title: Predicting mortality for paediatric inpatients where malaria is uncommon.
abstract: OBJECTIVE
  As the proportion of children living low malaria transmission areas in sub-Saharan Africa increases, approaches for identifying non-malarial severe illness need to be evaluated to improve child outcomes.
  
  
  METHODS
  As a prospective cohort study, we identified febrile paediatric inpatients, recorded data using Integrated Management of Childhood Illness (IMCI) criteria, and collected diagnostic specimens.
  
  
  METHODS
  Tertiary referral centre, northern Tanzania.
  
  
  RESULTS
  Of 466 participants with known outcome, median age was 1.4 years (range 2 months-13.0 years), 200 (42.9%) were female, 11 (2.4%) had malaria and 34 (7.3%) died. Inpatient death was associated with: Capillary refill >3 s (OR 9.0, 95% CI 3.0 to 26.7), inability to breastfeed or drink (OR 8.9, 95% CI 4.0 to 19.6), stiff neck (OR 7.0, 95% CI 2.8 to 17.6), lethargy (OR 5.2, 95% CI 2.5 to 10.6), skin pinch >2 s (OR 4.8, 95% CI 1.9 to 12.3), respiratory difficulty (OR 4.0, 95% CI 1.9 to 8.2), generalised lymphadenopathy (OR 3.6, 95% CI 1.6 to 8.3) and oral candidiasis (OR 3.4, 95% CI 1.4 to 8.3). BCS <5 (OR 27.2, p<0.001) and severe wasting (OR 6.9, p<0.001) were independently associated with inpatient death.
  
  
  CONCLUSIONS
  In a low malaria transmission setting, IMCI criteria performed well for predicting inpatient death from non-malarial illness. Laboratory results were not as useful in predicting death, underscoring the importance of clinical examination in assessing prognosis. Healthcare workers should consider local malaria epidemiology as malaria over-diagnosis in children may delay potentially life-saving interventions in areas where malaria is uncommon.
authors.affiliation: Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
authors.forename: Dana C
authors.initials: DC
authors.lastname: Clifton
authors.forename: Habib O
authors.initials: HO
authors.lastname: Ramadhani
authors.forename: Levina J
authors.initials: LJ
authors.lastname: Msuya
authors.forename: Boniface N
authors.initials: BN
authors.lastname: Njau
authors.forename: Grace D
authors.initials: GD
authors.lastname: Kinabo
authors.forename: Ann M
authors.initials: AM
authors.lastname: Buchanan
authors.forename: John A
authors.initials: JA
authors.lastname: Crump
mesh_terms: D000293:Adolescent; D002423:Cause of Death; D002648:Child; D002673:Child, Hospitalized / Q000706:statistics & numerical data*; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007223:Infant; D007297:Inpatients; D016778:Malaria, Falciparum / Q000401:mortality*; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013636:Tanzania / Q000453:epidemiology; D062606:Tertiary Care Centers