Brals Daniella, Pradhan Ananda, Andre-von Arnim Amelie von Saint, Oron Assaf P, Ngari Moses, Ngao Narshion, Mupere Ezekiel, Chisti Mohammod J, Lwanga Christopher, Afroze Farzana, Bandsma Robert, Walson Judd L, Berkley James A, Voskuijl Wieger
Amsterdam UMC, location University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands.
Departments of Paediatrics and Global Health, University of Washington, Seattle Children's, Seattle, Washington, USA.
J Glob Health. 2024 Dec 30;14:04235. doi: 10.7189/jogh.14.04235.
Risk prediction tools for acutely ill children have been developed in high- and low-income settings, but few are validated or incorporated into clinical guidelines. We aimed to assess the performance of existing paediatric early warning scores for use in low- and middle-income countries using clinical data from a recent large multi-country study in Africa and South-Asia.
We used data (children across three nutritional strata) from the Childhood Acute Illness and Nutrition (CHAIN) Network cohort study (n = 3101). We assessed 10 scores where similar predictor variables were available in the CHAIN cohort. We evaluated performance using the area under the receiver operating curve (AUC) (primary outcome), sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio (secondary outcomes).
Most scores showed poor discrimination, and all scores had low sensitivity. The paediatric early death index for Africa (AUC = 0.80; 95% confidence interval (CI) = 0.77-0.83), respiratory index of severity in children (AUC = 0.77; 95% CI = 0.74-0.81), and respiratory index of severity in children in Malawi (AUC = 0.78; 95% CI = 0.75-0.82) showed acceptable/good overall discrimination. Among children without wasting, most scores had acceptable/good performance, some even excellent. Poor discrimination was found for most scores among children with moderate and severe wasting or kwashiorkor.
All scores demonstrated lower validation performance than originally reported. Among children without wasting, most risk prediction scores performed acceptably whilst in malnourished children they performed poorly. There is a need for a malnutrition specific score. Further research is needed on specific actions in responding to scores. Integration into future guidelines will require acknowledging staffing, resources and workflows.
针对重症儿童的风险预测工具已在高收入和低收入环境中开发出来，但很少经过验证或纳入临床指南。我们旨在利用近期一项在非洲和南亚开展的大型多国研究的临床数据，评估现有儿科早期预警评分在低收入和中等收入国家的表现。
我们使用了儿童急性疾病与营养（CHAIN）网络队列研究的数据（来自三个营养层次的儿童）（n = 3101）。我们评估了10种评分，这些评分在CHAIN队列中有相似的预测变量。我们使用受试者工作特征曲线下面积（AUC）（主要结局）、敏感性、特异性、阳性和阴性预测值以及阳性和阴性似然比来评估表现（次要结局）。
大多数评分显示出较差的区分能力，所有评分的敏感性都较低。非洲儿科早期死亡指数（AUC = 0.80；95%置信区间（CI）= 0.77 - 0.83）、儿童呼吸严重程度指数（AUC = 0.77；95% CI = 0.74 - 0.81）以及马拉维儿童呼吸严重程度指数（AUC = 0.78；95% CI = 0.75 - 0.82）显示出可接受/良好的总体区分能力。在没有消瘦的儿童中，大多数评分表现可接受/良好，有些甚至非常出色。在中度和重度消瘦或夸希奥科病患儿中，大多数评分的区分能力较差。
所有评分的验证表现均低于最初报告的水平。在没有消瘦的儿童中，大多数风险预测评分表现尚可，而在营养不良的儿童中表现较差。需要一个针对营养不良的特定评分。需要对针对评分的具体行动进行进一步研究。要纳入未来的指南，需要考虑人员配备、资源和工作流程。
