Performance of five risk stratification tools for paediatric pneumonia against WHO scores using data from the PediCAP trial in sub-Saharan Africa

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Abstract
Objectives: Risk stratification tools for childhood pneumonia may improve identification of children at highest risk of death in low-resource settings. However, added value over the WHO Integrated Management of Childhood Illness (IMCI) criteria and danger signs remains uncertain. We compared the performance of published paediatric pneumonia risk scores with WHO-IMCI criteria and WHO danger signs. Design: Secondary analysis of a multi-country randomised controlled trial Setting: Thirteen hospitals in Mozambique, South Africa, Uganda, Zambia, and Zimbabwe. Participants: Children aged 2-59 months without HIV hospitalised with WHO-defined severe community-acquired pneumonia in the PediCAP trial. Children requiring intensive care or invasive ventilation were excluded. Primary and secondary outcome measures: The primary outcome was in-hospital mortality. The exploratory outcome was readmission or death by day 28. Discrimination was assessed using area under the receiver operating characteristic curve (ROC-AUC). Results: Among 1052 children, 18 (1.7%) died in hospital and 22 (2.1%) died in hospital or within 7 days of discharge. Among 1010 children with day-28 follow-up, 63 (6.2%) died or were readmitted by day 28. ROC-AUC point estimates for in-hospital mortality ranged from approximately 0.73 to 0.87. WHO danger signs had lower point estimate than the other scores, although confidence intervals overlapped substantially and no score demonstrated clear superiority. In contrast, all approaches showed limited discrimination for the exploratory outcome of 28-day readmission or death (ROC-AUC approximately 0.54-0.57). Conclusions: In this multi-country cohort of children hospitalised with severe pneumonia, no score demonstrated clear superiority for mortality prediction, although point estimates of AUC-ROC scores ranged from 0.75 (Danger signs) to 0.87 (RISC-MGMU). Published risk scores and WHO-IMCI criteria showed broadly similar performance. These findings suggest that opportunities to improve risk stratification in low-resource settings may lie not only in developing new tools, but also in optimising the delivery and use of existing WHO IMCI-based assessment. Trial Registration: ISRCTN63115131 What is already known on this topic: Several clinical risk scores have been developed to predict mortality in childhood pneumonia, with some validation studies in low-resource settings, although direct comparisons across multiple risk stratification tools within the same population are limited. WHO IMCI criteria are widely used in many low-resource settings, but performance relative to published risk stratification tools remains uncertain. What this study adds: In a multi-country African cohort of children hospitalised with severe pneumonia, published paediatric pneumonia risk scores and WHO IMCI criteria showed broadly similar point estimates for mortality prediction, with no score demonstrating clear superiority. WHO danger signs generally had lower point estimates than the published risk scores and WHO IMCI criteria, although confidence intervals overlapped substantially. How this study might affect research, practice, or policy: These findings suggest that opportunities to improve risk stratification in low-resource settings may lie not only in developing new tools, but also in optimising the delivery and use of existing WHO IMCI-based assessment.

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