Background About 90 percent of the deaths from malaria are inAfrican children, but criteria to guide the recognition andmanagement of severe malaria have not been validated in them.
Methods We conducted a prospective study of all children admittedto the pediatric ward of a Kenyan district hospital with a primarydiagnosis of malaria. We calculated the frequency and mortalityrate for each of the clinical and laboratory criteria in thecurrent World Health Organization (WHO) definition of severemalaria, and then used logistic-regression analysis to identifythe variables with the greatest prognostic value.
Results We studied 1844 children (mean age, 26.4 months) witha primary diagnosis of malaria. Not included were 18 childrenwho died on arrival and 4 who died of other causes. The mortalityrate was 3.5 percent (95 percent confidence interval, 2.7 to4.3 percent), and 84 percent of the deaths occurred within 24hours of admission. Logistic-regression analysis identifiedfour key prognostic indicators: impaired consciousness (relativerisk, 3.3; 95 percent confidence interval, 1.6 to 7.0), respiratorydistress (relative risk, 3.9; 95 percent confidence interval,2.0 to 7.7), hypoglycemia (relative risk, 3.3; 95 percent confidenceinterval, 1.6 to 6.7), and jaundice (relative risk, 2.6; 95percent confidence interval, 1.1 to 6.3). Of the 64 childrenwho died, 54 were among those with impaired consciousness (n= 336; case fatality rate, 11.9 percent) or respiratory distress(n = 251; case fatality rate, 13.9 percent), or both. Hence,this simple bedside index identified 84.4 percent of the fatalcases, as compared with the 79.7 percent identified by the currentWHO criteria.
Conclusions In African children with malaria, the presence ofimpaired consciousness or respiratory distress can identifythose at high risk for death.
Source Information
From the Kenya Medical Research Institute–Clinical Research Centre, Kilifi Unit, Kilifi, Kenya (K.M., D.F., C.W., I.M., M.W., V.M., C.N., P. Winstanley, P. Warn, N.P., G.P., R.S.); and the Nuffield Department of Clinical Medicine (K.M., D.F., P. Winstanley, P. Warn, G.P., R.S.) and the Department of Paediatrics (C.N.), Oxford University, John Radcliffe Hospital, Headington, Oxford, United Kingdom.
Address reprint requests to Dr. marsh at the KEMRI Unit, P.O. Box 230, Kilifi, Kenya.
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