Data on outcomes after admission in pediatric emergency departments are sparse in India. Our objectives were to determine the clinical and epidemiologic profile of acutely ill children and to identify risk factors for mortality. Prospective, longitudinal study, conducted in 1999. Pediatric emergency department at the Institute of Child Health, a multiple specialty, children's referral, public hospital in Madras, India. Children of <12 yrs of age who required acute care in the pediatric emergency department (excluding minor illnesses) recruited consecutively during a 2-mo period. Data included demographic variables, clinical profile, diagnoses, therapy, and in-hospital mortality after admission (outcome). In a cohort of 1155 children, there were 141 deaths (12.2%). Mortality was highest in the neonatal group (17.8%), which accounted for 67% of all deaths. Among neonates, breathlessness, poor feeding, birth asphyxia, and prematurity were the most common presenting problems. Among the postneonates, breathlessness, fever, and fits ranked high. Multivariate analyses to determine risk factors were done separately for neonates, postneonates, and those aged 1-12 yrs. Among neonates, age of 1 yr, central-peripheral temperature gap and respiratory failure were major risk factors. The incidence of mortality is high in our setting and further research is needed to identify causes of preventable deaths. Children presenting with signs of hypoperfusion and respiratory failure had poor outcomes. This raises the concern that children may be presenting late, with advanced, severe illness to our pediatric emergency department. The data also suggest that identification of serious illness in children is possible with simple clinical signs and symptoms.