Prognostic models for predicting in-hospital paediatric mortality in resource-limited countries: a systematic review

Abstract

Objectives: To identify and appraise the methodological rigour of multivariable prognostic models predicting in-hospital paediatric mortality in low-income and middle-income countries (LMICs).

Design: Systematic review of peer-reviewed journals.

Data sources: MEDLINE, CINAHL, Google Scholar and Web of Science electronic databases since inception to August 2019.

Eligibility criteria: We included model development studies predicting in-hospital paediatric mortality in LMIC.

Data extraction and synthesis: This systematic review followed the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies framework. The risk of bias assessment was conducted using Prediction model Risk of Bias Assessment Tool (PROBAST). No quantitative summary was conducted due to substantial heterogeneity that was observed after assessing the studies included.

Results: Our search strategy identified a total of 4054 unique articles. Among these, 3545 articles were excluded after review of titles and abstracts as they covered non-relevant topics. Full texts of 509 articles were screened for eligibility, of which 15 studies reporting 21 models met the eligibility criteria. Based on the PROBAST tool, risk of bias was assessed in four domains; participant, predictors, outcome and analyses. The domain of statistical analyses was the main area of concern where none of the included models was judged to be of low risk of bias.

Conclusion: This review identified 21 models predicting in-hospital paediatric mortality in LMIC. However, most reports characterising these models are of poor quality when judged against recent reporting standards due to a high risk of bias. Future studies should adhere to standardised methodological criteria and progress from identifying new risk scores to validating or adapting existing scores.

Prospero registration number: CRD42018088599.

Keywords: paediatric intensive & critical care; paediatrics; statistics & research methods.

Figure 1

PRISMA flow diagram showing the process used to identify prognostic models predicting in-hospital paediatric mortality included in this review. HDU, high-dependency unit; ICU, intensive care unit; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Prognostic models predicting in-hospital paediatric mortality identified by country. Text highlighted in red are the names of the models with their corresponding discrimination measures (area under the curve). CRT, classification and regression trees; ITAT, inpatient triage assessment and treatmentscore; LOD, lambarene organ dysfunction; mRISC, modified Respiratory Index of Severity in Children; PEDIA, Paediatric Early Death Index; PERCH, Pneumonia Etiology Research for Child Health; PET, paediatric emergency triage; PEWS-RL, paediatric early warning score for resource-limited settings; SICK, Signs of Inflammation in Children that Kill.

Figure 3

Top four categories of predictors in the models of the reviewed reports: altered consciousness (coma, prostration, not alert, unconscious); malnutrition indicators (kwashiorkor, oedema, weight-for-height z-score, weight-for-age z-score, mid-upper arm circumference, wasting); vital signs (temperature, respiratory rate, heart rate, oxygen saturation); signs of respiratory distress (indrawing, lung crepitation, difficult breathing, grunting).

Figure 4

Summary of the risk of bias of the included models using Prediction model Risk of Bias Assessment Tool.

Figure 5

Risk of bias assessment. Low means low risk of bias, high means a high risk of bias and unclear bias means it was not possible to assess the risk of bias. CRT, classification and regression trees; ITAT, inpatient triage assessment and treatment; LOD, lambarene organ dysfunction; mRISC, modified Respiratory Index of Severity in Children; PEDIA, Paediatric Early Death Index for Africa; PERCH, Pneumonia Etiology Research for Child Health; PET, paediatric emergency triage; PEWS-RL, Paediatric Early Warning Score for Resource-Limited; RISC, Respiratory Index of Severity in Children; SICK, Signs of Inflammation in Children that Kill.