Congenital Malaria in Non-Endemic Settings: A Literature Review and Update on Diagnosis and Management.

BACKGROUND: Congenital malaria (CM) is increasingly recognized as a potentially serious, though usually delayed complication of maternal malaria. Typically, neonates are asymptomatic at birth, and if symptoms appear, they are in the first few weeks after birth. Diagnosis in both endemic and non-endemic settings remains challenging, as in non-endemic settings it is rare and therefore often a missed diagnosis initially, and in endemic settings it is often mild and clears spontaneously, so is not diagnosed. A clinical case of CM in the UK with delayed diagnosis in 2023 highlighted the importance of and lack of clear guidance for this under-recognized but significant disease. METHODS: We performed a scoping literature review via PubMed and Embase of all English language articles published between June 2013 and June 2023 containing the MESH terms 'Congenital' AND 'malaria' and 'neonatal' AND 'malaria'. We consulted the international tropical community managing malaria in the non-endemic setting to share any guidance. The patient's mother and hospital clinicians consented and shared details of the UK case from 2023. RESULTS: Literature review revealed 26 papers published on CM between 2013 and 2023. Key themes were extracted to inform conclusions. CONCLUSIONS: We propose the definition of CM as 'A peripheral blood smear of neonatal blood with asexual forms of Plasmodium spp. OR DNA of Plasmodium spp. detected; presenting in an infant <28 days old, irrespective of clinical symptoms/travel history OR an infant <1 year old with no history of travel to a malaria endemic area' and outline a novel algorithm for follow-up of pregnant women with malaria and investigation of neonates for CM. This algorithm highlights the importance of using polymerase chain reaction to investigate neonates, who may have very low parasitaemia, below the limit of detection of light microscopy.