European Journal of Pediatrics

, Volume 173, Issue 1, pp 1–13

Use of risk stratification indices to predict mortality in critically ill children

  • Maria Grazia Sacco Casamassima
  • Jose H. Salazar
  • Dominic Papandria
  • James Fackler
  • Kristin Chrouser
  • Emily F. Boss
  • Fizan Abdullah

DOI: 10.1007/s00431-013-1987-6

Cite this article as:
Sacco Casamassima, M.G., Salazar, J.H., Papandria, D. et al. Eur J Pediatr (2014) 173: 1. doi:10.1007/s00431-013-1987-6


The complexity and high cost of neonatal and pediatric intensive care has generated increasing interest in developing measures to quantify the severity of patient illness. While these indices may help improve health care quality and benchmark mortality across hospitals, comprehensive understanding of the purpose and the factors that influenced the performance of risk stratification indices is important so that they can be compared fairly and used most appropriately. In this review, we examined 19 indices of risk stratification used to predict mortality in critically ill children and critically analyzed their design, limitations, and purposes. Some pediatric and neonatal models appear well-suited for institutional benchmarking purposes, with relatively brief data acquisition times, limited potential for treatment-related bias, and reliance on diagnostic variables that permit adjustment for case mix. Other models are more suitable for use in clinical trials, as they rely on physiologic variables collected over an extended period, to better capture the interaction between organ systems function and specific therapeutic interventions in acutely ill patients. Irrespective of their clinical or research applications, risk stratification indices must be periodically recalibrated to adjust for changes in clinical practice in order to remain valid outcome predictors in pediatric intensive care units. Longitudinal auditing, education, training, and guidelines development are also critical to ensure fidelity and reproducibility in data reporting. Conclusion: Risk stratification indices are valid tools to describe intensive care unit population and explain differences in mortality.


Mortality risk predictors Pediatrics Quality of care Risk stratification indices Scoring system 



Acute Physiologic and Chronic Health Evaluation


Australian and New Zealand Neonatal Network


Critical Risk Index for Baby


Extracorporeal membrane oxygenation


Glasgow Coma Scale


Intensive care unit


Neonatal del Cono Sur Network


National Institute of Child Health and Human Development


Pediatric multiple organ dysfunction


Pediatric logistic organ dysfunction


Pediatric intensive care unit


Pediatric Index of Mortality


Pediatric multiple organ dysfunction score


Physiologic Stability Index for Pediatric Patients


Pediatric Risk of Mortality III


Receiver operating characteristics


Standard mortality ratio


Score for Neonatal Acute Physiology


Very low birth weight

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Maria Grazia Sacco Casamassima
    • 1
  • Jose H. Salazar
    • 1
  • Dominic Papandria
    • 1
  • James Fackler
    • 2
  • Kristin Chrouser
    • 3
  • Emily F. Boss
    • 4
  • Fizan Abdullah
    • 1
    • 5
  1. 1.Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric SurgeryJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Anesthesiology/Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.Department of Otolaryngology—Head and Neck Surgery, Division of Pediatric OtolaryngologyJohns Hopkins University School of MedicineBaltimoreUSA
  5. 5.Division of Pediatric Surgery, Bloomberg Children’s CenterJohns Hopkins HospitalBaltimoreUSA