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malaria is responsible for an estimated 1 million  under five  deaths annually , with about 500  700 children dying daily in nigeria from malaria infection . in jos ,
malaria ranks among the top three causes of mortality among children visiting the emergency room of a tertiary hospital .
prior reports have suggested that neonatal malaria is a rare clinical condition even in endemic regions , because of some reported  protective  factors .
contrary to such assertions , more recent review indicate that the incidence of neonatal malaria is on the rise in nigeria .
a well documented risk factor for developing neonatal and congenital malaria is maternal 3 trimester malaria infection .
ibhanesebhor reported that presentation of neonatal malaria is not different from that of other neonatal infectious diseases , thus increasing the rate of under or miss diagnosis , neonatal morbidity and mortality .
the diagnosis of neonatal malaria is also difficult because of inconsistencies in the results reported from available test samples .
studies suggest considering a diagnosis of neonatal malaria in critically ill neonates with fever , unresponsive to antibiotics [ 7 , 9 ] , because malarial complications like convulsion , seen in older children have also been documented in neonates .
this study aimed at describing and discussing the clinical presentations and outcome of 24 cases of neonatal malaria seen at our facility , and to emphasize the high mortality still associated with this infection .
this is a prospective descriptive study , done at the special care baby unit ( scbu ) of the jos university teaching hospital ( juth ) , which is a 500 bed government owned tertiary hospital in nigeria . for the purpose of this study
, we adopted the following definitions ; normal weight infant is birth weight of 2500 g , low birth weight ( lbw ) is < 2500 g and preterm is a gestational age ( ga ) of < 37 completed weeks .
all consecutive infants seen within a 6 months period ( january to june ) at the scbu were considered for recruitment .
parental informed consent and juth 's ethical committee approval was obtained prior to enrolling neonates and administering questionnaires .
clinical information collected include ; use of intermittent preventive treatment ( ipt ) of malaria at least twice in the index pregnancy , maternal hiv status , and birth history until admission ; applicable information was verified from the prenatal clinic records .
films were fixed and stained using 4% giemsa stain for thirty minutes and was washed off in tap water .
parasite density was determined by counting parasites against 400 leucocytes in a thick film and multiplying by 6000 ( the average white blood cell count/l ) .
blood samples were drawn for full blood count , serum electrolytes and urea , microscopy and culture to exclude or confirm the presence of other co - morbidities .
data was analyzed using spss v18 for windows and results presented in tables using means ( sd ) , ranges , frequencies and percentages .
thirty one neonates were inborn , 10 were admitted via the emergency room ( out - born ) , 24 of 41 i.e. 58.5% of neonates had malaria , 12(50% ) of whom were males .
twenty - three ( 95.8% ) neonates had a negative maternal hiv status , 2(8.3% ) had a  positive  history of maternal malaria infection in pregnancy with majority or 70.8% having congenital malaria which is neonatal malaria diagnosed in the first 7 days of life ( table 1 ) .
mean age at presentation was 6.174.98 days , average ga , birth weight , pre - treatment parasite count and duration of hospital stay were 36.883.710 weeks , 2.510.65 kg , 480320/ml and 3.711.94 days respectively ( table 2 ) . 
 
pregnancy history , demographic characteristics and malaria types mean ( sd ) , minimum and maximum values of some clinical characteristics of the neonates sd : standard deviation all neonates presented with fever , with the next most common symptom being inability to suck ( 45.8% ) followed by anemia ( 37.5% ) .
other co - morbidities were jaundice 6(25.0% ) , respiratory difficulty 6(25.0% ) , features of sepsis 8(33.3% ) , convulsion 5(20.8% ) , disseminated intravascular coagulation , diarrhea , vomiting , cyanosis , birth asphyxia , and myelomeningocoele ( table 3 ) .
all neonates with malaria responded to treatment as evidenced by an average post - treatment parasite count ( ptpc ) of almost zero ( not shown ) , although 1 neonate had a ptpc of 2/ml .
amodiaquine was the most commonly used anti - malaria therapy ( it is the standard of care for neonatal malaria in our center ) with 83.0% responding to it , mortality among our patients was 25.0% ( table 4 ) .
there was diagnosed case of maternal 3 trimester malaria infection and all mothers reported using mosquito nets at home during the index pregnancy . 
 
distribution of clinical presentation and co - morbid medical conditions among neonates anti - malaria drug used for treatment and neonatal outcome
this study , although with a small sample size , shows that neonatal malaria is more common than earlier report suggested .
it is not clear why this is the case , but one hypothesis might be increasing resistance of plasmodium falciparum to sulphadoxine / pyrimethamine ( fansidar ) , the chemoprophylaxis commonly used for ipt in many centers in nigeria .
all neonates had fever at presentation , with others having in addition , anemia , pallor , feeding difficulty , jaundice , respiratory difficulty , convulsion , bleeding , diarrhea , vomiting and cyanosis .
all neonates in our study were exclusively breastfed , which does not support prior reports that breastfeeding confers protection from neonatal malaria .
the ipt approach is a very key component of effort to control malaria in pregnancy and vertical transmission that results in congenital and neonatal malaria .
our data showed that there was a 75.0% uptake of ipt among mothers ; but with 58.5% of neonates having malaria , and
70.8% having congenital malaria , there may be a problem with the prophylaxis program or its implementation .
our study firmly support prior report of malaria being a cause of premature birth , since 7(29.2% ) neonates were born pre - term .
we have also shown that the clinical presentation of neonatal malaria can vary widely , and support similar findings in another study from nigeria .
majority of neonates responded to amodiaquine , with four neonates needing an alternate form of anti - malarial therapy .
these 4 neonates later had culture proven sepsis in addition to a positive malaria parasite test .
the percentage of neonates diagnosed with neonatal malaria in our study was surprisingly high , given that the study was done during the off - peak season for malaria transmission in jos .
in addition , none of the cases of neonatal malaria were transfusion related , because none of the patients had blood transfusion .
it could be reasoned that the problem in our environment might be resistance to chemoprophylaxis and/or non - compliance .
whatever the cause(s ) , the incidence of neonatal malaria seems to be making a comeback or getting worse in nigeria .
the high percentage of neonates with neonatal malaria in our study is a small testament to this .
neonatal malaria is one more child health problem to deal with amidst a myriad of other causes of poor neonatal outcome .
improvement in the ipt program , routine blood screening and early intervention could reduce neonatal mortality .
objectiveneonatal malaria is a serious cause of morbidity and mortality in sub - saharan africa . 
 diagnosis of neonatal malaria is difficult because of the similarity in clinical presentation with other neonatal infections . 
 this study aim to highlight the clinical presentations and high mortality still associated with neonatal malaria.methodstwenty four out of 41 neonates seen during a 6 months period were studied . 
 gestational age , age at presentation , birth weight and other clinical symptoms were documented . 
 questionnaires were used to collect pertinent pregnancy and perinatal history from the mothers . 
 data was analyzed using spss v18 and results expressed in tables using means , frequencies and percentages.findingsall 24 neonates , 50% of whom were males , had a positive smear for malaria parasite . 
 29.2% were preterm , 17(70.8% ) had congenital malaria , 18(75.0% ) mothers used intermittent preventive treatment ( ipt ) of malaria prophylaxis in the index pregnancy and 1(4.2% ) mother had hiv in pregnancy . 
 fever was the principal presenting symptom and 83.0% responded to treatment with amodiaquine.conclusionneonatal malaria is still an important cause of mortality , a more effective malaria prophylaxis program and routine malaria parasite screening for neonates is recommended .