Neonatal malaria

Dr. MUNYENGABE Francois

Pediatric Resident: RMH
Supervisor : Dr. Florent RUTAGARAMA

Neonatal malaria
Dr. MUNYENGABE Francois
Pediatric Resident: RMH
Supervisor : Dr. Florent RUTAGARAMA

Clinical case
Preterm baby born at 28 weeks , now is 56 days old
baby ,
DOA 56
Problem list NEONATAL INFECTION RISK
RDS, VLBW, PREMATURITY, neonatal
malaria
PMH: BABY born to a 29 y . o mother G1P1+1( IUFD WHY?)
had PPROM > 18 hours , received 4 doses of steroids IV
baby born by C-section APGAR at 1,5, and 10 min 7,8,8
respectively
TORCHS screening not done,
MOTHER denies history of malaria during pregnancy

CASE PRESENTATION
Physical exam on admission
Weight: 1.08 kg 25-50 percentile,
temp : 36.7, O2 SAT: 89%
HR: 161 bpm RR: 77BPM
Lengh34 cm : 9th percentile
Head circ: 25 cm 2-9th percentile
No dysmorphic features

CASE PRES
Baby with respiratory distress , nasal flaring,
desaturating on room air
Hypotonic baby with week suck reflexes, absent
moro, abnormal grasp reflexes
Acrocyanosis, otherwise : normal findings ,
started on IV Ampicillin , Cefotaxime,? aminophylline
and putted on CPAP 7 cm , H2O,iv Fluids D10%
80ML/KG/DAY
Then the patient slightly improved but continue to
desaturate on room air, feeding intolerance and with
poor weight gain, CPAP stopped after 8 days

Clinical case
Since DOL 37, then the baby continue to have, fever
, feeding intolerance, respiratory distress, episodes
of apnea septic work up done were not conclusive,
( look lab results sheet)
It was on 42 days of life ( post delivery) WHEN
BLOOD SMEAR TAKEN BECOME POSITIVE tropho ++
+( Plasmodium falciparum)
With anemia ,Hb : 6,4 mg/dl then patient receive
PRBC transfusions,
Then the baby was putted on IV Artesunate
3mg/kg/dose ,the blood smear was repeated after
4days and was negative, since then patient
improved well,

Analysis

16220 full
blood count
(fbc)

parasitology

28/11/

30/11/

01/12/

01/12/

03/12

07/12/

10/1
07/12/ 2/20 14/12
15

7.1
2
2.8
6

WBC (10^3/uL) [-]

6.99

7.45

7.45

6.45

12.50

RBC (10^6/l) [3.2-5.2]

2.29

3.03

3.03

2.78

3.78

HGB (g/dl) [12.2-16.4]

6.3

8.5

8.5

8.0

10.6

HCT (g/dl) [38-51]

21.1

27.3

27.3

24.0

33.1

MCV (FL) [74-94]

92.1

90.1

90.1

86.3

87.6

MCH (pg) [28-35]

27.5

28.1

28.1

28.8

28.0

MCHC (g/dl) [30-36]

29.9

31.1

31.1

33.3

32.0

PLT (10^3/uL) [150-450]

66

40

40

49

80

46

46

LYMPH% (%) [20-40]

55.2

6805

68.5

60.9

74.6

MONO% (%) [2-14]

17.0

10.2

10.2

18.8

15.8

EOSINOPHILS % (%) [1-4]

0.1

0.4

0.4

0.6

0.5

0.4

1.2

BASOPHILES % (%) [0-1]

0.4

0.4

0.4

0.2

0.3

0.3

0.3

BLOOD SMEAR (G.E) () [-]

Tropho+
++

7.9
26.
0
90.
9
27.
6
30.
4

Nega
tif

7.78
3.42
9.4
31.8
93.0
27.5
29.6

Negatif

Literature review
At the end of this presentation each one will
be able:
Define neonatal malaria
Differentiate congenital to acquired malaria in
neonates
Prevalence of congenital malaria
Effects of Malaria on Pregnant Women

At the end of this presentation each one will be

able:

Effects on Unborn Babies

Clinical presentation
Diagnosis of neonatal malaria
Management of neonatal malaria
Prevention

INTRODUCTION
Malaria causes between 200 and 500 million
episodes and between 1 and 3 million deaths
each year.
Four species of the malarial parasites

P.
P.
P.
P.

falciparum,
vivax,
ovale and
malariae.

GLOBAL SCOPE OF MALARIA

3.3 billion people at risk

worldwide
98% of Malarial deaths in Africa
Second leading cause of death
from infectious diseases after
HIV/AIDS in Africa

CDC MALARIA MAP

Red: Malaria
Everywhere

Yellow: Malaria
in Provence
Green: No
Known Malaria

http://cdc-malaria.ncsa.uiuc.edu/

MALARIA DURING PREGNANCY

Leads to 5-12% of all low birth weights in
children worldwide
Contributes to 35% of all preventable low birth
weights in children worldwide
Low birth weights can lead to premature
births and intrauterine growth retardation
75,000-200,000 infant deaths worldwide each
year attributed to malarial infection during
pregnancy

Neonatal
malaria
Neonatal malaria is a type of malaria
that occurs during the first month of life.
In the last half century, the reports of
malaria parasites in neonates generally
have been associated with congenital
transmission.

Three types of neonatal

malaria
congenital,
acquired and
transfusional.

Definition of congenital
malaria
Malaria parasites cross the placenta either
during pregnancy or at the time of delivery.
The presence of asexual forms of malaria
parasites in the peripheral blood within the
first 7 days of life, or later.

Acquired neonatal malaria

Acquired malaria on the other hand
results from mosquito bites anytime
after delivery, with asexual
parasitaemia detected after the
minimum incubation period of one
week

neonatal transfusional
Neonatal transfusional malaria is said to occur
when malaria parasites are detected in a
neonate, whose peripheral blood film was
previously negative, after a blood transfusion.
The mean interval between blood transfusion
and the presence of symptoms is said to be
three days.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507092/

Prevalence of congenital
malaria
Congenital malaria has been documented for many
years but it was previously thought to be
uncommon especially in indigenous populations.
Congenital malaria was first described in 1876.
More recent studies, however, suggest that
incidence has increased and values between 0.3 to
33% have been observed from both endemic and
non-endemic areas.

The variability of congenital

malaria
Differences in the definitiiion of congenital
malaria
Levels of maternal immunity
The type of blood sample{ peripheral blood of
neonates or cord blood}

-Seminaris in fetal & neonatal medicine (2007),10,207-213

The variability in the

presence
The expertise in blood smear examinations
The method of parasite detection {GIEMSA
staining or polymerase chain reaction( PCR)
A reflection of true environmental differences

Mechanism of congenital
malaria
The mechanism of transplacental passage of the malaria
parasite from mother to foetus is still obscure.
It has been postulated that the possible mechanisms
include direct penetration through chorionic villi, premature
separation of the placenta, and the possible physiologic
transfusion of maternal red blood cells to the foetal
circulation in utero or at the time of delivery (De Silva et al.,
1982; Menendez & Mayor, 2007; Reynolds et al., 2007).

Effects of Malaria on Pregnant

Women
All pregnant women in malaria-endemic
areas are at risk
Parasites attack and destroy red blood cells
Malaria causes up to 15% of anemia in
pregnancy
Can cause severe anemia
In Africa, anemia due to malaria causes up to
10,000 maternal deaths per year
Prevention and Control of Malaria during Pregnancy

23

Effects on Unborn Babies

Parasites hide in placenta
Interferes with transfer of oxygen and
nutrients to the baby, increasing risk of:
Spontaneous abortion
Preterm birth
Low birthweightsingle greatest risk factor for
death during first month of life
Stillbirth
Prevention and Control of Malaria during Pregnancy

24

Clinical presentation
Onsets occurring as early as 8 hours and as
late as 8 weeks of age have been reported.
Ibhanesebhor reported that presentation of
neonatal malaria is not different from that of
other neonatal infectious diseases, thus
increasing the rate of under or miss
diagnosis, neonatal morbidity and mortality

Clinical presentation
most common clinical features in 80% of
cases are fever, anemia and splenomegaly.
Children with congenital malaria can present
with fever, irritability,
feeding problems, loose stools , poor feeding,
restlessness and cyanosis
hepato-splenomegaly,
anemia
and jaundice.

Diagnosis
There is evidence proving that congenital
malaria is usually mistaken for sepsis or
infections in the TORCHS syndrome (Hulbert,
1992).

Therefore for the purpose of performing accurate

diagnosis of congenital malaria, a good index of
suspicion, a careful physical examination and
repeated peripheral blood smears are therefore
needed (Perrault et al., 2009).

Diagnosis
The diagnosis of malaria is established by
the microscopic identification of organisms
on Giemsa-stained smears of peripheral
thick or thin blood smears.
The Giemsa-stained smears diagnostic
technique is widely used in most malarious
areas for the diagnosis of congenital malaria.

Diagnosis cont
Studies suggest considering a diagnosis of
neonatal malaria in critically ill neonates
with fever, unresponsive to antibiotics .
Sometimes, parasitemia cannot be shown on
BS , and plasmodial antigen detection or
polymerase chain reaction of the blood may
be necessary (Perrault et al., 2009).

 A well documented risk factor for developing

neonatal and congenital malaria is maternal
3rd
trimester malaria infection,

Management
There are very few studies reporting the use
of drugs such as quinine, artesunate and
mefloquine in neonates and the studies with
use of oral artesunate is even scanty (Patel
& Belsare, 2002; Ming, 2008).
These drugs have been used effectively in
older children and could be hence adapted
for neonates to treat congenital malaria.

Management of neonatal
malaria
Infant less than 5 kg body weight:
uncomplicated malaria
Treat infant weighninh < 5 kg with
uncomplicated P. falciparum malaria an ACT at
the same mg/kg wb target dose as for children
weigning 5 kg
Strong recommendation, very low quality evidence

WHO malaria guidelines 2015

Revised dose recommendation for

parenteral ARTESUNATE in young
children
Children weighing < 20 kg should receive a high

dose of artesunate ( 3mg/kg bw /per dose ) than

larger children and adults ( 2.4 mg/kg bw per
dose ) to ensure equivalent exposure to the drug
Strong recommendation based on
pharmacokinetic modelling

If artesunate is not available , use artemether in

preference to quinine for treating children and
adults with severe malaria
WHO malaria guidelines 3 rd edition 2015

Management of neonatal
malaria
In China, a study comparing the efficacy of
artesunate versus quinine in the treatment of
congenital malaria observed that the total effective
rates of the artesunate treatment group and the
quinine group were 92.31% and 83.33% and the
clearance rates of plasmodium were 92.31% and
78.57%, respectively (Patel & Belsare, 2002).

Management Cont
The study therefore demonstrated that
efficacy of artesunate over quinine and
noted that it can be used as drug of first
choice for treatment of congenital malaria.
More studies are however required to further
elucidate the potency of artesunate in the
treatment of congenital malaria.
Tanzania Journal of Health Research Volume 13, Number
3, July 2011

MALARIA PREVENTION
HISTORY
1950s first preventative malaria strategies
with chemoprophylaxis with chloroquine
1980s became a public health issue
Chloroquine resistance and poor adherence
(weekly/bi-monthly administration required)
led to poor effectiveness
2004 Intermittent preventative treatment (IPT)
replaced chemoprophylaxis

Prevention of congenital
malaria
WHO recommends that pregnant women
living in stable ( high)malaria endemic areas
should be :
Protected against the infection by using ITNs
Receiving intermitent preventive
treatment( IPT) with SULPHADOXINEPYRIMETHAMIN ( IPTp)

Home message
Congenital malaria is the least known manifestation
of malaria and a very neglected area of research..
Onsets occurring as early as 8 hours and as late as 8
weeks of age have been reported.
Public health policy on malaria control should also
take into cognizance the importance of integrating
guidelines on congenital malaria management and
control.
And ARTESUNATE is the treatment of choice
3mg/kg/dose more useful than2.4mg/kg/dose
http://www.sfnmjournal.com/article/S1744-165X(07)00019-4/abstract

REFERENCES
WHO malaria guidelines 3rd edition 2015
http://www.sfnmjournal.com/article/S1744165X(07)00019-4/abstract
Tanzania Journal of Health Research Volume 13,
Number 3, July 2011
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507092/
-Seminaris in fetal & neonatal medicine (2007),10,207213
Uptodate.com
Nelson textbook of pediatrics 20 edition

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