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Is there a sex difference in mortality rates in paediatric intensive care units?: a systematic review
Ofran Almossawi1,2, Amanda Friend3, Luigi Palla4,5
1Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
Insights
In pediatric intensive care units (PICU), females have a slightly higher mortality rate than males, despite lower overall admission rates. This systematic review analyzed over 278,000 children to understand sex-based differences in PICU mortality.
Area of Science:
- Pediatric critical care medicine
- Epidemiology
- Biostatistics
Background:
- Infant and childhood mortality rates are generally lower in females than males.
- However, children admitted to Pediatric Intensive Care Units (PICU) show a reversed trend, with higher mortality reported in females despite lower admission rates.
- The reasons for this female mortality excess in the PICU subgroup remain unclear.
Purpose of the Study:
- To conduct a systematic literature review on sex-based differences in mortality among children (0 to <18 years) admitted to PICU.
- To determine if a significant difference in PICU mortality exists between males and females.
- To quantify the magnitude and direction of any observed sex-based mortality difference.
Main Methods:
- Systematic literature search of MEDLINE, Embase, and Web of Science for studies reporting PICU mortality rates by sex.
- Inclusion criteria encompassed studies reporting mortality data for children admitted to intensive care, stratified by sex.
- Study reliability was assessed using a modified ROBINS-E tool; pooled analysis was considered if ≥3 studies were comparable.
Main Results:
- Analysis included 114 studies with 278,274 children (56% males, 44% females).
- Female mortality rate was 4.61% (5,614 deaths) and male mortality rate was 4.36% (6,828 deaths).
- Pooled analysis indicated an odds ratio for female to male mortality of 1.06 (fixed effect) and 1.10 (random effects), suggesting a slight excess female mortality.
Conclusions:
- Overall, males exhibit higher PICU admission rates and potentially lower mortality compared to females.
- The findings suggest a subtle but statistically significant increase in mortality risk for females admitted to the PICU.
- Further research is warranted to elucidate the underlying mechanisms contributing to this observed sex disparity in pediatric intensive care outcomes.
Introduction:
Mortality rates in infancy and childhood are lower in females than males. However, for children admitted to Paediatric Intensive Care Units (PICU), mortality has been reported to be lower in males, although males have higher admission rates. This female mortality excess for the subgroup of children admitted in intensive care is not well understood. To address this, we carried out a systematic literature review to summarise the available evidence. Our review studies the differences in mortality between males and females aged 0 to <18 years, while in a PICU, to examine whether there was a clear difference (in either direction) in PICU mortality between the two sexes, and, if present, to describe the magnitude and direction of this difference.
Methods:
Any studies that directly or indirectly reported the rates of mortality in children admitted to intensive care by sex were eligible for inclusion. The search strings were based on terms related to the population (those admitted into a paediatric intensive care unit), the exposure (sex), and the outcome (mortality). We used the search databases MEDLINE, Embase, and Web of Science as these cover relevant clinical publications. We assessed the reliability of included studies using a modified version of the risk of bias in observational studies of exposures (ROBINS-E) tool. We considered estimating a pooled effect if there were at least three studies with similar populations, periods of follow-up while in PICU, and adjustment variables.
Results:
We identified 124 studies of which 114 reported counts of deaths by males and females which gave a population of 278,274 children for analysis, involving 121,800 (44%) females and 156,474 males (56%). The number of deaths and mortality rate for females were 5,614 (4.61%), and for males 6,828 (4.36%). In the pooled analysis, the odds ratio of female to male mortality was 1.06 [1.01 to 1.11] for the fixed effect model, and 1.10 [1.00 to 1.21] for the random effects model.
Discussion:
Overall, males have a higher admission rate to PCU, and potentially lower overall mortality in PICU than females.
Systematic Review Registration:
www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=203009, identifier (CRD42020203009).
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