Malaria

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

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Aim

To guide PCH staff with the assessment and management of malaria.

Background

Malaria is a notifiable infectious disease in Western Australia.
The possibility of malaria should be considered in all children with a history of fever within 12 months of returning from a malaria endemic area.
- Refer to map of where malaria occurs (WHO) to determine malaria endemic areas.
Incubation period ranges from 7 days to several weeks but exposure to antimalarial prophylaxis can delay the onset of symptoms by weeks or months. This is particularly important with P.vivax / P. ovale which produce dormant liver stage parasites.¹
Young children (<5 years old) are more likely to develop severe disease.
Severe malaria is associated with a high rate of concurrent bacteraemia and may be covered for with IV ceftriaxone.²
Malaria can be broadly classified according to plasmodium parasite species into:
- falciparum malaria (caused by P. falciparum - P. knowlesi infection can cause a similar clinical picture).
- non-falciparum malaria ( P. vivax, P. ovale, P. malariae).

Assessment

History and examination

History should include questions about:
- Location and timing of travel
- Be aware of increasing artemisinin resistance in malaria from:
  - Greater Mekong Subregion (Thailand, Vietnam, Cambodia, Laos and Myanmar)
  - East and Central Africa (Uganda, Rwanda, South Sudan, Tanzania, Ethiopia, Eritrea and Democratic Republic of the Congo)
  - Papua New Guinea.
- Whether malaria prophylaxis was used and which drugs
- What prior treatment (if any) has been given
- Recurrent P. malariae has occurred after artemether and lumefantrine therapy. In these patients, consider therapy with chloroquine or hydroxychloroquine (discuss with Infectious Diseases Consultant).
Examination findings suggestive of malaria include:
- Jaundice and / or pallor
- Hepatosplenomegaly
These features are not always present and their absence should not preclude further investigation.
Be conscious of features of severe malaria on history and examination.
Consider other causes of Fever in the returned traveller.

Severe malaria

Severe malaria is defined as one or more of the following features:

Impaired consciousness / coma
seizures
prostration (unable walk or sit up without assistance)
vomiting / unable to tolerate oral intake
circulatory collapse / shock / hypotension
clinical jaundice plus evidence of other vital organ dysfunction
haemoglobinuria
spontaneous bleeding
respiratory distress / pulmonary oedema

Laboratory findings:

High parasite load > 2%
severe anaemia (Hb < 50 g/L)
hypoglycaemia (BGL < 2.2mmol)
metabolic acidosis (plasma bicarbonate < 15 mmol/L)
hyperlactataemia (lactate > 5 mmol/L)
renal impairment

Investigations

Diagnostic Testing (2 x EDTA tubes)
- Thick and thin films from finger prick or venepuncture
  and
- Rapid Diagnostic Test (RDT) for malaria antigen
  - One negative RDT / blood film does not exclude malaria
    (Sensitivity of a single blood film is 85%, sensitivity of RDT is 99% for P. falciparum, 86% for non-falciparum malaria)
  - Repeat 12-24 hourly (total 3 samples) if tests initially negative
  - Perform blood films and RDT in all children with a suggestive history – even if patient is not febrile at time of Emergency Department (ED) presentation
  - Urgent results from Binax^® RDT are available 24/7 through the haematology laboratory – mark samples as 'urgent' if required
  - Malaria polymerase chain reaction (PCR) / nucleic acid testing (NAT).

Additional investigations (in an unwell child) should include:

Blood gas (including glucose)
Full blood count (FBC), urea, electrolytes and creatinine (UEC), liver function tests (LFT), coagulation studies, blood culture
Blood group and hold
Urine pregnancy test (pregnant adolescents and women are at high risk of maternal and fetal complications)
Glucose-6-phosphate dehydrogenase (G6PD) assay (if known P. vivax / P. ovale infection prior to primaquine)
Sickle cell solubility test

Management

Please discuss all patients receiving treatment with Infectious Diseases Consultant on call.

For more information, refer to ChAMP monographs.
Ensure an interpreter is available for families with whom effective communication in English is not possible.

Severe malaria
Medical emergency - admit all patients and discuss with Infectious Diseases Consultant on call Most often caused by P. falciparum (occasionally P. knowlesi or P. vivax) ABC (caution with the use of IV fluid boluses) 1st line - IV artesunate immediately:⁴ Dosing in Overweight and Obese Children: No information, dose based on actual body weight. Children ≥ 4 weeks old: Weight < 20 kg: 3 mg/kg/dose immediately. Repeat at 12 and 24 hours.³ Weight ≥ 20 kg: 2.4 mg/kg/dose immediately. Repeat at 12 and 24 hours.³ Then continue artesunate once daily until the patient has clinically improved and oral therapy is tolerated AND parasitemia is ≤ 1%, for up to an additional 6 days. Parasite density can be reassessed 4 hours post the 3rd dose of artesunate.^3,8 For disease acquired in the Greater Mekong subregion, Eastern Africa and Central Africa, and Papua New Guinea addition of IV quinine dihydrochloride is recommended and should be considered, especially in the setting of very high parasitaemia or severe organ dysfunction,10 dosing as below. Discuss with Infectious Diseases Consultant. Switch to artemether plus lumefantrine (Riamet®) oral treatment once patient has clinically improved and can tolerate oral therapy. A full course of oral therapy should be given.³ AND IV ceftriaxone 50 mg/kg/dose (max 2g) once daily for two days then reassess with blood culture results.³ AND PO / enteral paracetamol 15 mg/kg/dose (max 1 g) 6 hourly for 72 hours. This has been shown to be renoprotective.⁵ If meningitis suspected refer to Meningitis and Meningoencephalitis - ChAMP guideline Or if Artesunate not available 2nd line - IV quinine dihydrochloride Contact ward pharmacist or on-call pharmacist (after hours) for stock. Ideal body weight should be used to calculate dosing in the obese patient.³ Refer to Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Clinical Practice Manual. If previous prophylaxis / treatment (e.g. quinine, mefloquine) has been given a loading dose may not be required.3 Discuss with the Infectious Diseases Consultant. Children ≥ 4 weeks old: Loading dose: 20 mg/kg (maximum 1.4 g) given over 4 hours.¹⁰ Maintenance dose: 10 mg/kg/dose (maximum 700 mg) every 8 hours given over 4 hours starting 4 hours after the completion of the previous dose.¹⁰ Rapid administration may cause severe cardiotoxicity. Administer via slow IV infusion over 4 hours. Slow the rate of infusion if dysrhythmias occur.² If IV quinine is still needed after 48 hours a dose reduction may be required. Discuss with the Infectious Diseases Consultant.^2,3 Quinine may cause hypoglycaemia, arrhythmias and hypotension.¹⁰ Cardiac monitoring required;³ quinine should be administered in Paediatric Critical Care where possible. Monitor blood pressure and blood glucose levels (BGL) 4 hourly.

Severe malaria

Medical emergency - admit all patients and discuss with Infectious Diseases Consultant on call
Most often caused by P. falciparum (occasionally P. knowlesi or P. vivax)
ABC (caution with the use of IV fluid boluses)
1st line - IV artesunate immediately:⁴
- Dosing in Overweight and Obese Children: No information, dose based on actual body weight.
- Children ≥ 4 weeks old:
  - Weight < 20 kg: 3 mg/kg/dose immediately. Repeat at 12 and 24 hours.³
  - Weight ≥ 20 kg: 2.4 mg/kg/dose immediately. Repeat at 12 and 24 hours.³
- Then continue artesunate once daily until the patient has clinically improved and oral therapy is tolerated AND parasitemia is ≤ 1%, for up to an additional 6 days. Parasite density can be reassessed 4 hours post the 3rd dose of artesunate.^3,8
- For disease acquired in the Greater Mekong subregion, Eastern Africa and Central Africa, and Papua New Guinea addition of IV quinine dihydrochloride is recommended and should be considered, especially in the setting of very high parasitaemia or severe organ dysfunction,10 dosing as below. Discuss with Infectious Diseases Consultant.
- Switch to artemether plus lumefantrine (Riamet®) oral treatment once patient has clinically improved and can tolerate oral therapy. A full course of oral therapy should be given.³
AND IV ceftriaxone 50 mg/kg/dose (max 2g) once daily for two days then reassess with blood culture results.³

AND PO / enteral paracetamol 15 mg/kg/dose (max 1 g) 6 hourly for 72 hours. This has been shown to be renoprotective.⁵

If meningitis suspected refer to Meningitis and Meningoencephalitis - ChAMP guideline

Or if Artesunate not available
2nd line - IV quinine dihydrochloride
- Contact ward pharmacist or on-call pharmacist (after hours) for stock.
- Ideal body weight should be used to calculate dosing in the obese patient.³ Refer to Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Clinical Practice Manual.
- If previous prophylaxis / treatment (e.g. quinine, mefloquine) has been given a loading dose may not be required.3 Discuss with the Infectious Diseases Consultant.
- Children ≥ 4 weeks old:
  - Loading dose: 20 mg/kg (maximum 1.4 g) given over 4 hours.¹⁰
  - Maintenance dose: 10 mg/kg/dose (maximum 700 mg) every 8 hours given over 4 hours starting 4 hours after the completion of the previous dose.¹⁰
- Rapid administration may cause severe cardiotoxicity. Administer via slow IV infusion over 4 hours. Slow the rate of infusion if dysrhythmias occur.²
- If IV quinine is still needed after 48 hours a dose reduction may be required. Discuss with the Infectious Diseases Consultant.^2,3
- Quinine may cause hypoglycaemia, arrhythmias and hypotension.¹⁰
- Cardiac monitoring required;³ quinine should be administered in Paediatric Critical Care where possible.
- Monitor blood pressure and blood glucose levels (BGL) 4 hourly.

Uncomplicated malaria
Falciparum malaria Admit all children with P. falciparum (and P. knowlesi) malaria as deterioration may occur following initiation of treatment (selected patients with uncomplicated falciparum malaria may occasionally be suitable for outpatient management in discussion with Infectious Diseases).^6,7 1st line - Artemether plus lumefantrine (Riamet^®)^9,10 or 2nd line - Atovaquone plus proguanil (Malarone^®) Not to be used as treatment if previously used as prophylaxis. Also consider the risk of artemisinin resistance in region of travel (i.e. Greater Mekong subregion, Eastern Africa and Central Africa, and Papua New Guinea, discuss all cases with infectious diseases. For patients with Falciparum malaria who are being treated in malaria-receptive regions of northern Australia, a single dose of primaquine is recommended, discuss with Infectious Diseases.
Non-falciparum malaria Admit under General Paediatrics or consider outpatient management (in discussion with Infectious Diseases team) if: Parasite count <1% Tolerating oral medications The family has sufficient understanding to ensure compliance, follow-up and representation if required No significant co-morbidities and Age >5 years old 1st line - Artemether-lumefantrine (Riamet^®)^9,10 or 2nd line - Atovaquone plus proguanil (Malarone^®)^9,10 AND Hypnozoite eradication (all patients with P.vivax or P.ovale) Patients ≥ 6 months old: Primaquine - Check G6PD status prior to prescribing Patients < 6 months old: discuss with Infectious Diseases Consultant.

Uncomplicated malaria

Falciparum malaria

Admit all children with P. falciparum (and P. knowlesi) malaria as deterioration may occur following initiation of treatment (selected patients with uncomplicated falciparum malaria may occasionally be suitable for outpatient management in discussion with Infectious Diseases).^6,7

1st line - Artemether plus lumefantrine (Riamet^®)^9,10

2nd line - Atovaquone plus proguanil (Malarone^®)

Not to be used as treatment if previously used as prophylaxis. Also consider the risk of artemisinin resistance in region of travel (i.e. Greater Mekong subregion, Eastern Africa and Central Africa, and Papua New Guinea, discuss all cases with infectious diseases.

For patients with Falciparum malaria who are being treated in malaria-receptive regions of northern Australia, a single dose of primaquine is recommended, discuss with Infectious Diseases.

Non-falciparum malaria

Admit under General Paediatrics or consider outpatient management (in discussion with Infectious Diseases team) if:
- Parasite count <1%
- Tolerating oral medications
- The family has sufficient understanding to ensure compliance, follow-up and representation if required
- No significant co-morbidities and
- Age >5 years old
1st line - Artemether-lumefantrine (Riamet^®)^9,10

2nd line - Atovaquone plus proguanil (Malarone^®)^9,10

AND

Hypnozoite eradication (all patients with P.vivax or P.ovale)
- Patients ≥ 6 months old: Primaquine - Check G6PD status prior to prescribing
- Patients < 6 months old: discuss with Infectious Diseases Consultant.

Follow up

Malaria statutory notification requirements - all cases should be notified to public health via the WA Health Department website
Monitor blood glucose, blood film / parasitaemia (daily), blood gases, FBC and UEC in all patients admitted to the ward.
Consult the infectious diseases team for all admitted patients.
All children require follow up in Infectious Diseases clinic a week after discharge with repeat blood film.
- Blood film should be repeated again at ~28 days post treatment to ensure cure. Consider screening other family members for malaria (if similar travel history).
- Prior to discharge, consult with Infectious Diseases on-call regarding any child treated for malaria to arrange appropriate follow up.
Ensure all children have a discharge letter stating that they have been admitted with malaria.

References

World Health Organisation [Internet]. Geneva (Switzerland): WHO Guidelines for Malaria; [last updated November 2024; cited 2026 May 07]. Available from: https://iris.who.int/server/api/core/bitstreams/ce77cf41-2afe-4598-a221-dbd1a1a7243d/content
Church J, Maitland K. Invasive bacterial co-infection in African children with Plasmodium falciparum malaria: a systematic review. BMC Med. 2014;12:31-.
Therapeutic Guidelines. [Internet]. Melbourne (VIC): Therapeutic Guidelines Ltd. Malaria; [last updated April 2026; cited 2026 May 07]. Available from: https://app-tg-org-au.pklibresources.health.wa.gov.au/viewTopic?etgAccess=true&guidelinePage=Antibiotic&topicfile=malaria&guidelinename=Antibiotic&sectionId=toc_d1e716#toc_d1e716
Sinclair D, Donegan S, Isba R, Lalloo DG. Artesunate versus quinine for treating severe malaria. Cochrane Database of Systematic Reviews 2011. [Last updated 16 March 2011; cited 21 May 2026]. Available from: https://doi.org/10.1002/14651858.CD005967.pub3
Kofoed P-E, Ursing J, Rodrigues A, Rombo L. Paracetamol versus placebo in treatment of non-severe malaria in children in Guinea-Bissau: a randomized controlled trial. Malaria Journal. 2011;10(1):148. [Last updated 1 Jun 2011; cited 21 May 2026]. Available from: 10.1186/1475-2875-10-148
Cherian S, Burgner D. Selective ambulatory management of Plasmodium falciparum malaria in paediatric refugees. Arch Dis Child. 2007;92(11):983-6. [Last updated 29 Jun 2007; cited 21 May 2026]. Available from: https://doi.org/10.1136/adc.2006.114801
Gogtay N, Kannan S, Thatte UM, Olliaro PL, Sinclair D. Artemisinin-based combination therapy for treating uncomplicated Plasmodium vivax malaria. The Cochrane Database Syst Rev. 2013(10):Cd008492. [Last updated 25 Oct 2025; cited 21 May 2026]. Available from: doi:10.1002/14651858.CD008492
Visser BJ, Wieten RW, Kroon D, Nagel IM, Belard S, van Vugt M, et al. Efficacy and safety of artemisinin combination therapy (ACT) for non-falciparum malaria: a systematic review. Malar J. 2014;13:463.
Plewes K, Kingston HWF, Ghose A, Wattanakul T, Hassan MMU, Haider MS, Dutta PK, Islam MA, Alam S, Jahangir SM, et al., Acetaminophen as a Renoprotective Adjunctive Treatment in Patients With Severe and Moderately Severe Falciparum Malaria: A Randomized, Controlled, Open-Label Trial. Clin Infect Dis. 2018 Sep 14;67(7):991-999. https://doi.org/10.1093/cid/ciy213. PMID: 29538635; PMCID: PMC6137116.
Australian Medicines Handbook. [Internet]. Adelaide (SA): Australian Medicines Handbook PTY Ltd; c2026. Quinine; [Last updated January 2026; cited 2026 May 07] Available from: https://amhonline-amh-net-au.pklibresources.health.wa.gov.au/chapters/anti-infectives/antiprotozoals/antimalarials/quinine

Endorsed by:	CAHS Drug & Therapeutic Committee	Date:	May 2026
		Review date:	May 2029

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