Olayinka Rasheed IbrahimAmudalat IssaAisha Funmilayo LawalMosunmola Rafiat FolorunshoMariam AbdulbakiMohammed Baba AbdulkadirOlugbenga Ayodeji Mokuolu2025-04-292025-04-292025-04-18https://doi.org/10.1186/s12936-025-05317-6https://dspace.ughe.org/handle/123456789/531Background The use of pre-referral injectable artesunate is among the strategies adopted to improve the outcome of childhood severe malaria in Nigeria. However, the extent of its implementation and impact on outcomes remain unknown. This study assessed the pre-referral treatment with injectable artesunate for severe malaria, associated factors, and hospitalisation outcomes (discharge or death) among a cohort of children managed at a secondary health facility in Nigeria. Methods This cross-sectional study included children diagnosed with severe malaria admitted to a secondary health facility in Nigeria. Data on pre-referral treatment with injectable artesunate and other medications, demographics, clinical features, and outcomes among children were prospectively gathered and analysed them using SPSS. Results Of the 137 children recruited, 7(6.3%) received pre-referral injectable artesunate; other medications received included antipyretics (53;47.3%), antibiotics (16;14.3%), artemisinin-based combination therapy (14;12.5%), and supplements (11;9.8%). Pre-referral injectable artesunate treatment was not associated with age, sex, and socioeconomic status (p > 0.05), and most of the clinical features except impaired consciousness with an adjusted odds ratio of 17.876 (95% CI 2.050 to 155.883). Of the 137 children, two deaths occurred, with a crude mortality rate of 1.5% (95% CI 0.04–5.2%). Pre-referral injectable artesunate treatment was not associated with hospitalisation durations and outcomes (death or discharge). Conclusion This study showed a very low uptake of pre-referral injectable artesunate among children with severe malaria, and the presence of impaired consciousness increased the odds of a child receiving injectable artesunate. In addition, most children with severe malaria had received pre-hospitalisation medications that were mostly inappropriate.enPre-referral injectable artesunateSevere malariaChildrenOutcomesjournal-article