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A chatty, 4 year-old girl is brought to the emergency department (ED) by her mother with a 3-day history of fever and loose stool. They returned from Nigeria 7 days earlier, having visited friends and relatives for the school holidays. Clinical examination is unremarkable, she is currently afebrile, and there are no signs of serious bacterial infection. A malaria blood film and histidine rich protein-2 (HRP-2) based rapid diagnostic test (RDT) are both negative. RDTs are for malaria antigens such as HRP-2 and lactate dehydrogenase (LDH).
The paediatric registrar discharges the patient but expresses concern regarding the ability of a single RDT and blood film to rule out malaria, following current guidelines, and insists she returns in 24 and 48 hours to repeat the tests. You wonder if this is really necessary.
Structured clinical question
In children returning from malaria-endemic areas with a history of fever do multiple blood films or RDTs improve the sensitivity and negative likelihood ratio for the diagnosis of malaria?
Search strategy: ‘malaria’ and ‘returning traveller’ and ‘diagnos*’
Secondary sources: Cochrane database of systematic reviews—12 results, two relevant.
Two large reviews of RDTs for Plasmodium falciparum and non-falciparum malaria, in all ages in endemic settings.1 2
Primary sources: CINAHL, EMBASE, MEDLINE and Pubmed—134 results, three relevant.
Search strategy 2: ‘malaria’ and ‘child*’ and (‘rapid diagnostic test’ OR blood film’)
Primary sources: CINAHL, EMBASE, MEDLINE and Pubmed—378 results. Sixty identified as potentially relevant and abstracts reviewed.
Published data on malaria diagnostics in febrile children returning from endemic areas are sparse. We identified a single abstract presented at the RCPCH meeting describing the results of a small study in this group, and one further study reporting on both returning adults and children. We identified and report two further studies, including a large meta-analysis of returning adults, along with a large study of diagnostics in children in endemic settings. Five studies are included in this narrative review (table 1).
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