Page 42 - 80 guidelines for the treatment of malaria_opt

nd
Guidelines for the treatment of malaria – 2 edition

 second and third trimesters:
b
• ACT known to be effective in the country/region or artesunate plus clindamycin to be given for 7 days or
quinine plus clindamycin to be given for 7 days.
Pharmacovigilance programmes need to be established to continually monitor safety of antimalarial
medicines in all trimesters, including inadvertent exposures in the early first trimester.
a. If clindamycin is unavailable or unaffordable, then the monotherapy should be given.
b. With the exception of DHA+PPQ for which there is insufficient information in second and third trimesters of pregnancy to use as first-
line therapy.

7.9.2 Lactating women

The amounts of antimalarials that enter breast milk and are consumed by the breastfeeding
infant are relatively small. Tetracycline is contraindicated in breastfeeding mothers
because of its potential effect on the infant’s bones and teeth. Primaquine should not
be used in nursing women, unless the breastfed infant has been determined not to be
G6PD-deficient.

box 7.6
recommendation: treatment for lactating women with uncomplicated falciparum malaria

 lactating women should receive the recommended antimalarial treatment (including acts),
except for primaquine and tetracycline.

7.9.3 Infants and young children

7.9.3.1 Choice of antimalarial drug
There are important differences in the pharmacokinetic parameters of many medicines
in young children. Accurate dosing is particularly important in infants. Despite this, only
a few clinical studies have focused specifically on this age range; this is partly because
of ethical considerations relating to the recruitment of very young children to clinical
trials, and it is also because of the difficulty of repeated blood sampling. In the majority
of clinical studies, subgroup analysis is not used to distinguish between infants and older
children. As a result, the available evidence in young infants (< 5 kg) is insufficient for
confident recommendations for any of the ACTs, to the extent that many of the drugs
carry label restrictions that they should not be used. Furthermore, dosing is often difficult
where paediatric formulations are unavailable.
The artemisinin derivatives are safe and well tolerated by young children, and so
the choice of ACT will be determined largely by the safety and tolerability of the
28