**5. Special populations**

Children and pregnant women are at the highest risk for severe malaria when traveling to endemic areas and increased vigilance should be taken when dealing with these populations. It should be recommend that travel to endemic areas with a risk of transmission be avoided by these populations if possible, however if patients insist, the provider should stress that the traveler or the parents of the traveler insure that both personnel protective measures and chemoprophylaxis are strictly adhered to.

### **5.1 Pregnancy**

Contracting malaria while pregnant puts the mother at an increased risk for adverse outcomes. Malaria infection during pregnancy has been associated with premature labor, abortion and stillbirth. The traveler should be counseled that the diagnosis of malaria in pregnancy may be difficult due to relatively low parasitemia at clinical presentation. A very high degree of suspicion should be taken when a pregnant women presents with fever in an endemic area, as missing the diagnosis could have grave consequences (McGready et al., 2004). Appropriate precautions should be followed including mosquito avoidance and control measures discussed previously as well as chemoprophylaxis when clinically indicated. Reviewing label-specific information and current CDC recommendations should be adhered to. There are no published data indicating elevated risks with the use of DEET in pregnant or lactating women, and current U.S. Environmental Protection Agency and CDC sources do not advise additional precautions for using FDA-approved insect repellants in this population (Koren et al., 2003; Zielinski-Gutierrez et al., 2012). Chemoprophylaxis in pregnancy is limited, as both doxycycline and primaquine are contraindicated, and atovoquone/proguanil is not currently recommended due to lack of safety data from clinical studies. Medications considered safe during pregnancy include chloroquine and mefloquine. While data in the past have only recommended mefloquine in the last half of pregnancy, current recommendations state that there is no evidence of adverse outcome if taken in any of the three trimesters of pregnancy when no other option is available (CDC, 2012).

#### **5.2 Children**

Children are at risk of malaria and the associated complications while traveling to endemic areas, and should have the same personal protective measures as adults. DEET has been shown to be safe and effective and is recommended for use by both the CDC and the American Academy of Pediatrics (AAP) for all children over 2 months of age at concentrations between 10-30% based on duration of protection required (Koren et al., 2003; AAP, 2009, 2011; CDC, 2012). Chemoprophylaxis for children is not as restricted as for pregnant women, with contraindications including doxycyline usage in children under 8 and primaquine usage in G6PD deficient patients. Atovaquone/proguanil is FDA approved for children greater than 11kg but recommended for off-label use by the CDC and AAP for children >5 kg. Mefloquine is only FDA approved for children > 5 kg and older than 6 months of age, but when necessary recommend off-label for children < 5kg and any age (AAP, 2009; CDC, 2012). Parents of very young infants should be counseled to avoid areas endemic for malaria given the risk of severe disease in this population. Adherence to personal protective measures and chemoprophylaxis if often poor in children, and thus it must be stressed to the traveling parent the importance of these precautions.
