Severe malaria: recognise and pre-referral care
WHO malaria guidelines · reviewed October 2026 · gpreasoning.uk/global
Reasoning GP
Global Primary Care
Who / when
- Any child or adult with fever (or recent fever) in a malaria area who has a danger sign or any sign below.
- Do not wait for a test result: if severe malaria is possible, give pre-referral treatment now. Do an RDT if it takes no time.
- Pregnant women in any trimester and infants are treated the same way.
Red flags: refer now
Bedside signs of severe malaria (any one is enough):
- Impaired consciousness or coma; unusually sleepy or confused.
- Prostration: cannot sit, stand or walk without help.
- More than two convulsions in 24 hours, or convulsing now.
- Deep, laboured or fast breathing (acidosis or fluid in the lungs).
- Severe pallor; jaundice; bleeding from gums, nose or puncture sites.
- Shock: cold hands, capillary refill 3 seconds or more, weak pulse.
- Little or no urine; dark (cola-coloured) urine.
- Vomiting everything or unable to drink or breastfeed.
Treat and refer: both, nowPre-referral treatment saves lives only if the patient then reaches full treatment. Arrange transport while you treat.
Assess
- Airway, breathing, circulation. Turn an unconscious or convulsing patient on the side.
- Check blood glucose if you can. Below 2.2 mmol/L (40 mg/dL) is severe hypoglycaemia; if you cannot test, treat as if low.
- Weigh the patient (or estimate) for dosing.
- Ask about pregnancy, recent antimalarials and how long the illness has lasted.
- Look for other serious causes: stiff neck (meningitis), severe pneumonia, severe dehydration.
Classify
| Finding | Classify as | Action |
|---|
| Any sign of severity, with fever in a malaria area (test positive, or not yet tested) | Severe malaria (very severe febrile disease in IMCI) | Pre-referral artesunate, antibiotic if meningitis possible, prevent low sugar, refer urgently |
| Positive test, no sign of severity, keeps tablets down | Uncomplicated malaria | Oral ACT for 3 days (uncomplicated malaria protocol) |
| Cannot keep oral ACT down, but no other sign of severity | Treat as severe | Pre-referral artesunate and refer |
Treat
1. One dose of artesunate before transfer
- Intramuscular artesunate (first choice where injections are possible): 3 mg/kg if under 20 kg; 2.4 mg/kg if 20 kg or more. Prepare fresh; inject into the front of the thigh. Follow the product leaflet for dilution.
- No IM artesunate: IM artemether; if that is not available either, IM quinine.
- Rectal artesunate where no injection can be given: children under 6 years only, single dose 10 mg/kg. If it comes out within 30 minutes, insert another and hold the buttocks together for 10 minutes. Do not use in older children or adults.
2. Supportive care
- Prevent low blood sugar: breastfeed, or give 30 to 50 mL of milk or sugar water by mouth or nasogastric tube (sugar water: 4 level teaspoons of sugar in 200 mL of clean water).
- Convulsing: diazepam 0.5 mg/kg rectally (child); repeat once after 10 minutes if still fitting. Give oxygen if available.
- Possible meningitis or very severe febrile disease: first dose of an appropriate antibiotic per your IMCI chart.
- High fever: paracetamol. Keep a child warm but not overwrapped.
Follow-up
- Write a referral note: time and dose of artesunate, glucose, weight, convulsions, other medicines.
- In hospital, artesunate is continued IV or IM for at least 24 hours and until oral medicine is tolerated, then a full 3-day ACT.
- Referral truly impossible: keep giving artesunate (IM again after 12 hours then daily, or rectal every 24 hours) until the patient can take oral medicine, then a full 3-day ACT. Seek senior advice.
Counsel
- Explain that this is an emergency and that the first dose is only a start.
- Keep breastfeeding or giving sips on the way if the patient can swallow.
- Lay an unconscious patient on the side during the journey.
Your child has a very dangerous kind of malaria. I have given the first medicine, but it must be finished in hospital today. Go now; keep her on her side and keep feeding her if she can swallow.
When to refer
- Every patient with a sign of severe malaria, after pre-referral artesunate, to a facility that can give IV or IM artesunate.
- Any patient who cannot swallow or keep down the oral ACT.
- Pregnant woman with any danger sign.
- Send with a carer, the referral note, and ORS or milk for the journey.
Sources
World Health Organization. WHO guidelines for malaria (10 September 2026 version). 2026. World Health Organization. Pre-referral treatment with rectal artesunate of children with suspected severe malaria: a field guide. 2023. World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014.Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.