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Are Pediatric early warning scores reliable in malnourished children? A prospective validation study in a
Varuna Sugha1, Arun Bansal1, Suresh Kumar Angurana1
1Divisions of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
Insights
The Cardiac Children's Hospital Early Warning Score (CCHEWS) and Brighton Pediatric Early Warning Score (PEWS) showed the best predictive performance for clinical deterioration in malnourished children. However, improved malnutrition-specific tools are needed for resource-limited settings.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Assessment Tools
- Malnutrition Research
Background:
- Malnourished children presenting to emergency departments face a high risk of clinical deterioration.
- Existing Pediatric Early Warning Scores (PEWS) require evaluation for their effectiveness in this vulnerable population.
- Assessing PEWS performance is crucial for timely intervention in low-middle-income countries.
Purpose of the Study:
- To compare the predictive performance of five PEWS (Brighton, CCHEWS, Cardiff and Vale, BPEWS, Birmingham and Toronto) in identifying clinical deterioration in malnourished children.
- To evaluate the utility of current PEWS in a resource-limited pediatric emergency department setting.
- To inform the development of improved early warning systems for malnourished children.
Main Methods:
- A prospective observational study enrolled 1326 malnourished children (1 month to 12 years) in a northern Indian tertiary public hospital.
- Malnutrition was defined per Indian Academy of Pediatrics guidelines.
- Clinical deterioration (ICU transfer, ventilation, inotropes, mortality) within 48 hours was the primary outcome, assessed using Area Under the Receiver Operating Characteristic Curve (AUROC), sensitivity, and specificity.
Main Results:
- Clinical deterioration occurred in 27% of the cohort.
- CCHEWS (AUROC 0.819) and Brighton PEWS (AUROC 0.813) demonstrated the highest predictive ability.
- CCHEWS offered superior sensitivity (96%) and negative predictive value (98%), while Brighton PEWS had better specificity (78%). Birmingham and Toronto PEWS and BPEWS showed poor performance.
Conclusions:
- CCHEWS and Brighton PEWS were the most effective among the evaluated scores for predicting clinical deterioration in malnourished children.
- No single PEWS demonstrated optimal accuracy, indicating a need for malnutrition-specific tools.
- Clinical judgment remains essential, and further research into tailored early warning systems for resource-limited settings is warranted.
Background:
To evaluate and compare the predictive performance of five Pediatric Early Warning Scores (PEWS)-Brighton, Cardiac Children's Hospital Early Warning Score (CCHEWS), Cardiff and Vale, Bedside PEWS (BPEWS), and Birmingham and Toronto PEWS-in identifying clinical deterioration in malnourished children presenting to a pediatric emergency department in a low-middle-income country.
Methods:
This prospective observational study was conducted in the Pediatric Emergency Department of a tertiary public hospital in northern India. A total of 1326 malnourished children aged 1 month to 12 years were enrolled between January and December 2022. Malnutrition was defined using the Indian Academy of Pediatrics (IAP) 2007 growth guidelines. The primary outcome was clinical deterioration within 48 h, defined as requiring ICU transfer, mechanical ventilation, inotropic support, or resulting in mortality. The discriminatory ability of each PEWS was assessed using the area under the receiver operating characteristic curve (AUROC), along with sensitivity, specificity, and predictive values.
Results:
Clinical deterioration occurred in 27 % of the cohort. CCHEWS and Brighton had the highest AUROCs (0.819 and 0.813, respectively). CCHEWS showed the highest sensitivity (96 %) and negative predictive value (98 %), while Brighton demonstrated better specificity (78 %) and diagnostic accuracy. Cardiff and Vale PEWS showed moderate performance (AUROC 0.752), whereas Birmingham and Toronto PEWS (AUROC 0.694) and BPEWS (AUROC 0.559) performed poorly.
Conclusion:
While CCHEWS and Brighton PEWS were the most effective tools, none showed optimal accuracy. These findings highlight the need to explore malnutrition-specific early warning systems suitable for resource-limited emergency settings. Clinical judgment should guide decision-making alongside existing PEWS systems.
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