Neonatal malariaDr. MUNYENGABE Francois

Pediatric Resident: RMHSupervisor : Dr. Florent RUTAGARAMA

Neonatal malariaDr. MUNYENGABE Francois

Pediatric Resident: RMHSupervisor : Dr. Florent RUTAGARAMA

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

respectivelyTORCHS screening not done,MOTHER denies history of malaria during pregnancy

Clinical case

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

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,

Clinical case

Analysis 28/11/ 30/11/ 01/12/ 01/12/ 03/12 07/12/ 07/12/ 10/12/2015

14/12

16220 full blood count (fbc)

WBC (10^3/uL) [-] 6.99 7.45 7.45 6.45 12.50 7.12 7.78

RBC (10^6/l) [3.2-5.2] 2.29 3.03 3.03 2.78 3.78 2.86 3.42

HGB (g/dl) [12.2-16.4] 6.3 8.5 8.5 8.0 10.6 7.9 9.4

HCT (g/dl) [38-51] 21.1 27.3 27.3 24.0 33.1 26.0 31.8

MCV (FL) [74-94] 92.1 90.1 90.1 86.3 87.6 90.9 93.0

MCH (pg) [28-35] 27.5 28.1 28.1 28.8 28.0 27.6 27.5

MCHC (g/dl) [30-36] 29.9 31.1 31.1 33.3 32.0 30.4 29.6

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

parasitology BLOOD SMEAR (G.E) () [-] Tropho+++ Negatif Negatif

At the end of this presentation each one will be able: Define neonatal malariaDifferentiate congenital to acquired malaria in neonatesPrevalence of congenital malaria Effects of Malaria on Pregnant Women

Literature review

Effects on Unborn Babies Clinical presentation Diagnosis of neonatal malaria Management of neonatal malaria Prevention

At the end of this presentation each one will be able:

Malaria causes between 200 and 500 million episodes and between 1 and 3 million deaths each year.

Four species of the malarial parasitesP. falciparum,P. vivax,P. ovale and P. malariae.

INTRODUCTION

GLOBAL SCOPE OF MALARIA

3.3 billion people at risk worldwide

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

• Red: Malaria Everywhere

• Yellow: Malaria in Provence

• Green: No Known Malaria http://cdc-malaria.ncsa.uiuc.edu/

CDC MALARIA MAP

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 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.

Neonatal malaria

 congenital, acquired and transfusional.

Three types of neonatal 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.

Definition of congenital 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

Acquired neonatal malaria

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.

neonatal transfusional

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507092/

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.

Prevalence 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}

The variability of congenital malaria

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

The expertise in blood smear examinations

The method of parasite detection {GIEMSA

staining or polymerase chain reaction( PCR)

A reflection of true environmental differences

The variability in the presence

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).

Mechanism of congenital malaria

Prevention and Control of Malaria during Pregnancy 23

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 24

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 birthweight—single greatest risk factor for

death during first month of life Stillbirth

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.

Clinical presentation

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

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).

Diagnosis con’t

A well documented risk factor for developing neonatal and congenital malaria is maternal

3rd trimester malaria infection,

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

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

Management of neonatal malaria

WHO malaria guidelines 2015

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

Revised dose recommendation for parenteral ARTESUNATE in young

children

WHO malaria guidelines 3 rd edition 2015

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 of neonatal malaria

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.

Management Con’t

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

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 SULPHADOXINE-PYRIMETHAMIN ( IPTp)

Prevention of congenital malaria

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

Home message

http://www.sfnmjournal.com/article/S1744-165X(07)00019-4/abstract

WHO malaria guidelines 3rd edition 2015 http://www.sfnmjournal.com/article/S1744-165X(07)00

019-4/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),10,207-213

Uptodate.com Nelson textbook of pediatrics 20 edition

REFERENCES

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