Hypoglycaemia in severe malaria, clinical associations and relationship to quinine dosage

Abstract

BackgroundHypoglycaemia is an independent risk factor for death in severe malaria and a recognized adverse treatment effect of parenteral quinine. In 2006 our hospital changed quinine treatment policy from 15 mg/kg loading (plus 10 mg/kg 12-hourly) to 20 mg/kg loading (plus 10 mg/kg 8-hourly) to comply with new WHO guidelines. This presented us with the opportunity to examine whether there was any dose relationship of quinine and hypoglycaemia occurrence.MethodsRetrospective case notes review of all children admitted to hospital with severe falciparum malaria between April 2002 - July 2009, before and after the introduction of the new WHO quinine regimen. Four-hourly bedside glucose levels were measured until intravenous quinine was discontinued. Clinical events immediately preceding or concurrent with each episode of hypoglycaemia (glucose < = 3.0 mmol/l) were recorded.Results954 children received the old quinine regime and 283 received the new regime. We found no evidence of an increased prevalence of hypoglycaemia (< = 3.0 mmol/L) on the new regime compared to former (15% vs. 15%); similar findings were noted for profound hypoglycaemia (< 2.2 mmols/L) 8% v 5%, P = 0.07. Episodes were co-incident with disease severity markers: coma (57%), circulatory failure (38%) and respiratory distress (21%) but less commonly with seizures (10%). Disruption of maintenance fluids and/or blood transfusion concurred with 42% of the hypoglycaemia episodes. Post admission hypoglycaemia increased odds of fatal outcome (24%) compared to euglycaemic counterparts (8%), odds ratio = 3.45 (95% confidence interval = 2.30-5.16) P < 0.01.ConclusionThere was no evidence to indicate a dose relationship between quinine and occurrence of hypoglycaemia. Hypoglycaemia concurred with severity features, disruption of glucose infusion and transfusion. Careful glucose monitoring should be targeted to these complications where resources are limited.

Blood Glucose Concentration Abnormalities in Children with Severe Malaria: Risk Factors and Outcome

“…This frequency is much higher than that would have been noted if blood glucose had been measured only on arrival and if the WHO definition was used [2]. Wilcox in Mali, Ogetii in Nigeria and Madrid in Mozambique found slightly lower frequencies despite the fact that they also took into account moderate hypoglycemia in their study [12] [13] [25]; differences in the definition of hypoglycemia, blood glucose monitoring modalities and population profile explain this. The frequency of moderate hypoglycemia was significantly greater than that of severe hypoglycemia in this study as in that of most authors consulted [12] [12].…”

“…The peculiarity of our results is that the blood glucose threshold exposing to an increased risk of death is significantly higher than that set by the WHO (3.3 mmol/L vs. 2.2 mmol/L). Like us, other African authors have also reached to the same conclusion [12] [25]. It is therefore relevant and important to review the blood glucose levels defining the severity of malaria and determining the management.…”

‘We just dilute sugar and give’ health workers’ reports of management of paediatric hypoglycaemia in a referral hospital in Malawi

“…In resource-constrained countries with weak health systems, care seeking is often delayed due to financial and physical barriers [14,15] that may result in children presenting in late stages of illness. This may be one of the several explanations [12,16–18] why low and hypoglycaemia are common in children in sub-Saharan African hospitals [1,12]. The potential long-term neurological outcomes following hypoglycaemia in acute paediatric illness as described in neonates [19,20] have not been investigated to date.…”

Pediatric Cerebral Malaria: A Scourge of Africa

“…A total of 70% of hypoglycemic episodes occur within 24 h of hospital admission [50]. Hypoglycemia may not be clinically apparent in patients with CM and it is imperative to monitor serum glucose to assure early recognition and correction [50,51]. When hypoglycemia is detected, it should be corrected with 5 ml per kilogram of intravenous 10% dextrose, if available.…”

“…Hypoglycemia is a known independent risk factor for death [9,49] in children with severe malaria and is present in 15% of children. A total of 70% of hypoglycemic episodes occur within 24 h of hospital admission [50]. Hypoglycemia may not be clinically apparent in patients with CM and it is imperative to monitor serum glucose to assure early recognition and correction [50,51].…”