BNF for Children (BNFC) 2018-2019

2 months of age. It can also be used during pregnancy and
breast-feeding. However, ingestion should be avoided,
therefore breast-feeding mothers should wash their hands
and breast tissue before handling infants. The duration of
protection varies according to the concentration of DEET
and is longest for DEET 50 %. When sunscreen is also
required, DEET should be applied after the sunscreen. DEET
reduces the SPF of sunscreen, so a sunscreen of SPF 30 – 50
should be applied. Long sleeves and trousers worn after dusk
also provide protection against bites.

Length of prophylaxis
In order to determine tolerance and to establish habit,
prophylaxis should generally be started one week ( 2 – 3 weeks
in the case of mefloquine p. 396 ) before travel into an
endemic area;Malarone®or doxycycline p. 352 prophylaxis
should be started 1 – 2 days before travel. Prophylaxis should
be continued for 4 weeks after leaving(except for
Malarone®prophylaxis which should be stopped 1 week after
leaving). For extensive journeys across different regions, the
traveller must be protected in all areas of risk.
In those requiring long-term prophylaxis, chloroquine
p. 395 and proguanil hydrochloride p. 397 may be used.
However there is considerable concern over the protective
efficacy of the combination of chloroquine and proguanil
hydrochloride in certain areas where it was previously useful.
Mefloquine is licensed for up to 1 year (although, if it is
tolerated in the short term, there is no evidence of harm
when it is used for up to 3 years). Doxycycline can be used for
up to 2 years.Malarone®can be used for up to 1 year.
Prophylaxis with mefloquine, doxycycline, orMalarone®
may be considered for longer durations if it is justified by the
risk of exposure to malaria. Specialist advice should be
sought for long-term prophylaxis.

Return from malarial region
It is important to be aware thatany illnessthat occurs
within 1 year andespecially within 3 months of return
might be malariaeven if all recommended precautions
against malaria were taken. Travellers should bewarnedof
this and told that if they develop any illnessparticularly
within 3 monthsof their return they should go
immediatelyto a doctor and specifically mention their
exposure to malaria.

Epilepsy
Both chloroquine and mefloquine are unsuitable for malaria
prophylaxis in individuals with a history of epilepsy. In areas
without chloroquine resistanceproguanil alone is

recommended; in areaswith chloroquine resistance,

doxycycline orMalarone®may be considered.

Asplenia

Asplenic individuals (or those with severe splenic

dysfunction) are at particular risk of severe malaria. If travel

to malarious areas is unavoidable, rigorous precautions are

required against contracting the disease.

Pregnancy

Travel to malarious areas should be avoided during

pregnancy; if travel is unavoidable, effective prophylaxis

must be used. Chloroquine and proguanil hydrochloride can

be given in the usual doses during pregnancy, but these

drugs are not appropriate for most areas because their

effectiveness has declined, particularly in Sub-Saharan

Africa; in the case of proguanil hydrochloride, folic acid

p. 574 (in doses greater than standard pregnancy

prophylaxis) should be given for at least thefirst trimester.

The centres listed (see Malaria, treatment p. 392 ) should be

consulted for advice on prophylaxis in chloroquine-resistant

areas. Although the manufacturer advises that mefloquine

should not be used during pregnancy, particularly in thefirst

trimester, unless the potential benefit outweighs the risk,

studies of mefloquine in pregnancy (including use in thefirst

trimester) indicate that it can be considered for travel to

chloroquine-resistant areas. Doxycycline is contra-indicated

during pregnancy; however, it can be used for malaria

prophylaxis if other regimens are unsuitable, and if the

entire course of doxycycline can be completed before

15 weeks’gestation [unlicensed].Malarone®should be

avoided during pregnancy, however, it can be considered

during the second and third trimesters if there is no suitable

alternative.

Breast-feeding

Prophylaxis is required inbreast-fed infants; although

antimalarials are present in milk, the amounts are too

variable to give reliable protection.

Anticoagulants

Travellers taking warfarin sodium p. 97 should begin

chemoprophylaxis 2 – 3 weeks before departure. The INR

should be stable before departure. It should be measured

before starting chemoprophylaxis, 7 days after starting, and

after completing the course. For prolonged stays, the INR

should be checked at regular intervals.

Standby treatment

Children and their carers visiting remote, malarious areas for

prolonged periods should carry standby treatment if they are

Key to recommended regimens for prophylaxis against malaria

Codes for regimens Details of regimens for prophylaxis against malaria

• No risk
  1 Chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever presents
  2 Chloroquine only
  3 Chloroquine with proguanil
  4 Atovaquone with proguanil hydrochloride or doxycycline or mefloquine

Specific recommendations

Country Comments on risk of malaria and regional or seasonal variation Codes for regimens

Yemen Risk below 2000 m 3

Very low risk on Socrota Island; no risk above 2000 m, including Sana’a city 1

Zambia High risk 4

Zimbabwe High risk all year in Zambezi valley, and from November–June in areas below

1200 m

4

Low risk from July–October in areas below 1200 m; very low risk all year in Harare

and Bulawayo

1

BNFC 2018 – 2019 Malaria 391

Infection

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