Pediatric post-discharge mortality in resource-poor countries: a systematic review and meta-analysis
Martina Knappett1, Vuong Nguyen1, Maryum Chaudhry1
1Institute for Global Health, BC Children's Hospital and BC Women's Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada.
Insights
Post-discharge mortality in children remains high in low-resource countries, particularly for those with malnutrition or anemia. Addressing this critical issue requires focused research and policy interventions.
Area of Science:
- Global Health
- Pediatrics
- Epidemiology
Background:
- Under-five mortality disproportionately affects resource-poor nations.
- Post-discharge mortality is a significant, growing concern in child mortality.
- This study addresses the need for updated evidence on pediatric post-discharge mortality.
Purpose of the Study:
- To provide a nuanced understanding of pediatric post-discharge mortality burden.
- To identify key risk factors associated with post-discharge mortality in children.
- To synthesize current evidence using novel data methods.
Main Methods:
- Systematic review and meta-analysis of studies published 2017-2023.
- Inclusion of studies from low/low-middle Socio-Demographic Index countries with >7-day follow-up.
- Risk of bias assessment using a modified Joanna Briggs Institute tool.
Main Results:
- Pooled 6-month post-discharge mortality was 4.4% for general acute illness (n=34,457).
- Highest mortality rates observed in severe malnutrition (12.2%) and severe anemia (6.4%).
- Key risk factors identified: unplanned discharges, severe malnutrition, and HIV seropositivity.
Conclusions:
- Pediatric post-discharge mortality remains high in resource-poor settings.
- Malnutrition and anemia are critical conditions associated with elevated mortality.
- Global health strategies must prioritize research and policy for this issue.
Background:
Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness.
Methods:
Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975.
Findings:
Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity.
Interpretation:
Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation.
Funding:
No specific funding was received.
