Clinical Manifestations and Predictors of Severe Malaria in Indian Children

Although the greatest morbidity and mortality attributable to malaria occurs among children in Africa, up to one third of the world's malaria burden is borne by non-African countries, where levels of endemicity are lower. Because there are few published criteria for managing life-threatening malaria in children in these countries, we conducted a study of major syndromes and predictors of death among critically ill Indian children to identify factors that could be used to improve the approach to their treatment. A prospective study was conducted at the pediatric ward of SCB Medical College in eastern India (Orissa). Baseline demographic data were collected on all of the patients with confirmed slide-positive falciparum malaria. Patients satisfying any 1 of the 2000 World Health Organization criteria for severe malaria were included in the analysis. Prevalence of and mortality as a result of major symptoms were calculated followed by multiple regression modeling to identify major predictors of death. Of 1682 confirmed cases of malaria during a 32-month period, 374 subjects met the World Health Organization criteria for severe malaria. The case fatality rate was 12% in this series. Multiple regression analysis identified respiratory distress, coma, multiple organ dysfunctions, and hyperparasitemia as major predictors of death. Anemia and jaundice did not emerge as important markers of mortality. Many patients presented with multiple major complications, and the mortality rate was consistently high when >1 major predictor was present in a patient. Clinical features in Indian children differed from those reported in most studies that involved an African population. Multiple organ dysfunctions emerged as an important presenting feature and a new predictor of death in childhood malaria.