Severe Malaria In Children

Severe malaria is falciparum malaria complicated by major organ dysfunction or life threatening physiological disturbance. It is a medical emergency.

The major mechanisms include heavy parasitaemia, sequestration of infected erythrocytes in the microcirculation, haemolysis, impaired tissue perfusion, inflammatory activation and metabolic dysfunction.

Children frequently develop cerebral malaria, severe anaemia, hypoglycaemia and metabolic acidosis.

Severe features include:

• Impaired consciousness or coma
• Repeated convulsions
• Inability to drink
• Prostration
• Hypoglycaemia
• Severe anaemia
• Deep acidotic breathing
• Respiratory distress
• Shock
• Haemoglobinuria
• Jaundice with organ dysfunction
• Acute kidney injury
• Significant bleeding

Hypoglycaemia may be caused by severe malaria itself and can be worsened by quinine therapy.

Confirm with malaria microscopy or RDT whenever possible, but do not delay emergency treatment in a critically ill child with strong clinical suspicion.

Assess immediately:

• Glucose
• Haemoglobin or haematocrit
• Conscious level
• Respiratory pattern
• Perfusion
• Renal function
• Electrolytes
• Acid base status

Severe anaemia is typically defined as Hb below 5 g/dL or haematocrit below 15% in the relevant clinical context.

Hypoglycaemia is particularly dangerous and requires immediate correction.

Give parenteral artesunate immediately.

For children weighing 20 kg or less:

Artesunate 3 mg/kg IV or IM at 0, 12 and 24 hours, then once daily

For children weighing more than 20 kg:

Artesunate 2.4 mg/kg IV or IM at 0, 12 and 24 hours, then once daily

Continue parenteral therapy for at least 24 hours.

Once the child is clinically improved and able to tolerate oral medication, complete treatment with a full 3 day course of ACT, usually artemether lumefantrine, starting approximately 8 to 12 hours after the last artesunate dose.

If artesunate is unavailable, IV quinine is an alternative.

Quinine loading dose 20 mg salt/kg IV infused over at least 4 hours, followed by 10 mg/kg every 8 hours, each maintenance dose infused over at least 2 hours. Do not exceed 5 mg/kg/hour.

Do not give the quinine loading dose if adequate quinine or mefloquine has recently been administered.

Treat hypoglycaemia immediately.

Avoid routine rapid crystalloid boluses unless true hypovolaemic shock is present. Children with severe malaria and acidosis may deteriorate with unnecessary aggressive fluid loading.

For severe anaemia with respiratory distress or cardiac compromise:

• Packed red cells 10 mL/kg

or

• Whole blood 20 mL/kg

Transfuse urgently.

Treat seizures promptly.

Monitor glucose repeatedly, particularly with quinine.

Monitor urine output, consciousness, respiratory status and haemoglobin.