Burden, Clinical Spectrum, Predictors of Severe Anaemia, and In-hospital Outcomes ofPediatric Severe Malaria: A Retrospective study from a Tertiary Hospital Cohort
Keywords:
Clinical Spectrum, Outcome, Paediatric Severe Malaria, Severe Malaria Anaemia, Predictors, Tertiary Hospital CohortAbstract
Severe malaria (SM) remains a leading cause of childhood morbidity and mortality in Nigeria, with severe malarial anaemia (SMA) driving transfusion demand and poor outcomes. Recent contemporary hospital-based data from Southwestern Nigeria are limited. This study described the burden, clinical spectrum, predictors of severe anaemia, and in-hospital outcomes of paediatric SM at a tertiary hospital in Southwest Nigeria. We retrospectively reviewed case records of children aged 1 month–14 years admitted with SM to Olabisi Onabanjo University Teaching Hospital, between January–December 2023. Demographic, clinical, laboratory, treatment, and outcome data were extracted while predictors of SMA were assessed using logistic regression. Of 699 paediatric admissions, 65 (9.3%) were confirmed SM cases; 55.4% were <5 years, and 72.3% males. Nearly two-thirds were underweight, and 89% belonged to low-middle socioeconomic classes. The most frequent WHO severity criteria were multiple convulsions (35.4%), prostration (33.8%), cerebral malaria (16.9%), and SMA (16.9%). Eleven children developed SMA; with pallor as a presenting complaint being the strongest independent predictor (adjusted OR 8.94, 95% CI 1.60–49.8, p=0.012). All patients received intravenous artesunate, and 87.5% received empiric antibiotics. Median hospital stay was 6 days (IQR 3.5–9.5). Overall survival was 96.9%, with 2 deaths (3.1%). However, 18.5% were discharged against medical advice. Conclusively, severe malaria accounted for nearly one-tenth of paediatric admissions, predominantly affecting under- fives and socioeconomically disadvantaged children. Pallor strongly predicted SMA, underscoring its bedside triage value. High survival with artesunate contrasts with high discharged-against-medical-advice rates, highlighting the need for caregiver support and financial protection.
References
1. World Health Organization. Malaria: Fact sheet. 11 Dec 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/malaria. [Accessed 2026 Mar 12].
2. World Health Organization. World malaria report 2024. Geneva: WHO; 2024. ISBN: 978-92-4-010444-0. Available from: https://www.who.int/publications/i/item/9789240104440. [Accessed 2026 Mar 12].
3. White NJ, Pukrittayakamee S, Hien TT, Faiz MA, Mokuolu OA, Dondorp AM. Severe malaria. Lancet (Clin Rev in PMC). 2022;399(10332):155–68.
4. World Health Organization. WHO guidelines for malaria (version: 30 November 2024). Geneva: WHO; 2024. Available from: https://iris.who.int/handle/10665/379635 [Accessed 2026 Mar 12].
5. White NJ. Anaemia and malaria. Malar J.2018;17:371.
6. Edelu BO, Igbokwe OO, Ikefuna AN, Emodi IJ, Adimora GN. Severe falciparum malaria in children in Enugu, South-East Nigeria. Niger J Clin Pract. 2018;21(10):1349–1355.
7. Ibrahim OR, Issa A, Alao MA, Suleiman BM. Outcomes and factors associated with severe malaria-related anaemia in paediatric patients in northern Nigeria. Ghana Med J. 2024 Dec;58(4):262-268. doi: 10.4314/gmj.v58i4.3.
8. Lugga AS, Ibrahim OR, Ibrahim N, Ajide OB, Abubakar AA, Aladesua O, et al. Predictors of poor outcome in children with severe malaria at a tertiary health facility in Northern Nigeria. Sahel Medical Journal 25(4):p 109-115, Oct–Dec 2022. doi: 10.4103/smj.smj_90_20
9. Oyedeji GA. Socio-economic and cultural background of hospitalized children in Ilesha. Niger J Paediatr. 1985;12(4):111–117.
10. World Health Organization. Global Health Observatory indicator metadata registry: Underweight among children under 5 years of age (weight-for-age <−2 SD). Geneva: WHO; 2024.
11. Ibrahim OR, Alao MA, Issa A, Mohammed B, Suleiman BM, Mokuolu OA. Trends of incidence and outcomes of childhood severe malaria in a tertiary health facility in Nigeria: A 4-year cross-sectional study from 2019 to 2022. J Pediatr Infect Dis. 2024;19(4):217-226. doi:10.1055/s-0044-1788059
12. Jalo I, Warnow IE, Aliu R, Shina HK. Burden, clinical manifestation and outcome of severe malaria in children at a tertiary hospital in Northeast Nigeria. Int J ContempPediatr. 2020 Aug 22;7(8):1659-64.
13. National Malaria Elimination Programme (NMEP), National Population Commission (NPC), National Bureau of Statistics (NBS), and ICF. Nigeria Malaria Indicator Survey 2021 Final Report. Abuja, Nigeria: NMEP, NPC, and ICF; 2022. Available from: https://dhsprogram.com/pubs/pdf/MIS41/MIS41.pdf [Accessed 2026 Mar 12].
14. Sa'idu HI, Shiaka GP, Balogun JB. Prevalence and pattern of severe malaria among children in two general hospitals, Jigawa State-Nigeria. FJS 2021 Jul 16;5(2):511-8.
15. Nwaneli EI, Eguonu I, Ebenebe JC, Osuorah CDI, Ofiaeli OC, Nri-Ezedi CA. Malaria prevalence and its sociodemographic determinants in febrile children: a hospital-based study in a developing community in South-East Nigeria. J Prev Med Hyg. 2020 Jul 4;61(2):E173-E180. doi: 10.15167/2421-4248/jpmh2020.61.2.1350.
16. Degarege A, Fennie K, Degarege D, Chennupati S, Madhivanan P. Improving socioeconomic status may reduce the burden of malaria in sub–Saharan Africa: A systematic review and meta-analysis. PLoS One. 2019 Jan 24;14(1):e0211205. doi: 10.1371/journal.pone.0211205.
17. Asifat OA, Adenusi A, Adebile TV, Aderinto N, Azu E, Ivey-Waters A, et al. Relationship between unimproved household sanitation facilities and malaria infection among under-five children in Nigeria: insights from Malaria Indicator Survey 2021. Malar J. 2025 Mar 27;24(1):103. doi: 10.1186/s12936-025-05340-7.
18. Bouyou-Akotet MK, Dzeing-Ella A, Kendjo E, Etoughe D, Ngoungou EB, Planche T, et al. Impact of Plasmodium falciparum infection on the frequency of moderate to severe anaemia in children below 10 years of age in Gabon. Malar Journal. 2009 Jul 20;8(1):166.
19. Ocen E, Opito R. Severe malaria burden, clinical spectrum and outcomes at Apac district hospital, Uganda: a retrospective study of routine health facility-based data. Malar J.2023;22:313.
20. Namayanja C, Paasi G, Alunyo JP, Amorut D, Okalebo CB, Okiror W, et al. Epidemiology, clinical spectrum, and outcomes of severe malaria in Eastern Uganda: a prospective study. Malar J. 2025;24:37. doi:10.1186/s12936-024-05221-5.
21. Foko LPK, Narang G, Tamang S, Hawadak J, Jakhan J, Sharma A, et al. The spectrum of clinical biomarkers in severe malaria and new avenues for exploration. Virulence. 2022;13(1):634–53. doi:10.1080/21505594.2022.2056966
22. Weber MW, Kellingray SD, Palmer A, Jaffar S, Mulholland EK, Greenwood BM. Pallor as a clinical sign of severe anaemia in children: an investigation in the Gambia. Bull World Health Organ. 1997;75 Suppl 1(Suppl 1):113-8.
23. Novelli EM, Hittner JB, Davenport GC, Ouma C, Were T, Obaro S, et al. Clinical predictors of severe malarial anaemia in a holoendemic Plasmodium falciparum transmission area. Br J Haematol. 2010 Jun;149(5):711-21. doi: 10.1111/j.1365-2141.2010.08147.x.
24. Ajetunmobi WA, Orimadegun AE, Brown BJ, Afolabi NK, Olabiyi FA, Anetor JI, et al. Haemoglobinuria among children with severe malaria attending tertiary care in Ibadan, Nigeria. Malar J. 2012 Oct 5;11:336. doi: 10.1186/1475-2875-11-336.
25. Conroy AL, Hawkes MT, Leligdowicz A, Mufumba I, Starr MC, Zhong K, et al. Blackwater fever and acute kidney injury in children hospitalized with an acute febrile illness: pathophysiology and prognostic significance. BMC Med. 2022;20(1):221. doi:10.1186/s12916-022-02410-4.
26. Olupot-Olupot P, Nteziyaremye J, Agaba B, Ikiror J, Acom L, Engoru C, et al. Azithromycin in severe malaria bacterial co-infection in African children: current management recommendations and trial rationale. Wellcome Open Res. 2021;6:161.
27. Kniss JM, Kibaba G, Baguma E, Bhattarai Chhetri S, Hendren C, Ntaro M, et al. Quality of care and post-discharge morbidity among children diagnosed with severe malaria in rural Uganda: a prospective cohort study. PLOS Glob Public Health. 2024;4(10):e0003794. doi:10.1371/journal.pgph.0003794.
28. Babatola AO, Olatunya OS, Ogundare EO, Ajibola AE, Ojo TO, Oluwayemi IO, et al. Pediatric discharges against medical advice: a review of cases in Ado-Ekiti, Nigeria. J Compr Ped. 2021 Jan 1;12(3):e107577.
