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Severe Malaria in Children

Malaria is a parasitic infection caused by Plasmodium falciparum and can present
as uncomplicated or severe malaria. This section discuss on management of severe malaria in children. Management of Uncomplicated malaria in discussed in the next section

Severe malaria presents with signs of severe illness and/ or evidence of organ

Diagnostic Criteria:

A positive rapid diagnostic test or a positive blood slide for malaria parasites AND One or more of the following features:


  • Prostration

  • Inability to drink or breast feed

  • Vomiting everything

  • Respiratory distress

  • Behavioral changes

  • Lethargy

  • Coma

  • Convulsion

  • Hypoglycemia

  • Metabolic acidosis

  • Shock

  • Severe pallor

  • Jaundice

  • Dark colored urine


It is important to consider Meningitis and septicaemia in a child presenting with
altered consciousness or convulsions



  • mRDT and Blood slide for MPS

  • RBG

  • FBP

  • Lumbar puncture to exclude meningitis

  • Blood culture and sensitivity



Non pharmacological treatment


  • Encourage breastfeeding and ensure adequate fluid and calorie intake, 
    give IV Fluids if oral intake is not possible.


Pharmacological treatment

1. Artesunate

Give injection Artesunate: 3.0mg/kg for children <20kg and 2.4mg/kg for children >20kg IV or IM at 0 hour, 12 hours and 24 hours, there after complete treatment by giving a complete course of oral Artemether-Lumefantrine or Dihydro artemisinin-Piperaquine

NOTE: Injectable Artesunate has 2-steps dilutions

Step1: The powder for injections hould be diluted with 1ml of 5% Sodium bicarbonate and shaken vigorously two to three minutes till the solution becomes clear.

Step2: For IV infusion (3-4minutes), add 5ml of 5% dextrose or normal saline to obtain Artesunate concentration of 10mg/ml and for IM injection, add 2 ml of 5% dextrose or normal saline to obtain Artesunate concentration of 20 mg/ml.

2. Quinine

Quinine is indicated in infants less than 5kg or when Artesunate is not available. Give Quinine10 mg/kg diluted in 5-10ml/kg body weight of 5% Dextrose to run for 4 hours.


If the patient has to receive blood transfusion, IV fluid for severe dehydration, correction of electrolyte imbalance or failed IV or intra osseous access give the first dose of quinine by intramuscular route (IM). Administration of quinine by Intramuscular route (IM)

  • Dose is 10mg of quinine/kg (maximum 600 mg/dose)

  • Quinine should be diluted to a concentration of 60mg/ml for IM injection and given on the anterolateral aspect of the thigh in two divided doses on each thigh.


Dilution: dilute four times in water for injection to a concentration of 60mg/ml.

This dilution will minimize the risk of sterile abscess formation.

NOTE: In neonates give Quinine and antibiotics to cover for septicemia

3. Artemether

Give Artemether when Artesunate is not available in the following dose: 3.2mg/kg loading dose IM then 1.6mg/kg at 24hrs and 48hrs.

If patient can tolerate oral medication after 24 hours provide a full treatment course of ALu. Initiate the first dose of ALu 8 hours after the last injection.

Last updated on 14.09.2020

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  1. Tanzanian Standard treatment guideline for children 2017 edition page 81-83

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