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Background In children, the value of routine blood pressure measurement in first assessment at the emergency department has been questioned. This has, however, not yet been evaluated in low- and middle-income countries (LMICs) where the incidence of serious illness is high. This study assessed the predictive value of low systolic blood pressure to detect serious illness in children attending acute care settings in LMICs.Methods This observational study is based on data from children attending three acute care settings in The Gambia and Suriname. Hypotension was defined by age-adjusted reference values according to Advanced Paediatric Life Support (APLS) and Paediatric Advanced Life Support (PALS) cut-offs. The outcome measure was a composite marker of serious illness consisting of admission or referral to a higher level of care. A logistic regression analysis was used to evaluate the association between hypotension and serious illness for each setting separately.Results 20 185 visits from Gambia rural, 398 visits from Gambia urban and 1817 visits from Suriname were included. Hypotension was present in 8.3–17.3% of visits and serious illness in 3.9–15.7%. Hypotension was not significantly associated with serious illness in Gambia urban (OR APLS 3.2 (0.7–10.9) and ORPALS 1.4 (0.1–7.6)) and Suriname (ORAPLS 1.3 (0.9–1.9) and ORPALS 1.7 (0.9–3.2)), and with an inverse association in Gambia rural (ORAPLS 0.6 (0.5–0.7) and ORPALS 0.9 (0.5–1.4)).Conclusions Our results do not show a significant association between hypotension and serious illness in LMICs. Our results suggest that routine blood pressure measurement does not aid in the evaluation of well-appearing children attending acute care settings in LMICs.