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close this bookGuidelines for the Treatment of Malaria (WHO; 2006; 266 pages) View the PDF document
View the documentGlossary
View the documentAbbreviations
open this folder and view contents1. Introduction
View the document2. The clinical disease
open this folder and view contents3. Treatment objectives
open this folder and view contents4. Diagnosis of malaria
open this folder and view contents5. Resistance to antimalarial medicines9
open this folder and view contents6. Antimalarial treatment policy
close this folder7. Treatment of uncomplicated P. Falciparum malaria10
View the document7.1 Assessment
View the document7.2 Antimalarial combination therapy
View the document7.3 The choice of artemisinin-based combination therapy options
View the document7.4 Practical aspects of treatment with recommended ACTs
View the document7.5 Incorrect approaches to treatment
View the document7.6 Additional aspects of clinical management
View the document7.7 Operational issues in treatment management
View the document7.8 Management of treatment failures
View the document7.9 Treatment in specific populations and situations
View the document7.10 Coexisting morbidities
open this folder and view contents8. Treatment of severe falciparum malaria14
open this folder and view contents9. Treatment of malaria caused by P. vivax, P. ovale or P. malariae19
View the document10. Mixed malaria infections
open this folder and view contents11. Complex emergencies and epidemics
open this folder and view contentsAnnexes

7.6 Additional aspects of clinical management

7.6.1 Can the patient take oral medication?

Some patients cannot tolerate oral treatment, and will require parenteral or rectal administration for 1-2 days until they can swallow and retain oral medication reliably. Although such patients may not show signs of severity, they should receive the same antimalarial dose regimens as for severe malaria (see section 8.4).

7.6.2 Does the patient have very high parasitaemia (hyperparasitaemia)?

Some patients may have no signs of severity but on examination of the blood film are found to have very high parasitaemia. The risks associated with high parasitaemia vary depending on the age of the patient and on transmission intensity. Thus cut-off values and definitions of hyperparasitaemia also vary. Patients with high parasitaemias are at an increased risk of treatment failure and of developing severe malaria, and therefore have an increased risk of dying. These patients can be treated with the oral ACTs recommended for uncomplicated malaria. However, they require close monitoring to ensure that the drugs are retained and that signs of severity do not develop, and they may require a longer course of treatment to ensure cure. Details of definitions and management are provided in sections 8.1 and 8.15.

7.6.3 Use of antipyretics

Fever is a cardinal feature of malaria, and is associated with constitutional symptoms of lassitude, weakness, headache, anorexia and often nausea. In young children, high fevers are associated with vomiting, including of medication, and seizures. Treatment is with antipyretics and, if necessary, tepid sponging. Care should be taken to ensure that the water is not too cool as, paradoxically, this may raise the core temperature by inducing cutaneous vasoconstriction. Paracetamol (acetaminophen) 15 mg/kg bw every 4 h is widely used; it is safe and well tolerated given orally or as a suppository. Ibuprofen (5 mg/kg bw) has been used successfully as an alternative in malaria and other childhood fevers, although there is less experience with this compound. Acetylsalicylic acid (aspirin) should not be used in children because of the risks of Reye's syndrome. There has been some concern that antipyretics might attenuate the host defence against malaria, as their use is associated with delayed parasite clearance. However, this appears to result from delaying cytoadherence, which is likely to be beneficial. There is no reason to withhold antipyretics in malaria.

EVIDENCE: trials of routine use of antipyretics in uncomplicated falciparum malaria

Interventions: oral paracetamol, oral nonsteroidal antiinflammatory drugs, mechanical methods

Summary of RCTs: a systematic review of 12 trials (n = 1509) in children using paracetamol.

Systematic review of 3 randomised trials in adults did not provide any evidence that antipyretic medicines prolonged illness.

In 2 trials, where all children received an antipyretic medicine, physical methods resulted in a higher proportion of children without fever at one hour (n = 125, RR: 11.76; 95% CI: 3.39-40.79). In a third trial (n = 130), which only reported mean change in temperature, no difference was detected.

Expert comment: symptomatic treatment of fever is indicated and is particularly important in small children in whom fever can cause seizures and induce vomiting (more likely if core temperature is >38 °C). Mechanical antipyretic measures, such as exposure and fanning cause a transient reduction in temperature, oral antipyretics may be more effective for reducing temperature.

Recommendation: use paracetamol or ibuprofen for treating fever (particularly if temperature is >38.5 °C). Mechanical methods have an additive effect.

Summary of recommendations on management of fever



An antipyretic medicine and physical methods for fever reduction should be administered to children with fever. This is particularly important in children when core temperature is ≥38.5 oC.

S, E

Paracetamol (acetaminophen) and ibuprofen are the preferred options for reducing fever.

S, E

7.6.4 Use of antiemetics

Vomiting is common in acute malaria and may be severe. Antiemetics are widely used. There have been no studies of their efficacy in malaria, and no comparisons between different antiemetic compounds, although there is no evidence that they are harmful.

7.6.5 Management of seizures

Generalized seizures are more common in children with falciparum malaria than in those with the other malarias. This suggests an overlap between the cerebral pathology resulting from malaria and febrile convulsions. Sometimes these seizures are the prodrome of cerebral malaria. If the seizure is ongoing, the airway should be maintained and anticonvulsants given (parenteral or rectal benzodiazepines or intramuscular paraldehyde). If it has stopped, the child should be treated as indicated in section 7.6.3 if core temperature is above 38.5 oC. There is no evidence that prophylactic anticonvulsants are beneficial in otherwise uncomplicated malaria.

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