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Published on: August 16, 2019
Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline
Anis Ben Abdeljelil1,2, Gabrielle C Freire3,4, Natalie Yanchar5
1Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Quebec City, Quebec, Canada.
Insights
Clinical practice guidelines for pediatric traumatic brain injury (TBI) show variability. Many recommendations lack strong evidence, emphasizing the need for more pediatric TBI research.
Area of Science:
- Pediatric Neurology
- Neurotrauma
- Evidence-Based Medicine
Background:
- Traumatic brain injury (TBI) is a primary cause of childhood death and disability.
- Existing clinical practice guidelines (CPGs) for pediatric TBI exhibit considerable variability in application.
- A need exists to systematically review and evaluate current CPGs for moderate-to-severe pediatric TBI.
Purpose of the Study:
- To systematically review CPG recommendations for pediatric moderate-to-severe TBI.
- To assess the quality of these CPGs and the evidence supporting their recommendations.
- To identify knowledge gaps in current pediatric TBI management guidelines.
Main Methods:
- Systematic literature search across major databases (MEDLINE, Embase, Cochrane, Web of Science).
- Inclusion of CPGs from high-income countries (2012-2023) for pediatric moderate-to-severe TBI.
- Quality assessment using AGREE II tool and evidence synthesis via GRADE framework.
Main Results:
- Fifteen CPGs were identified; 9 met moderate-to-high quality standards (AGREE II).
- Of 90 recommendations, 40 (45%) were evidence-based; 11 had moderate-to-high evidence.
- Key evidence-based areas included transfer, imaging, ICP control, and discharge advice.
Conclusions:
- Significant gaps exist in evidence-based recommendations for transfusions, thromboprophylaxis, and mental health management in pediatric TBI.
- Despite available CPGs, a lack of robust supporting evidence necessitates urgent clinical research for this population.
- Findings can guide clinicians, administrators, researchers, and guideline developers in pediatric TBI care.
Abstract:
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.
