By the end of this article, one should be able to,

  1. Recognize severe malaria.
  2. Describe management of severe malaria.

Signs and symptoms of Severe Malaria

Severe malaria is a life threatening condition defined as Peripheral parasitaemia in the presence of the following clinical or laboratory features

  • Prostration,
  • altered consciousness,
  • respiratory distress,
  • multiple generalized convulsions,
  • severe anaemia (Hb<5g/dl),
  • hypoglycaemia (<2.2mmol/l),
    NB- features may occur singly or in combination
  • Conjugate deviation of the eyes to the left

Role of laboratory diagnosis in severe malaria

  •  Parasitological confirmation is recommended.
  •  Presumptive treatment should be started immediately while waiting for parasitological confirmation.
  • Antimalarial treatment should not be withheld if parasitological diagnosis is not possible or delayed.
  •  Other investigations to determine severity and prognosis should be undertaken where feasible;
    (HB, Blood sugar, Urea and electrolyte).
  • Positive slides do not rule out other causes of severe disease

Clinical Manifestations of Severe Malaria

  •  Severe Anaemia
  •  Cerebral Malaria
  •  Hypoglycaemia
  1. All the clinical manifestations are primarily due to the involvement of red blood cells.
  2. P. Vivax predominantly invades young red cells and the number of parasites infected rarely exceeds 2%.
  3. P. Malariae develops mostly in mature red cells and parasitaemia is rarely greater than 1%.
  4. P. falciparum affects red cells of all ages and parasitaemia can be as high as 20-30% .

I. How to assess cerebral malaria clinically

  • Assess level of consciousness using coma score.
  • Determine the presence of severe anaemia.
  • Examine for presence of respiratory distress.
  • Determine hydration status
  • Assess for renal insufficiency
  •  Look for evidence of Disseminated Intravascular Coagulopathy (DIC)
  •  Assess for stiff neck and do lumbar puncture

II. Laboratory Tests Assessment

  1.  In children with altered consciousness, start treatment for both malaria, and meningitis until lumbar puncture results exclude meningitis.
  2.  Do blood glucose to rule out hypoglycemia.
  3.  Determine hemoglobin levels, blood group and cross match where applicable.

Inpatient management of severe malaria

Quinine administration in children

  • Loading dose of 20mg/kg in 15ml/kg of 5% dextrose or normal saline to run over 4 hours
  •      Omit loading dose if any quinine has been given in the previous 24 hours 8 hours from commencement of initial dose, give 10mg/kg quinine in 10ml/kg of 5% dextrose or normal saline to run over 4 hours
  • Repeat 10mg/kg infusion every 8 hours until the patient is able to sit up and take oral medication

Quinine administration in adults

  • Loading dose of 20mg/kg (maximum of 1200mg)in 5% dextrose or normal saline to run over 4 hours
  • Omit loading dose if any quinine has been given in the previous 24 hours
  •  Maintain with 10mg/kg (maximum of 600mg) infusion 8 hourly until the patient is able to take oral medication

Follow on treatment after IV quinine

  • Once all patients are able to take oral medication: Give a full course of artemether-lumefantrine for 3 days
  • OR
  • Continue oral quinine at 10mg/kg (max 600mg) 8 hourly for a total of 7 days of treatment.

Supportive treatment

  • Hypoglycaemia – IV or oral glucose (10% glucose 5 ml/kg)
  • Convulsions;
     diazepam 0.3mg/kg IV or 0.5 mg/kg rectally
     Phenytoin or phenobarbitone
  • Severe anaemia – transfuse
  • Fluid and electrolyte balance
  • Fever and nursing care


Frequent questions

  1. Would you give Artesunate / IV Quinine to a child with severe malaria and Hb of 3g/dl?
  2. Would you give fluid to a child with Hb of 3g/dl before giving a blood transfusion?


  1.  Yes, Artesunate or quinine must be given as soon as possible while waiting for blood transfusion.
  2. Yes, children with severe malaria and severe anaemia can be given fluids while waiting for blood transfusion

Doc bob

Am Robert Mathenge, a healthcare provider in Nakuru county. i love this profession as it gives me chance to serve my call, interacting with people from various social backgrounds makes me feel good.

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