John Kendall

Background/Objectives: Accurate prediction of pediatric appendicitis diagnosis, management, and severity is critical for clinical decision-making. We aimed to evaluate the predictive performance of a wide range of machine learning models, combined with various feature selection techniques, on a pediatric appendicitis dataset. A particular focus was placed on the role of ultrasound (US) image-descriptive features in model performance and explainability. Methods: We conducted a retrospective cohort study on a dataset of 781 pediatric patients aged 0–18 presenting to Children’s Hospital St. Hedwig in Regensburg, Germany, between January 2016 and February 2023. We developed and validated predictive models; machine learning algorithms included the random forest, logistic regression, stochastic gradient descent, and the light gradient boosting machine (LGBM). These were paired exhaustively with feature selection methods spanning filter-based (association and prediction), embedded (LGBM and linear), and a novel redundancy-aware step-up wrapper approach. We employed a machine learning benchmarking study design where AI models were trained to predict diagnosis, management, and severity outcomes, both with and without US image-descriptive features, and evaluated on held-out testing samples. Model performance was assessed using overall accuracy and area under the receiver operating characteristic curve (AUROC). A deep learner optimized for tabular data, GANDALF, was also evaluated in these applications. Results: US features significantly improved diagnostic accuracy, supporting their use in reducing model bias. However, they were not essential for maximizing accuracy in predicting management or severity. In summary, our best-performing models were, for diagnosis, the random forest with embedded LGBM feature selection (98.1% accuracy, AUROC: 0.993), for management, the random forest without feature selection (93.9% accuracy, AUROC: 0.980), and for severity, the LGBM with filter-based association feature selection (90.1% accuracy, AUROC: 0.931). Conclusions: Our results demonstrate that high-performing, interpretable machine learning models can predict key clinical outcomes in pediatric appendicitis. US image features improve diagnostic accuracy but are not critical for predicting management or severity.