Research finds that half of deaths among children admitted to hospital happens after discharge

Young children in sub-Saharan Africa and South Asia who become sick or malnourished continue to have a high risk of death in the six months after being hospitalized, according to findings by researchers in the Childhood Acute Illness & Nutrition (CHAIN) Network. Appearing in The Lancet Global Health, the study of 3,101 acutely ill children at nine hospitals in six countries across sub-Saharan Africa and South Asia found that 48% of the 350 deaths recorded occurred within six months after discharge from hospital.

“The finding that many children die after being discharged from hospital is tragic. This calls for a review of the treatment guidelines and for home-based interventions to prevent these unfortunate deaths,” said Dr. Tahmeed Ahmed, Executive Director of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and one of CHAIN’s lead researchers.

In the 6 months after discharge, a large proportion of children were high-risk with a 1 in 5 chance of dying. Post-discharge deaths could be predicted as easily as inpatient deaths when from children’s admission, discharge, nutritional status and social circumstance information. Despite being highly predictable, post-discharge deaths are not addressed by clinicians and health facilities that rely on current national or WHO treatment and care guidelines. Importantly, the researchers also found that many children admitted to hospital had very low risks of mortality.

The researchers found children classified as malnourished, who comprised most study deaths, had substantial risks arising from non-nutritional issues such as access to medical care, household resources and children’s other underlying medical conditions. To reduce their risk of death, socioeconomic issues and management of maternal physical and mental health conditions need to be addressed alongside medical and nutritional management.

The CHAIN researchers conducted detailed interviews with families and found that while caregivers attempted to seek care for their children, many faced barriers in accessing care and managing illness. These findings indicate opportunities to improve the resilience and choices for caregivers, which in turn may improve timely access to medical services in case of becoming ill after discharge from hospital.

“When acutely ill children present to care, there is not enough digging to understand how we should support these children when they go back home. These children end up in a vicious cycle of vulnerability and sometimes die. There is a lot of focus on the clinical condition of acutely ill children without putting the same magnitude as to where they are coming from and the factors which contribute to their vulnerability,” said Dr. Ezekiel Mupere, Chair of the Department of Paediatrics & Child Health at Makerere University, and the lead CHAIN researcher in Uganda.

The authors suggest a fundamental shift in guidelines to risk-based approaches to inpatient and post-discharge management to further reduce childhood mortality. Assessment of risk at discharge from hospital will be an important step in preventing child deaths. Furthermore, the authors suggest that identifying children at very low-risk of death may enable reallocation of staff and resources to higher-risk children in under-resourced health systems.

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The Childhood Acute Illness & Nutrition (CHAIN) Network is headquartered in Nairobi, Kenya within the KEMRI/Wellcome Trust Research Programme, with sites in Bangladesh, Burkina Faso, Kenya, Malawi, Pakistan, and Uganda led by local investigating teams. CHAIN works closely with the Centre for Tropical Medicine & Global Health at the University of Oxford in the United Kingdom and the Department of Global Health at the University of Washington in the United States. The CHAIN Network is financially supported by the Bill & Melinda Gates Foundation.

The Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme was established in 1989, and is a partnership between KEMRI, Oxford University and the Wellcome Trust. It conducts basic, epidemiological and clinical research in parallel, with results feeding directly into local and international health policy and aims to expand the country’s capacity to conduct multidisciplinary research that is strong, sustainable and internationally competitive.

The Centre for Tropical Medicine and Global Health is a world leading centre within the Nuffield Department of Clinical Medicine, University of Oxford, comprised of research groups who are permanently based in Africa and Asia as well as across two sites in Oxford. Its research ranges from clinical studies to behavioural sciences, with capacity building integral to all of our activities.

The Department of Global Health at the University of Washington was established in 2007 through a generous gift and endowment from the Bill & Melinda Gates Foundation and complementary Washington state resources. Bridging the schools of Medicine and Public Health at UW, the Department of Global Health harnesses the expertise and interdisciplinary power of all UW schools and colleges. It has more than 440 faculty and includes 23 centers, programs and initiatives.