Aims & Objectives: In 2019, 80% of child deaths were in low- and middle-income countries (LMICs). LMICs have a range of available resources, which could influence outcomes. This analysis determined case-fatality rates (CFRs) for common causes of pediatric hospital mortality in LMICs and explored differences by sociodemographic index (SDI). Methods: For this systematic review, we searched MEDLINE, EMBASE, CINAHL, and LILACS for observational studies from LMICs published 1/1/2005-2/26/2021. Eligible studies included a general pediatric (aged >28d-12yrs) hospital population. We performed meta-analyses of cause of mortality (number of deaths/1000 admissions) and CFRs (number of deaths/total cases) using random-effects models, analyzed differences by SDI, and report 95% confidence intervals (95%CI) and p-values (p<0.05 statistically significant). Results: Overall, 253 studies representing 21.8million hospitalizations, 293 sites, and 59 LMICs were analyzed. Top causes of hospital mortality and CFRs are shown; CFR improved as SDI increased for malaria, pneumonia, and sepsis (Table). Common causes of hospital mortality (per 1000 admissions) and cause-specific CFR by SDI - Mortality(95%CI) CFR(95%CI)* Diagnosis Overall Low-SDI Low-Middle-SDI Middle-SDI p-value Malaria 12.8(9.7-16.2) 5.1(3.7-6.6) 6.9(4.3-9.9) 3.5(2.3-4.9) 1.3(0.8-1.9) <0.0001 Shock 11.6(4.3-22.4) 12.9(9.8-16.3) NR 12.9(9.8-16.3) NR - Malnutrition 9.4(6.3-13.0) 12.2(9.4-15.4) 11.6(7.3-16.7) 12.8(8.8-17.3) 12.9(9.4-17.3) 0.92 Pneumonia 7.9(3.6-13.9) 4.8(1.7-9.3) 6.2(0.3-18.3) 5.5(3.6-7.7) 1.0(0.5-1.6) <0.0001 Sepsis 4.8(3.1-6.7) 19.9(13.6-26.9) 18.0(11.5-25.4) 23.3(17.5-29.7) 8.6(0.6-22.8) 0.14 NR:not reported *pooled estimates Conclusions: Lower SDI countries had a higher risk of death for common diagnoses, suggesting that resource availability and access to care, including critical care, impact pediatric hospital outcomes. Global collaboration is needed for knowledge exchange, best practices development, and resource investments to address child health disparities. Keywords: Resource-limited settings, low- and middle-income countries, global health, acute critical illness,