P. Falciparum Malaria in Children

Scott J. Cohen, M.D.

Plasmodium Falciparum malaria remains a major global health threat to children. Along with respiratory disease, dehydration, measles and malnutrition, malaria is one of the top five killers of children in the tropics. The increasing occurrence of drug resistance only exacerbates this tragedy.

Severe malaria in children, especially in children under 5 years of age, can develop quite rapidly and progress to multi-system organ involvement if prompt diagnosis and treatment are not instituted. Any child, who is febrile in an area endemic for malaria, should be tested for this infection. If no diagnostic facilities are available, then empiric therapy should be instituted. If facilities are available for thick and thin smears then a febrile child who is ill appearing, should be started on anti-malarial treatment while awaiting laboratory results.

The diagnosis of malaria in children may be difficult. Many of the symptoms may represent other diseases. Also, many children have a baseline parasitemia, which may be clinically insignificant relative to their presenting symptoms. Fever may be variable and not synchronized; vomiting and diarrhea may represent an intestinal infection. Many causes of anemia are present in the tropics and may not necessarily be from malaria. And, febrile seizures, hypoglycemia, epilepsy, and bacterial meningitis may all mimic the presentation of cerebral malaria.

Although any child may be vulnerable to all of the complications of severe malaria seen in adults, the four most common complications in children are:
• Cerebral malaria
• Severe anemia
• Metabolic acidosis (presenting as respiratory distress)
• Hypoglycemia

MANAGEMENT

GENERAL PRINCIPLES:
• Assess Airway, Breathing, Circulation
• Monitor vital Signs
• Assess level of consciousness and general state of health
• Assess level of hydration
• Check blood sugar immediately
• Do Thick and thin films
• Check hemoglobin or hematocrit
• Consider lumbar puncture for bacterial meningitis

IMMEDIATE INTERVENTIONS:
• Airway, Breathing, and Circulation resuscitation if warranted
• Treat seizures
• Correct hypoglycemia
• Restore intravascular volume
• Nasogastric tube if child is unconscious
• Begin empiric treatment for P. Falciparum
• Treat fever
• Consider empiric antibiotic treatment

CEREBRAL MALARIA

CLINICAL PRESENTATION:
• Fever, decreased activity, refusing food or drink, emesis
• Brief period of 1-2 days prodromal symptoms prior to coma
• Seizures, nystagmus, salivation, myoclonic activity
• Hypoperfusion, cold extremities, shock

MANAGEMENT:
• See "Immediate Interventions" above
• Meticulous nursing care
• Nurse patient in lateral position to avoid aspiration
• Manage nasogastric tube
• Turn patient every 2 hours to prevent bed sores
• Strict records intake and output
• Monitor urine volume, spec. gravity, and asses for hemoglobinuria
• Meticulous attention to IV fluid rate to avoid overly rapid infusions
• Vital signs and Glasgow coma scale assesment every 4 hours
• Fever reduction with fans, tepid sponging, and medications
• Monitor blood glucose every 4-8 hours
• Packed red blood cell transfusion if severe anemia present

SEVERE ANEMIA

CLINICAL PRESENTATION:
• Assess effect of anemia on clinical presentation, rather than an absolute hemoglobin value
• A rapid drop in RBC’s from a high parasitemia will result in:
• Shock/Circulatory collapse
• Metabolic Acidosis and respiratory distress from hypoxemia

MANAGEMENT:
• Generally, a child who presents with a hemoglobin level of < 4.5gm/dl should be transfused with 10-15cc/kg of packed red blood cells immediately
• A child with a hemoglobin level of 4-6 gm/dl and shows signs of circulatory compromise, respiratory distress, impaired consciousness, or high parasitemia (>20%), should be transfused immediately

METABOLIC ACIDOSIS/ RESPIRATORY DISTRESS

CLINICAL PRESENTATION
• Tachypnea
• Intercostal and subcostal retractions
• Circulatory compromise/ shock

MANAGEMENT:
• Secure intravenous or intraosseous line
• Correct cause of acidosis:
   • Dehydration
   • Anemia
   • Shock
• Bolus 20cc/kg of Saline as needed to restore circulating volume
• Packed red blood cell transfusion as indicated
• Close and serial monitoring of level of consciosness, hydration, anemia, and blood glucose

HYPOGLYCEMIA

CLINICAL PRESENTATION:
• Common in children under age 3 yrs. with malaria
• Commonly associated with seizures, hyperparasitemia, and coma
• Easily overlooked as it may mimic symptoms of cerebral malaria

MANAGEMENT:
• 0.5gm/kg IV of Dextrose: (5cc/kg of D10W) (Dextrose 10g/100cc solution.)
• Give initial bolus over ~10-15 minutes
• Maintenance infusion of 5% dextrose should follow initial bolus, to prevent further hypoglycemia
• May give via nasogastric tube if parenteral routes unavailable
• Serial monitoring of blood glucose levels

PHARMACOLOGIC TREATMENT OF P. FALCIPARUM MALARIA IN CHILDREN

IF IV TREATMENT IS POSSIBLE:
• Loading Dose: 20mg/kg Quinine IV diluted in 10mg/kg Nl. saline; give over 4-6hrs.
• Do not give loading dose if child received quinine, quinidine, or mefloquine in past 12hrs
• Maintenance Dose: 12 hours after loading dose infused, give Quinine 10mg/kg IV, infused over 2 hrs.
• Repeat this dosing every 12 hours.
• When patient can tolerate PO’s, give Quinine 10mg/kg (600mg maximum.) every 8 hrs to complete a 7 day course.

IF IV TREATMENT NOT POSSIBLE:
• Loading Dose: 20mg/kg quinine diluted in 60mg/ml saline; inject IM in thighs
• Maintenance Dose: 10mg/kg IM every 12 hrs until able to take oral medications.

IF NO PARENTERAL TREATMENT POSSIBLE:
• Quinine tablets 10mg/kg by mouth or nasogastric tube every 8 hours to complete 7-day course
• Refer to higher level of care if possible

ALTERNATIVE ORAL TREATMENTS:
• Sulfadoxine 25mg/kg, and pyrimethamine 1.25mg/kg, single oral dose after 3 days of quinine
• Mefloquine 15mg/kg orally, single dose; then 10mg/kg orally in 24 hrs if patient remains ill

REFERENCES

Management of Severe Malaria; A Practical Handbook

World Health Organization, 2nd Edition, 2000.

O’Dempsey, Tim. Malaria in Children. Africa Health (supplement). Sept. 2000; 21-26.

Bell, Dion; Tropical Medicine. Blackwell Science, Ltd. 4th Edition. 1995.

(Scott is a general pediatrician living in Oakland, California. He is involved in both inpatient and outpatient services and has been a clinical instructor to pediatric residents and medical students since l993. He has a strong interest in international health. He is currently volunteering for three months in the rain forest in Eastern Guatemala, working with indigenous families. Scott is also the Director of a new organization, Global Pediatric Alliance; a non-profit group offering pediatric conferences and seminars for all levels of practitioners in developing countries.)