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Information for the Public: Preventing Malaria in Infants and Children

Know Your Family’s Risk of Malaria

Malaria is a serious illness transmitted by the bite of an infective mosquito. Travelers to Africa, Central and South America, the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific may be at risk for this potentially deadly disease.

Children of any age can get malaria. All travelers to areas with malaria transmission, including infants, children, and former residents of these areas, should protect themselves from malaria by taking an antimalarial drug and by preventing mosquito bites.

To find out if your foreign travel will take you and your family into an area with malaria:

• Visit CDC’s Traveler’s Health website at http://wwwn.cdc.gov/travel
• Go to the online malaria map application at http://www.cdc.gov/malaria/risk_map.

See Your Child’s Health Care Provider

Take your child to their health care provider at least 4-6 weeks before the time of your trip. Any vaccinations your child may need will have time to become fully protective. In addition, all the antimalarial drugs are prescription drugs and your child will need to start taking them before travel. Dosages for infants and children usually have to be specially prepared; allow your pharmacist sufficient time to prepare your prescriptions.

Find Out Which Antimalarial Drug is Right for Your Child

Your health care provider will decide which antimalarial drug is the right one for your child. Some drugs may not be effective in some countries in the world. A medical condition may prevent your child from taking a particular antimalarial drug. In addition, children’s dosages are based on their age and weight and need to be carefully calculated.

Antimalarial Warnings and Instructions

• Give your child their antimalarial drug exactly on schedule. Missing or delaying doses may increase their risk of getting malaria.
• For the best protection against malaria, your child should continue taking their drug as recommended after leaving the malaria-risk area (4 weeks for mefloquine, doxycycline, or chloroquine; 7 days for atovaquone/proguanil or primaquine). Otherwise, they can develop malaria.
• Overdosage (taking too much of an antimalarial drug) can be fatal. Keep drugs in childproof containers out of the reach of children.
• Buy your drugs before traveling overseas. Drugs purchased overseas may not be made according to United States standards and may not be effective. They may also be dangerous, contain the wrong drug or no active drug, or be contaminated.
  • Halofantrine (also called Halfan) is widely used overseas to treat malaria. CDC recommends that you and your child not use Halfan because of serious heart-related side effects, including deaths.
  • You should avoid using antimalarial drugs that are not recommended unless your child has been diagnosed with life-threatening malaria and no other treatment options are available.
• Most antimalarial drugs are well-tolerated; most travelers do not need to stop taking their drug because of side effects. However, if you are particularly concerned about side effects, discuss the possibility of starting your drug early (3-4 weeks in advance of your trip) with your health care provider. If you cannot tolerate the drug, ask your doctor to change your medication.

Antimalarial Drug Information

Infants and children traveling to malaria-risk areas in Africa, South America, South Asia, Tajikistan, Asia, and the South Pacific may be given one of the following antimalarial drugs (listed alphabetically):

• atovaquone/proguanil
• doxycycline
• mefloquine
• primaquine (in special circumstances).

Atovaquone/proguanil (Brand Name: Malarone™)

Atovaquone/proguanil is a combination of two drugs, atovaquone plus proguanil, in one tablet. It is available in the United States as the brand name, Malarone.

Your child’s health care provider will prescribe atovaquone/proguanil based on your child’s weight . Note: Atovaquone/proguanil should not be used to prevent malaria in infants that weigh less than 11 pounds (5 kilograms). (Updated December 22, 2006).

Directions for Use

• Give the first dose of atovaquone/proguanil 1 to 2 days before travel to the malaria-risk area.
• Give atovaquone/proguanil once a day during travel in the malaria-risk area.
• Give atovaquone/proguanil once a day for 7 days after leaving the malaria-risk area.
• Give the dose at the same time each day and have your child take the pill after a meal or with milk. Atovaquone/proguanil is better absorbed if taken with food or a milky drink.

Side Effects and Warnings

Side effects are uncommon. When they do occur, the most common side effects reported by travelers taking atovaquone/proguanil are stomach pain, nausea, vomiting, and headache. Most people taking this drug do not have side effects serious enough to stop taking it; If your child cannot tolerate atovaquone/proguanil, see their health care provider for a different antimalarial drug.

Travelers Who Should NOT Take Atovaquone/proguanil to Prevent Malaria

• children weighing less than 11 pounds (5 kilograms) (Updated December 22, 2006)
• pregnant women
• women breast-feeding infants weighing less than 11 pounds (5 kilograms) (Updated December 22, 2006)
• persons with severe renal impairment (severe kidney disease)
• persons allergic to atovaquone or proguanil

Chloroquine Phosphate (Brand Name Aralen™ and Generics)

Travelers to malaria-risk areas in Mexico, the Caribbean, and certain countries in Central America, the Middle East, and Eastern Europe may take chloroquine as their antimalarial drug

Directions for Use

• Your child’s health care provider will prescribe chloroquine based on your child’s weight.
• Give the first dose of chloroquine 1 week before arrival in the malaria-risk area.
• Give the dose once a week, on the same day of the week, while in the risk area.
• Give the dose once a week for 4 weeks after leaving the risk area.
• Chloroquine should be taken on a full stomach to lessen the risk of nausea and stomach upset.

Side Effects and Warnings

The most common side effects reported by travelers taking chloroquine include nausea and vomiting, headache, dizziness, blurred vision, and itching. Chloroquine may worsen the symptoms of psoriasis. Most children taking chloroquine do not have side effects serious enough to stop taking the drug. Other antimalarial drugs are available; see their health care provider.

Note: In malaria-risk areas where chloroquine is the recommended drug but chloroquine cannot be taken, atovaquone/proguanil, doxycycline, mefloquine, or primaquine would also be effective and can be used as your child’s antimalarial drug.

The following children should not take chloroquine; you should ask their health care provider for a different drug:

• patients allergic to chloroquine
• persons traveling to areas where chloroquine-resistant malaria exists

Doxycycline (Many Brand Names and Generic Brands Are Available)

Doxycycline is related to the antibiotic tetracycline.

Directions for Use

• Your child’s health care provider will prescribe doxycycline based on your child’s weight.
• Give the first dose of doxycycline 1-2 days before travel to the malaria-risk area.
• Give doxycycline once a day, at the same time each day, while in the risk area.
• Give doxycycline once a day for 4 weeks after leaving the risk area.

Side Effects and Warnings

One of the most common side effects reported in children taking doxycycline includes sunburning faster than normal (sun sensitivity). To prevent sunburn, your child should avoid midday sun, wear a high SPF sunblock, long-sleeved shirts, long pants, and a hat.

Doxycycline may cause nausea and stomach pain. Give your child the drug after a meal and have them drink a full glass of liquid. They should not lie down for 1 hour after taking the drug to prevent reflux of the drug (stomach contents backing up into the esophagus).

Most children taking doxycycline do not have side effects serious enough to stop taking it. If your child cannot tolerate doxycycline, see their health provider. Other drugs are available.

Travelers Who Should Not Take Doxycycline

• children under the age of 8 years; teeth may become permanently stained.
• children allergic to doxycycline or other tetracyclines
• pregnant women
• Very limited safety data exists on the use of doxycycline by breast-feeding women. Most experts consider the likelihood of harmful effects to be remote.

Hydroxychloroquine Sulfate (Brand Name: Plaquenil™)

Hydroxychloroquine sulfate is an alternative to chloroquine phosphate, although less evidence exists on its effectiveness as an antimalarial drug.

Directions for Use

• Your child’s health care provider will prescribe hydroxychloroquine sulfate based on your child’s weight.
• Give the first dose 1 week before arrival in the malaria-risk area.
• Give the dose once a week, on the same day of the week, while in the risk area.
• Give the dose once a week for 4 weeks after leaving the risk area.
• Give hydroxychloroquine sulfate after a meal to lessen nausea and stomach upset.

Side Effects and Warnings

Nausea and vomiting, headache, dizziness, blurred vision, difficulty sleeping, and itching have been reported with hydroxychloroquine sulfate use. Minor side effects usually do not require stopping the drug. Hydroxychloroquine sulfate may worsen the symptoms of psoriasis. Other antimalarial drugs are available; see your health care provider.

The following travelers should not take hydroxychloroquine and should ask their health care provider for a different drug:

• persons allergic to hydroxychloroquine
• persons traveling to areas where chloroquine-resistant malaria exists

Mefloquine (Brand Name Lariam™ and Generic)

Directions for Use

• Your child’s health care provider will prescribe mefloquine based on your child’s weight.
• Give the first dose of mefloquine 2 weeks before travel to the malaria-risk area.
• Give the drug once a week, on the same day of the week, while in the risk area.
• Give mefloquine once a week for 4 weeks after leaving the malaria-risk area.
• Mefloquine should be given on a full stomach after a meal.

Side Effects and Warnings

The most common side effects reported by travelers taking mefloquine include headache, nausea, dizziness, difficulty sleeping, anxiety, vivid dreams, and visual disturbances. Mefloquine has rarely been reported to cause serious side effects, such as seizures, depression, and psychosis. These serious side effects are more frequent with the higher doses used to treat malaria; fewer occurred at the weekly doses used to prevent malaria.

Mefloquine is eliminated slowly by the body and thus may stay in the body for a while even after the drug is discontinued. Therefore, side effects caused by mefloquine may persist weeks to months after the drug has been stopped.

Most children taking mefloquine do not have side effects serious enough to stop taking the drug. (Other antimalarial drugs are available if your child cannot tolerate mefloquine; see your health care provider.)

Children Who Should NOT Take Mefloquine

If your child has a condition that is listed below, they should not take mefloquine and you should ask their health care provider for a different antimalarial drug:

• persons with active depression or a recent history of depression
• persons with a history of psychosis, generalized anxiety disorder, schizophrenia, or other major psychiatric disorder
• persons with a history of seizures (does not include the type of seizure caused by high fever in childhood)
• persons allergic to mefloquine
• Mefloquine is not recommended for persons with cardiac conduction abnormalities (for example, an irregular heartbeat).
• persons traveling to areas where mefloquine-resistant malaria exists

Primaquine

Directions for Use

Note: Children must be tested for G6PD deficiency (glucose-6-phosphate-dehydrogenase) and have a documented G6PD level in the normal range before primaquine use. G6PD is an enzyme; your health care provider will do a blood test to find out if your child has a high enough level of this enzyme to safely take primaquine. Primaquine can cause a bursting of the red blood cells (hemolysis) which can be fatal, if your child is deficient in G6PD.

• Your child’s health care provider will prescribe primaquine based on your child’s weight.
• Give the first dose 1-2 days before travel to the malaria-risk area.
• Give primaquine once a day, at the same time each day, while in the risk area.
• Give primaquine once a day for 7 days after leaving the risk area.

Side Effects and Warnings

The most common side effects reported by travelers taking primaquine include stomach cramps, nausea, and vomiting.

If your child has a condition listed below, they should not take primaquine and you should ask their health care provider for a different drug:

• persons with G6PD deficiency
• persons who have not had a blood test for G6PD deficiency
• pregnant women (the fetus may be G6PD deficient, even if the mother’s blood test is in the normal range)
• women breast-feeding infants unless the infant has a documented normal G6PD level
• persons allergic to primaquine
• Do not share primaquine with others; they may be G6PD deficient and suffer bursting of their red blood cells, which can be fatal.

Protect Yourself from Mosquito Bites

Malaria is transmitted by the bite of an infected mosquito; these mosquitoes usually bite at night (between dusk and dawn). To avoid being bitten, remain indoors in a screened or air-conditioned area during the peak biting period. If out-of-doors, wear long-sleeved shirts, long pants, and hats. Apply insect repellent (bug spray) to exposed skin.

For the prevention of malaria, CDC recommends use of one of four types of insect repellents. 

• DEET (Chemical Name: N,N-diethyl-m-toluamide or N,N-diethly-3-methyl-benzamide). Products containing DEET include but are not limited to: Off!, Cutter, Sawyer and Ultrathon.
• Picaridin (KBR 3023, aka Bayrepel, and icaridin outside the US, Chemical Name: 2-(2-hydroxyethyl)-1-piperidinecarboxylic acid 1-methylpropyl ester ) Products containing picaridin include but are not limited to: Cutter Advanced, Skin so Soft Bug Guard Plus and Autan (outside the US)
• Oil of Lemon Eucalyptus or PMD (Chemical Name: para-menthane-3,8-diol) the synthesized version of oil of lemon eucalyptus. Products containing OLE and PMD include but are not limited to: Repel
• IR3535 (Chemical Name: 3-[N-Butyl-N-acetyl]-aminopropionic acid, ethyl ester) Products containing IR3535 include but are not limited to: Skin so Soft Bug Guard Plus Expedition

In general, higher concentrations of the active ingredient provide longer duration of protection. Products with ≤10% active ingredient may offer only limited protection, often from 1-2 hours. Products that offer sustained release or controlled release (micro-encapsulated) formulations, even with lower active ingredient concentrations, may provide longer protection times. Studies suggest that concentrations of DEET above ~50% do not offer a marked increase in protection time against mosquitoes (e.g. DEET efficacy tends to plateau at around 50%). Regardless of what product is used, if travelers start to get mosquito bites they should reapply the repellent according to the label instructions or remove themselves from the area with mosquitoes if possible.

Precautions When Using Any Repellent

• Read and follow the directions and precautions on the product label.
• Use only when outdoors and thoroughly wash off the repellent from the skin with soap and water after coming indoors.
• Do not breathe in, swallow, or get repellent into the eyes or mouth. If using a spray product, apply to your face by spraying your hands and rubbing the product carefully over the face, avoiding eyes and mouth.
• Never use repellents on wounds or broken skin
• Pregnant women should use insect repellent as recommended for other adults. Wash off with soap and water after coming indoors.
• Repellents may be used on infants older than 2 months of age
• Children under 10 years old should not apply insect repellent themselves. Do not apply to young children’s hands or around their eyes and mouth.

Other Recommended Anti-mosquito Measures

• Travelers should take a flying insect spray on their trip to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
• Travelers not staying in well-screened or air-conditioned rooms should sleep under bed nets (mosquito nets), preferably nets treated with the insecticide permethrin. Permethrin both repels and kills mosquitoes as well as other biting insects and ticks. In the United States, permethrin is available as a spray or a liquid (e.g. Permanone™). Pre-treated nets, permethrin or another insecticide deltamethrin, are available overseas.
• Protect infants (especially infants under 2 months of age not wearing insect repellent) by using a carrier draped with mosquito netting with an elastic edge for a tight fit.
• Clothing, shoes, and camping gear, can also be treated with permethrin. Treated clothing can be repeatedly washed and still repel insects. Some commercial products (clothing) are now available in the United States that have been pretreated with permethrin.

Know the Signs and Symptoms of Malaria

Your child can still get malaria despite taking an antimalarial drug and using protection against mosquito bites. Taking an antimalarial drug greatly reduces your chances of getting malaria. Symptoms are very flu-like and can include fever, shaking chills, headache, muscle aches, and tiredness. Nausea, vomiting, and diarrhea may also occur.

Malaria symptoms will occur at least six to nine days after being bitten by an infected mosquito. Therefore, fever in the first week of travel in a malaria-risk area cannot be malaria; however, ill travelers should still seek immediate medical care and any fever should be promptly evaluated.

If you or your child becomes ill with a fever or flu-like illness while traveling in a malaria-risk area and up to 1 year after returning home, seek immediate medical care. Delaying treatment can lead to serious complications such as coma, kidney failure, and death. Tell your health care provider where you have been traveling and that you have been exposed to malaria.