BNF for Children 2011-2012

334 5.4.1 Antimalarials BNFC 2011–20125 InfectionsCentral and South America and theCaribbeanVery low risk Risk very low in Jamaica:chemoprophylaxis not recommended but avoidmosquito bites and consider malaria if fever presentsVariable to low risk Risk variable to low in Argentina(rural areas along northern borders only), rural Belize(except Belize district), Costa Rica (Limon Provinceexcept Puerto Limon and northern canton of Pococci),Dominican Republic, El Salvador (Santa Ana province inwest), Guatemala (below 1500 m), Haiti, Honduras,Mexico (states of Oaxaca and Chiapas), Nicaragua,Panama (west of Panama Canal but variable to highrisk east of Panama Canal, see below), rural Paraguay:chloroquine or (if chloroquine not appropriate) proguanilhydrochlorideVariable to high risk Risk variable to high andchloroquine resistance present in rural areas of Bolivia(below 2500 m; see below for Amazon basin area),Ecuador (below 1500 m; no malaria in GalapagosIslands and Guayaquil; see below for Esmeraldas Province),Panama (east of Panama Canal), Peru (ruralareas east of the Andes and west of the Amazon basinarea below 1500 m; see below for Amazon basin area),Venezuela (north of Orinoco river; high risk south of andincluding Orinoco river and Amazon basin area, seebelow; Caracas free of malaria):chloroquine + proguanil hydrochloride or (ifchloroquine + proguanil not appropriate) mefloquineor doxycycline (if child over 12) or Malarone cHigh risk Risk high and marked chloroquine resistancein Bolivia (Amazon basin area; see also variable tohigh risk above), Brazil (throughout ‘Legal Amazon’ areawhich includes the Amazon basin area, Mato Grossoand Maranhao only; elsewhere very low risk—no chemoprophylaxis),Colombia (most areas below 800 m),Ecuador (Esmeraldas Province; variable to high risk inother areas, see above), French Guiana, all interiorregions of Guyana, Peru (Amazon basin area; see alsovariable to high risk above), Suriname (except Paramariboand coast), Venezuela (Amazon basin area, areassouth of and including Orinoco river; see also variableto high risk above):mefloquine or doxycycline (if child over 12) orMalarone cStandby treatment [unlicensed]Children and their carers visiting remote, malariousareas for prolonged periods should carry standbytreatment if they are likely to be more than 24 hoursaway from medical care. Self-medication should beavoided if medical help is accessible.In order to avoid excessive self-medication, thetraveller should be provided with written instructionsthat urgent medical attention should be soughtif fever (388C or more) develops 7 days (or more)after arriving in a malarious area and that self-treatmentis indicated if medical help is not availablewithin 24 hours of fever onset.In view of the continuing emergence of resistantstrains and of the different regimens required fordifferent areas expert advice should be sought onthe best treatment course for an individual traveller.A drug used for chemoprophylaxis should not beconsidered for standby treatment for the same traveller.Artemether with lumefantrineArtemether with lumefantrine is licensed for the treatmentof acute uncomplicated falciparum malaria.ARTEMETHER WITH LUMEFANTRINECautions electrolyte disturbances, concomitant usewith other drugs known to cause QT-interval prolongation;monitor patients unable to take food (greaterrisk of recrudescence); avoid in acute porphyria(section 9.8.2); interactions: Appendix 1 (artemetherwith lumefantrine)Skilled tasks Dizziness may affect performance of skilledtasksContra-indications history of arrhythmias, of clinicallyrelevant bradycardia, and of congestive heartfailure accompanied by reduced left ventricular ejectionfraction; family history of sudden death or ofcongenital QT interval prolongationHepatic impairment manufacturer advises caution insevere impairment—monitor ECG and plasmapotassium concentrationRenal impairment manufacturer advises caution insevere impairment—monitor ECG and plasmapotassium concentrationPregnancy toxicity in animal studies with artemether;manufacturer advises use only if potential benefitoutweighs riskBreast-feeding manufacturer advises avoid breastfeedingfor at least 1 week after last dose; present inmilk in animal studiesSide-effects abdominal pain, anorexia, diarrhoea,vomiting, nausea; palpitation, prolonged QT interval;cough; headache, dizziness, sleep disturbances, asthenia,paraesthesia; arthralgia, myalgia; pruritus, rash;less commonly ataxia, hypoaesthesia, clonusIndication and doseTreatment of acute uncomplicated falciparummalaria see p. 330Treatment of benign malaria see p. 331