Permethrin-treated Baby Wraps Cut Malaria Risk in Children: NEJM
USA: A randomized trial conducted in Uganda has shown that permethrin-treated baby wraps reduced malaria incidence by 66% in young children before vaccine-induced immunity developed. The intervention was well-tolerated, with only a small percentage of children in both the treatment and control groups reporting mild rash.
The findings were published online in The New England Journal of Medicine on September 24, 2025.
Ross M. Boyce from the Institute for Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill, along with colleagues, conducted this double-blind, randomized, placebo-controlled trial to evaluate whether insecticide-treated cloth wraps—traditionally used by mothers to carry children on their backs—could offer an additional layer of malaria protection.
The study enrolled mothers with children aged 6 to 18 months. Participants were randomly assigned to either receive permethrin-treated wraps or sham-treated wraps. All mothers and children also received new, pyrethroid-only long-lasting insecticide-treated bed nets. Participants in the intervention group were retreated every four weeks, and the pairs visited trial clinics every two weeks for a total of 24 weeks, with additional unscheduled visits in case of febrile illness. The primary outcome measured was clinical malaria in the children, defined by fever along with a positive rapid diagnostic test for malaria.
The study led to the following notable findings:
- Between June 2022 and April 2024, 419 mother–child pairs were screened, and 400 were randomized, with 200 pairs assigned to each group.
- Compliance with clinic visits was very high, with 5194 out of 5200 planned visits attended.
- No participants were lost to follow-up during the trial.
- The incidence of clinical malaria was 0.73 cases per 100 person-weeks in the intervention group.
- The incidence of clinical malaria in the control group was 2.14 cases per 100 person-weeks.
- The incidence rate ratio comparing the intervention and control groups was 0.34.
- Mild rash occurred slightly more often in the treatment group than in the control group (8.5% vs. 6.0%).
The researchers highlighted several limitations of the trial. The findings are most generalizable to settings where baby wraps are commonly used and may not reflect other geographic areas or malaria transmission contexts. Bed-net usage and wrap washing frequency were self-reported, which could introduce reporting bias, though it is unlikely to differ between groups. While sham retreatments were performed to maintain blinding, the distinct smell of permethrin might have revealed group assignment; participant surveys indicated similar expectations of benefit across both groups. Finally, the study did not examine potential changes in mosquito behavior in response to permethrin-treated wraps.
Despite these limitations, the study demonstrated a substantial reduction in malaria incidence among young children using permethrin-treated wraps, with no significant safety concerns. The authors suggest further research to optimize permethrin application methods, evaluate cost-effectiveness, and explore long-term outcomes, including potential neurodevelopmental effects in children. Future studies could also incorporate entomological measures to better understand how the wraps influence mosquito feeding behavior.
"The trial provides promising evidence that integrating permethrin-treated baby wraps with existing bed-net strategies could offer an effective, culturally compatible tool to further reduce malaria burden among children in high-risk regions," the authors concluded.
Reference:
Boyce RM, et al "Permethrin-treated baby wraps for the prevention of malaria" N Engl J Med 2025; DOI: 10.1056/NEJMoa2501628.
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