Malaria In Pediatrics

By Azene Bantamlak
(MSc in Pediatrics and Child health)

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 Outlines

 Definition  Diagnosis
 Epidemiology  Differential diagnosis
 Etiology  Complicated form of
 Mode of transmission malaria
 Life cycle  Treatment of malaria
 Clinical feature  Prevention of malaria

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 What is malaria ?
 Literally, the word malaria comes from Italian
“mala aria” meaning “bad air”.
 Malaria is an acute and/or chronic infectious
disease which is caused by a protozoan parasites
(gnus plasmodium).
 Malaria is a parasitic infection of erythrocytes
(red blood cells) that can lead to other organ
failure.

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 Epidemiology
 According to the latest World malaria report,
released in November 2018, there were 219 million
cases of malaria in 2017, up from 217 million cases
in 2016.
 The estimated number of malaria deaths stood at
435 000 in 2017, a similar number to the previous
yea.
 Children especially under 5 years of age are the
most vulnerable group affected by malaria; in 2017,
they accounted for 61% (266 000) of all malaria
deaths worldwide.

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 Cont.…
 Among these malarial childhood deaths, 90% were
in Africa.
 Malaria is found throughout the tropical and
subtropical regions of the world.
 Malaria continues to be a major global health
problem, with over 40% of the world’s population.
 On average, 60%-70% of malaria cases have been
due to P. falciparum.
 Cerebral malaria affects more than 750, 000 children
a year, is one of a deadliest form of malaria.

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Cont.…

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 Cont.…
 Malaria is the third leading cause of deaths in under
five children as EDHS 2016.
 Approximately 52 million people (68%) live in
malaria risk areas in Ethiopia, primarily at altitudes
below 2,000 meters of humidity and ambient
temperature.
 Malaria seasonal patter of climatic factors:
 From September to December-> Major
 From May to July -> Minor

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 Cont.…
Malaria endemic transmission areas:
 Hyperendemic or Holoendemic (High transmission area):
area in which the prevalence rate of P. falciparum
parasitaemia is over 50%.
 Mesoendemic area (Moderate transmission area): in
which the prevalence rate of P. falciparum parasitaemia is
11–50%.
 Hypoendemic area (Low transmission area): in which the
prevalence rate of P. falciparum parasitaemia is 10%. a

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 Causes
 Malaria can occur when a bites mosquito infected
with the plasmodium parasite.
 There are more than 400 different species
of Anopheles mosquito.
• Anopheles arabiensis is the main malaria vector.
• Anopheles pharoensis
• Anopheles funestus Secondary vectors.
• Anopheles nili

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 Cont…
There are many different types of plasmodium parasite,
but only 5 types cause malaria in humans.
1. Plasmodium falciparum-Mainly found in Africa.
It is the most common type of malaria parasite and
responsible for most malarial deaths worldwide. It
is the most lethal form of malaria infection.
2. Plasmodium vivax-Mainly found in Asia and south
America. This causes milder symptoms than F.P,
but can stay in the liver for up to 3 years, which can
result in relapses.

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 Cont…

3. Plasmodium ovale- fairly uncommon and usually

found in west Africa, it can remain in the liver for
several years without producing symptoms.
4. Plasmodium malariae- This is quite rare and
usually found in Africa.
5. Plasmodium knowlesi- This is very rare and
found in parts of Southeast Asia. Recognized by
WHO in 2008 that used to infect apes exclusively.

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 Risk factors
 Children (especially under 5 years of age)
 Pregnant women
 Patients with chronic disease (HIV/AIDS…)
 Non-immune migrants
 Mobile populations and travellers.
 Fisherpersons

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 Mode of transmission
 Malaria parasites are mainly transmitted
from one person to another by the bite of a
female anopheles mosquito.
 The female mosquito bites during dusk and
dawn and needs a blood meal to feed her
eggs.
 Male mosquitoes do not transmit malaria as
they feed on plant juices and not blood.
 Malaria also can be transmitted through
blood transfusion, use of contaminated
needles, and transplacentally from a
pregnant woman to her fetus.

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 Life cycle of Anopheles mosquitoes
 The mosquito life cycle has four distinct
developmental stages: egg->larva-> pupa->adult.
 Eggs which are laid singly by the female Anopheles.
Eggs are about 0.5 mm in length, boat-shaped and nearly
all species are provided with tiny air-filled floats that
allow them to remain on the water surface.
 The larvae hatch from the eggs as small ‗wrigglers‘ and
have a distinct head and thorax, and an abdomen
composed of nine segments.
 The pupa is comma-shaped and differs greatly from the
larva in appearance.
 The length of each stage is dependent on a range of
environmental conditions, including temperature.
 In favorable conditions, it takes an average of seven
to ten days from egg to emerging adult.

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 Life cycle of malaria
The life cycle of malaria infection follow three stages:
I. Infection of human with sporozoite
II. Asexual reproduction
III. Sexual reproduction
The malaria parasite develops both in human and
anopheles mosquitoes with the following series cycles.

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1. Malaria infection begins when an infected female
anopheles bites a person and injecting plasmodium
parasites in the form of sporozoites saliva into
bloodstream. That is the first life stage of
plasmodium.
2. The sporozoites pass quickly into the human liver
only with in 30-60 munities after the parasite
inoculation.
3. The sporozoites enter into the liver cells asexually
dividing and leading to schizonts in 6 to 10 days,
causing no symptoms.
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 Cont…

4. Each schizont gives birth to thousands of merozoites

(exoerytrocytic schizogony), that are released into the
blood steam marking the end of exo-erytrocytic phase of
asexual reproductive stage. It is worth mentioning that,
concerning [Link] and [Link], sporozoites may stay
dormant (hypnozoites) in the liver and they may be
relapsed after ward.
5. In the bloodstream, the merozoites invade red blood cells
and they mark the beginning of erytrocytic phase and
forms a ring stage called trofozoite (not able to digest the
haem so they convert it into haemozoite and digest the
globin that is used as asource of aminoacids for their
reproduction to produce erytrocytic schizonte.

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 Cont…
6. Each erytrocytic schizonte gives birth to new generation
merozoites (erytrocytic schizogony), this causes rupture of
RBCs and released into blood stream to invade other RBCs.
This is when parasitemia occurs and clinical manifestations
appear. Hypnozoite or the liver phase occurs only once while
the erytrocytic phase undergone multiplying cycle.
7. The merozoites in RBCs develop into sexual forms of
parasites, called gametocytes that circulate in the blood
stream.
8. When mosquito bites an infected human, it ingests the
gametocytes which develop further into mature sex cells
called gametes.

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 Cont…
9. The fertilized female gametes develop into
actively ookinates that burrow through the
mosquito’s mid gut wall and form oocysts on the
exterior surface.
10. Inside the oocyst, thousands of active sporozites
develop. The oocyst bursts and releasing
sporoziotes into the body cavity that travel to the
mosquito’s salivary glands.
11. The cycle of human infection begins again when
the mosquito bites an other person.

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 Clinical manifestations
The onset of clinical manifestations of malaria infection coincide
with incubation periods plasmodium species.
 Usual incubation periods are:

 P. Falciparum 9–14 days

 P. Vivax 12–17 days
 P. Ovale 16–18 days
 P. Malariae 18–40 days
 P. Knowlesi- The only primate malaria species known to
have a 24- hours cycle of asexual development in blood and
mosquito.
A prodrome lasting 2–3 days is noted in some patients before
parasites are detected in the blood.

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 Cont…
There are three stages in classical malaria fever attack:
1. cold stage
 Feeling very cold/chills
 Vigorous shivering/
 Symptoms last 15–60 minutes
2. hot stage
 Feeling very hot – higher than normal temperature
 Dry burning skin
 muscle pain
 Severe headache
 Severe vomiting and diarrhea
 Symptoms last 2–6 hours

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 Cont…
3. Sweating stage:
 Intense sweating.
 Fall in temperature
 Feeling exhausted and weak
 Tendency to fall asleep
 Symptoms last 2–4 hours
On examination, a child with malaria may have an
enlarged liver and spleen, jaundice (yellowing of the
whites of the eyes, urine and nail beds) and pain over
the abdomen.

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 Diagnosis of malaria
Malaria infection can be diagnosed with:
 A patient‘s clinical assessment
 Microscopic examination of thick and thin blood
films.
Thick blood smear-detect the presentation of
malaria parasite
Thick blood smear-to species
identification/confirmation
 Microscopic diagnosis remains the ‘gold standard
diagnosis malaria infection. This is the most common
and accurate diagnostic test.

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 Cont…
 Rapid diagnostic test (RDT)/ malaria antigen test
(MAT)- detect specific antigen (protein) produced
by malaria parasite.
 Molecular test (PCR): Useful for confirming the species
of malaria parasite after other diagnostic methods and
when low number of parasite.
 Antibody (Serology) test: Detect antibodies in the blood
that are produced by the body in response to malaria
infection. Not used for acute infection.
 Blood test (Hematocrit, Blood sugar, Serum electrolytes
Renal function test): To know the seriousness of infection
( like anemia, RF…).

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 Complicated form of malaria
Complicated form of malaria ( sever malaria) can resulted
from late parasite detection and nature of species.
Cerebral malaria:
 Impaired consciousness or unusable coma (Blantyre
coma score <2/3).
 Due to Falciparum
 No other cause of coma.
Sever hypoglycemia:
 RBS < 40 or 45 mg/dl
 Due to [Link]
 No other cause of hypoglycemia.

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 Cont…
Liver failure:
 LFT increase by >5 times normal
 Jaundice
 Due to [Link]
 No other cause of HF.
Acute renal failure:
 Creatinine > 3 times normal
 Due to [Link]
 No other cause of RF.

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 Cont…
Severe anemia due to “anti- kell antibodies???”
 Hgb < 5/6mg/dl or Hct 15%
 Duto [Link]
 No other cause of anemia .
Metabolic acidosis:
 PH <7 or bicarbonate < 15mg/l
 Due to [Link]
 No other cause of acidosis
Hyperparasitaemia:
 high parasite densities (above 5% or 250 000/μl).
 Embolism->DIC.
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 Cont…
Other WHO criteria for sever malaria:
 Prostration (generalized weakness)
 Multiple convulsions (more than two episodes in 24 h).
 Respiratory distress (acidotic breathing)
 Circulatory collapse /shock
 Clinical jaundice Haemoglobinuria and failure to feed
 Abnormal spontaneous bleeding
 Pulmonary oedema (radiological) and vital organ dysfunction

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 Management of malaria

 The
four principles the “ ABCD” of malaria infection
management.
 Be Aware of the risk.
 Avoid Being bitten by mosquitoes
 Taka antimalarial (Chemoprophylaxis)
 Immediate seeking Diagnosis and Treatment
Antipyretics
Analgesia

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 Antimalarial drugs:

Choice of antimalarial drugs depends on severity infection and

plasmodium species.
 P. Falciparum = Complicated P. Falciparum malaria,

 Artesunate is the treatment of choice.

 Artesunate 2⋅4 mg/kg (for children >20 kg) and 3mg/kg (for

children <20 kg ) by intravenous or intramuscular injection at 0,

12 and 24 hrs; continue injection once daily if necessary.
 Preparation doses, 30mg, 60mg, 120mg with in each there are:

1ml = 5% sodium bicarbonate

5ml = distilled water or 0.9% sodium chloride.
 The amount obtained ; IV = 6ml, IM = 3ml

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 Cont…

Exercise:
If a child has weight of 10kg, how much ml of
Artesunate will you give ?

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 Cont…

P. Falciparum = Uncomplicated P. Falciparum

malaria:
 First line- Artemether + Lumefantrine (coartem) 3.2
mg/kg by immediate Im (no IV preparetion), followed
by 1.6 mg/kg daily.
 Alternative- Quinine dihydrochloride 20 mg /kg in
10ml/kg of 10% dextrose infused for 4hrs, followed by
maintenance of 10 mg /kg infused every 8 hrs (can also
be given by intramuscular injection).

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 Cont…
 For P. Vivax, [Link], [Link] and p. knowlesi-
Chloroquine phosphate 5-25mg/kg for 14 days.
 Mixed ([Link] and [Link])-ACTfor
[Link]
 Primaquine used in P. Vivax and [Link]- for
eradicating the persisting liver forms and in
[Link] malaria to destroy the gametocytes.

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 Malaria prevention and control
Reducing man-mosquito contact:
 Insecticide-treated nets
 Avoiding perfume
 Indoor house-spraying with residual insecticides
 Wearing of protective clothing and insect repellents
at dawn and dusk.
 Covering window
 Drainage of stagnant H2O

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 Cont…
 Chemoprophylaxis- The administration of drugs to
individuals likely to be exposed to malaria (started 2
weeks before departure and 4 weeks after return from
the malarious area).
P. Falciparum
 First line: Mefloquine
 Alternative: Doxycycline
P. vivax: Primaquine phosphate, chloroquine

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 Cont…
National malaria control strategy (2014-2020):
 By 2020, to achieve near zero malaria deaths (no more
than malaria death per 100,000 population at risk) in
Ethiopia.
 By 2020, to reduce malaria cases by 75 % from base
line of 2013.

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