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To identify the risk factors for mortality after admission for suspected malaria in a pediatric emergency ward in Sierra Leone.Retrospective case-control.Pujehun Hospital Pediatric Ward in Pujehun, Sierra Leone.All cases were pediatric deaths after admission for suspected malaria at the Pujehun Hospital Pediatric Ward between January 1, 2015, and May 31, 2016. The case-control ratio was 1:1. The controls were infants admitted at Pujehun Hospital Pediatric Ward for malaria and discharged alive during the same period. Controls were selected as the next noncase infant admitted for malaria and discharged alive, as recorded in local medical records.None.Children characteristics, vital variables on hospital access, comorbidity status at admission, antibiotic and antimalarial therapy at admission; presence of hematemesis, respiratory arrest or bradypnea, abrupt worsening, and emergency interventions during hospital stay; final diagnosis before discharge or death. In total, 320 subjects (160 cases and 160 controls) were included in the study. Multivariable analysis identified being referred from peripheral health units (odds ratio, 4.00; 95% CI, 1.98–8.43), cerebral malaria (odds ratio, 6.28; 95% CI, 2.19–21.47), malnutrition (odds ratio, 3.14; 95% CI, 1.45–7.15), dehydration (odds ratio, 3.94; 95% CI, 1.50–11.35), being unresponsive or responsive to pain (odds ratio, 2.17; 95% CI, 1.15–4.13), and hepatosplenomegaly (odds ratio, 3.20; 95% CI, 1.74–6.03) as independent risk factors for mortality.Risk factors for mortality in children with suspected malaria include cerebral malaria and severe clinical conditions at admission. Being referred from peripheral health units, as proxy of logistics issue, was also associated with increased risk of mortality. These findings suggest that appropriate interventions should focus on training and resources, including the increase of dedicated personnel and available equipment.