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:

1. 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).
2. Treat hypoglycaemia promptly (IV dextrose) and recheck glucose frequently.
3. Manage convulsions and coma — protect airway, control seizures, nurse carefully.
4. Cautious fluid management — avoid aggressive bolus fluids (FEAST trial: boluses increased mortality); transfuse for severe anaemia per thresholds.
5. Supportive care — antipyretics, monitor for AKI/acidosis, treat concurrent bacterial sepsis if suspected.
6. 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.