Neonatal malaria management: a global survey of current practice

Background: Neonatal malaria remains underrecognised despite persistent high neonatal mortality in endemic regions. Evidence to guide diagnosis, classification, and treatment during the first 28 days of life is scarce, and neonatal-specific recommendations are largely absent. We conducted an international survey to describe current practices in neonatal malaria management and identify gaps in care. Methods: We performed an anonymous online survey of healthcare professionals involved in neonatal malaria care between April 2024 and July 2025. The questionnaire, available in English, French, Portuguese, and Spanish, was distributed through professional networks and targeted invitations, assessing screening practices, diagnostic approaches, disease definitions, treatment strategies, dosing approaches, and perceived challenges. Data were analysed descriptively. Results: A total of 173 respondents from malaria-endemic and non-endemic settings were included; most (91%) were based in sub-Saharan Africa. Most (61%) reported diagnosing neonatal malaria at least once yearly and 39% at least once a month. Most respondents (72%) did not distinguish between asymptomatic and symptomatic neonatal parasitaemia, and half (49%) did not differentiate between uncomplicated or severe malaria in neonates. The most used drugs were intravenous artesunate and artemether-lumefantrine for oral treatment. Among those using oral therapy, 71% reported using paediatric formulations, while 38% crushed tablets prior to administration. Crushed tablets were mostly mixed with water (90%), followed by expressed breast milk (23%) and infant formula (20%). In a case vignette of neonatal malaria, 87% of respondents recommended inpatient management with initial intravenous artesunate (92%) followed by oral artemisinin-based combination therapy (66%) with treatment duration ranging from 1 to 10 days and follow-up within 28 days (33%). Conclusions: This survey demonstrates consensus in antimalarial drug selection alongside significant practice variation in disease classification and dosing, highlighting the need for evidence-based guidelines and improved access to age-appropriate formulations for neonatal malaria management.