Malaria in children under five

Last update: 1 April 2017

Children under 5 years of age are one of most vulnerable groups affected by malaria. There were an estimated 429 000 malaria deaths around the world in 2015, of which an estimated 303 000 (70.6%) were in children under 5 years of age.

In high transmission areas, partial immunity to the disease is acquired during childhood. In such settings, the majority of malarial disease, and particularly severe disease with rapid progression to death, occurs in young children without acquired immunity. Severe anaemia, hypoglycemia and cerebral malaria are features of severe malaria more commonly seen in children than in adults.

WHO recommends the following package of interventions for the prevention and treatment of malaria in children:

  • use of long-lasting insecticidal nets (LLINs);
  • in areas with highly seasonal transmission of the Sahel sub-region of Africa, seasonal malaria chemoprevention (SMC) for children aged between 3 and 59 months;
  • in areas of moderate-to-high transmission in sub-Saharan Africa, intermittent preventive therapy for infants (IPTi), except in areas where WHO recommends administration of SMC;
  • prompt diagnosis and effective treatment of malaria infections.

Diagnosis and treatment

As with any patient, children with suspected malaria should have parasitological confirmation of diagnosis before treatment begins, provided that diagnosis does not significantly delay treatment.

Artemisinin derivatives are safe and well tolerated by young children, so the choice of ACT will be determined largely by the safety and tolerability of the partner drug. Many antimalarials lack paediatric formulations, necessitating the division of adult tablets, which can lead to inaccurate dosing.

WHO recommends new adjusted dosing schemes for dihydro-artemisinin + piperaquine in children weighing less than 25 kg and for parenteral artesunate in children weighing less than 20 kg. For infants weighing less than 5 kg with uncomplicated P. falciparum, WHO recommends treatment with an ACT at the same mg/kg body weight dose as for children weighing 5 kg.

Use of parenteral treatment

Because the clinical condition of children with malaria can deteriorate rapidly, there should be a low threshold for the use of parenteral treatment. Recent data support the use of intravenous artesunate in preference to quinine for the treatment of severe malaria in children.

A single dose of rectal artesunate as pre-referral treatment reduces the risk of death in children under 6 years of age. When injectable treatment cannot be given, artesunate should be administered rectally and the child transferred to a facility for full parenteral treatment.

Key documents