From 1983 to 1992 a total of 64 children were admitted with a diagnosis of malaria to Children's National Medical Center in Washington, DC. Specific etiology is available in 59 of 64. Of these 59 cases 52 (88%) were caused byPlasmodium falciparum. Fifty-one of 52 infections were acquired in Africa, 35 (67%) of these in traveling United States citizens. Eleven (21%) of 52 children were initially admitted to the Intensive Care Unit for iv quinidine or quinine therapy. Eight (73%) of these 11 patients compared with 12 (29%) of 41 general ward admissions had been misdiagnosed within 10 days before admission (P= 0.012). Five of 11 Intensive Care Unit patients underwent exchange transfusion. One child died and one was left with severe neurologic deficit. Malaria must be considered in the differential diagnosis for any febrile child who has traveled to or from a malarious area within the previous 12 months. Delayed diagnosis of pediatricPlasmodium falciparummalaria is associated with an increased severity of illness. Because of the frequency of international travel, United States physicians will need to be familiar with the presentation and management of importedP. falciparummalaria.