Prediction of Disease Severity in Young Children Presenting With Acute Febrile Illness in Resource-limited Settings

Background

Febrile illnesses are amongst the most common reasons that parents seek non-routine healthcare for their children and a proportion progress to severe disease with substantial risk of mortality. Sepsis, defined as acute life-threatening organ dysfunction caused by a dysregulated host response to infection, carries significant morbidity. Incidence is highest in the paediatric age-range, with an estimated over four million children developing sepsis each year. This estimate is necessarily conservative, as the burden of sepsis is greatest in low- and middle-income countries (LMICs) where population-level data are not readily available.

Distinguishing febrile children that require referral or admission to hospital, from those who can safely be cared for in the community, is challenging. In many tropical settings rational triage is especially difficult: healthcare providers receive limited training, and many acute febrile syndromes are clinically indistinguishable yet have different disease trajectories and require different interventions. Particularly in conflict settings, referral decisions involve complex mechanisms, costs and risks to both patient and provider. Consequently, patient outcomes are compromised: children with severe disease go unrecognised, whilst those with milder illnesses are unnecessarily hospitalised.

Healthcare providers are trained to perform systematic clinical assessments, which focus on eliciting symptoms and signs that predict poor outcomes. Whilst tools such as the World Health Organization's Integrated Management of Childhood Illness (IMCI) aim to support this, results are inconsistent and adherence is poor. Integration of several syndrome-specific algorithms is impractical for many limited-skill health workers. A recent systematic review concluded that validity of existing paediatric triage tools is uncertain and that none are likely to be reliable in resource-constrained environments.

Numerous clinical severity scoring systems predict deterioration in hospitalised patients and recent attempts have been made to adapt these to the paediatric population.