Treatment and care for malaria children

Article by Dr. Pham Thi Van Hanh – Children's Center – Share99 Times City International Health Hub.

Malaria (SR) is an infectious disease caused by parasites (KST) Plasmodium, which is transmitted mainly by anOpheles mosquito that burns the person and then transmits it to the healer. KST lives in red blood cells, causing a typical disease of malaria with cycles accompanied by liver, spleen, anemia, diseases with serious complications, brain damage, kidney failure, liver failure, hemolytic hematoma, fatal cardiovascular disease.

Naturally spread malaria must be full of 3 factors:

• Pathogens: Malaria-causing parasites have 5 species: lasmodium: Plasmodium falciparum, P.vivax, P.malariae, P.ovale and P.knowlesi. In particular, P.knowlesi is a species of parasite that causes malaria from monkeys transmitted to humans in Southeast Asia, in Vietnam has been identified in some mountainous areas in the Central (Khanh Hoa, Quang Tri …).
• Malaria medial intermediate: Due to the Anopheles mosquito. In Vietnam, there are 2 main vectors: An.minimus, An.dirus and 5 sub-vectors.
• Receptor mass: Humans are in a malaria-prone place and occupation, the manifestation of which depends on a specific immune condition with each stage of development of the parasite that causes malaria in the human body.

Treatment of malaria is difficult because the parasite that causes malaria is resistant to most treatment fever drugs.

2.1 Clinical manifestations of on-on-the-go

Clinical manifestations of the on-top stage of malaria are diverse, patients often have high fever, headache,general fatigue, loss of appetite, dark urination. Children are usually atypical (constant fever, abdominal obstruction, gastrointestinal disorders, diarrhea,vomiting, separation, coma, rapid weight loss – typidal hypocgestion). Pregnant women are prone to miscarriages.

2.2 Full-play phase

Typical malaria manifestations 3 stages:

• Cold period: After millions: Chills, shivers, tremors of limbs, children begin to tremble violently, last 1-2 hours, skin recurs, purple lips, cold limbs, fast vessels, enlarged spleen, piss a lot.
• Hot fever stage: Lasts 2-4 hours, high fever 39-40oC, hot skin, blood pressure eyes, headache, muscle pain, back pain, abdominalpain, nausea, little urination, rapid pulse, rapid breathing … then the fever diminishes. There may be severe complications of liver failure, kidney failure,convulsions, severe anemia …
• Sweating stage: Fever fades, sweats a lot, thirsts, then pleasantly.

Malaria has a cyclical nature:

• P. ovale and P. Vivax : every 48hours;
• P.. Malariae : Every 72hours;
• P.. Falciparum : daily bout

2.3 Atypical malaria manifestations

Manifestations of malaria are usually atypical when the first infection (primary malaria), when malaria has other infections attached or in young children 6 months to 4 years of age: usually without tremor, or convulsions when high fever , there are digestive disorders, rapid anemia, rapid enlarged spleen, hypoglycemia, increased liver enzymes,acute renal failure ..

Manifestations accompanied by malaria: Enlarged spleen, rapidly increasing anemia after each fever, jaundice in the presence of severe hemolysis, possible hemolysis. Big liver, dark skin, physical retretness …

Based on 3 basic factors: Epidemiology, clinical, malaria parasite testing

3.1 Epidemiology

Living in malaria areas circulating mountains and forests in the Southeast, Central Highlands) or have contracted malaria in the last 6 months. New entered the SR region, it should be noted the time from the time of entering to the on the first fever. Incubation period of P. Falciparum is 9–14 days; P.. Vivax is 12–17 days (up to 6 months); Ovale is 16–18 days; P. Malariae is 18–40days.

3.2 Clinical

Clinical malaria case: Must meet 4 criteria

• Have a typical or atypical fever or have a fever in the last 3 days
• No other causes of fever found
• Have been or are in the SR area of circulation for 14 days or history of SR in the last 2 years
• There is a response to malaria medications.

3.3 Testing for malaria parasites

Malaria case determination:

• Unpliced SR/commonmalaria : No severe signs and 3 factors: Epidemiology + Clinical typical 3-stage or atypical fever (continuous fever or oscillation or first-time malaria) and other signs (anemia, enlarged liver) + testing with asymetic malaria parasites or RDTs that detect malaria antigen or PCR positive
• SR complications/malignant SR, severe SRcomplications : Occurs when P. falciparum infection or coordination has P. falciparum. P. vivax or P. knowlesi infection alone causes malignant malaria when resistant to chloroquins. It should be noted signs of malignant SRforecasting: Consciousness disorders (separation, hysteria, wrestling …); constant high fever; gastrointestinal disorders (vomiting, diarrhea, abdominal pain); severe headache; high KST density(P. falciparum ++++ or ≥ 100,000 KST/μl of blood); severe anemia.
• Severe manifestations that may be encountered in malignant malaria caused by P.falciparum: Disorders of consciousness; coma; fatigue; seizures per 2 times/24 hours. Acute respiratory failure : shortnessof breath, SpO2 < 92%, rối loạn nhịp thở, acute pulmonaryedema , bilular failure or shock: rapid, small, difficult to catch vessels. Blood pressure<90 mmHg hoặc giảm 20 mmHg so với HA bình thường theo tuổi của trẻ em, lạnh chi, thiểu niệu. Renal impairment: urine < 0,5 ml/kg/giờ (ở cả người lớn và trẻ em). Mucosal jaundice. Natural bleeding (subcutaneous, in the muscles, digestive bleeding) or at the injection site, or prolonged bleeding; black stools or vomiting blood.
• Test: Density of KST: >10% of red blood cells infected with P. Falciparum ; hypothmemia; metabolic acid; severe anemia; urine with hemoglobin (hemoglobin mellitus); increased blood lactate >4 mmol/l; blood creatinine > 3mg% (> 265 μmol/l) or blood ure > 20mmol/l; Pulmonary XQ has a watermark of 2 pulmonary navels and the bottom of the lungs; serum bilirubin > 50 μmol/l (3mg/dl).
• Malignant SR in children note: Severe anemia, coma, convulsions, hypoglycemia, respiratory failure, metabolic acidosis. Malignant SR in pregnant women with hypoglycemia or miscarriage, premature birth.
• Blood malaria parasite detection test: Finger-tip blood droplets, thick droplet giemsa staining, and thin drops to find and categorise malaria parasites (definitive diagnosis). If the first test is negative, it should be done 3 times more, 8 hours apart when the fever is fever.

4.1 Principles

Early detection and treatment. Choose the right medication and enough doses according to the regimen.

• Artemisinin coordinated therapy (ACTs) to limit resistance and increase vir effectiveness.
• Combined anthectectecting treatment with the treatment of sterilization. Combining specific treatment, symptomatic treatment, care, physical enhancement.
• Malignant malaria must be transferred to the resuscitation, monitoring and active resuscitation department

4.2 Treatment of unsym complications of malaria (according to Decision No. 4845/QD-BYT of September 8, 2016)

Malaria drugs by group of patients and types of malaria parasites:

(1) DHA(Dihydroartemisinin)-PPQ (Piperaquin phosphate): Special pharmacy is CV Artecan, Arterakine.

4.3 Based on diagnosis to choose the right treatment drug

First line treatment according to the instructions

If treatment fails, re-test and consider treatment according to the Second line:

• In the region where SR P is located. Drug-resistant Falciparum: People with P. falciparum infection or coordination with P. falciparum both treat anti-resistance SR regimens:
• Pay attention not to treat Primaquins for pregnant women, children under 6 months of age and people lacking G6PD yeast; do not treat DHA-PPQ for pregnant women for the first 3 months.

4.4 Treatment of complications of malaria (malignant malaria)

Combination of specific treatment and supportive treatment:

• First line specific treatment: Artesunat injects until the provincial patient switches to taking the drug DHA-PPQ for 3 days. children < 20kg liều là 3mg/kg.
• Second line replacement treatment): + Quinin dihydrochloride: intravenously at 20mg/kg for the first 8 hours, then 10 mg/kg for every 8 hours until the province switches to Quinin sulfate + Doxycyclin For full 7 days or DHA-PPQ dose 3 days.

Do not take Artemether for pregnant women during the first 3 months, when taking Quinin to prevent hypoth glucose and cardiovascular bleeding due to rapid transmission.

4.5 Supportive treatment

Cooling down: Apply cool compresses + medicines if ≥ 38°5C with children or ≥ 39°C for adults, only acetaminophen(Paracetamol)doses 10-15mg/kg once, 4 times in 24 hours.

Cut seizures: Diazepam 0.1-0.2 mg/kg intravenously or pumped into the anus (0.5-1.0 mg/kg). Repeat the dose if there is still a seizure, caution when the child < 1 tuổi.

Shock treatment: Measure CVP, maintain CVP no more than 6.5 cm H2O using Noradrenalin or Dopamine vascular medications – maintain systophytoysis blood pressure > 90 mmHg. In case children have shock of handling vascular medicines, ensuring sysental blood pressure according to age. Additional broad-spectrum antibiotics are used to prevent infection and blood should be implanted before use.

Treatment of respiratory failure: placing canule of the throat; generous suction of sputum; 30°- 45°; gastric cathetro; oxygen breathing 4-6 liters/min maintain SpO2 > 92%;. if glasgow coma is ≤ 10 points, in the ineoculartube, ventilator, if the lung damage is severe, then ventilator according to ARDS; antibiotics in the course of multiple infections, limiting the opening of the ineterm management and taking respiratory inhibitors

Handling of renal failure: in case of anuria or oliguria, it is necessary to limit the infusion and maintain the balance of water in the following:

• If there is metabolic acid (HCO3- < 15 mmol/l): truyền Natri bicarbonat 1,4%.
• If HA > 90 mmHg, urine < 0,5ml/kg cân nặng cần dùng thêm Furosemid từ 40 mg – 80mg tiêm tĩnh mạch, theo dõi đáp ứng của thận và điều chỉnh dịch truyền và duy trì nước tiểu 80-100 ml/giờ, nếu vẫn không có kết quả thì phải lọc máu.
• Dialysis is in place for dialysis at < 500 ml sau khi đã được bù dịch đủ và dùng thuốc lợi tiểu hoặc người bệnh có phù hoặc đe dọa phù phổi cấp hoặc có một trong các tiêu chuẩn sau: Creatinin máu > 24:500 μmol/l, potassium > 6 mmol/l, pH < 7,25 mà không điều chỉnh được bằng Bicacbonat; Lactac máu > 5 mmol/l. The daily or daily dialysis distance depends on the degree of excess, the condition of the patient.

Treatment of hemolysis anemia or hemorrhage: Infusion of cubic red blood cells when Hematocrit < 20% hoặc hemoglobin < 7g/dl.

Treatment of hypoth glucose: Maintain eating through the gastric cathex continuously or multiple meals. If hypoglycemia: slow intravenously 30-50 ml of 20% preferred glucose (children 1-2 ml/kg), then 10% continuous 24-hour glucose maintenance infusion avoids recurrent hypoglycemia, on the contrary, if >10 mmol/l is increased, continuous intravenous insulin infusion is low dose 1-2 units/hour (maintaining blood glucose about 8-10 mmol/l).

Treatment of hemolysis: Medical history, new medications, KSTSR blood tests and urine tests for hemoglobin should be carefully questioned, the number of red blood cells repeatedly (in hematemia the number of red blood cells decreases very quickly) and G6PD testing if conditions are available.

Treatment of sodium chloride infusion by 0.9% and other outbreaks maintains a urine volume of ≥ 2500 ml/24 hours, 10-12 ml/kg/24 hours with children; transmission of esthrosis when Hematocrit < 25% hoặc hemoglobin < 7g/dl, nếu đang dùng Primaquin hoặc Quinin mà xuất hiện đái huyết cầu tố thì ngừng ngay thuốc và thay bằng thuốc SR khác, nếu suy thận thì xử trí như SR ác tính.

Note: Soliosis is common in people with G6PD deficiency, when encountering agents such as medications, bacterial infections and certain foods.

Correction of electrolysed water disorders, alkalineacidity : Daily scales + calculation of the amount of in-and-out of the solution. + If there are signs of dehydration: reduce skin elasticity, dry lips, rapid pulse, lower blood pressure, reduce urine tension less: issentiinal infusion not exceeding 2.5 liters / day for adults and 20ml / kg in the first 1-2 hoursfor children + electrolytic tests, blood pressure, urine. If hemophilic acidosis (HCO3- <15 mmol/l): truyền natri bicarbonat 1,4% + theo dõi khí máu .

Pay attention to the determination of oliguria, anuria by measuring the amount of fluid discharged (urine, vomit …) and the amount of fluid introduced. It is necessary to take caution of rehydration to avoid acute pulmonary edema (especially for patients with renal failure), monitoring blood pressure, vein pressure.

5.1 Clinical

If the disease is severe or during 3 days of treatment there is still a fever or worsening condition and malaria parasites (KSTSR) are used instead.

If the disease worsens or during 3 days of treatment, the person still has a fever or the condition deteriorates and there are no more malaria parasites – another cause should be found.

If the person vomits within 30 minutes after taking the medicine, another dose must be taken instead or injectable.

5.2 Monitoring of parasites

Blood blue check KSTSR daily.

Only the patient is discharged from the hospital when the blue ultrasound result is negative.

• Malaria prevention treatment: In addition to those who do not have immunity go into the malaria zone. Use only the first 3-6 months from entering the malaria zone.
• Kill mosquitoes, avoid mosquito bites.

When detecting patients with manifestations of malaria, it is necessary to urgently take the patient to the nearest medical facility for timely treatment, avoiding dangerous complications for the patient.

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