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7. Treatment of uncomplicated P. falciparum malaria

partner drug. Sulfadoxine-pyrimethamine should be avoided in the first weeks of life
because it competitively displaces bilirubin with the potential to aggravate neonatal
hyperbilibinemia. Primaquine should also be avoided in the first month and tetracyclines
avoided throughout infancy and in children < 8 years of age. With these exceptions there
is no evidence for specific serious toxicity for any of the other currently recommended
antimalarial treatments in infancy.
Delay in treating P. falciparum malaria in infants and young children may have fatal
consequences, particularly for more severe infections. The uncertainties noted above
should not delay treatment with the most effective drugs that are available, with attention
to accurate dosing and ensuring the administered dose is retained, as infants are more
likely to vomit or regurgitate antimalarial treatment than older children or adults.
Taste, volume, consistency and gastrointestinal tolerability are important determinants
of whether the child retains the treatment. Mothers often need advice on techniques of
medicine administration and the importance of administering the drug again if it is
regurgitated within an hour of administration. Because deterioration in infants can be
rapid, there should be a much lower threshold for the use of parenteral treatment.

7.9.3.2 Dosing
Although dosing based on body area is recommended for many drugs in young children,
for the sake of simplicity, dosing of antimalarials has traditionally been based on
administering a standard dose per kg body weight for all patients (including young
children and infants); however, the disposition of many medicines are different from
that of older children and adults. The currently recommended doses of lumefantrine,
piperaquine, sufladoxine-pyrimethamine and chloroquine achieve substantially lower
drug concentrations in young children than older patients. Small studies did not find
any effect of age on plasma concentrations of amodiaquine or mefloquine. Although the
absorption and disposition of many drugs differ between infants and young children,
there are very limited data on antimalarial pharmacokinetics in the first year of life.

For the majority of antimalarials, the lack of an infant formulation necessitates the
division of adult tablets; this leads to inaccurate dosing. There are now paediatric
formulations and paediatric tablet strengths for some of the antimalarial medicines.
These have the potential for improving the effectiveness and accuracy of ACT dosing in
young children.

In situations where it is not possible to give parenteral treatment, such as severely sick
infants that vomit antimalarial drug treatment repeatedly, or are too weak to swallow,
artesunate should be given by the rectal route prior to transfer to a facility where
parenteral treatment is possible. Evidence from recent studies demonstrates that in
situations where parenteral medication is not possible, using a single dose of rectal
artesunate as pre-referral treatment reduces the risk of death or permanent disability
(as long as this initial treatment is followed up with appropriate parenteral antimalarial
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