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Global variation in injury patterns, interventions, and post-operative outcomes for children and adolescents
Riaz Aziz1, Michael F Bath1, Sarah M Abdelmohsen2
1International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK.
Insights
Paediatric trauma laparotomy is more common in lower-resource settings, but children face significantly higher mortality risks. Global health leaders must prioritize developing pediatric trauma care to address these disparities.
Area of Science:
- Global Health
- Paediatric Surgery
- Trauma Care
Background:
- Trauma is a leading cause of death and disability in children globally.
- Paediatric trauma care is often overlooked in health system development.
- Understanding global standards in paediatric laparotomy care is crucial.
Purpose of the Study:
- To assess global standards of laparotomy care for paediatric blunt or penetrating traumatic injuries.
- To analyze variations in paediatric trauma patient injury patterns, interventions, and outcomes.
- To identify disparities in care based on socioeconomic factors.
Main Methods:
- Post-hoc analysis of the prospective, observational Global Outcomes After Laparotomy for Trauma (GOAL-Trauma) Study.
- Inclusion of patients aged 18 or younger undergoing laparotomy within 5 days of presentation.
- Stratification of countries by Human Development Index (HDI) to analyze mortality risk.
Main Results:
- 237 paediatric patients from 85 hospitals in 32 countries were analyzed.
- Longer injury-to-operation times were observed in lower and middle HDI countries.
- Patients in lower HDI countries had a nearly sixfold higher adjusted risk of 30-day mortality post-laparotomy.
Conclusions:
- Children in lower-resource settings undergo proportionally more trauma laparotomies but experience substantially higher mortality.
- Significant global variations exist in paediatric trauma care pathways.
- Prioritizing the development of paediatric trauma care is essential for policymakers and healthcare leaders worldwide.
Background:
Trauma is the leading cause of death and disability in children and adolescents worldwide; however, paediatric trauma care is often neglected during health system development. We aimed to understand current global standards of laparotomy care for paediatric patients with blunt or penetrating traumatic injury and variation in patient injury patterns, intervention, and post-operative outcomes.
Methods:
This is a planned post-hoc analysis of the international, multicentre, prospective, observational cohort from the Global Outcomes After Laparotomy for Trauma (GOAL-Trauma) Study, which was conducted between April 1 and Dec 31, 2024. Patients aged 18 years or younger with a blunt or penetrating traumatic injury who underwent a laparotomy within 5 days of presentation were eligible. Countries were stratified by the Human Development Index (HDI), and the primary outcome was post-operative in-hospital 30-day mortality. Adjusted mortality risk was calculated using least absolute shrinkage and selection operator regression analysis. The study was registered with ClinicalTrials.gov (NCT06180668).
Findings:
237 paediatric patients who underwent a trauma laparotomy were recruited from 85 hospitals in 32 countries, with the highest proportion of patients living in countries in the lower HDI tertile (110 [20%] of 563 cases overall). The median age among paediatric cases was 16·0 years (IQR 12·0-18·0), and most patients were male (195 [82%] of 237 patients) and had sustained a blunt injury (135 [57%] patients). The median time globally from injury to operation was 7·4 h (IQR 3·5-18·8; n=235), with longer times observed across the patient pathway for patients in the lower and middle HDI tertiles than for those in the upper HDI tertile (p=0·0008). The overall 30-day in-hospital crude mortality rate was 8% (19 of 237 patients); however, after adjustment, patients in the lower HDI tertile were nearly six times more likely to die post-operatively than those in the upper HDI tertile (odds ratio 5·69 [95% CI 1·58-20·44], p=0·0079).
Interpretation:
Proportionally more children undergo trauma laparotomy in lower-resource settings than in higher-resource settings; however, their mortality risk is substantially higher. Marked variation exists in paediatric pathways globally, and policy makers and health-care leaders should prioritise the development of paediatric trauma care worldwide.
Funding:
Royal College of Surgeons Ratanji Dalal Research Fellowship and the Engineering and Physical Sciences Research Council.
