Malaria in Children: Testing, Treatment and Fevers That Come Back

What Malaria Looks Like in Children

Malaria is an infection of the blood caused by a parasite called Plasmodium. It is passed on by the bite of an infected Anopheles mosquito, which bites mostly between dusk and dawn. In Nigeria almost all malaria is caused by Plasmodium falciparum, the type most likely to become severe. Symptoms usually start one to four weeks after the bite.

The main sign is fever. In children it is often the only clear sign, and it does not have to follow a pattern of chills and sweating every other day, as many adults expect. Other signs that often come with it:

• Shivering, then feeling hot and sweaty
• Headache, body aches, tiredness
• Poor appetite, tummy ache, vomiting or loose stools
• In babies and toddlers: fussiness, crying more, refusing feeds, sleeping more than usual
• Pale palms, lips or inner eyelids, from anaemia (a low blood count), especially after repeated attacks

Pneumonia, urine infections, typhoid, meningitis and ordinary viral infections cause the same signs, so no one can tell malaria from the symptoms alone. That is why the test matters.

Children under five, pregnant women, children with sickle cell disease, and children who grew up outside a malaria area (for example, visiting family from abroad) are the most likely to become seriously ill. Babies under six months get malaria less often but can still get it.

When to Come In

Severe malaria can develop within a day of the first fever. If your child has any one of the "come in now" signs, come to Limi Children's Hospital now, day or night. If you cannot get here quickly, go to the nearest emergency department. Have someone else drive if you can, so you can watch your child, and call 0813 408 5400 on the way so the team can prepare.

Not sure whether a fever needs to be seen? Our fever checker walks you through the signs for your child's age.

Test Before You Treat

For more than a decade the World Health Organization, and Nigeria's National Malaria Elimination Programme, have advised that every suspected case of malaria is confirmed with a test before treatment. There are two tests, and both are reliable when done properly:

• Malaria rapid diagnostic test (RDT). A drop of blood from a finger-prick goes on a small plastic cassette. Lines appear in about 15 to 20 minutes. RDTs are used in clinics, pharmacies and primary health centres across Nigeria.
• Blood film (microscopy). A trained laboratory scientist looks for parasites in a stained drop of blood under a microscope. It can also show how many parasites there are, which helps the doctor judge how ill the child is and whether treatment is working.

A negative test means the doctor should look for the real cause of the fever. If the child stays unwell, the test may be repeated, because very early in an infection parasites can be missed.

Treatment and Finishing the Course

Uncomplicated malaria (malaria without any danger signs) is treated with tablets or a syrup taken by mouth. The recommended medicines in Nigeria are artemisinin combination therapies (ACTs), such as artemether-lumefantrine or artesunate-amodiaquine. Each contains two medicines that attack the parasite in different ways, which clears the infection and makes resistance less likely.

• Use the dose prescribed for your child, which is worked out from their weight or age. Measure syrups with the syringe or spoon that comes with the medicine.
• Give every dose, for the full course — usually three days — even if your child seems well after the first day. Stopping early is one of the main reasons malaria comes back.
• Some ACTs work better when taken with food or milk. Ask the pharmacist or doctor how to give the one your child has.
• If your child vomits soon after a dose, ask the doctor or pharmacist whether to repeat it. Do not guess. If they keep vomiting, they need to be seen, because they may need treatment in hospital.
• Buy medicines from a registered pharmacy. Check the packet has a NAFDAC number and is not out of date. Fake and poor-quality antimalarials are a real problem in West Africa.

Severe malaria is treated in hospital, usually with artesunate injections into a vein or muscle, then a full ACT course by mouth once the child can swallow. Children may also need a blood transfusion for severe anaemia, fluids, glucose for low blood sugar, and treatment for convulsions.

Medicines That Should Not Be Used for Malaria

• Chloroquine. Nigeria stopped using it for malaria in 2005 because the parasite no longer responds to it reliably.
• Sulfadoxine-pyrimethamine (SP) on its own. It is used for prevention in pregnancy and in seasonal programmes, not to treat a sick child.
• Tablets with only one artemisinin medicine in them (artesunate or artemether alone). Used alone, they allow the parasite to become resistant.
• Injections given at a chemist or at home. Injections are for severe malaria in hospital, where the child can be watched. At home they can cause abscesses, nerve damage and dangerous delays.

"We Treated Malaria but the Fever Came Back"

There are five common explanations, and most of them are not "stronger malaria".

1. It may never have been malaria. If treatment started without a test, or after a test that was not read properly, the fever may have come from something else all along: a viral infection, pneumonia, a urine infection, an ear infection, tonsillitis, or, less often, typhoid or meningitis. Urine infections are easy to miss in young children because they often cause fever and nothing else.
2. It may have been called "typhoid" too. Many children are told they have "malaria and typhoid" after a Widal test, which is not reliable. They may take two courses of medicine that do not treat the real cause. See our guide to typhoid.
3. The course was not finished. Stopping when the fever settles leaves parasites in the blood, which can multiply again within two to four weeks.
4. The medicine did not work as it should. A fake or poor-quality product, a dose that was too small for the child's weight, vomiting soon after doses, or an ACT given without food when it needed food, can all leave the infection partly treated.
5. It is a new infection. In a high-malaria area a child can be bitten and infected again within weeks, especially without a net.

What to do: see a doctor rather than starting another course at home. Tell them which medicine your child had, how much, for how many days, and whether a test was done. Bring the packets. The doctor examines your child and checks a blood film, a full blood count and a urine test, with other tests as needed. A rapid test can stay positive for several weeks after successful treatment, so a microscope test is more useful in this situation.

Caring for Your Child at Home

• Offer fluids often: breast milk, water, pap, soups, oral rehydration solution (ORS) if there is vomiting or diarrhoea. Our dehydration checker shows the signs to watch.
• Paracetamol can ease the discomfort of fever, using the dose on the pack for your child's age, measured with the syringe or spoon that comes with it. It does not treat malaria.
• Dress your child lightly and keep the room airy. Do not sponge with cold water, and never use alcohol or kerosene rubs on the skin.
• Keep them under the net while they are ill, so mosquitoes do not pass the infection on to others in the house.
• Check them at night: breathing, colour, and how easy they are to wake.

Preventing Malaria

Insecticide-Treated Nets

A long-lasting insecticide-treated net (LLIN) is one of the most effective protections a family has. It blocks mosquitoes and the insecticide kills the ones that land on it. Nets are distributed free in national campaigns and at antenatal and immunisation clinics.

• Every night, every season. Malaria is carried all year in Abuja, not only in the rainy season.
• Tuck it in all round, under the mattress or mat, so there are no gaps. Put children to bed under the net early, as mosquitoes start biting at dusk.
• Check for holes and mend them with a needle and thread or a patch.
• Wash gently and not too often, with plain soap in cool water, and dry it in the shade. Sun and strong detergent weaken the insecticide.
• Air a new net in the shade for a day before first use.
• Babies and pregnant women first if there are not enough nets for everyone.

Around the Home

• Fit mesh screens on windows and doors, and close them from evening.
• Empty or cover anything that holds still water: old tyres, buckets, tins, flower pots, blocked gutters. Fill puddles near the house. Mosquitoes lay eggs in still water.
• Insect repellents made for children can help in the evening outdoors. Follow the age advice and instructions on the label, and do not put them on babies' hands, which go in the mouth.

Seasonal Malaria Chemoprevention

In many northern states, health workers give children under five a course of malaria medicine once a month during the rainy season, when malaria is at its peak. This is called seasonal malaria chemoprevention (SMC). It is run in selected states, not everywhere. Ask your primary health centre whether it is offered where you live; if it is, take part: it prevents a large share of malaria episodes in young children.

The Malaria Vaccine

Two malaria vaccines are now recommended by the World Health Organization for children in areas with moderate to high malaria: RTS,S (2021) and R21 (2023). They are given as a series of doses starting from around five months of age. Together with nets, they reduce malaria and severe malaria in young children, but they do not prevent every case — so nets and testing are still needed.

Nigeria began introducing the malaria vaccine in some states from late 2024, with further states planned. Availability depends on where you live and changes over time. Ask at your primary health centre or at your child's immunisation visit whether it is offered in your area. Our vaccine schedule tool shows your child's routine vaccines.

Sickle Cell, Travel and Malaria

Children with Sickle Cell Disease

Malaria is one of the most common triggers of a sickle cell crisis and of severe anaemia. Children with sickle cell disease in Nigeria are usually advised to take a malaria prevention medicine regularly, as prescribed by their haematology team, as well as sleeping under a net. A temperature of 38 °C or more in a child with sickle cell disease means come to Limi Children's Hospital now, or the nearest emergency department if you cannot get here quickly. See our guide to sickle cell disease.

Sickle cell trait (AS) gives some protection against severe malaria. Sickle cell disease (SS, SC) does not; it makes malaria more dangerous.

Travel

Children who live outside a malaria area, including families living abroad and visiting home, have no protection and can become very ill quickly. See a doctor four to six weeks before the trip about preventive medicine. After returning, any fever in the following months needs a malaria test.

Myths and What Is True

Questions Parents Ask