Synopsis
Assess a febrile child after international travel without missing falciparum malaria, severe imported infection or a high-consequence exposure, while also recognising that common childhood infections remain common.
- Ask about fever after travel before anchoring on a familiar diagnosis: exact countries and regions, dates, transit, rural or urban stay and reason for travel change the differential.
- UKHSA advises considering malaria in every ill traveller returning from the tropics during the previous year, especially the previous 3 months; prophylaxis does not exclude it.
- Reference-standard testing is urgent thick and thin blood-film microscopy. Send EDTA venous blood labelled ‘Urgent, suspected malaria’ so it reaches the laboratory within 1 hour.
- Do not wait for a fever spike. Falciparum fever is often irregular, and delay allows parasitaemia and organ dysfunction to progress over hours.
- A rapid diagnostic test is an adjunct, not a replacement for microscopy. One negative film or rapid test does not exclude malaria.
- If suspicion persists, examine blood films daily for 3 days while investigating other causes; seek tropical or infection advice when all are negative but malaria remains plausible.
- Assess severity at the same time as diagnosis: consciousness, seizures, ability to sit or stand, respiratory effort, perfusion, urine output, glucose, acid-base state, haemoglobin and parasitaemia.
- Treat severe malaria immediately with intravenous artesunate under specialist guidance; do not delay for final species identification, reference-laboratory confirmation or a second film.
- Take blood cultures and assess bacterial sepsis because malaria can coexist with bacterial infection and an apparent travel diagnosis does not remove ordinary paediatric risk.
- Enteric fever, dengue, rickettsial disease, leptospirosis, viral hepatitis and common respiratory, urinary and gastrointestinal infections are important alternatives guided by incubation and exposure.
- Before routine sampling, check whether travel and exposure meet the current national viral-haemorrhagic-fever or other high-consequence-infection pathway and involve infection control and health protection.
- Malaria is notifiable. Confirm treatment, species, clearance plan, delayed haemolysis follow-up after artesunate and prevention advice with an experienced infection or tropical team.
Key red flags
Any unwell child who has returned from a malaria-endemic area within the previous year needs urgent malaria consideration, particularly when travel was within 3 months.
Altered consciousness, repeated seizure, inability to sit or stand, respiratory distress, acidosis, shock or oliguria suggests severe malaria or another critical infection.
Check bedside glucose immediately because malaria, sepsis, poor intake and quinine treatment can each cause dangerous hypoglycaemia.
Severe pallor, jaundice, haemoglobinuria, bleeding, hepatosplenomegaly or rapidly falling haemoglobin or platelets needs urgent senior and haematology-informed care.
Fever plus relevant travel, healthcare, animal, funeral or sick-contact exposure may meet a viral-haemorrhagic-fever risk definition; use the current national pathway before routine handling.
An infant, immunocompromised child, child with sickle cell disease or child without a functioning spleen can deteriorate rapidly and warrants a lower admission threshold.
A petechial or purpuric rash, meningism, severe abdominal pain, persistent vomiting or clinical shock must trigger parallel assessment for meningococcal disease, sepsis and surgical causes.
Investigation priorities
Detect parasites, identify species, quantify parasitaemia and monitor response.
Management branches
A child is unwell after travel to a malaria-risk area within the previous year.
- Assess ABCDE, consciousness, perfusion and bedside glucose, obtain IV or IO access when indicated and call senior paediatric and infection support.
- Send an EDTA venous sample marked ‘Urgent, suspected malaria’ for immediate thick and thin films plus an adjunct rapid test, without waiting for a fever spike.
- Take cultures and severity bloods, treat shock, hypoglycaemia, seizures and suspected bacterial sepsis, and decide monitored or critical-care placement from physiology.