Prevalence, aetiology, and hospital outcomes of paediatric acute critical illness in resource-constrained settings (Global PARITY): a multicentre, international, point prevalence and prospective cohort study

Background: Children in resource-constrained settings (RCS) have disproportionately high illness and mortality; however, the prevalence in RCS of paediatric acute critical illness (P-ACI; life-threatening conditions that require time-sensitive interventions) is unknown. Most P-ACI can be managed with basic critical care (stabilisation, fluid resuscitation, oxygen, and vital-organ support), but RCS hospitals often lack such essential services. This study estimated the prevalence and examined the aetiology of P-ACI among children at RCS hospitals to support critical care capacity building and inform resource allocation. Methods: We conducted a hybrid prospective cohort and multinational point prevalence study of acutely ill or injured children aged 28 days to 14 years who presented to RCS hospitals on four designated days between July 20, 2021, and July 12, 2022. We measured the proportion of participants with P-ACI, applying the definition for acute paediatric critical illness (DEFCRIT) framework for research in resource-variable settings, and followed up admitted patients for hospital outcomes. In participants with P-ACI, we report diagnoses associated with critical illness. We used descriptive statistics to summarise site and cohort data by country sociodemographic category (Socio-demographic Index; SDI) and multivariable logistic regression to assess whether country sociodemographic category was independently associated with P-ACI. Findings: The study included 46 sites, 19 countries, and 7538 children, among whom 2651 (35·2%) were admitted to hospital and 68 died (all-cause mortality 0·9% [95% CI 0·7–1·1]). 985 (13·1% [95% CI 12·3–13·9]) participants had P-ACI. Among all sociodemographic categories, P-ACI prevalence was highest (28·0% [26·0–30·1]; 512 of 1828 participants) in low-SDI countries (p<0·0001). Mortality among those with P-ACI was 6·3% (4·9–8·0; 62 deaths). The most common P-ACI diagnoses were pneumonia (152 [15·4%] of 985 participants), sepsis or septic shock (102 [10·4%]), and malaria (95 [9·6%]). In an adjusted model, country sociodemographic category was not significantly associated with P-ACI frequency. Among all 68 deaths in the study, 40 (59% [46–71]) occurred within 48 h of presentation. Interpretation: P-ACI in RCS hospitals is common, associated with high mortality, disproportionately elevated in low-SDI countries, and associated with conditions that can be managed with basic critical care. This study underlines the need for investment in basic critical care services in RCS to address a major contributor to preventable mortality in hospitalised children. Funding: National Institutes of Health (USA); Medical Research Council (Singapore); Grand Challenges Canada; and University of Maryland, Baltimore (USA). Translations: For the French, Portuguese and Spanish translations of the abstract see Supplementary Materials section.