pediatrics 1995 berman 126 31

1995;96;126PediatricsStephen Berman

Otitis Media in Developing Countries

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126 PEDIATRICS Vol. 96 No. I July 1995

REVIEW ARTICLE


Stephen Berman, MD

ABSTRACT. Objective. This article reviews the avail-able information concerning the disease burden, epide-miology, and etiology of otitis media in developingcountries and the likelihood that case management withappropriate antibiotic therapy can reduce the burden ofthis disease.

Methodology. The available literature was reviewed todetermine the extent to which otitis media impactsmortality and morbidity in developing countries.

Epidemiology. In community studies, perforation waspresent in 0.4% to 33.3% of children and youth; otorrheaoccurred in 0.4% to 6.1%; and mastoiditis occurred in0.19% to 0.74%. In school surveys, perforation was iden-tified in 1.3% to 6.24% of students, and otorrhea wasfound in 0.6% to 4.4% . Mastoiditis was diagnosed in 18%of children and youth who presented to a hospital ear,nose, and throat (ENT) clinic in Uganda. The proportionof patients presenting to ENT clinics with mastoiditisregardless of their initial symptoms varied from 1.7% to5%. Patients presenting to these ENT clinics withmastoiditis often experience severe complications, in-cluding subperiosteal abscess, labyrinthitis, facial palsy,meningitis, and brain abscess. Hearing impairment was amajor public health problem compromising the qualityof life in approximately one third of the population ofdeveloping countries.

Etiology. The pathogens isolated from ear aspirates inchildren with acute otitis media and chronic suppurativeotitis (CSOM) carried out in developing countries aresimilar to those isolated in studies carried out indeveloped countries.

Case Management. Historical data supports the effec-tiveness of antibiotic therapy in reducing the frequenciesof mastoiditis and CSOM complicating acute otitis me-dia. In addition, the introduction of primary care servicestargeted at otitis media for high-risk populations livingin developed countries may have reduced the prevalenceof mastoiditis and CSOM. However, it is not clearwhether there is a causal relationship between these pro-grams and the reduction because of the use of historicalcontrols.

Conclusions. International research organizationsshould support controlled intervention studies to docu-ment the impact of case management of otitis in devel-oping countries. In addition, the efficacy of a conjugatedpneumococcal vaccine to prevent otitis and its complica-lions should be evaluated in a developing country site.Pending the results of studies, developing countries

should develop primary care case management programs

to diagnose and treat otitis and its associated complica-

From the Department of Pediatrics, University of Colorado School of

Medicine, Denver.

Received for publication Jul 25, 1994; accepted Oct 14, 1994.

Reprints are not available.PEDIATRICS (ISSN 0031 4005). Copyright © 1995 by the American Acad-

emy of l’ediatrics.

tions. Pediatrics 1995;96:126-131; developing countries,otitis media, hearing impairment, mastoiditis, chronicsuppurative otitis.

ABBREVIATIONS. DALYs, disability-adjusted life years; CSOM,

chronic suppurative otitis; AOM, acute otitis media.

Although otitis media is a common condition in

developing countries, the value of targeting limitedhealth care resources to the diagnosis and manage-ment of otitis media is controversial. This articlereviews the available information concerning the dis-ease burden, epidemiology, and etiology of otitismedia in developing countries and the likelihoodthat case management with appropriate antibiotictherapy can reduce the burden of this disease.

BURDEN OF OTITIS MEDIA

Death and Severe Disability

Although impaired hearing is the most frequent

effect of otitis media, death or severe disability often

complicates this disease in developing countries. Inthe World Development Report 1993: Investing in Health

published by the World Bank and the World HealthOrganization, otitis media is estimated to cause thedeaths of 51 000 children younger than 5 years of ageeach year in developing countries.’ This report also

estimates the combined loss of life from prematuredeath with the loss of healthy life from disability. Theoutcome measure used in this analysis is called dis-ability-adjusted life years (DALYs). In the develop-ing world, otitis media is estimated to result in 23.1(xIOO 000) DALYs lost. Other conditions with a sim-

ilar impact on the quality of life in developing coun-tries are meningitis (30.1 DALYs), syphilis (29.0DALYs), trachoma (23.7 DALYs), and polio (19.9

DALYs).The mortality and severe disabilities associated

with otitis media are primarily related to the compli-cations of mastoiditis or chronic suppurative otitis

(CSOM), defined as otorrhea lasting 6 weeks orlonger. Complications that result in death include

sepsis (shock), meningitis, brain abscess, subduralempyema, and lateral sinus vein thrombosis. These

complications also can cause disabilities of the cen-tral nervous system, including spasticity, paralysis,mental retardation, cortical blindness, and seizures.Labyrinthitis and facial nerve paralysis are addi-tional complications associated with acute otitis me-dia (AOM) and CSOM that cause severe disability.

Children living in developing countries have a



REVIEW ARTICLE 127

high risk of developing mastoiditis and/or CSOM

(Table 1) (A.W. Smith, personal communication,1992).3-12 Possible reasons for this include: (1) a high

risk of having compromised nonimmune and im-

mune defenses because of malnutrition, deficienciesof vitamin A or other trace minerals, and humanimmunodeficiency virus or other chronic viral and

parasitic infections; (2) colonization with pathogenicorganisms at an early age; (3) a large infecting inoc-ulum size because of crowding, large family size,

and poor hygiene; and (4) lack of access to medicalservices so that therapy may not be available, be

delayed, or be inadequate.

Hearing Impairment

Hearing impairment associated with otitis mediais common in many developing countries. In Thai-land, a mild hearing impairment of 31 to 40 dB was

identified in 26.6% of the rural population (all ages)surveyed.2 Another survey of all ages found a mod-erate loss (41 to 55 db) in I I .4%, severe or profoundloss (56 to 91 db) in 2.2%, and deafness (>91 db) in0.5%.2 In a pediatric population less than 16 years ofage, a moderate loss was identified in 4%, a severe orprofound loss in 0.5%, and deafness in 0.5%.2 Hear-ing impairment impacts the ability to work, to learnin school, or to develop basic language skills. Long-

term hearing loss related to CSOM persisting

throughout childhood and adolescence can be a sig-nificant handicap. For example, in Bangkok, Thai-land, low academic achievement levels among 6 year

olds were directly correlated with current hearingloss.2 Wilson’3 also makes a strong case that hearingsufficient to comprehend normal speech is extremelyimportant for illiterate individuals in developingcountries. Unfortunately, many individuals whosehearing loss has progressed over time to the moder-ate and severe range are further impaired by their

lack of access to amplification aids. Wilson’3 statesthat case management and control of otitis media,measles, mumps, meningitis, and rubella would

reduce by half the amount of avoidable hearingimpairment in developing countries.

Epidemiology

Published data from developing countries describ-ing the prevalence of perforation, otorrhea, and mas-

toiditis from community- and school-based studiesare reviewed in Table I (A.W. Smith, personalcommunication, 1992).5-12 In community studies, per-foration was present in 0.4% to 33.3% of children andyouth; otorrhea occurred in 0.4% to 6.1 %; andmastoiditis occurred in 0.19% to 0.74%. In schoolsurveys, perforation was identified in I .3% to 6.24%

of students, and otorrhea was found in 0.6% to 4.4%.The best pediatric prevalence data on otitis media

and mastoiditis in developing countries are availablefrom Thailand.2 A research team conducted monthlyvisits from 1986 to 1991 and examined 1000 to 1500

subjects during a 3- to 5-day period. The encounterincluded completion of a history form, otoscopic ex-amination, tympanometry, and pure tone audiologyat 500, 1000, and 2000 Hz. In 2681 children youngerthan 16 years of age, the prevalence of AOM was0.8%; otitis media with effusion, 9.6%; otorrhea,2.6%; perforation without otorrhea, I .9%; ossiculardamage, 0.056%; adhesive otitis media, 0.037%; cho-lesteatoma, 0.03%; and postradical mastoidectomy,

0.013%.Published incidence data on CSOM are difficult to

find. Simoes (personal communication, 1993) foundan incidence of otorrhea during the first 2 years oflife in Vellore, India, of 0.173 episodes per child year

with a cumulative prevalence of 23%.Data have been published on the frequency of

CSOM and mastoiditis among patients seen in hos-pital otolaryngology clinics.’42’ These reports, re-

viewed in Table 2, suggest that mastoiditis and othercomplications occur frequently in many areas of de-veloping countries. In Uganda, 18% of patients withchronically draining ears seen in the hospital clinichad mastoiditis.’4 In Tanzania, Nigeria, Angola, and

TABLE 1. Prevale nce of Pe rforation, Otorrhea, and Mastoi ditis in Com munity- and School-B ased Studies in D eveloping Countries*

Country Ref Date Setting Age (y) Perforation (%) Otorrhea (%) Mastoiditis (%)

S Africa 3 1985 R community 0-15 0.4 0.4 NA

S Africa 3 1985 R community >15 2.8 1.4 NA

Nigeria 4 1979 U school 3-11 NA 0.6 NA

Nigeria 4 1979 R school 3-11 NA 3.6 NA

Swaziland t 1987 U/R community 5-14 2.5 2.1 NA

Kenya 5 1992 U/R school 5-21 NA I .1 NA

Guam 6 1966 R school 5-18 2.2-8.3 NA NA

Solomon Islands 7 1984 R community 0- 5 NA 6.1 NA

Solomon Islands 7 1984 R community 0-15 NA 3.8 0.74

Micronesia 8 1985 R community 0-25 4 NA NA

Malaysia 9 1990 U/R school 7-12 NA 4.36 NA

Thailand 2 1986 U/R community 0-15 4.7 2.63 0.19

Thailand 2 1986 R school 6-12 1.23 0.88 0

Thailand 2 1986 U school 6-12 1.38 1 .20 0

S Korea 10 1981 U/R community 0-10 5.72 NA NA

S Korea 10 1981 U/R community All 3.3 NA NA

S Korea 10 1981 U school 6-12 1.69-6.24 NA NA

Israel 11 1984 U school 8-13 0.3 NA NA

Kuwait 12 1983 U/R school 7-10 1.6 NA NA

* U, urban; R, rural.

t A.W. Smith, personal communication, 1992.



TABLE 2. Prevalence of Perforation, Otorrhea, and Mastoiditis in Hospital Clinic-Based Studies in Developing Countries

128 OTITIS MEDIA IN DEVELOPING COUNTRIES

Country

Uganda

Ref

14

Date Clinic_Setting Age (yr) Perforation (%) Otorrhea (%) Mastoiditis (%)

1969 Urban 0-12 NA NA 18*

Gambia 15 1981 Rural 0-16 55 NA NA

Gambia 15 1981 Urban 0-16 48 NA NA

Zaire 16 1976 Urban All NA NA 3.2

Nigeria 17 1978 Urban All NA NA 1.8

Nigeria 18 1986 Urban 3-11 NA 7.2 NA

Tanzania 19 1978 Urban All NA 11.1 1.7

Angola 20 1981 Urban 0-15 NA NA 1.8

Sudan 21 1986 Urban All NA NA 5.0

* Mastoiditis in children presenting with otorrhea.

the Sudan, mastoiditis was associated with 1.7% to

5% of patients seen in hospital ear, nose, and throat

clinics.Patients who present to an ear, nose, and throat

clinic with CSOM often have severe complications.In Nigeria, 10.9% of patients presenting with CSOMhad complications.’7 In a hospital-based clinic in theSudan, the frequency of complications among pa-tients presenting with draining ears were: subperios-teal abscess, 5%; labyrinthitis, 2.5%; facial palsy,1.7%; meningitis, 1%; and brain abscess, 0.3%.22

When surgery is needed, a high proportion of pa-tients will have complicated disease. In Bangkok,Thailand, 815 patients operated on during a 5-year

period (1971 through 1975) for ear disease had the

following complications: postauricular abscess(11%), postauricular fistula (7%), facial palsy (3%),

meningitis (1 .5%), extradural abscess (0.9%), labyrin-

thitis (0.7%), brain abscess (0.5%), and Bezold’sabscess (0.4%).2

Etiology

Etiologic pathogens isolated from ear aspirates inchildren with AOM carried out in developing coun-

tries are similar to isolations obtained from childrenliving in developed countries. In Medellin, Colom-bia, bacterial pathogens were isolated in 82 of III

children (74%)23 Haeinophilus influenzae (32 nontype-able strains and 8 type B strains) was isolated in 36%of the cases, and Streptococcus pneilmoniae was foundin 22%. Other isolations included Staphylococcus au-reus (3%), enterobacter (1 %), Moraxella catarrhalis

(1%), 5 pyogeiies (1%), Gram-negative enterics (3%)and others (7%).

The etiology of CSOM is also similar in developingand developed countries. Persistent otorrhea oftenindicates a secondary infection with pseudomonasand or other Gram-negative organisms. These inva-sive organisms are difficult to eradicate with antibi-otics, are very destructive, and often lead to compli-cations. In Costa Rica, organisms isolated from 40

patients with CSOM in 1991 and 1992 includedPseudotnonas species (41 .9%), Gram-negative enterics(29%), Staphylococcus (9.8%), and others (9.8%).�#{176}During 1985 and 1986, ear swab cultures obtainedfrom 58 children living in the Solomon Islandsyielded two or more pathogens in 67% of the chil-dren. Proteus was identified in 41 %, Pseudoinotuas in26%, Klebsiella in 16%, Escherichia coli in 9%, and S

aureus in 7%#{149}7Some developing countries report tu-

berculosis as a cause in a small proportion of pa-

tients. For example, I .2% of patients seen at a clinic in

Uganda and 0.38% in Tanzania had CSOM associ-

ated with tuberculosis.

Case Management With Antibiotic Therapy

Because data are not available for populationsliving in developing countries, there is an urgent

need to conduct randomized clinical trials of anti-biotic treatment of AOM in areas with high rates ofmastoiditis and CSOM. It is inappropriate to gen-eralize the results of recent clinical trials of antibi-otic therapy in developed countries to developingcountries, because CSOM and mastoiditis arerarely seen in developed countries regardless oftherapy. Because the etiology of otitis is similar indeveloped and developing countries, the differingrates of CSOM and mastoiditis most probably re-flect differences in population characteristics and

environmental factors.Therefore, an assessment of the value of case man-

agement of otitis media includes: (1) reviewingantibiotic clinical trials for AOM carried out duringthe 1940s and 1950s in Europe and the United Stateswhen the prevalence of CSOM and mastoiditis was

similar to that currently observed in many develop-ing countries; and (2) reviewing the effectiveness ofproviding enhanced primary care services to under-

served populations having a high prevalence of otitismedia such as Native American and Eskimo

populations.The high rates of CSOM currently observed in

many areas of the developing world are comparableto the rates reported in the preantibiotic era, when

approximately 20% of untreated AOM cases pro-gressed to CSOM and or clinical mastoiditis. The

complication rates for patients with CSOM describedcurrently in many developing countries are also sim-ilar to those described in Europe in the preantibiotic

era. For example, complications occurred in 6.5% of3225 patients with AOM and/or CSOM seen byKafka4’ in the preantibiotic era compared with the

10.9% complication rate reported in 1978 and 1980 byOkafor in Nigeria.17 There is a precedent for usingthis type of historical comparison. The World Health

Organization has used historical comparisons ofmortality rates from pneumonia and influenza toassess the gap in health status between developed

and developing countries.42 For example, the 1987infant mortality rates from pneumonia and influenza

for the countries of Central America (Guatemala,

Honduras, Nicaragua, and El Salvador) can be corn-



REVIEW ARTICLE 129

pared with the rates reported by Canada from 1930to 1987. The 1987 mortality rate for Guatemala cor-responds to the Canadian rate in 1937; the 1987 rate

for Honduras corresponds to the Canadian rate of1945; and the 1987 rates for Nicaragua and El Salva-dor correspond to the Canadian rate in 1949. Theobservation that current infant mortality rates frompneumonia and influenza among infants in develop-ing countries are comparable with rates reported in

Canada in the preantibiotic era suggests that popu-lation characteristics, living conditions, and primarymedical care services also may be similar.

Antibiotic therapy reduced the frequency of mas-toiditis and CSOM in Europe and North America

during an era when living conditions and mortalityrates were similar to current conditions in many

developing countries. Numerous studies from Eu-rope and North America reviewed in Tables 3 and 4documented the efficacy of antibiotic treatment.22’2439

Twelve studies carried out from 1939 to 1947 corn-

pared patients who received sulfonamide therapywith untreated control patients (Table 3). The fre-quency of mastoiditis and/or CSOM in 3431 un-

treated patients was 32% (frequency range, 9% to70%).22.24�� The frequency of clinical mastoiditis

and/or CSOM in 3131 patients treated with sulfon-amides was 6% (range, I .5% to 28%). The differencebetween untreated patients and those treated withsulfonamide was statistically significant in 1 1 of the12 studies. From 1949 to 1953, six studies assessedthe effectiveness of penicillin treatment to preventclinical mastoiditis and CSOM.�39 The frequency ofmastoiditis among 1247 untreated patients was 8%(range, 0% to 30%) compared with I % in 1561 pa-

tients treated with penicillin (range, 0% to 3.5%)(Table 4). In all six of the studies, the differencesbetween treated and untreated patients were signif-icant. Although most of the studies presented in the

tables were not randomized, blinded, placebo-con-

trolled trials, Rudberg-� published an extensive ran-domized controlled trial in 1951 documenting theefficacy of antibiotic treatment in reducing mastoid-itis in 1365 patients with acute uncomplicated otitismedia seen in Gothenburg, Sweden (Tables 3 and 4).The incidence of clinical mastoiditis and CSOM washigher for children younger than 3 years of age than

for older patients, and clinical mastoiditis was found

to be more common when organisms were identified

that were resistant to the antibiotics used. An addi-

tional finding of this study was that untreated pa-tients had ear discharges of longer durations than

treated patients.The medical effectiveness of antibiotic therapy is

supported by additional reports from this era thatdocument a large decline in surgery for mastoiditisand CSOM as well as mortality related to intracranialcomplications after the introduction of antibiotictreatment for AOM. Sorensen43 reported a decreasein the proportion of patients with otitis media and

mastoiditis requiring mastoidectomy from 20% in

1938 to 2.5% in 1948. Lund44 reported a decrease inthe mortality rate from intracranial complications of

otitis media from 36% in 1939 to 0% in 1971.There are no published controlled community in-

tervention trials of the effectiveness of primary carecase management of otitis media in developing coun-tries. However, there are prevalence surveys before

and after the introduction of primary care servicesfor otitis media in Native American and Eskimopopulations. Unfortunately, it is not possible to es-tablish a causal relationship when a study designuses historical controls. Todd and Bowman45 studiedthe impact of improved primary care services on

perforations and CSOM in the Apache Native Amer-ican population. Although the prevalence of epi-

sodes of otitis media did not decline, there werereductions in chronic perforations and CSOM. In

New Zealand, the prevalence of CSOM among Maorichildren was reduced from 10% to 3% in 4 years withthe implementation of a treatment program for otitismedia.44 However, investigators could not documentany benefit of a special treatment program for Ab-original children with otitis in Western Australia.47

CONCLUSIONS

A review of the available literature supports the

belief that otitis media is responsible for a significantburden of disease in developing countries. Otitis me-dia has a direct impact on mortality and severe mor-bidity because of high rates of mastoiditis and CSOM

and because it is the major contributor to hearingimpairment. Hearing impairment is a major publichealth problem compromising the quality of life in

approximately one third of the population of devel-

TABLE 3. Results of Clinical Trials

Antibiotic Therapy

Comp aring Outcomes of Mastoiditis or CSOM with S ulfonamide Therapy Compared With No

Trial Ref Date No Antibiotic Therapy Sulfonamide Therapy

No. Cases No. (%) Mastoiditis/CSOM No. Cases No. (%) Mastoiditis/CSOM

Fisher 24 1939 95 66 (69.5) 88 7 (7.9)

Hansen 22 1940 130 22(17.0) 127 16 (12.6)

Horan and French 25 1938 607 137 (22.7) 155 7 (4.5)

Horan and French 26 1940 621 21 (3.4)

Key-Aberg 27 1940 201 42 (21.0) 213 8 (3.7)

Duggan 28 1941 108 43 (39.8) 96 11 (11.5)

Hamberger 29 1942 203 43 (21.1) 202 18 (8.9)

Falbe-Hansen and Becker-Christensen 30 1944 323 30 (9.3) 335 5 (1.5)Hansen 31 1945 468 73(15.5) 500 23 (4.5)

House 32 1946 1241 570 (45.9) 193 34 (17.6)

Bateman 33 1947 372 35 (9.5) 334 50 (15.0)

Rudberg 34 1954 254 44 (17.3) 267 4 (1.5)



130 OTITIS MEDIA IN DEVELOPING COUNTRIES

TABLE 4. Results of C

Antibiotic Therapy

linical Tn als Compar ing Outcomes of Mastoiditis or CSOM With Penicillin Therapy Compared With No

Trial

Gulsvik

Riskaer

Jersild and Kiorboe

Rudberg

Lahikainen

Rudberg

Ref Date No Antibiotic Therapy Penicillin Therapy*

No. Cases No. (%)Mastoiditis/CSOM

No. Cases No. (%)Mastoiditis/CSOM

35

36

37

38

39

34

1949

1949

1950

1950

1953

1954

57 17 (29.8)

177 19(11.0)

66 20 (30.3)

240 33(13.7)

453 9 (2.0)

254 44 (17.3)

186 4 (2.2)

175 0

144 5 (3.5)

272 4(1.5)

176 0

608 0

* Total of 267 cases treated with penicillin tablets and 275 cases treated with injectable penicillin.

oping countries. In addition, the hospital-basedresources spent treating complications of CSOM and

mastoiditis could be saved if primary care manage-ment can prevent the progression of AOM. Historicaldata support the effectiveness of antibiotic therapy inreducing the frequencies of mastoiditis and CSOM

complicating AOM. In selected high-risk populationsliving in developed countries, the introduction of

primary care and case management programs forotitis have been associated with a reduction in the

frequency of CSOM and mastoiditis. Internationalresearch organizations should support controlled in-tervention studies to document the impact of casemanagement of AOM in developing countries. Inaddition, the efficacy of a conjugated pneumococcalvaccine to prevent AOM and its complications

should be evaluated in a developing country site.Pending the results of studies, developing coun-

tries should develop primary care case manage-

ment programs to diagnose and treat AOM and itsassociated complications.

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41. Kafka MM. Mortality of mastoiditis and cerebral complications with 45. Todd NW, Bowman CA. Otitis media at Canyon Day, Ariz: a 16-year

review of 3225 cases of mastoiditis with complications. Larilngoscope. follow up in Apache Indians. Arc/i Otolartitigol. 1985;111:606-608

1935;45:790-822 46. Hamilton M, McKenzie-Pollack M, Heath M. Aural health in 227 North-

42. Arias SJ, Benguigui Y, Bossio JC. Acute Respiratory Infections in t/ie land school and preschool children. N Z Med I. 1980;91 :59-62

Americas: Magnitude. Trends, and Advances in Control. Pan American 47. Watson OS, Clapin M. Ear health of Aboriginal primary schol children

Health Organization; 1992:40. HPM/ARI/02-92 in the Eastern Goldfields region of Western Australia. Aust I Public

43. Sorenson H. Antibiotics in suppurative otitis media. Otolaryngol Cliii Healt/i. 1992;16:26-30

COMPARISON OF INTRAMUSCULAR AND INTRAVENOUS QUININE

FOR THE TREATMENT OF SEVERE AND COMPLICATED MALARIA IN

CHILDREN

Schapira A, Solomon T, Julien M, et al

Abstract. Intravenous (IV) quinine is the standard treatment for severe malaria

where chloroquine resistant Plasmodiurn falCiparuni is found. Because of the advan-

tages of intramuscular (IM) administration, a study was performed to compare

these methods of administration in children with severe and complicated malaria.

The study population was children from 6 months to 7 years of age, all of whom

had asexual Plasmodium falCiparum in the blood smear and at least one of the

following: rigorously defined cerebral malaria; probable cerebral malaria; hyper-

parasitemia; or severe malaria. Exclusions included those who had: received qui-

nine within a week; received an excessive dose of chloroquine within 48 hours;

a history of quinine intolerance; or signs of circulatory shock or hemorrhagic

diathesis.

Patients were randomly allocated to one of two treatment groups: 1) quinine

dihydrochloride administered intravenously with an initial loading dose of 20

mg/kg in 5% glucose, 20 mL/kg over 4 hours, followed by 10 mg/kg in 5%

glucose, 10 mL/kg intravenously over 2 hours every 8 hours; 2) quinine dihydro-

chloride 10 mg/kg by deep IM injection at alternating sites every 8 hours. A

loading dose was applied by repetition of the initial dose after 2 hours. Treatment

was changed to oral medication 10 mg/kg every 8 hours when they were well

enough to do so.

There were 47 patients in the IV group and 57 in the IM group. The two groups

were comparable in all aspects including malnutrition, anemia, and splenomegaly.

Seventeen percent (17%) of the IV group died and 7% of the IM group died. The

mean parasite clearance, fever clearance, and coma clearance times were similar in

both groups. There were two sterile abscesses in the IM group.

The authors conclude that IM quinine is as effective as IV in children with severe

and complicated malaria.

Commentary: One possible weakness in the study is that laboratory personnel

were blinded but clinical personnel were not. It appears from this study that IM

does the trick and therefore should be used. J Trop Med Hyg. 1993;87:299-302.

Submitted by the Committee on International Child Health



1995;96;126PediatricsStephen Berman


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