This study investigated the clinical patterns and mortality in 242 children with complicated falciparum malaria, aged 6.5 years on average, from January 2001 to February 2003 in Orissa, India. Common complications included unarousable coma (40.5%), severe anemia (26.03%), repeated seizures (46.2%), and hepatopathy (32.2%). Under-five children had higher risk of cerebral malaria, severe anemia, and seizures, while above-five children had higher risk of acute renal failure and hepatopathy. Overall mortality was 9.9%, with cerebral malaria being the main cause (6.6%). Multi-system involvement was present in 58.4% of deaths. Children with pulmonary edema, shock, and cerebral malaria had higher case fatality rates. The study found that under-five children had higher incidence of cerebral malaria and anemia, while above-five children had higher incidence of acute renal failure and hepatopathy. Post-mortem liver biopsies in 11 cases showed various liver pathologies. The study highlights the importance of age-based differences in clinical manifestations and mortality in severe falciparum malaria. The findings suggest that the clinical patterns and mortality in severe malaria vary based on parasitic, epidemiological, host defense, and risk factors. The study emphasizes the need for age-specific management strategies in malaria endemic regions.This study investigated the clinical patterns and mortality in 242 children with complicated falciparum malaria, aged 6.5 years on average, from January 2001 to February 2003 in Orissa, India. Common complications included unarousable coma (40.5%), severe anemia (26.03%), repeated seizures (46.2%), and hepatopathy (32.2%). Under-five children had higher risk of cerebral malaria, severe anemia, and seizures, while above-five children had higher risk of acute renal failure and hepatopathy. Overall mortality was 9.9%, with cerebral malaria being the main cause (6.6%). Multi-system involvement was present in 58.4% of deaths. Children with pulmonary edema, shock, and cerebral malaria had higher case fatality rates. The study found that under-five children had higher incidence of cerebral malaria and anemia, while above-five children had higher incidence of acute renal failure and hepatopathy. Post-mortem liver biopsies in 11 cases showed various liver pathologies. The study highlights the importance of age-based differences in clinical manifestations and mortality in severe falciparum malaria. The findings suggest that the clinical patterns and mortality in severe malaria vary based on parasitic, epidemiological, host defense, and risk factors. The study emphasizes the need for age-specific management strategies in malaria endemic regions.