Article title:

Pediatric SOFA and PELOD-2 Scores to Predict Mortality in Critically Ill Children in PICU
Haji Adam Malik Hospital Medan, Indonesia

Authors:
 Dr. Rizal Marubob Silalahi
 Dr. Badai Buana Nasution, M.Ked(Ped), Sp.A(K)
 DR. Dr. Bugis Mardina Lubis, M.Ked(Ped), Sp.A(K)
 DR. Dr. Juliandi Harahap, MA
 Dr. Wisman Dalimunthe, M.Ked(Ped), Sp.A(K)
 Dr. Karina Sugih Arto, M.Ked(Ped), Sp.A(K)

Institutions:
Department of Child Health, Faculty of Medicine, Universitas Sumatera Utara, Medan, North
Sumatra 20155, Indonesia

Corresponding Author:
Name Rizal Marubob Silalahi
Address Jalan Paya Bakung No. 19 C Sumber Melati Diski, Medan, North
Sumatra 20351, Indonesia
Phone number +62 812 6395 940
E-mail address dr_rizalms@yahoo.com
 Pediatric SOFA and PELOD-2 Scores to Predict Mortality in
Critically Ill Children in PICU Haji Adam Malik Hospital Medan,
Indonesia
Rizal Marubob Silalahi, Badai Buana Nasution, Bugis Mardina Lubis, Juliandi Harahap, Wisman
Dalimunthe, Karina Sugih Arto

Abstract
Background pSOFA and PELOD-2 scoring systems provide an overview of the extentive organ
dysfunction and disease prognosis and mortality prediction in critically ill children. The pSOFA has
variables that can be easily measured and available. Unlike PELOD-2 that comes with more intricate
variables. However, whether pSOFA is better than PELOD-2 at predicting mortality remains a question.
Aim Comparing pSOFA score to PELOD-2 score in predicting mortality in critically ill pediatric patients.
Methods Scoring systems pSOFA and PELOD-2 were used to predict the mortality in patients using data
from the medical record dated May 2019 – May 2020. The difference between PELOD-2 and pSOFA
scores on illness outcome was determined by bivariate analysis. ROC curve and cut-off value provided the
sensitivity, specificity, PPV, and NPV for mortality prediction of each scoring system.
Results PELOD-2 score predicted mortality with 96.8% sensitivity, 95% specificity, 93.8% PPV, 97.4%
NPV, and 95.8% accuracy. In comparison, pSOFA score predicted mortality with 96.8% sensitivity, 96.2%
specificity, 95.2% PPV, 97.5% NPV, and 96.5% accuracy 96.5%.
Conclusion The pediatric SOFA (pSOFA) outperformed PELOD-2 score in predicting mortality in
critically ill children patients admitted to the PICU of Haji Adam Malik hospital Medan, Indonesia.

Keywords: scoring system, PELOD-2, SOFA, mortality, pediatric

Introduction
Multiple organ dysfunction syndrome (MODS) is a common occurrence in pediatric intensive

care unit (PICU), where mortality is related to organ system failure and the extensive organ

dysfunction. MODS is one of the indicators of the severity of diseases and the major cause of

deaths in PICU1,2. Scoring systems are used to assess the degree of severity of diseases as one

of the predictive indicators for the outcome of critically ill patients. They can also be used to

provide an overview to doctors in the intensive care unit in terms of possible mortality,

outcome anticipation, prediction of diseases’ severty, and organ failure3,4.

 There has been some reviews on the criteria and development of scoring system to

assess organ dysfunction in children. The main objectives are to have reproducible

assessment of organ failure based on the changes in organ function 5. It is critical to have

multiple scoring system that account for the high and low risk of death associated with

different organ failure. MODS in adults have been developed with mortality being taken as a

dependent variable. Therefore, pediatric-multiple organ dysfunction (P-MODS), pediatric

logistic organ dysfunction (PELOD), and modified sequential organ failure assessment

(SOFA) scoring are developed for children.

The PELOD score is a scoring system used to asses the degree of organ dysfunction in

severely ill children and provide a descriptive overview of the diseases’ outcome, especially

in children treated in PICU6. Leteurte et al developed the scoring system and validated

PELOD-2 in 2013, as an update from PELOD score, to determine the degree of severity of

the diseases in the PICU by analyzing multi-organ dysfunction syndrome (MODS). The

update to the PELOD score contains ten variables, including five organ dysfunctions5.

Sequential organ failure assessment (SOFA) score is a collective of 6 variables

consisting of respiratory system, cardiovascular system, hepatic system, coagulation system,

kidney, and the nervous systems. SOFA quantitatively and objectively describes the degree of

organ dysfunction. The score, initially developed for adult patients, is subsequently adjusted

for pediatric patients with sepsis (pSOFA), with adjustment on the cardiovascular and renal

systems according to age – adapted from PELOD-2 score7.

Gogia, Priya, and Prasad conducted a study on SOFA and PELOD scores to determine

prognosis and predict the mortality in critically ill children in the intensive care unit in India.

The study showed that SOFA scoring at the first 72 hours of treatment, SOFA and PELOD

were statistically correlated with the prognosis to predict mortality. They were equally as

good, with 96% sensitivity, 98% specificity, 90% positive predictive value (PPV), and 99%
negative predictive value (NPV)8. SOFA scoring system has variables that are easily

measured and available, which has become a routine assessment in the ICU. On the other

hand, PELOD score is more complex and intricate with many variables required 8,9. However,

whether pSOFA is better than PELOD-2 at predicting mortality remains a question. This

study compared pSOFA and PELOD-2 scores in predicting mortality in critically ill children

treated in PICU Haji Adam Malik hospital, Medan, Indonesia.

Methods
This research used a retrospective design study to compare pediatric SOFA (pSOFA) score to

PELOD-2 score in predicting mortality in pediatric patients in PICU. The research was

carried out in Haji Adam Malik Hospital, Medan, Indonesia, using medical record of the

research subjects dated May 2019 – May 2020. Research subjects were all pediatric patients

aged 1 month – 18 years old with chronic condition and admitted to the PICU. Exclusion

criteria were pediatric patients with incomplete medical record, died in less than 24 hours of

admission, admitted for more than 28 days in the PICU, and patients who were re-admitted to

PICU. The mortality determination of the research partcipants were carried out by using

pSOFA and PELOD-2 scores at the first 24 hours of patients’ admission to the PICU.

Data Analysis
Data analysis was carried by using a computerized software system SPSS. Univariate analysis

was performed on the basic demographic data of the research subjects, supporting test results,

and scoring. Categorical data was presented as frequency distribution and tables. Numerical

data was presented as mean and standard deviation or as median and min-max values.

Bivariate analysis was performed to assess the difference between PELOD-2 and pSOFA

scores in the diseases’ outcome against chi-square, Kruskal Wallis, Mann-Whitney, and t-

independent tests. ROC curve and cut-off value in predicting mortality were separately
analyzed to obtain sensitivity, specificity, positive predictive value (PPV), and negative

predictive value (NPV). All data was plotted in tables.

Ethical Considerations
This study was approved by Health Research Ethical Committee, Medical Faculty of

Sumatera Utara and Haji Adam Malik Hospital, Medan. The initials of the research subjects

were used to ensure the condifentiality of the research subjects’ identitiy. Data was

exclusively used for scientific purposes only.

Results
Characteristic Data of Research Subjects
This research involved 142 pediatric patients who met the inclusion criteria. Table 1

presented the demographic characteristic of research subjects. Over half the research subjects

(66.2%) were male. There were 49 (34.5%) patients aged below 12 months old, 6 (4.2%)

patients aged 1 – 2 years old, 10 (7.0%) patients aged 2 – 5 years old, 36 patients (25.4%)

were 5 – 12 years old, and 41 (28.9%) patients were above 12 years old. The average body

weight and height was 21.22 kg and 108.65 cm respectively. From the nutritional status, over

half (50.7%) had good nutritional status, while 29.6% of them had poor nutritional status and

were malnutrition, and the rest, 19.8% of the research participants were overweight and

obese. There were 109 (76.8%) patients who required ventilators. Based on PICU treatment

requirement, 49 (31.7%) patients were in post-op condition, 36 (25.4%) patients had

respiratory problems, 21 (14.8%) patients underwent treatment for central nervous system

(CNS) infection, 17 (12.0%) patients were treated for renal failure, 13 (9.2%) patients had

cardiovascular diseases, and 10 (7.0%) patients were in pediatric shock. The average hospital

stay recorded was 7.67 days (SD = 6.56 days). The calculation for pSOFA showed an average

of 3.90 (SD = 4.19), whereas the average score for PELOD-2 was 7.6 (SD – 4.24). There

were 62 (43.7%) death recorded and 80 (56.3%) patients survived.

 Table 1. Subject characteristic data
Demographic characteristic n = 142
Gender, n (%)
Male 94 (66.2)
Female 48 (33.8)
Age, n (%)
< 12 months old 49 (34.5)
12 – 23 months old 6 (4.2)
24 – 59 months old 10 (7)
60 – 143 months old 36 (25.4)
≥ 144 months old 41 (28.9)
Body weight, average (SD),kg 21.22 (17.45)
Body height, average (SD), cm 108.65 (41.52)
Nutritional status, n (%)
Malnutrition 13 (9.2)
Poor nutrition 29 (20.4)
Good nutrition 72 (50.7)
Overweight 16 (11.3)
Obese 12 (8.5)
Ventilator use, n (%)
Yes 109 (76.8)
No 33 (23.2)
Indication, n (%)
Respiratory issues 36 (25.4)
Cardiovascular disease 13 (9.2)
CNS 21 (14.8)
Pediatric shock 10 (7)
Renal failure 17 (12)
Post-op 45 (31.7)
Length of stay, average (SD), days 7.67 (6.56)
pSOFA, average (SD) 3.9 (4.19)
PELOD-2, average (SD) 7.6 (4.24)
Outcome, n (%)
Death 62 (43.7)
Lived 80 (56.3)

PELOD-2 Score and Mortality

The analysis results for the characteristic relationshiop between PELOD-2 score and

mortality incidences is shown in Table 2. The average Glasgow Coma Scale (GCS) score in

died patients was 7.10 and the score was higher in the patients who lived – at an average

score of 11.23. Using the Mann-Whitney test, a significant relationship between GCS value

and the outcome of patients was observed (p < 0.001). The observation of MAP value showed

that patients who died had lower MAP values than patients who lived. A significant

relationship (p=0.011) between MAP value and the outcome of patients was observed in
patients in ≥144 months old age group, where the average MAP value in died patients was

68.4 mmHg, while the average MAP value in patients who lived was 80.74 mmHg. On the

requirement of ventilator in the PICU, there was a significant relationship between ventilator

uses and the outcome of patients (p=0.007). From the medical record, among 111 children

who required ventilators, almost half (49.5%) patients died, while among 31 children who did

not require ventilators, there were only 7 patients who did not survive. The assessment by

using PELOD-2 score showed an average score of 11.13 in died patients and 3.91 in survived

patients. By using Mann-Whitney test, there was a significant relationship between PELOD-2

score and the outcome of patients (p<0.001).

Other parameters from PELOD-2 scoring system, such as reflects to light, lactate

content, renal status, respiratory status, platelet and white blood cell counts, were not

significant to the outcome of the research participants.

Table 2. PELOD-2 score characteristic and mortality

Died Lived RP
Characteristic p
(n=62) (n=80) 95% CI
Neurology, average (SD)
Consciousness (GCS) 7.10 (2.90) 11.23 (2.38) <0.001a -
Light reflects, n (%)
Reactive 51 (42.5) 69 (57.5) 0.514b 0.850
Non-reactive 11 (50) 11 (50) 0.533-1.356
Cardiovascular, average (SD)
Lactatemia (mmoI/L) 2.04 (1.29) 1.86 (1.01) 0.720a -
MAP (mmHg) (months)
< 12 months old 60.40(14.53) 63.52 (14.53) 0.372c -
12 – 23 months old 63.50 (4.95) 68.33 (8.79) 0.355a -
24 – 59 months old 61.67 (2.89) 67.6 (10) 0.606a -
60 – 143 months old 76.26 (19.54) 79.22 (19.75) 0.739a -
≥ 144 months old 68.4 (14.57) 80.74 (13.13) 0.011c -
Renal, average (SD)
Creatinine (moL/L)
< 12 months old 9.76 (44.23) 1.60 (2.15) 0.215a -
12 – 23 months old 0.56 (0.12) 0.41 (0.06) 0.165a -
24 – 59 months old 0.77 (0.58) 1.41 (1.58) 0.199a -
60 – 143 months old 4.31 (5.33) 2.07 (3.15) 0.222a -
≥ 144 months old 2.43 (3.72) 2.65 (3.78) 0.374a -
Respiratory, average (SD)
PCO2 34.48 (14.48) 32.27 (13.57) 0.312a -
PO2 156.23 (40.81) 163.83 (33.65) 0.500a -
 Pa02 126.07 (28.74) 132.81 (21.60) 0.183a -
SaO2 97.67 (3.45) 98.90 (1.36) 0.110a -
Fi02 59.84 (22.18) 54.93 (16.24) 0.425a -
PaO2 (mmHg)/FiO2 242.16 (107.77) 261.48 (86.21) 0.183a -
SaCO2 (mm Hg)/FiO2 187.95 (70.68) 196.28 (61.91) 0.318a -
Ventilator, n (%)
Yes 55 (49.5) 56 (50.5) 0.007a 2.194
No 7 (22.6) 24 (77.4) 1.114-4.324
Hematologic, average (SD)
WBC count ( x 103/µL ) 11.62 (9.52) 15.84 (16.09) 0.051a -
Platelets (x 10 /µL)
3
254.78 (175.86) 276.73 (186.64) 0.614a -
PELOD-2 score, average (SD) 11.13 (1.59) 3.91 (2.65) <0.001a -
a
Mann Whitney, bChi Square, cT Independent

PSOFA Score and Mortality

The analysis results for the characteristic relationshiop between pSOFA score and mortality

incidences is shown in Table 3. Most parameters in pSOFA scoring system were not far

different from the parameters in PELOD-2 score. The additional parameters in pSOFA

scoring were hepatic, such as total and direct bilirubin. The average total bilirubin in died

patients was 10.70 mg/dL and in survived patients was much lower at 4.22 mg/dL. The

average direct bilitubin on died patients was 6.68 mg/dL and in survived patients was lower at

2.47 mg/dL. The assessment by using pSOFA score showed an average score of 7.81 in died

patients, while in survived patients the average score was 0.88. By using Mann-Whitney test,

there was a significant relationship between pSOFA score and the outcome of the patients (p

< 0.001).

Table 3. PSOFA score characteristic and mortality

Died Lived RP
Characteristic p
(n=62) (n=80) 95% CI
Neurology, average (SD)
Consciousness (GCS) 7.10 (2.90) 11.23 (2.38) <0.001a -
Light reflects, n (%)
Reactive 51 (42.5) 69 (57.5) 0.514b 0.850
Non-reactive 11 (50) 11 (50) 0.533-1.356
Cardiovascular, average (SD)
Lactatemia (mmoI/L) 2.04 (1.29) 1.86 (1.01) 0.720a -
MAP (mmHg) (months)
< 12 months old 60.40(14.53) 63.52 (14.53) 0.372c -
12 – 23 months old 63.50 (4.95) 68.33 (8.79) 0.355a -
24 – 59 months old 61.67 (2.89) 67.6 (10) 0.606a -
 60 – 143 months old 76.26 (19.54) 79.22 (19.75) 0.739a -
≥ 144 months old 68.4 (14.57) 80.74 (13.13) 0.011c -
Renal, average (SD)
Creatinine (moL/L)
< 12 months old 9.76 (44.23) 1.60 (2.15) 0.215a -
12 – 23 months old 0.56 (0.12) 0.41 (0.06) 0.165a -
24 – 59 months old 0.77 (0.58) 1.41 (1.58) 0.199a -
60 – 143 months old 4.31 (5.33) 2.07 (3.15) 0.222a -
≥ 144 months old 2.43 (3.72) 2.65 (3.78) 0.374a -
Respiratory, average (SD)
PCO2 34.48 (14.48) 32.27 (13.57) 0.312a -
PO2 156.23 (40.81) 163.83 (33.65) 0.500a -
Pa02 126.07 (28.74) 132.81 (21.60) 0.183a -
SaO2 97.67 (3.45) 98.90 (1.36) 0.110a -
Fi02 59.84 (22.18) 54.93 (16.24) 0.425a -
PaO2 (mmHg)/FiO2 242.16 (107.77) 261.48 (86.21) 0.183a -
SaCO2 (mm Hg)/FiO2 187.95 (70.68) 196.28 (61.91) 0.318a -
Ventilator, n (%)
Yes 55 (49.5) 56 (50.5) 0.007a 2.194
No 7 (22.6) 24 (77.4) 1.114-4.324
Hematologic, average (SD)
WBC count ( x 103/µL ) 11.62 (9.52) 15.84 (16.09) 0.051a -
Hepatic (mg/dL)
Total bilirubin 10.70 (3.78) 4.22 (5.67) <0.001a -
Direct bilirubin 6.68 (3.30) 2.47 (3.57) <0.001a -
pSOFA score, average (SD) 7.81 (.25) 0.88 (1.36) <0.001a -
a
Mann Whitney, Chi Square, T Independent
b c

PELOD-2 and pSOFA Scores in Predicting Mortality

By using ROC curve analysis, the area under curve (AUC) for PELOD-2 score in predicting

mortality was 98.7%, with p <0.001 and 95% CI 97.2% - 100%. The results showed that

PELOD-2 score had a good performance in predicting mortality (AUC > 90%). The cut-off

point for PELOD-2 score to predict mortality was 8.5. With that data, the sensitivity obtained

was 96.8%, specificity 95%, PPV 93.8%, and NPV 97.4%. The accuracy for PELOD-2 score

was 95.8%. Meanwhile, for pSOFA, the AUC was 97/4% with p < 0.001 and 95% CI 94.5% -

100%. The results also indicated that pSOFA score had a good performance in predicting

mortality (AUC > 90%). The cut-off point for pSOFA score to predict mortality was 3.5.

With that data, the sensitivity obtained was 96.8%, specificity 96.2%, PPV 95.2%, and NPV

97.5%. The accuracy for PELOD-2 score was 96.5%.

Table 4. PELOD-2 and pSOFA accuracy in predicting mortality
Scoring Mortality
Sensitivity Spesificity PPV NPV
System Yes No
PELOD-2
≥ 8.5 60 4 96.8% 95% 93.8% 97.4%
< 8.5 2 76
pSOFA
≥ 3.5 60 3 96.8% 96.2% 95.2% 97.5%
< 3.5 2 77

Discussion
Both PELOD-2 and pSOFA scoring systems in this research conducted on 142 pediatric

patients receiving treatment in the PICU of Haji Adam Malik hospital Medan, Indonesia

showed good performance with AUC <90%. The cut-off values to predict mortality were 8.5

for PELOD-2 and 3.5 for pSOFA. For PELOD-2, the sensitivity was 96.8%, specificity was

95%, PPV was 93.8%, NPV was 97.4%, and the accuracy was 95.8%. In comparison, pSOFA

had 96.8% sensitivity, 96.2% specificity, 95.2% PPV, 97.5% NPV, and 96.5% accuracy. The

results showed that pSOFA had better performance than PELOD-2 in predicting mortality in

the research participants.

Dewi and Fatimazzuhroh from the Department of Child Health, Faculty of Medicine,

Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital Jakarta conducted a study based on

the PELOD-2 scoring system from the profile of critically ill patients receiving treatement

from Dr. Cipto Mangunkusumo Hospital. PELOD-2 score had 84.5% specificity, 84.3%

sensitivity, AUC 93.4% (95% CI 90.6 – 96.2). The results concluded that PELOD-2 scoring

could predict life-threatening organ dysfunction in children without immunosuppression.

Higher PELOD-2 scores were followed by longer hospital stay and higher mortality. 10)

Adaptation and validation of pSOFA scores were carried out by Matics and Sanchez-Pinto. In

their research, they compared pSOFA to other organ dysfunction assessment system, such as

PELOD, PELOD-2, and PMODS. In addition, pSOFA components were clinically evaluated

and compared to the pediatric risk of mortality (PRISM) III, which is a scoring system to
assess the severity of diseases. The mortality prediction by pSOFA showed better

performance compared to the other assessment and the same as PRISM III evaluation system

with AUC 0.88; 95% CI, 0.86-0.91, p≤0.02.11)

SOFA and quick SOFA (qSOFA) scores have been adjusted to age limit, and SOFA

score for cardiovascular and renal dysfunctions are defined following PELOD-2 score. SOFA

and PELOD-2 are significantly more accurate in mortality prediction compared to systemis

inflammatory response syndrome (SIRS) and qSOFA. It is crucial to emphasis that qSOFA is

only a screening tool for sepsis, and not for diagnosis. SOFA scoring system has easily

measured and available variables, and it has become a routine assessment in the ICU. Unlike

PELOD score that uses larger number and more intricate variables.8,9)

Both PELOD-2 and pSOFA scores could be used to assess organ dysfunctions in

pediatric patients with chronic condition treated in the PICU and predict mortality risk.

Reassessment of either PELOD-2 or pSOFA is required at a regular basis with any changes in

the patients’ conditions.

Conclusion
The pediatric SOFA (pSOFA) outperformed PELOD-2 score in predicting mortality in

critically ill children patients admitted to the PICU of Haji Adam Malik hospital Medan,

Indonesia.

Conflict of Interest
None declared.
Funding Acknowledgement
The authors received no specific grant from any funding agency in the public, commercial, or
not-for-profit sectors.

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