Paediatric Acute care Guidelines PMH Emergency Department

Background

  • The possibility of malaria should be considered in all children with a history of fever within 12 months of returning from a malaria endemic area. Refer to CDC Malaria Table
  • If not recognised and treated appropriately, malaria can progress rapidly to serious complications and / or death.
  • Incubation period ranges from 7 days to several weeks but exposure to antimalarial prophylaxis can delay the onset of symptoms by weeks or months. This is particularly important with P.vivax / P. ovale which produce dormant liver stage parasites.
  • Young children (<5 years old) are more likely to develop severe disease
  • Malaria can be broadly classified according to parasite species into:
    • falciparum malaria (caused by Plasmodium falciparum knowlesi infection can cause a similar clinical picture)
    • non-falciparum malaria ( P. vivax, P. ovale, P. malariae)

Assessment

History and Examination

  • History should include questions about:
    • Area of travel
    • Whether malaria prophylaxis was used (and which drug/s)
    • What prior treatment (if any) has been given
  • Examination findings suggestive of malaria include:
    • Jaundice and / or pallor
    • Hepatosplenomegaly
      These features are not always present and their absence should not preclude further investigation

Severe Malaria

Severe malaria is defined as one or more of the following features:

  • impaired consciousness / coma
  • seizures
  • prostration (unable walk or sit up without assistance)
  • vomiting / unable to tolerate oral intake
  • circulatory collapse / shock / hypotension
  • clinical jaundice plus evidence of other vital organ dysfunction
  • haemoglobinuria
  • spontaneous bleeding
  • respiratory distress / pulmonary oedema

Laboratory findings:

  • hyperparasitaemia (> 2%)
  • severe anaemia (Hb < 50 g/L)
  • hypoglycaemia (BSL < 2.2mmol)
  • metabolic acidosis (plasma bicarbonate < 15 mmol/l)
  • hyperlactataemia (lactate > 5 mmol/l)
  • renal impairment

Investigations

  • Diagnostic Testing (2 x EDTA tubes)
    • Thick and thin films from finger prick or venepuncture
      and
    • Rapid Diagnostic Test (RDT) for malaria antigen
      • One negative RDT / blood film does not exclude malariaa
        (Sensitivity of a single blood film is 85%, sensitivity of RDT is 99% for P. falciparum, 86% for non-falciparum malaria)
      • Repeat 12-24 hourly (total 3 samples) if tests initially negative
      • Perform blood films and RDT in all children with a suggestive history – even if patient is not febrile at time of ED presentation
      • Urgent results from Binax® RDT are available 24/7 through the haematology laboratory – mark samples as ‘urgent’ if required
      • Malaria PCR / NAT

Additional Investigations (in an unwell child) should include:

  • Blood gas (including glucose)
  • FBC, UEC, LFT, coagulation studies, blood culture
  • Blood group and hold
  • Urine pregnancy test (pregnant adolescents and women are at high risk of maternal and fetal complications)
  • G6PD assay (if known Pvivax / P. ovale infection prior to primaquine)

Please discuss all patients receiving treatment with the Infectious Diseases fellow (if after hours page / call at 0800 the next day). If urgent after hours advice is required contact the clinical microbiologist on call.

Management

Severe malaria

  • Medical emergency – admit all patients
  • Most often caused by falciparum (occasionally P. knowlesi or P. vivax)
  • ABC (caution with the use of IV fluid boluses)
  • 1st line – IV artesunate immediatelyb
    • Repeat at 12 and 24 hours then continue daily until oral therapy is tolerated
    • Switch to Artemether plus lumefantrine oral treatment once patient improved. A full course of oral therapy should be given. 

OR

  • 2nd line – IV quinine dihydrochloride 20mg/kg over 4 hours as a loading dose (if IV artesunate is not available)b
    • Ideal body weight should be used to calculate dosing in the obese patient
    • If previous prophylaxis/treatment (e.g. mefloquine) a loading dose may not be required. Discuss with the Infectious Diseases Consultant
    • Continue at a dose of 10mg/kg every 8 hours given over 4 hours starting 4 hours after the completion of the loading dose. 
    • Quinine may cause hypoglycaemia, arrhythmias and hypotension
    • Cardiac monitoring required, monitor BP and BSL closely

Uncomplicated malaria

  • Falciparum malaria
    • Admit all children with falciparum (and P. knowlesi) malaria as deterioration may occur following initiation of treatment
    • 1st line – Artemether plus lumefantrine (Riamet)c
      OR
    • 2nd line – Atovaquone plus proguanil (Malarone)c
      • Not to be used as treatment if previously used as prophylaxis
  • Non-falciparum malaria
    • Admit under general paediatrics or consider outpatient management (in discussion with Infectious Diseases) if:
      • Parasite count <1%
      • Tolerating oral medications
      • The family has sufficient understanding to ensure compliance, follow-up and representation if required
      • No significant co-morbidities and
      • Age >12 months old
    • Artemether-lumefantrine (Riamet)d 
      or Atovaquone plus proguanil (Malarone)
      AND
    • Hypnozoite eradication (all patients with P.vivax or P. ovale)
      • Primaquine 
      • Check G6PD status prior to prescribing

Follow Up

  • Monitor blood glucose, blood film / parasitaemia (daily), blood gases, FBC and UEC in all patients admitted to the ward.
  • Consult the infectious diseases team for all admitted patients.
  • Speak to the Infectious Diseases fellow (if after hours or page/call at 0800 the next morning) regarding any child treated for malaria prior to discharge to arrange appropriate follow up.
  • All children require follow up in Infectious Diseases clinic a week after discharge with repeat blood film. Blood film should be repeated again at ~28 days post treatment to ensure cure. Consider screening other family members for malaria (if similar travel history).
  • Ensure all children have a discharge letter stating that they have been admitted with malaria.

References

  1. Stauffer WM, Cartwright CP, Olson DA, Juni BA, Taylor CM, Bowers SH, et al. Diagnostic performance of rapid diagnostic tests versus blood smears for malaria in US clinical practice. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2009;49(6):908-13.
  2. Sinclair D, Donegan S, Isba R, Lalloo DG. Artesunate versus quinine for treating severe malaria. The Cochrane database of systematic reviews. 2012;6:Cd005967.
  3. Grynberg S, Lachish T, Kopel E, Meltzer E, Schwartz E. Artemether-lumefantrine compared to atovaquone-proguanil as a treatment for uncomplicated Plasmodium falciparum malaria in travelers. The American journal of tropical medicine and hygiene. 2015;92(1):13-7.
  4. Visser BJ, Wieten RW, Kroon D, Nagel IM, Belard S, van Vugt M, et al. Efficacy and safety of artemisinin combination therapy (ACT) for non-falciparum malaria: a systematic review. Malaria journal. 2014;13:463.
  5. Gogtay N, Kannan S, Thatte UM, Olliaro PL, Sinclair D. Artemisinin-based combination therapy for treating uncomplicated Plasmodium vivax malaria. The Cochrane database of systematic reviews. 2013;10:Cd008492.
  6. World Health Organization (WHO). Guidelines for the treatment of malaria. 2nd ed. Geneva: WHO; 2010
  7. Centers for Disease Control and Prevention (CDC). Treatment of malaria (guidelines for clinicians). Atlanta, GA: CDC; 2013
  8. Malaria. In: Therapeutic Guidelines: Antibiotic. Version 15. Melbourne: Therapeutic GuidelinesLimited; 2014
  9. Cherian S, Burgner D. Selective ambulatory management of Plasmodium falciparum malaria in paediatric refugees. Arch Dis Child 2007; 92(11) 983-6

Guideline Developed by: Daniel Yeoh (Infectious Diseases Fellow) July 2015 
External Review: PMH Infectious Diseases team August 2015
External Review: Zoy Goff (Pharmacy Department) August 2015

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