Malaria in children: SAQ

This child has severe falciparum malaria. His travel to Papua New Guinea without prophylaxis, the impaired consciousness with a low Blantyre coma scale, the deep sighing respirations of metabolic acidosis, and the high parasitaemia of six per cent together meet several World Health Organization severity criteria. He needs immediate resuscitation, intravenous artesunate, and cautious supportive care, with paediatric intensive care and retrieval organised early. [2]

Question 1 (10 marks)

Outline your immediate assessment and investigation plan for this child, and justify why this is classified as severe malaria. [2]

Begin with an airway, breathing, circulation assessment and an overall sick-or-well judgement. This boy is critically unwell, with a reduced conscious level, deep acidotic breathing, and pallor. Check a fingerprick glucose immediately because hypoglycaemia is common and treatable in severe malaria, and measure a full set of vital signs including heart rate, blood pressure, capillary refill, and oxygen saturation. [2]

Establish intravenous access and draw a confirmatory blood sample while the team prepares artesunate. Send a full blood count, blood gas, lactate, glucose, urea and electrolytes, bilirubin, and a blood culture, because bacterial co-infection is common in severe malaria. Confirm the species and parasite density on a thin film and run a rapid diagnostic test for falciparum if one is available at the point of care. [1]

Classify this as severe malaria because he has several World Health Organization severity features, namely cerebral malaria with a Blantyre coma scale of three, respiratory distress with deep sighing breathing, and a parasitaemia above two per cent in a non-immune child. Any one of these would justify intravenous artesunate, and the combination confirms a high-mortality presentation that needs paediatric intensive care and urgent retrieval. [1]

Question 2 (10 marks)

Describe your initial management including intravenous artesunate, fluid strategy, and the approach to his anaemia. [2]

Give intravenous artesunate immediately at 2.4 mg per kilogram intravenously, repeated at 12 and 24 hours and then once daily until he can swallow, after which a full oral artemisinin-combination therapy course completes the regimen. The AQUAMAT and SEAQUAMAT trials showed that artesunate reduces mortality by about a quarter compared with quinine, making it the clear first-line treatment for severe falciparum malaria in children. [2]

Manage fluids cautiously. The FEAST trial showed that large boluses of isotonic fluid increased mortality in African children with severe febrile illness and impaired perfusion, including malaria, so resuscitation uses small reassessed boluses only for clear shock and maintenance fluids to keep him euvolaemic. Avoid hypotonic fluids because of the risk of hyponatraemia, and watch for pulmonary oedema as he is resuscitated. [3]

Treat his hypoglycaemia with an intravenous dextrose bolus and a continuing dextrose-containing maintenance fluid, control any seizures with benzodiazepines, and transfuse packed red cells for his severe malarial anaemia guided by the degree of anaemia and any respiratory or cardiac compromise. Arrange paediatric intensive care for ventilation if his coma deepens, and plan follow-up blood counts over the four weeks after discharge because post-artesunate delayed haemolysis can occur. [2]