BNF for Children 2011-2012

330 5.4.1 Antimalarials BNFC 2011–20125 Infectionsmalaria with quinine, Malarone c (proguanil withatovaquone), or Riamet c (artemether with lumefantrine).Falciparum malaria can progress rapidly inunprotected children and antimalarial treatment shouldbe considered in those with features of severe malariaand possible exposure, even if the initial blood tests forthe organism are negative.Falciparum malaria (treatment)Falciparum malaria (malignant malaria) is caused byPlasmodium falciparum. In most parts of the world P.falciparum is now resistant to chloroquine which shouldnot therefore be given for treatment.Quinine, Malarone c (proguanil with atovaquone), orRiamet c (artemether with lumefantrine) can be given bymouth if the child can swallow and retain tablets andthere are no serious manifestations (e.g. impairedconsciousness); quinine should be given by intravenousinfusion (see below) if the child is seriously ill or unableto take tablets. Mefloquine is now rarely used fortreatment because of concerns about resistance.Oral. Quinine is well tolerated by children although thesalts are bitter.The dosage regimen for quinine by mouth is:10 mg/kg (of quinine salt 1 ; max. 600 mg) every 8hours for 7 daystogether with or followed byeither clindamycin 7–13 mg/kg (max. 450 mg)every 8 hours for 7 days [unlicensed indication]or, in children over 12 years, doxycycline 200 mgonce daily for 7 daysIf the parasite is likely to be sensitive, pyrimethaminewith sulfadoxine as a single dose [unlicensed] may begiven (instead of either clindamycin or doxycycline)together with, or after, a course of quinine.The dose regimen for pyrimethamine with sulfadoxineby mouth is:Child up to 4 years and body-weight over 5 kgpyrimethamine 12.5 mg with sulfadoxine 250 mg asa single doseChild 5–6 years pyrimethamine 25 mg with sulfadoxine500 mg as a single doseChild 7–9 years pyrimethamine 37.5 mg with sulfadoxine750 mg as a single doseChild 10–14 years pyrimethamine 50 mg with sulfadoxine1 g as a single doseChild 14–18 years pyrimethamine 75 mg with sulfadoxine1.5 g as a single doseAlternatively, Malarone c , or Riamet c may be giveninstead of quinine. It is not necessary to give clindamycin,doxycycline, or pyrimethamine with sulfadoxineafter Malarone c or Riamet c treatment.The dose regimen for Malarone c by mouth is:Child body-weight 5–8 kg, 2 ‘paediatric’ tabletsonce daily for 3 daysChild body-weight 9–10 kg, 3 ‘paediatric’ tabletsonce daily for 3 daysChild body-weight 11–20 kg, 1 ‘standard’ tabletonce daily for 3 daysChild body-weight 21–30 kg, 2 ‘standard’ tabletsonce daily for 3 days1. Valid for quinine hydrochloride, dihydrochloride, andsulphate; not valid for quinine bisulphate which containsa correspondingly smaller amount of quinine.Child body-weight 31–40 kg, 3 ‘standard’ tabletsonce daily for 3 daysChild body-weight over 40 kg, 4 ‘standard’ tabletsonce daily for 3 daysThe dose regimen for Riamet c by mouth is:Child body-weight 5–15 kg 1 tablet initially, followedby 5 further doses of 1 tablet each given at 8,24, 36, 48, and 60 hours (total 6 tablets over 60hours)Child body-weight 15–25 kg 2 tablets initially, followedby 5 further doses of 2 tablets each given at 8,24, 36, 48, and 60 hours (total 12 tablets over 60hours)Child body-weight 25–35 kg 3 tablets initially, followedby 5 further doses of 3 tablets each given at 8,24, 36, 48, and 60 hours (total 18 tablets over 60hours)Child 12–18 years and body-weight over 35 kg, 4tablets initially followed by 5 further doses of 4tablets each given at 8, 24, 36, 48, and 60 hours(total 24 tablets over 60 hours)Parenteral. If the child is seriously ill or unable toswallow tablets, quinine should be given by intravenousinfusion. The dose regimen for quinine by intravenousinfusion is calculated on a mg/kg basis:Neonates and children, loading dose 2 ; 3 of 20 mg/kg(up to maximum 1.4 g) of quinine salt 1 infused over4 hours then 8 hours after the start of the loadingdose, maintenance dose of 10 mg/kg 4 (up to maximum700 mg) of quinine salt 1 infused over 4 hoursevery 8 hours (until child can swallow tablets tocomplete the 7-day course together with or followedby either clindamycin or doxycycline asabove).Specialist advice should be sought in difficult cases (e.g.very high parasite count, deterioration on optimal dosesof quinine, infection acquired in quinine-resistant areasof south-east Asia) because intravenous artesunatemay be available for ‘named-patient’ use.Pregnancy Falciparum malaria is particularly dangerousin pregnancy, especially in the last trimester. Thetreatment doses of oral and intravenous quinine givenabove (including the loading dose) can safely be given inpregnancy. Clindamycin [unlicensed indication] shouldbe given for 7 days with or after quinine. Doxycyclineshould be avoided in pregnancy (affects teeth and skeletaldevelopment in fetus); pyrimethamine with sulfadoxine,Malarone c , and Riamet c are also best avoideduntil more information is available. Specialist adviceshould be sought in difficult cases (e.g. very highparasite count, deterioration on optimal doses ofquinine, infection acquired in quinine-resistant areas ofsouth east Asia) because intravenous artesunate may beavailable for ‘named patient’ use.2. In intensive care units the loading dose can alternatively begiven as quinine salt 1 7 mg/kg infused over 30 minutesfollowed immediately by 10 mg/kg over 4 hours then (after8 hours) maintenance dose as described.3. Important: the loading dose of 20 mg/kg should not beused if the patient has received quinine or mefloquineduring the previous 12 hours4. Maintenance dose should be reduced to 5–7 mg/kg ofquinine salt 1 in children with severe renal impairment,severe hepatic impairment, or if parenteral treatment isrequired for more than 48 hours.