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 developsevere 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)
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
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 P. vivax / 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.
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.
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.
Sinclair D, Donegan S, Isba R, Lalloo DG. Artesunate versus quinine for treating severe malaria. The Cochrane database of systematic reviews. 2012;6:Cd005967.
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.
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.
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.
World Health Organization (WHO). Guidelines for the treatment of malaria. 2nd ed. Geneva: WHO; 2010
Centers for Disease Control and Prevention (CDC). Treatment of malaria (guidelines for clinicians). Atlanta, GA: CDC; 2013