Anti-Malarial Drugs Used in Pediatrics with Updates
Classification of Pediatric Anti-Malarial Drugs
1. 4-Aminoquinolines: Chloroquine - First-line for sensitive P. vivax in children
2. Artemisinin-Based Combination Therapies (ACTs): Artemether-Lumefantrine - Preferred first-line for uncomplicated P. falciparum
3. Hydroxynaphthoquinones: Atovaquone-Proguanil - Well-tolerated prophylaxis option for children
4. Quinoline Methanols: Mefloquine - Alternative prophylaxis for children >5kg
5. Cinchona Alkaloids: Quinine - For severe malaria in children
6. 8-Aminoquinolines: Primaquine - For radical cure in G6PD-normal children
7. Tetracyclines: Doxycycline - Limited to children >8 years
Pediatric Malaria Treatment Guidelines
Assessment Priorities:
- Weight-based dosing is essential - accurate weight measurement required
- Age-appropriate formulations should be selected
- Consider local resistance patterns
Risk Factors for Severe Disease:
- Age <5 years
- Non-immune status
- Delayed treatment
- Malnutrition
Treatment Considerations:
| Age Group | Special Considerations | Preferred Drugs |
|---|---|---|
| Neonates (<28 days) | Limited drug options, close monitoring required | Quinine, Artesunate |
| Infants (1-12 months) | Weight-based dosing crucial | ACTs, Chloroquine |
| Toddlers (1-3 years) | Palatability important | ACTs, Atovaquone-Proguanil |
Chloroquine in Children
Clinical Use: First-line for chloroquine-sensitive P. vivax, P. ovale, and P. malariae in children.
Pediatric Advantages:
- Available in syrup form
- Well-established safety profile
- Extensive clinical experience
Pediatric Dosing:
- Treatment Course:
- Day 1: 10 mg/kg (max 600 mg)
- Day 2: 5 mg/kg (max 300 mg)
- Day 3: 5 mg/kg (max 300 mg)
- Prophylaxis: 5 mg/kg weekly (max 300 mg)
Administration Tips:
- Can be crushed and mixed with food
- Syrup should be well-shaken
- Give with food to minimize GI upset
Monitoring in Children:
- Regular eye examinations for long-term use
- Monitor for compliance
- Watch for GI tolerance
Red Flags:
- Visual changes
- Severe vomiting
- Neurological symptoms
Artemether-Lumefantrine for Children
Clinical Use: First-line treatment for uncomplicated P. falciparum malaria in children.
Pediatric Advantages:
- Rapid fever clearance
- Available in dispersible tablets
- Good safety profile
Weight-Based Dosing:
| Weight (kg) | Tablet Strength | Duration |
|---|---|---|
| 5-14 | 1 tablet twice daily | 3 days |
| 15-24 | 2 tablets twice daily | 3 days |
| 25-34 | 3 tablets twice daily | 3 days |
Administration Guidelines:
- Give with fatty food/milk
- Space doses 8-12 hours apart
- Repeat dose if vomiting within 1 hour
Special Considerations:
- Not recommended under 5kg
- Complete full course
- Monitor intake and tolerance
Atovaquone-Proguanil in Pediatrics
Clinical Use: Prophylaxis and treatment in children ≥5kg.
Pediatric Benefits:
- Well-tolerated in children
- Available in pediatric tablets
- Once-daily dosing for prophylaxis
Weight-Based Prophylaxis:
| Weight (kg) | Daily Dose | Duration |
|---|---|---|
| 5-7.9 | 1/2 pediatric tablet | Daily |
| 8-10.9 | 3/4 pediatric tablet | Daily |
| 11-20 | 1 pediatric tablet | Daily |
Administration Tips:
- Take with food or milk
- Can be crushed and mixed with condensed milk
- Start 1-2 days before travel
- Continue for 7 days after leaving endemic area
Mefloquine in Pediatric Practice
Clinical Use: Prophylaxis in children >5kg traveling to chloroquine-resistant areas.
Key Considerations:
- Start 2-3 weeks before travel
- Monitor neuropsychiatric symptoms
- Parents should maintain symptom diary
Weight-Based Dosing:
| Weight (kg) | Weekly Dose | Tablet Division |
|---|---|---|
| 5-10 | 62.5 mg | 1/4 tablet |
| 11-20 | 125 mg | 1/2 tablet |
| 21-30 | 187.5 mg | 3/4 tablet |
Safety Monitoring:
- Initial loading dose effects
- Sleep patterns
- Behavioral changes
- Balance/coordination
Quinine in Pediatric Severe Malaria
Clinical Use: Treatment of severe malaria in children; second-line for uncomplicated malaria when first-line treatments are unavailable.
Critical Considerations:
- Reserved for severe cases
- Requires careful monitoring
- Available in multiple formulations
Pediatric Dosing:
| Administration Route | Loading Dose | Maintenance |
|---|---|---|
| Intravenous | 20 mg/kg | 10 mg/kg q8h |
| Oral | 15-20 mg/kg | 10 mg/kg q8h |
| Intramuscular | 20 mg/kg | 10 mg/kg q12h |
Administration Guidelines:
- IV administration:
- Dilute appropriately
- Never bolus
- Infuse over 4 hours
- Monitor cardiac function
- Oral administration:
- Give with food if possible
- Can mix with sweetened fluids
- Monitor for vomiting
Required Monitoring:
- Blood glucose every 4-6 hours
- Cardiac monitoring during IV therapy
- Daily blood counts
- Neurological status
Warning Signs:
- Hypoglycemia
- Cardiac arrhythmias
- Cinchonism symptoms
- Visual disturbances
Primaquine in Pediatric Patients
Clinical Use: Radical cure of P. vivax and P. ovale in children with normal G6PD levels.
Essential Pre-treatment:
- Mandatory G6PD testing
- Baseline complete blood count
- Assessment of risk factors
Pediatric Dosing:
| Indication | Daily Dose | Duration |
|---|---|---|
| Standard Therapy | 0.5 mg/kg | 14 days |
| High-dose Regimen | 0.75 mg/kg | 14 days |
| Weekly Regimen* | 0.75 mg/kg | 8 weeks |
*For G6PD intermediate deficiency
Safety Monitoring:
- Weekly hemoglobin checks
- Signs of hemolysis:
- Pallor
- Jaundice
- Dark urine
- Fatigue
- Methemoglobin levels if symptomatic
Administration Tips:
- Give with food
- Tablets can be crushed
- Consider mixing with small amount of food/liquid
- Complete full course for effectiveness
Doxycycline in Pediatric Malaria
Clinical Use: Prophylaxis and treatment in children >8 years old.
Age Restrictions:
- Contraindicated in children <8 years
- Risk of dental staining
- Impact on bone growth
Pediatric Dosing:
| Indication | Dose | Duration |
|---|---|---|
| Prophylaxis | 2.2 mg/kg/day | Daily |
| Treatment | 4 mg/kg/day | 7 days |
Administration Guidelines:
- Give with full glass of water
- Keep upright for 30 minutes
- Avoid dairy products within 2 hours
- Use before bedtime if once daily
- Divide doses if twice daily
Sun Protection:
- Strict sun protection required
- Use broad-spectrum sunscreen
- Wear protective clothing
- Avoid peak sun hours
Monitoring Needs:
- Gastrointestinal tolerance
- Photosensitivity reactions
- Compliance with administration rules
- Dental/bone development in long-term use
Warning Signs:
- Severe heartburn/esophagitis
- Severe photosensitivity reaction
- Vision changes
- Persistent GI symptoms
