CLINICAL ALGORITHM FOR TREATMENT OF PLASMODIUM-FALCIPARUM MALARIA IN CHILDREN

Background Identification of children who need antimalarial treatment is difficult in settings where confirmatory laboratory testing is not available, as in much of sub-Saharan Africa. The current national poli cy in Malawi is to treat all children with fever, usually defined as t he mother's report of fever in the child, for presumed malaria. To ass ess this policy and to find out whether a better clinical case definit ion could be devised, we studied acutely ill children presenting to tw o hospital outpatient departments in Malawi. Methods The parent or gua rdian of each enrolled child (n=1124) was asked a standard series of q uestions about the symptoms and duration of the child's illness. Each child was examined, axillary and rectal temperatures and blood haemogl obin concentrations were measured, and a giemsa-stained thick smear wa s examined for malaria parasites. Logistic regression procedures were used to identify clinical predictors of parasitaemia. Findings High te mperature (37.7 degrees C or above), nailbed palter, enlarged spleen, and being seen at one of the clinics rather than the other were associ ated with an increased risk of malaria parasitaemia in univariate anal yses. A revised malaria case definition of rectal temperature of 37.7 degrees C or higher, spienomegaly, or nailbed pallor was 85% sensitive in identifying parasitaemic children and 41% specific; the correspond ing sensitivity and specificity for the nationally recommended definit ion that equates mother's history of fever with malaria were 93% and 2 1%. The revised case definition had 89% sensitivity in identifying par asitaemic children with concentration below g/L and 89% sensitivity in identifying children with parasite density greater than 10 000/mu L, characteristics that indicate a clear need for antimalarial treatment. Interpretation These results suggest that better clinical definitions are feasible, that splenomegaly and pallor are helpful in identifying children with malaria, and that much overtreatment of children withou t parasitaemia could be avoided.