Malaria in children: Viva

Branch 1: Recognising the time-critical problem

The candidate should immediately recognise that this child has fever with altered consciousness and a travel history to a malaria-endemic area, which places severe malaria at the top of the differential. The combination of drowsiness, pallor, and deep sighing breathing is the clinical signature of severe falciparum disease, and a blood film must be requested within the hour while resuscitation proceeds. [1]

The candidate should state that any febrile child with relevant travel in the preceding three months has malaria until the blood film proves otherwise, and that the severity features here mean treatment must begin before the film returns. The first priorities are airway, breathing, and circulation, a fingerprick glucose, and intravenous access so that artesunate can be given the moment severe disease is confirmed clinically. [2]

Branch 2: Investigations and the severity classification

The candidate should outline the blood film, rapid diagnostic test, full blood count, blood gas, lactate, glucose, electrolytes, bilirubin, and blood culture drawn on cannulation. The thick film gives sensitivity while the thin film identifies the species and the parasite density, and a histidine-rich protein two rapid test confirms falciparum quickly. [1]

The examiner will probe how severity is judged. The candidate should list the World Health Organization severity criteria, including cerebral malaria, convulsions, respiratory distress, severe anaemia, prostration, shock, bleeding, jaundice, and high parasitaemia, and should identify this child's deep breathing and drowsiness as enough to classify the illness as severe. Any one feature in a parasitaemic child converts the diagnosis to severe malaria and dictates intravenous artesunate. [2]

Branch 3: Definitive therapy, fluids, and the haemolysis trap

The candidate should give intravenous artesunate 2.4 mg per kilogram at diagnosis, at 12 hours, and at 24 hours, then once daily until oral therapy is tolerated, followed by a full artemisinin-combination therapy course. The AQUAMAT and SEAQUAMAT trials showed that artesunate reduces mortality by about a quarter compared with quinine, which is why it is the first-line treatment for severe disease in children. [2]

The examiner will test the fluid strategy. The FEAST trial showed that large fluid boluses increased mortality in African children with severe febrile illness, so the candidate should describe small reassessed boluses only for clear shock and cautious maintenance fluids, avoiding hypotonic solutions. The candidate should then flag the post-artesunate delayed haemolysis trap, explaining that haemolysis can occur one to four weeks after treatment and that follow-up blood counts over the four weeks after discharge are essential. [3]