Management of severe paediatric malaria in resource-limited settings

Abstract

Over 90% of the world’s severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the publication of the AQUAMAT trial in 2010, involving 5,425 children at 11 centres across 9 African countries, showing that in artesunate-treated children, the relative risk of death was 22.5% (95% confidence interval (CI) 8.1 to 36.9) lower than in those receiving quinine. Human trials of supportive therapies carried out on the basis of pathophysiology studies, have so far made little progress on reducing mortality; despite appearing to reduce morbidity endpoints, more often than not they have led to an excess of adverse outcomes. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.

How to Fairly Allocate Scarce Medical Resources: Ethical Argumentation under Scrutiny by Health Professionals and Lay People

“…However, societies are facing situations when medical resources are scarce, and access to means of prevention, diagnosis, and treatment of those in need is not always guaranteed. Insufficient supply of medical resources is obvious in many developing countries where basic services are widely lacking [ 4 – 5 ]. Yet, also well-off countries are confronted by scarcities of medical resources such as donor organs, hospital beds during epidemics or after severe disasters, or unusually expensive drugs like Sofosbuvir to cure HCV infection [ 6 ] or Myozyme to manage Pompe disease [ 7 ].…”

Factors hindering the adherence to clinical practice guideline for diabetes mellitus in the Palestinian primary healthcare clinics: a qualitative study

“…In many low-income and middle-income countries (LMICs), the medical resources are insufficient and the basic services are often unavailable. 21 WHO estimates that the average availability of essential drugs in LMICs is 35% in public sector facilities and 66% in the private sector. 22 In the Palestinian healthcare system, it seems that tackling the issue of irrational medicine use is considered to be quite essential to allow for optimal utilisation of scarce resources and to improve healthcare delivery.…”

Teaching Pediatric Life Support in Limited-Resource Settings: Contextualized Management Guidelines

“…• Respiratory failure: Administer PPV 24 • Neurological cause: Central apnea: aminophylline 18 ; Increased intracranial pressure (ICP): supportive measures, treat underlying cause 24,41 ; Meningitis: see guidelines for meningitis 18,19 ; Encephalitis/cerebral malaria: see guidelines for cerebral malaria 18,[42][43][44][45] ; Seizure: see guidelines for seizure 18 ). An oxygen concentrator can deliver up to 90% oxygen (maximum flow rate 10 LPM).…”

“…Detecting retinopathy, which is highly specific for cerebral malaria, can reduce incorrect diagnosis of the condition. 44 • Impaired consciousness: Recognize condition using a coma scale (e.g., modified Glasgow, Blantyre) [70][71][72][73][74][75] ; recognize and treat other causes of impaired consciousness in the setting of malaria; use NG PRN 18,44 • Malaria: See guidelines for severe malaria 18,[42][43][44][45] • Hyperpyrexia:…”

“…• Initial resuscitation: Recognize impaired consciousness, generalized weakness, respiratory distress/failure, jaundice, significant hemorrhage, hemoglobinuria, and dehydration/shock 18,[42][43][44][45] • Dehydration/shock: See guidelines for dehydration/hypovolemic shock and septic shock 17,18,46 • Antimalarial treatment 42 : See ►Table 3; follow local guidelines 42 • Bacterial infection: Recognize and treat common comorbidities (i.e., pneumonia, meningitis, bacteremia, diarrhea/ dehydration); see guidelines for serious bacterial infection 17,18,44 • Seizure: See guidelines for seizure 18 • Severe anemia: Confirm condition in severe malaria (i.e., Hb < 5 g/dL or hematocrit < 15% in children < 12 years þ parasite count > 10,000/µL) 44 ; see guidelines for severe anemia 18 • Hyperpyrexia:…”