Severe Malaria in Children
Definition and epidemiology
Severe malaria is Plasmodium infection (overwhelmingly P. falciparum, occasionally P. vivax) with one or more WHO-defined organ-dysfunction criteria and confirmed parasitaemia. Children under five in endemic areas carry the greatest burden of mortality. India remains endemic — P. vivax and P. falciparum both circulate, with falciparum concentrated in the east, north-east, and tribal/forested belts — so a travel and residence history is essential in any febrile child.
Clinical features
Early severe malaria can mimic sepsis or meningitis. Features cluster by organ system:
- Cerebral malaria: impaired consciousness, generalised/repeated convulsions, coma (Blantyre Coma Score ≤2)
- Severe anaemia: pallor, tachycardia, high-output failure
- Respiratory distress / acidosis: deep (Kussmaul) breathing — an ominous sign in children
- Hypoglycaemia, jaundice, shock (“algid malaria”), prostration (inability to sit/feed)
- Renal: dark urine, oliguria (acute kidney injury), haemoglobinuria
Diagnosis
Confirm parasitaemia by microscopy (thick/thin films) or a rapid diagnostic test, then apply the WHO severe-malaria criteria in a child with P. falciparum:
- Impaired consciousness (Blantyre ≤2 / GCS <11), prostration, or ≥2 convulsions/24 h
- Severe anaemia (Hb ≤5 g/dL or haematocrit ≤15% in children <12 y)
- Hypoglycaemia (<2.2 mmol/L; <40 mg/dL), acidosis (bicarbonate <15 mmol/L or lactate >5 mmol/L)
- Renal impairment, jaundice (bilirubin >50 µmol/L with parasitaemia >100,000/µL)
- Pulmonary oedema/ARDS, significant bleeding, shock, hyperparasitaemia (>10%)
See the full criteria: WHO Severe Malaria Criteria
Red flags
- Any impaired consciousness or convulsion in a malaria-endemic context
- Deep acidotic breathing or respiratory distress without obvious chest signs
- Severe pallor, hypoglycaemia, or shock
- Inability to drink/feed, repeated vomiting of oral therapy
- Spontaneous bleeding or haemoglobinuria
Management overview
Severe malaria is a medical emergency — start parenteral therapy immediately, do not wait for full work-up:
- IV (or IM) artesunate is first-line for all severe malaria, including children and pregnancy — superior to quinine for survival. Give for ≥24 h and until oral tolerated, then a full course of oral ACT (artemisinin-based combination therapy).
- Treat hypoglycaemia promptly (IV dextrose) and recheck glucose frequently.
- Manage convulsions and coma — protect airway, control seizures, nurse carefully.
- Cautious fluid management — avoid aggressive bolus fluids (FEAST trial: boluses increased mortality); transfuse for severe anaemia per thresholds.
- Supportive care — antipyretics, monitor for AKI/acidosis, treat concurrent bacterial sepsis if suspected.
- Avoid contraindicated practices — no routine corticosteroids, mannitol, or heparin.
India-aware note: follow NVBDCP drug policy; severe P. vivax also warrants IV artesunate, and confirm G6PD status before primaquine for radical cure.
References
- WHO Guidelines for the Treatment of Malaria / Severe Malaria criteria (2014)
- WHO Severe Malaria, Trop Med Int Health (2014)
- NVBDCP India malaria guidelines
- IAP severe malaria guidance
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.