SERIOUS MALARIA IN CHILDREN
Dr. Satish Deshpande*
Department of Pediatrics*
Malaria is most important public health problem in our country. Plasmodium falciparum causes 40-60% of all cases of malaria, but is responsible 95% or more of malaria deaths. When the Plasmodium falciparum density exceeds 3% of red blood cells in peripheral blood smear, then the infection becomes dangerous, therefore it is known as serious malaria. Serious malaria is defined as "series of complications occurring during the course of an infection of Plasmodium falciparum, which if not effectively treated threatens the life of the patient within 1-3 days. Clinically serious malaria is characterized by fever with various complications.

Non-serious Plasmodium falciparum malaria can be easily treated with routine anti-malarial drugs, considering regional chloroquine sensitivity. Serious Plasmodium falciparum malaria, on the other hand, requires intensive and prompt treatment with anti-malarial drugs and management of associated complications.

The problem of serious malaria has become more miserable because of (a) Development of multiple drug resistant strains resulting in treatment failure (b) Atypical presentation - resulting in delayed diagnosis and errors in treatment (c) In children serious malaria develops rapidly not giving sufficient time for anti-malarial drugs to produce their effect.

Pathogenesis: (1) Plasmodium falciparum infected RBC's become sticky and show irregularities on their surface. Uninfected RBC's adhere around infected RBC forming cluster of red blood cells in capillaries, (2) Sticky RBC's adhere to endothelium of capillaries and venules, (3) Plasmodium falciparum is relatively hard therefore parasitized RBC's are unable to change their shape while passing through capillaries, (4) Increased capillary permeability causes increased viscosity of blood.

Factors (1) (2) (3) & (4) cause obstruction to capillary blood flow of internal organs like brain, liver, lungs, and kidneys. The tissues of these vital organs get reduced supply of glucose and oxygen which together with hypoglycemia and lactic acidosis produce acute inflammation leading to endothelial damage. This causes failure of functions of these vital organs.

Hemolysis of infected RBC during schizogony may cause severe anemia. Hemoglobin liberated during hemolysis may cause Hyperbilirubinemia and Jaundice. During hemolysis, malarial toxins are liberated, which produce fever , hemolysis, endothelial cell damage, increasing capillary permeability and damage to tissues of internal organs.

Plasmodium falciparum inhibit antigen presenting cells and thus decrease antibody formation which may cause secondary bacterial infection or septicemia.

Diagnosis of Serious Malaria:

Peripheral blood smear shows Plasmodium falciparum density more than 3% of RBCs or schizontemia.

Complications of Severe Malaria in Children:

Common complications in children:
  1. Cerebral malaria
  2. Severe anemia
  3. Metabolic acidosis
  4. Hypoglycemia
  5. Dehydration
  6. Hyperthermia
  7. Convulsions

Uncommon complications in Children
  1. Liver failure
  2. Renal failure
  3. Pulmonary oedema

Rare complication in Children

Bleeding and clotting disturbances.

By the time child is brought for treatment, one or more of these complications are already developed.

If one complication is present it may precipitate other complication which may in turn enhance the original complications. Thus vicious cycle get established which perpetuate complications and patient's condition deteriorates. Therefore prompt treatment with antimalarial drugs and simultaneous treatment of complications is life saving.

Treatment of common complications in Children

Cerebral malaria - Earliest symptom of cerebral malaria in children is high grade fever, followed by failure to eat or drink, changes in level of consciousness. Cerebral malaria may be associated with hyperpyrexia, coma, paralysis, severe anemia, metabolic acidosis and shock, child develops coma in 1 to 2 days, corneal reflexes are absent, presence of doll's eye movement indicate profound coma. Transient abnormal eye movement like divergent eyes, nystagmus, pyramidal signs, decerebrate or decorticate rigidity may be present. Lock jaw and opisthotonus may confuse these cases with tetanus. Mild neck stiffness may be present. Convulsions may be subtle e.g., minor twitching of single digit or corner of mouth. Child regions consciousness in 1 to 2 days with prompt treatment.

Management:
  1. Meticulous nursing care, maintaining clear airway, nursing on side, aspiration of stomach contents, bowel and bladder care, and frequent changing of position are important.
  2. Monitor-vital signs, blood pressure, level of consciousness, input output chart.
  3. Investigations-Peripheral blood smear, parasite density every 6 to 8 hourly, funduscopy to detect retinal hemorrhages, blood sugar, blood urea, serum creatinine, SGOT, SGPT, serum electrolytes, acid base changes, bleeding and clotting time, CSF examination and CBC.
  4. For intravenous administration of drugs and fluids intraosseous route or femoral venous cannulation may be required. Treatment of convulsion-A slow intravenous Inj. Diazepam 0.3 mg/kg of body wt. or 0.4 mg/kg intrarectally or Inj. Paraldehyde 0.1 ml/kg intramuscularly.

Chloroquine-sensitive malaria

Inj. Chloroquine 10 mg base/kg in isotonic fluid by constant rate IV infusion over 8 hours, followed by 15 mg/kg given over the next 24 hours. If IV infusion is not possible chloroquine can be given 3.5 mg/kg every 6 hourly i.m. or s.c.

Chloroquine resistant malaria or sensitivity unknown

Inj. Quinine dihydrochloride 20 mg salt/kg (loading dose) diluted in 10 ml isotonic fluid/kg by IV infusion over 4 hours; than after 12 hours, after the start of loading dose give maintenance dose of Quinine, 10 mg/kg over 2 hours repeat maintenance dose every 12 hours until the patient can swallow, then Quinine tablets 10 mg/kg, 8 hourly to complete a 7 days course or a single dose of 25 mg/kg sulfadoxine and 1.25 mg/kg pyrimethamine, or Artesunate IV or Artemether IM,


  • Hyperpyrexia is treated with Paracetamol, 15 mg/kg body weight 4 hourly, use tepid sponging and fanning.

  • For dehydration and metabolic acidosis give normal saline IV but avoid circulatory overload

  • Severe anemia is treated with packed cell transfusion if hematocrit is less than 20%.

  • Hypoglycemia is treated by giving 1 ml/kg body weight 50% Dextrose well diluted. This should be followed by slow infusion of 10% dextrose.

  • For shock IV Dextran, blood transfusion, Dopamine, for septic shock-Antibiotics.

  • Hyperparasitemia-parasite density more than 15% or parasite density more than 5% with organ damage are indication for exchange transfusion.


Differential diagnosis of cerebral malaria

Reyes syndrome, heat stroke, meningitis, encephalitis, metabolic coma, head injury, febrile convulsion, brain abscess and tumor, typhoid and ascaris encephalopathy and narcotic poisoning.

Metabolic acidosis should be differentiated from pneumonia and pulmonary oedema.

To get best results, use accurate doses as per body weight. Parenteral route for drug administration is indicated if severe nausea, vomiting or coma. Mefloquine should not be combined with quinine to prevent drug toxicity. A loading dose of quinine should not be used if the patient has received quinine or mefloquine within preceding 12 hours.

To conclude, early diagnosis, best nursing care, frequent monitoring of vital signs and investigations, prompt treatment of complications and judicious use of antimalarial drugs are the key factors to reduce mortality due to serious malaria.
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