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Severe malaria in children: a proposal for clinical grading
Abstract
Background. Severe malaria (SM) mortality remains high (10 - 40%) despite treatment. Reports suggest that the World Health
Organization-defined SM of 2000 is not a homogeneous group.
Objective. To test the hypothesis that SM patients are heterogeneous, identify criteria that could be used for the grading of SM severity, and propose a method for clinically grading SM in children.
Method. A retrospective study of children aged 3 months to 12 years who fulfilled the WHO SM criteria and were seen at two
Nigerian hospitals during a specified period. The presenting clinical features (PCFs) and their calculated case fatality rates
(CFRs) were investigated to identify PCFs with the highest CFRs that could be separated from the rest and classified as major
PCFs. Major and minor PCFs were used to develop a three-grade system, with analysis of variance (ANOVA) to compare
grades.
Results. A total of 8 PCFs were identified in 155 children with SM; impaired consciousness, prostration, convulsions and
respiratory distress (in that order) had the highest CFRs (and were designated as major PCFs). The severity grading system
was developed using 4 major and 4 minor PCFs as follows: grade I SM – no major, and 1 - 4 minor PCFs; grade II and grade III
SM had 1 - 2 and 3 - 4 major PCFs respectively and 1 - 4 minor PCFs (p=0.05).
Conclusion. The proposed severity grading system requires validation by large prospective studies. It is suited for use at the
bedside and has the potential to be used in guidelines that are specific to various grades of disease severity and to reduce
unnecessary parenteral antimalarials and hospital admission.
Organization-defined SM of 2000 is not a homogeneous group.
Objective. To test the hypothesis that SM patients are heterogeneous, identify criteria that could be used for the grading of SM severity, and propose a method for clinically grading SM in children.
Method. A retrospective study of children aged 3 months to 12 years who fulfilled the WHO SM criteria and were seen at two
Nigerian hospitals during a specified period. The presenting clinical features (PCFs) and their calculated case fatality rates
(CFRs) were investigated to identify PCFs with the highest CFRs that could be separated from the rest and classified as major
PCFs. Major and minor PCFs were used to develop a three-grade system, with analysis of variance (ANOVA) to compare
grades.
Results. A total of 8 PCFs were identified in 155 children with SM; impaired consciousness, prostration, convulsions and
respiratory distress (in that order) had the highest CFRs (and were designated as major PCFs). The severity grading system
was developed using 4 major and 4 minor PCFs as follows: grade I SM – no major, and 1 - 4 minor PCFs; grade II and grade III
SM had 1 - 2 and 3 - 4 major PCFs respectively and 1 - 4 minor PCFs (p=0.05).
Conclusion. The proposed severity grading system requires validation by large prospective studies. It is suited for use at the
bedside and has the potential to be used in guidelines that are specific to various grades of disease severity and to reduce
unnecessary parenteral antimalarials and hospital admission.
