P.Falciparum Malaria, Severe, Complicated (Or If Repeated Vomiting)

Diagnostic criteria

General and supportive measures

Medicine treatment

Referral

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ICD-10 code: B50.0/B50.8

DIAGNOSTIC CRITERIA

Clinical

• Unable to drink or breast feed.
• Vomits everything.
• Renal failure.
• Cerebral malaria: manifests with convulsions, which may be subtle, and/or any change in mental state, ranging from irritability, lethargy to coma, stiff neck or bulging fontanelle.
• Respiratory distress and metabolic acidosis similar to pneumonia.
• Anaemia: can be severe and lead to cardiac failure and a depressed mental state.
• Shock: cold moist skin, low blood pressure and evidence of poor peripheral perfusion.
• Hypoglycaemia: can present with convulsions and a depressed mental state.
• Jaundice, bleeding, acute renal failure and ARDS are less common in children than adults.

Investigations

• Hyperparasitaemia: > 5% of RBCs infected indicates severe malaria but a lower parasite density does not exclude severe malaria.
• Low Hb (< 6 g/dL).
• Test glucose immediately with a fingerprick test. Low blood glucose: < 2.2 mmol/L.
• Acidosis: serum lactate (venous) > 5 mmol/L or bicarbonate < 15 mmol/L.
• Severe thrombocytopenia: < 50 x 109 /L.
• In severe cases, repeat smear after 72 hours and after the completion of the course of treatment.

GENERAL AND SUPPORTIVE MEASURES

• Check airway, breathing, circulation (ABC).
• Admit to a high care or intensive care unit.
• Review the child at least twice daily, including holidays.
• Avoid overhydration.
• Control convulsions.
• Ventilatory support, if necessary.
• Agitation and respiratory distress can be as a result of severe metabolic acidosis. Treat shock and acidosis. See: Shock.
• Nutritional support.

MEDICINE TREATMENT

Urgent:

Children ≥ 20 kg:

• Artesunate, IM or IV, 2.4 mg/kg at hours 0, 12 and 24, then daily until patient is able to tolerate oral treatment.

Children < 20 kg:

• Artesunate, IM or IV, 3 mg/kg at hours 0, 12 and 24, then daily until patient is able to tolerate oral treatment.

LoE III²

2–3 days after initiating treatment with artesunate and able to swallow, switch to any of the 2 regimens:

Children > 5 kg:

• Artemether/lumefantrine 20/120 mg, oral, with fat-containing food/milk to ensure adequate absorption.
  • Give first dose immediately.
  • Follow with second dose 8 hours later.
  • Then 12 hourly for another 2 days (total number of doses in 3 days = 6).

Weight	Dose	Total tablets per course
5–≤ 15 kg	1 tablet	6
15–≤ 25 kg	2 tablets	12
25–≤ 35 kg	3 tablets	18
> 35 kg	4 tablets	24

OR

Children < 5 kg

• Quinine, oral, 10 mg/kg/dose 8 hourly to complete 7–10 day course.

PLUS

• Clindamycin, oral, 10 mg/kg/dose 12 hourly for 7 days.

For concurrent bacterial sepsis:

• Ceftriaxone, IV, 100 mg/kg as a single daily dose once daily for 10 days.
  • Maximum dose: 4 g/day.

For fever:

• Paracetamol, oral, 15 mg/kg/dose 6 hourly as required.

For hypoglycaemia:

• Dextrose 10%, IV, 4 mL/kg.

If Hb < 7 g/dL:

• Packed red cells, IV, 10 mL/kg over 3 hours.

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Note:
Fluid loss is often underestimated in a febrile, vomiting, sweating child.

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REFERRAL

• Urgent: Severe or complicated malaria.
• High-risk children under 2 years, splenectomised patients.
• Malaria not responding clinically to adequate treatment within 48– 72 hours (possible resistance).

Click here for the pdf.

Click here for Erratum-3. Reference: 2024/07/EDP/01. 

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Standard Treatment Guidelines and Essential Medicines List for South Africa Paediatric Hospital _2023, 5th edition_Updated July 2024 
Chapter 8: Infective/Infectious Diseases,  8.9.2 P. Falciparum Malaria, Severe, Complicated (or If Repeated Vomiting)