BNF for Children 2011-2012

BNFC 2011–2012 5.4.1 Antimalarials 331Benign malarias (treatment)Benign malaria is usually caused by Plasmodium vivaxand less commonly by P. ovale and P. malariae.Chloroquine 1 is the drug of choice for the treatmentof benign malarias (but chloroquine-resistant P. vivaxinfection has been reported from Indonesia, NewGuinea and some adjacent islands).Chloroquine alone is adequate for P. malariae infectionsbut in the case of P. vivax and P. ovale, aradicalcure (to destroy parasites in the liver and thus preventrelapses) is required. This is achieved with primaquine 2given after the chloroquine.The dosage regimen of chloroquine by mouth for benignmalaria in children is:initial dose of 10 mg/kg of base (max. 620 mg) thena single dose of 5 mg/kg of base (max. 310 mg) after 6–8hours thena single dose of 5 mg/kg of base (max. 310 mg) daily for2 daysFor a radical cure, primaquine 2 [unlicensed] is thengiven to children over 6 months of age; specialist adviceshould be sought for children under 6 months of age.Primaquine is given in a dose of 250 micrograms/kg(max. 15 mg) daily for 14 days in P. ovale infection or500 micrograms/kg (max. 30 mg) daily for 14 days in P.vivax infection.Parenteral If the child is unable to take oral therapy,quinine can be given by intravenous infusion. The doseis 10 mg/kg 3 (max. 700 mg) of quinine salt 4 infused over4 hours every 8 hours, changed to oral chloroquine assoon as the child’s condition permits.Pregnancy Treatment doses of chloroquine can begiven for benign malaria. In the case of P. vivax or P.ovale, however, the radical cure with primaquine shouldbe postponed until the pregnancy is over; insteadchloroquine should be continued at a dose of 10 mg/kg (max. 310 mg) each week during the pregnancy.Prophylaxis against malariaThe recommendations on prophylaxis reflect guidelinesagreed by UK malaria specialists; the advice is aimed atresidents of the UK who travel to endemic areas. Thechoice of drug for a particular child should take intoaccount:. risk of exposure to malaria;. extent of drug resistance;1. For the treatment of chloroquine-resistant benign malariaMalarone c [unlicensed indication], quinine, or Riamet c[unlicensed indication] can be used; as with chloroquine,primaquine should be given for radical cure.2. Before starting primaquine, blood should be tested forglucose-6-phosphate dehydrogenase (G6PD) activity sincethe drug can cause haemolysis in G6PD-deficient patients.Specialist advice should be obtained in G6PD deficiency. Inmild G6PD deficiency, primaquine in a dose of 750 micrograms/kg(max. 45 mg) once a week for 8 weeks, hasbeen found useful and without undue harmful effects.3. Maintenance dose should be reduced to 5–7 mg/kg ofquinine salt 4 in children with severe renal impairment,severe hepatic impairment, or if parenteral treatment isrequired for more than 48 hours.4. Valid for quinine hydrochloride, dihydrochloride, andsulphate; not valid for quinine bisulphate which containsa correspondingly smaller amount of quinine.. efficacy of the recommended drugs;. side-effects of the drugs;. patient-related factors (e.g. age, pregnancy, renal orhepatic impairment, compliance with prophylacticregimen).Prophylactic doses are based on guidelines agreed byUK malaria experts and may differ from advice inproduct literature. Weight is a better guide than age.If in doubt obtain advice from specialist centre, seep. 329.Protection against bites Prophylaxis is not absolute,and breakthrough infection can occur with any ofthe drugs recommended. Personal protection againstbeing bitten is very important. Mosquito nets impregnatedwith permethrin provide the most effective barrierprotection against insects (infants should sleep with amosquito net stretched over the cot or baby carrier);mats and vaporised insecticides are also useful. Diethyltoluamide(DEET) 20–50% in lotions, sprays, or roll-onformulations is safe and effective when applied to theskin of adults and children over 2 months of age. It canalso be used during pregnancy and breast-feeding. Theduration of protection varies according to the concentrationof DEET and is longest for DEET 50%. Longsleeves and trousers worn after dusk also provide protection.Length of prophylaxis In order to determine toleranceand to establish habit, prophylaxis should generallybe started one week (preferably 2–3 weeks in the case ofmefloquine) before travel into an endemic area (or if notpossible at earliest opportunity up to 1 or 2 days beforetravel); Malarone c or doxycycline prophylaxis shouldbe started 1–2 days before travel. Prophylaxis should becontinued for 4 weeks after leaving (except forMalarone c prophylaxis which should be stopped 1week after leaving).In those requiring long-term prophylaxis, chloroquineand proguanil may be used for periods of over 5 years.Mefloquine is licensed for use up to 1 year (although ithas been used for up to 3 years without undue problems).Doxycycline can be used for up to 2 years.Malarone c is licensed for use for up to 28 days butcan be used for up to 1 year (and possibly longer) withcaution. Specialist advice should be sought for longtermprophylaxis.Return from malarial region It is important to beaware that any illness that occurs within 1 year andespecially within 3 months of return might be malariaeven if all recommended precautions against malariawere taken. Travellers and carers of children shouldbe warned of this and told that if they develop anyillness particularly within 3 months of their returnthey should go immediately to a doctor and specificallymention their exposure to malaria.Epilepsy Both chloroquine and mefloquine are unsuitablefor malaria prophylaxis in children with a history ofepilepsy. In areas without chloroquine resistance, proguanilalone is recommended; in areas with chloroquineresistance, doxycycline or Malarone c may be considered.The metabolism of doxycycline may be influencedby antiepileptics (see interactions: Appendix 1 (tetracyclines)).5 Infections