Peer-reviewed article

Prediction of hospitalisation in young children with pneumonia in Malawi: A machine learning-based approach.

Staunton P, Makrooni MA, Chisale M, Nyambolo B, Wu J et al. · 9 Jun 2026

Abstract

Background Globally, pneumonia remains the single biggest cause of mortality in children under 5 years of age. This study sought to train and test a prediction model for hospitalisation within 7 days after initial presentation in 2- to 59-month-old Malawian children with WHO-defined pneumonia in primary care and compare its performance to existing risk prediction models. Methods and findings BIOTOPE is a cohort study of children with pneumonia in a primary healthcare setting in Malawi. The training cohort involved nine primary care centres and the testing cohort involved two primary care centres in Northern Malawi. The training cohort was recruited between December 2022 and April 2023 while the testing cohort was recruited in 2016. Participants were consecutive children aged 2-59 months presenting with cough and/or difficulty breathing and who were diagnosed as WHO-defined pneumonia in primary care of any severity. The training cohort was used to train and validate a machine learning model with a prespecified primary outcome defined as hospitalisation and/or death within 7 days as the outcome. This model was then further evaluated in the testing cohort. Median age was 15 months (interquartile range 8-27) in the training and 17 months (interquartile range 9-29) in the external testing cohort (52.1% and 54.4% male, respectively). Hospitalisation occurred in 14.3% (294) of the training cohort and 12.1% (55) of the testing cohort. There was one death in the training cohort only. WHO danger signs were present in 17.6% (360) and 15.9% (70) of children in the training and testing cohorts, respectively. The optimal machine learning model achieved an area under the receiver operating characteristic and precision recall curves of 0.87 and 0.57, respectively, in the testing cohort outperforming existing risk prediction models; furthermore, this model produced an expected calibration error of 0.16 (a logistic regression model using severity status as the response variable and the log odds of the machine learning model's calibrated probabilities produced an intercept estimate of -0.32 and a slope estimate of 1.13). Key limitations include the use of hospitalisation and/or death as a severity outcome, which may reflect health system factors rather than true disease severity, that mortality-based comparisons were not possible due to low mortality in these primary care cohorts, and that comparator tools were developed for hospital populations rather than primary care populations. Conclusion This machine learning score outperformed traditional pneumonia risk scores in predicting hospitalisation within 7 days in Malawian children presenting to primary care. Traditional pneumonia risk scores diminish in performance when externally applied to new datasets suggesting they may not generalise well beyond their original derivation settings. Mortality-related findings are not applicable as there was only one death in this cohort. Overall these findings support the potential of machine learning to meaningfully improve early identification of children at risk of severe pneumonia in low-resource primary care settings. Further external validation and clinical impact studies are needed to confirm these results.