Table 2

Treatment for severe malaria—based on national guidelines from the UK, Canada, USA and Australia, and WHO malaria treatment guidelines 201013 19 20–22

Clinical diagnosis and speciesPaediatric drugDoseComments
Severe malaria
Any (or mixed)
Treatment of choice:
IV Artesunate

2.4 mg/kg IV at 0, 12, and 24 hours, then once daily until oral therapy is tolerated (see below)
P falciparum
P vivax
P ovale
P malariae
P knowlesi

Alternative treatment (if artesunate not available):
IV Quinine dihydrochloride

Loading dose: 20 mg/kg IV over 4 h

Maintenance dose: 10 mg/kg IV over 4 h, 8 hourly, starting 8 h after initiation of loading dose, until the patient is able to begin oral treatment (see below)

Requires slow infusion and cardiac monitoring (lethal hypotension possible if given rapidly)

Quinine may exacerbate hypoglycemia
Inability to tolerate oral therapyWhen patient is able to tolerate oral therapy, give: (as in table 3 for uncomplicated P falciparum)
(Riamet, Coartem)—full course of 6 doses
Quinine+(clindamycin OR doxycycline)—full 7 day course
Loading dose of quinine is not required if patient has received
– 3 or more doses of quinine or quinidine in the previous 48 h
– mefloquine prophylaxis in the previous 24 h
– mefloquine treatment dose within the previous 3 days
See also primaquine (table 4) to eradicate liver hypnozoites if species of Plasmodium is P vivax, P ovale, or unknown