
• Encourage oral fluids
• Encourage use of insecticide treated bed nets. Bed nets can be provided in A&E for children <5 years or those admitted with malaria.
• Tell mother to go to their nearest health centre after 2 - 3 days if fever persists or earlier if vomiting the medication.

Children in need of second review should be admitted to Short Stay Ward:

• i. e. with high parasitaemia (can have LA even if +++++), but should be monitored if deteriorating/ treatment failure. Repeat MPs after 12-24 h.
• i. e. clinically stable children with high MPs and low PCV (e.g., MPs +++/ ++++ and PCV <20%) Consider repeating MPs and/ or PCV after 12/24 h.
• Children with uncomplicated malaria and febrile convulsions.

Complicated/Severe Malaria

• Child is febrile and has positive blood smear
• There may be vomiting, diarrhoea, or cough
• Convulsions (>2 in 24h), altered conscious state (BCS < 3 or GCS < 11)
• Hypoglycaemia or acidosis (deep fast breathing, lactate > 5 mmol/l), severe anaemia (PCV < 12%), jaundice or prolonged bleeding
• Prostration (cannot sit on his own, has stopped sucking).
• Pulmonary oedema with crepitations and/ or Sats < 92% and/or high RR
• Decrease in urine output: ask for last urine output, challenge with fluids if failing to pass urine

Cerebral malaria

• Coma - often develops rapidly, usually within 1 - 2 days of onset of fever. Convulsions, hypoglycaemia, acidosis and hyperpyrexia are very common
-> Children with a BCS of 2/5 or lower should be discussed with the Paediatric Research Ward for admission and further management there as soon as possible.
• Opisthotonus, decorticate or decerebrate posturing, conjugate eye movements are very common.
• A unique retinopathy with patchy retinal whitening, hemorrhages, or vessel color changes may be seen on ophthalmoscopy and improves the specificity of the diagnosis of cerebral malaria
• Convulsions may be subtle - maintain a high index of suspicion! The EEG technicians on the PRW can, with approval of the clinician in charge, carry out "stat" EEGs to determine if the patient is actively convulsing.

No physical signs are pathognomonic for coma due to malaria, and incidental parasitaemia is common in endemic areas, so other causes of coma must always be sought and treated e.g. bacterial meningitis, septic shock, encephalitis (especially patients with no evidence of malarial retinopathy).

Malaria with severe anaemia

Beyond the blood: Treat all severe malaria anaemias with Albendazole STAT, investigate for HIV and prescribe Ferrous Sulphate on discharge (2 mg/kg/day for 3 months) to account for additional causes of that anaemia.

Transfusion criteria (preferably transfuse whole blood):

• Life threatening anaemia (acidosis, signs of congestive heart failure) or
• PCV < 12% or Hb < 4 g/dl and heavy parasitaemia with falling haemoglobin (look for jaundice) - in general those who are likely to develop life-threatening anaemia Anaemia Chapter

Investigations

• Blood film & PCV
• Blood glucose
• LP (unless contraindicated - lateralizing signs on neuro exam, patient too unstable to be positioned for LP, features of raised intracranial pressure). Do LP if BCS <3/5 and not postictal or if neurological signs indicating meningitis
• Blood culture if child very sick or if signs of shock present.

Management

• CORRECT HYPOGLYCAEMIA (< 2.5 mmol/l or < 45 mg/dl): give 1 ml/kg of 50% dextrose or 2 ml/kg of 25% dextrose or 5 ml/kg of 10% dextrose)
• TREAT CONVULSIONS, but don't give prophylactic anticonvulsants (increases mortality). For drugs to use Convulsion protocol. Subclinical seizures occur in 15-20% of cases. Watch carefully for subtle seizure signs (nystagmus, hypoventilation, drop in BCS... contact PRW for EEG/ further management as noted above).
• CORRECT ACIDOSIS AND SHOCK:
  • If very pale be cautious with fluids and rather give blood immediately. Too much fluid can harm children, esp. the ones with cerebral malaria
  • Shock is unusual in severe malaria. Always consider complications (hypoglycaemia, dehydration, septicaemia) or alternative differential diagnoses.
  • If child is in real need of iv fluids, apply as per Fluid protocol.

• ARTESUNATE IV/IM (dosing see box)
  • Only give IV treatment if the child can't keep oral medication down
  • Switch to oral LA as soon as the child is able to keep oral medication down. Give LA always for a complete course of 3 days BD no matter when you started it.

• IF ARTESUNATE NOT AVAILABLE: Quinine IM with initial doses of 10 mg/kg at 0 and 4 hours, then 12 hourly (watch out for hypoglycaemia induced by quinine!)

• TREAT FOR POSSIBLE BACTERIAL CO-INFECTION IF SUSPECTED:
• If LP has been done and it looks clear and severe malaria is a sufficient explanation for neurological symptoms then do not start antibiotics right away but await CSF results.
• Always think of the high incidence of non-typhoid salmonella co-infection in malaria-positive children and cover with Ceftriaxone or Ciprofloxacin if suspecting it.

Supportive care in severe malaria

• If depressed level of consciousness stop oral feeds and place NGT or give IV fluids (always including Dextrose!!!) until placing an NGT is safe
• Check blood sugar a least 2 times per day
• Turn child 3-hourly to prevent pressure sores
• If seizures: check blood sugar (correct it if low), treat convulsion
• Treat fever with paracetamol. If unconscious give rectally if available

Discharge and Follow Up

• Emphasize on the need to use insecticide treated bed nets. Bed nets can be provided in A&E for children <5 years and/or children with malaria.
• Patients with high parasitaemia that have been treated with artesunate should be clinically reviewed in their nearest Health Center after two weeks to pick out the 7% who may develop late-onset severe anaemia (described to develop at 8-32 days after Artesunate treatment).
• After transfusion children should be clinically reviewed in the nearest Health Center after one month even if discharge PCV was good for clinical follow-up

Prophylaxis with monthly SP

• Prophylaxis should be given to children with frequent, severe malaria or hypersplenism. These children should be followed up in the Wednesday afternoon general clinic.

REF

• WHO Malaria Treatment Guidelines
• UpToDate