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To review the clinical features and risk factors for complications and treatment of malaria in a pediatric cohort mainly composed of immigrant children. Retrospective cohort study of all cases of malaria diagnosed between 1991 and 2001 in Montreal, Canada. We have reviewed a total of 121 cases of malaria in children. The majority of which (78%) were immigrants or foreign-born visitors. Most children were originating from African countries and mainly infected with Plasmodium falciparum (63.9%, versus 21.0%, 5.9%, 3.4% for Plasmodium vivax), Plasmodium ovale and Plasmodium malariae} respectively). Seven patients (5.9%) were co-infected with more than one species. Median times from arrival to presentation were much shorter with P. falciparum (14 days) than other species: P. vivax (98 days), P. ovale (37 days) and P. malariae (31 days). The majority of children had fever, headache and rigors. Ten children (8.3%) had serious complications (cerebral malaria, anemia or shock). All ten patients presented within one month of arrival from their respective endemic country and all were infected with P. falciparum (P=0.03). Three patients required admission to a pediatric intensive care unit and seven required a blood transfusion. All recovered well although two children had P. falciparum recrudescence and three children infected with P. vivax or P. ovale relapsed. The number of complications observed in immigrant children was similar to that observed in travelers. Sickle cell disease was the most significant associated risk factor for serious complications of malaria (P<0.001). Immigrant children are at high risk of complications from malaria. Our study highlights sickle cell disease as a significant risk factor for serious complications of malaria in these children. It is essential to maintain a high index of suspicion in non-endemic areas in order to decrease the morbidity of malaria in immigrant children. [ABSTRACT FROM AUTHOR]