Proposed guidelines for severe imported malaria in children need more evidence

Editor—The proposed UK guidelines for severe childhood malaria are an excellent attempt to improve the care of children with severe imported malaria,¹ but we are concerned about the following.

Firstly, the use of parenteral antibiotics. The “high risk group” would include less than 5% of children with imported malaria.² Children with these features in the United Kingdom are likely to have bacterial septic shock or meningitis, even with a history of foreign travel. Furthermore, it is impossible to differentiate between septic shock or meningitis and severe malaria.³,⁴ The management algorithm should, therefore, recommend giving empirical broad spectrum antibiotics to children with high risk criteria until bacterial infection can be excluded.

Secondly, transfusion. The authors propose that children with haemoglobin counts < 100 g/l should be managed in a high dependency unit and be transfused. In east London 65/211 (31%) presented with haemoglobin counts of 50-100 g/l, and none developed complications despite being managed conservatively.² A Cochrane review found no difference in mortality between initial and expectant transfusion in children with malarial anaemia, but more adverse events with initial transfusion.⁵ Recommendations for transfusion should be reconsidered, given the current UK move to decrease transfusions.

Thirdly, oral quinine. The authors recommend that children should “never” receive oral quinine. However, according to the BNF, oral quinine remains effective, is cheap, and is well tolerated by children. In east London, only 1/192 children (0.5%) receiving quinine relapsed.² Treatment with mefloquine should be avoided because of concerns about resistance. Further studies are necessary before recommending newer antimalarials.

Fourthly, non-falciparum malaria. The proposed guidelines only apply to Plasmodium falciparum malaria and may lead to confusion about non-falciparum malaria, which is unlikely to be severe. The suggested treatment for “uncomplicated malaria” would also be inappropriate and more costly than currently recommended chloroquine. A 12 month study of imported malaria through the British Paediatric Surveillance Unit (http://bpsu.inopsu.com) will start later this year. We aim to collect comprehensive information to support future recommendations for the management of imported malaria.