Paeds · infectious-diseases
Malaria in children
Also known as Falciparum malaria · Cerebral malaria · Severe malaria · Plasmodium falciparum infection · Imported malaria
Fellowship guide to malaria in children: Plasmodium species and severe falciparum disease, the cyclical fever and pathophysiology of cytoadherence and sequestration, the time-critical recognition of severe malaria in a returning traveller, blood film and rapid diagnostic test interpretation, intravenous artesunate for severe disease with fluid and transfusion support, artemisinin-combination therapy for uncomplicated infection, post-artesunate haemolysis, and the RTS,S vaccine.
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Target exams
Red flags
- Any febrile child who has travelled to or lived in a malaria-endemic area in the preceding three months
- Impaired consciousness, prostration, or repeated convulsions suggesting cerebral malaria
- Deep sighing acidotic breathing, respiratory distress, or shock indicating severe disease
- Severe pallor or haemoglobinuria (dark urine) suggesting severe malarial anaemia
- Spontaneous bleeding, jaundice, or oliguria signalling multiorgan involvement
- High parasitaemia above two per cent in a non-immune child
- Hypoglycaemia or a low blood glucose in a sick febrile child with malaria
Life stages
Care settings
Clinical exam formats
Board mappings
- Takes a travel and exposure history in any febrile child
- Distinguishes uncomplicated from severe malaria using WHO severity criteria
- Initiates intravenous artesunate immediately for severe falciparum malaria
- Justifies antimalarial choice by species, immune status, and resistance patterns
- Interprets blood films, parasite density, and rapid diagnostic test results
- Manages cerebral malaria, severe anaemia, and fluid balance in severe disease
- Recognition and empiric treatment of severe malaria in a returning traveller
- Diagnosis of imported malaria in a non-immune child
- Counselling families on prevention, chemoprophylaxis, and prognosis
- Bedside assessment of the febrile returned traveller with suspected malaria
- Blood film and rapid diagnostic test interpretation and communication
- Communication of the artesunate decision and safety-netting advice
- Level 1: Recognises fever in a returning traveller as a red flag
- Level 2: Diagnosis and initial management of uncomplicated and severe malaria
- Level 3: Management of cerebral malaria, complications, and imported disease
- Plasmodium species and their clinical syndromes in children
- WHO severe malaria criteria and intravenous artesunate dosing
- Artemisinin-combination therapy for uncomplicated falciparum malaria
- History and examination of the febrile returned traveller
- Communication of blood film results and the severe-malaria plan
- Structured assessment of a child with impaired consciousness
- Diagnosis of malaria by blood smear and rapid diagnostic test
- Empiric treatment of severe malaria with intravenous artesunate
- Pre-travel counselling and chemoprophylaxis for children
- Recognition and resuscitation of the child with severe malaria
- Appropriate use and interpretation of malaria diagnostics
- Antimalarial selection and stewardship decisions
- Imported malaria in the Canadian paediatric returning traveller
- WHO first-line artesunate for severe disease and access pathways
- Public health notification and follow-up after a malaria case
Overview & Definition
Malaria is a mosquito-borne parasitic illness caused by Plasmodium protozoa and transmitted by the bite of an infected female Anopheles mosquito. In children it ranges from a self-limiting febrile illness to a rapidly fatal multisystem disease, and the difference between the two is the single most important judgement a clinician makes. Any febrile child who has been in a malaria-endemic area must be presumed to have malaria until the blood film proves otherwise. [1]
The parasite that dominates severe disease and death is Plasmodium falciparum, which kills through cytoadherence and sequestration of infected red cells in the microvasculature of the brain and other organs. The other species, vivax, ovale, malariae, and the zoonotic knowlesi, cause significant illness but are rarely as lethal, and vivax and ovale carry the added burden of relapse from dormant liver stages called hypnozoites. Recognising the species and the severity drives every treatment decision. [1]
The cardinal principle is speed. Severe falciparum malaria is a medical emergency in which every hour of delay in giving intravenous artesunate measurably increases mortality, so blood films and rapid tests must never postpone the first dose in a sick child. In Australia and New Zealand malaria is almost always imported through travel, which makes a travel history the hinge of the whole encounter. [2]
References12ShowHide
- [1]White NJ Malaria. Lancet, 2014.PMID 23953767
- [2]Dondorp AM Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet, 2010.PMID 21062666
- [3]Dondorp A Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet, 2005.PMID 16125588
- [4]Maitland K Mortality after fluid bolus in African children with severe infection. N Engl J Med, 2011.PMID 21615299
- [5]Bhatt S The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature, 2015.PMID 26375008
- [6]Newton CR Pathophysiology of fatal falciparum malaria in African children. Am J Trop Med Hyg, 1998.PMID 9598460
- [7]Calis JC Severe anemia in Malawian children. Malawi Med J, 2016.PMID 27895843
- [8]Jaita S Post-Artesunate Delayed Hemolysis: A Review of Current Evidence. Trop Med Infect Dis, 2023.PMID 36668956
- [9]Syed YY RTS,S/AS01 malaria vaccine (Mosquirix): a profile of its use. Drugs Ther Perspect, 2022.PMID 36093265
- [10]Guerra Mendoza Y Safety profile of the RTS,S/AS01 malaria vaccine in infants and children: additional data from a phase III randomized controlled trial in sub-Saharan Africa. Hum Vaccin Immunother, 2019.PMID 31012786
- [11]Barber BE Plasmodium knowlesi malaria in children. Emerg Infect Dis, 2011.PMID 21529389
- [12]Nayak S Population genomics and transcriptomics of Plasmodium falciparum in Cambodia and Vietnam uncover key components of the artemisinin resistance genetic background. Nat Commun, 2024.PMID 39639029