Development and validation of a machine learning model for in-hospital mortality prediction in children under 5 years with heart failure

Background: Heart failure (HF) in children under five years of age carries a high risk of in-hospital mortality, yet existing pediatric risk assessment tools lack specificity for this population. There is a pressing need for reliable, interpretable prediction models tailored to pediatric HF. Methods: We retrospectively analyzed 630 hospitalized children under five with heart failure from 2013 to 2024. After excluding those with uncorrected congenital heart disease or terminal comorbidities, 67 variables were assessed, and seven key predictors were identified using the Boruta algorithm. Six machine learning models were developed; the Extreme Gradient Boosting (XGB) model was selected and interpreted using SHAP. External validation included 73 additional cases. Results: The XGB model achieved high predictive performance (AUC: 0.916 training, 0.851 internal validation, 0.846 external validation). The top predictors were NT-proBNP, pH, PCT, LDH, WBC, creatinine, and platelet count. SHAP analysis confirmed the clinical relevance of these variables. Conclusion: This study presents a reliable, interpretable machine learning model for predicting in-hospital mortality in young children with heart failure. It holds promise for early risk stratification and timely intervention, potentially improving outcomes in this high-risk population.