A systematic review and quality analysis of pediatric traumatic brain injury clinical practice guidelines
A systematic review and quality analysis of pediatric traumatic brain injury clinical practice guidelines
Roselyn Appenteng 1 2
Taylor Nelp 2
Jihad Abdelgadir 0 2
Nelly Weledji 2
Michael Haglund 0 2
Emily Smith 0 2
Oscar Obiga 2
Francis M. Sakita 2 3
Edson A. Miguel 2
Carolina M. Vissoci 2
Henry Rice 2
Joao Ricardo Nickenig Vissoci 0 2
Catherine Staton 0 2
0 Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Duke University Medical Center , Durham , North Carolina, United States of America, 4 University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America, 5 Duke Global Health Institute, Duke University , Durham , North Carolina, United States of America, 6 Mbarara Regional Referral Hospital , Mbarara , Uganda
1 Duke University School of Medicine , Durham , North Carolina, United States of America, 2 Division of Emergency Medicine, Duke University Medical Center , Durham, North Carolina , United States of America
2 Editor: Yoshiyuki Tachibana, National Center for Child Health and Development , JAPAN
3 Kilimanjaro Christian Medical Center , Moshi , Tanzania , 8 Division of Pediatric Intensive Care, State University of Maring aÂ , Maring aÂ, Paran aÂ , Brazil , 9 Department of General Surgery, North Wing Regional Hospital , Asa Norte, Brasilia , Brazil , 10 Duke Division of Pediatric Surgery, Duke University Medical Center , Durham, North Carolina , United States of America
Articles were identified and retrieved from MEDLINE, EMBASE, Cochrane Library, LILACS, Africa-Wide Information and Global Index Medicus. These articles were screened by four reviewers independently. Based on the eligibility criteria, with the exception of literature reviews, opinion papers and editor's letters, articles published from 1995 to November 11, 2016 which covered clinical recommendations, clinical practice or treatment guidelines for the acute management of pediatric TBI (within 24 hours) were included for review. A reference and citation analysis was performed. Seven independent reviewers from low, middle and high income clinical settings with knowledge of pediatric TBI management appraised
Data Availability Statement: All relevant data are
within the paper and its' Supporting Information
Funding: Dr. Staton would like to acknowledge
salary support funding from the Fogarty
International Center (Staton, K01
TW01000001A1). The funders had no role in study design,
data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
Traumatic brain injuries (TBI) are a significant cause of mortality and morbidity for children
globally. Adherence to evidence-based treatment guidelines have been shown to improve
TBI outcomes. To inform the creation of a pediatric TBI management guideline for a low and
middle income country context, we assessed the quality of available clinical practice
guidelines (CPGs) for the acute management pediatric TBI.
the guidelines using the AGREE II instrument. Scores for the CPGs were aggregated by
domain and overall assessment was determined.
We screened 2372 articles of which 17 were retained for data extraction and guideline
appraisal. Except for one CPG from a middle income country, the majority (16/17) of the
guidelines were developed in high income countries. Seven guidelines were developed
specifically for the pediatric population, while the remaining CPGs addressed the acute
management of TBI in both adult and pediatric populations. The New Zealand Guideline Group
(NZGG, 2006) received the highest overall assessment score of 46/49 (93.88%) followed by
the Scandinavian Neurotrauma Committee (SNC, 2016) with a score of 45/49 (91.84%)
followed by the Scottish Intercollegiate Guideline Network (SIGN, 2009) and Brain Trauma
Foundation (BTF 2012) both with scores of 44/49 (89.80%). CPGs from Cincinnati
Children's Hospital (CCH 2006) and Sao Paulo Medical School Hospital/Brazilian Society of
Neurosurgery (USP/BSN, 2001) received the lowest score of 27/49 (55.10%) subsequently
followed by the Appropriateness Criteria (ACR, 2015) with 29/49 (59.18%). The domains
for scope and purpose and clarity of presentation received the highest scores across the
CPGs, while applicability and editorial independence domains had the lowest scores with a
wider variability in score range for rigor of development and stakeholder involvement.
To our knowledge, this is the first systematic review and guideline appraisal for pediatric
CPGs concerning the acute management of TBI. Targeted guideline creation specific to the
pediatric population has the potential to improve the quality of acute TBI CPGs.
Furthermore, it is crucial to address the applicability of a guideline to translate the CPG from a
published manuscript into clinically relevant local practice tools and for resource limited practice
Traumatic brain injuries (TBI) are a significant cause of mortality and morbidity among
children. [1±3] Between 2002 to 2006, for children between 0 to 14, emergency department visits
for fall-related TBIs increased by 62% from 290 to 470.5 per 100,000. Children now account
for the highest rates of TBI-related emergency room visits across the general population. [1,
Although the incidence of pediatric TBI varies broadly, the burden of trauma and
associated TBI is comparatively higher in low and middle income countries (LMIC). [
2, 7, 8
Globally, 95% of injuries in the pediatric population occurs in LMICs. An estimated 950,000 deaths
occur annually due to injuries sustained by children of which 90% are unintentional.
Worldwide, injuries are the leading cause of death for children aged 10 to 19 years. In children under
15 years, TBIs account for the highest rates of unintentional injuries. [
] The CRASH trial,
a multinational randomized controlled trial evaluating corticosteroid used to treat significant
head injury, demonstrated a 2 times higher odds of mortality following severe TBI in LMICs
in comparison high income countries (HICs). 
While the mechanism of injury varies by age, motor-vehicle crashes are the predominant
cause of injury followed by falls, in the US and worldwide. [
1, 2, 11
] The burgeoning
development of motorization and transportation systems remains unmatched by the existing safety
infrastructure in low and middle income countries. As such, children have an increased
vulnerability to traumatic injuries and TBIs within this context especially as pedestrians. [
Moreover, the sequelae of TBI extends beyond mortality to the potential for disability and
associated emotional and financial cost. [
2 / 17
To improve TBI outcomes for the LMIC pediatric population, evidence-based treatment
guidelines must serve a pivotal role alongside the continuum of care which integrates injury
prevention initiatives with a robust trauma system and comprehensive rehabilitation services.
In 1995, the Brain Trauma Foundation developed and subsequently published the Guidelines
for the Management of Severe Traumatic Brain Injury.[
] The fourth edition continues to
focus on identifying the best evidence to guide clinical practice and improve TBI outcomes in
the adult population.[
] The Guidelines for Medical Management of Severe TBI for infants,
children and adolescents was later developed in 2003 and a subsequent edition was released in
2012 to synthesize the best evidence and inform clinical practice in the pediatric population.
Adherence to guidelines have been shown to improve outcomes in the management of
TBIs. Keris et al. demonstrated a reduction in hospital case fatality rate in adult TBI patients
with the implementation of TBI guidelines in Latvia.[
] In a retrospective and prospective
data analysis, Palmer et al demonstrated an odds ratio of 9.13(95% CI 3.25, 25. 67) of a good
outcome in comparison to a poor outcome or death when American Association of
Neurological Surgeons Guidelines for the management of severe head injury were adapted for a TBI
protocol in community hospital setting.[
] Similar studies have demonstrated improvement in
clinical outcomes following the implementation of the Brain Trauma Foundation's guidelines
in both the adult and pediatric population[21±23].
However, implementing a suitable clinical practice guideline (CPG) for the management of
acute TBI in an LMIC poses a challenge. Literature on TBI guideline creation and use in LMIC
is limited. [
] Of the 24 TBI clinical practice guidelines appraised in a previous systematic
review, Patel et al found only one developed in a LMIC. [
] Furthermore, the gap between the
available resources and the requisite resource capacity necessary to effect guideline
recommendations as well as the variability in trauma systems often remain unaddressed. [
] In order
to inform the locally driven creation of acute pediatric TBI management guideline for an
LMIC context, we aim to assess the quality of available CPGs for the acute diagnostics and
management of pediatric TBI by undertaking a systematic review of the available literature.
Materials and methods
Protocol and registration
A protocol for this review is undergoing review for registration in the PROSPERO
(International Prospective Register of Systematic Reviews) database (S1 Text). This systematic review
is reported according to the Preferred Reporting Items for Systematic Review and
Meta-Analyses (PRISMA) Statement (S2 Table). [
The inclusion criteria for articles were the following: abstracts must mention either (clinical)
recommendations, (clinical) practice guidelines or treatment guidelines for the acute
management of TBI (within 24 hours). Subsequently, full texts were retrieved and excluded if the texts
were literature reviews, opinion papers or editor's letters, published prior to 1995.
Furthermore, the clinical practice guidelines (CPGs) had to include the pediatric population as defined
by the age range from birth to 18 years or a subset of the pediatric population. The newest
versions of the CPGs were included for review, if multiple editions were available. All levels of
TBI severity were included in this review. We contacted authors to find English versions of
candidate abstracts with published non-English full texts.
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Identification of studies
The search strategy was used to identify relevant abstracts from MEDLINE, EMBASE,
Cochrane Library, LILACS, Africa-Wide Information and Global Index Medicus is provided
in S1 Table. Additional abstracts were retrieved from the Duke University Medical Center
Guidelines repository. These guidelines are sourced from the National Guidelines
Clearinghouse, American College of Emergency Medicine, Canadian Medical Association-Clinical
Practice Guidelines and National Institute of Health and Clinical Excellence Guidelines. After
the full text review, we performed a reference and citation analysis primarily using Web of
Science. The citation analysis was augmented with Google Scholar and a manual search of
references was performed when necessary.
We identified candidate abstracts with ªCraniocerebral Traumaº, ªBrain injuryº, ªPractice
Guidelineº [Publication Type], ªEvidence-Based Medicineº as MeSH terms. Limits to exclude
animals, editorials, letters, case reports and comments were also applied in the search strategy
as demonstrated in S1 Table for MEDLINE. No language or date limits were applied to the
Four reviewers working in pairs, (R.A. and T.N.) and (J.A. and N.W.) evaluated the titles and
abstracts independently. Thereafter, full-text manuscripts were retrieved and independently
evaluated with the eligibility criteria for inclusion. Articles included from the reference and
citation analysis were also evaluated based on the eligibility criteria. We included articles based
on consensus and any disagreements were resolved by a third reviewer (C.S.)
The two pairs of reviewers, (R.A. and T.N.) and (J.A. and N.W.), independently extracted
general characteristics of the CPGs. The information obtained included the following: year of
publication, year updated (if multiple versions available), country of guideline development,
institution or organization responsible for guideline development and the type of group
responsible for the development of the guideline, specific descriptors including professional,
academic, non-profit, international or mixed were provided. Additionally, the focus of the
guideline whether prehospital care, early management, imaging, ICU or covering the complete
spectrum of care was also indicated. The patient population, if present and severity of brain
injury reported in the guideline was also extracted. We noted the income delineation of the
country or countries of origin for the guideline as high-, middle- or low- income with
according to the World Bank's determination. [
Seven appraisers from low, middle and high income clinical settings with knowledge of
pediatric TBI management independently evaluated the quality of the final CPGs using the Appraisal
of Guidelines for Research and Evaluation (AGREE) II instrument. [
] The appraisers
were from the USA, Brazil, Tanzania and Uganda. Both English and Portuguese translations of
the AGREE II user's manual were provided to the appraisers. The CPGs were evaluated using
an electronic form adapted from the user's manual. The AGREE II instrument is the current
gold standard tool for assessing the quality of CPGs and the quality of the development of the
guideline.  The tool consists of six thematic domains which are addressed using 23 items.
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Each item is graded on a seven-point scale with ªstrongly agreeº garnering the highest score of
7 and ªstrongly disagreeº associated with a 1. The six domains include the following: scope
and purpose, stakeholder involvement, rigor of development, clarity of presentation,
applicability and editorial independence. [
Domain one focuses on the scope and purpose of the guideline specifically evaluating the
overall objective, pertinent health questions and target population covered by guideline. The
stakeholder involvement addressed in domain two determines whether relevant professional
groups were involved in the development of the guideline, if the CPGs are reflective of the
views and preferences of the target population and seeks for a definition of the guideline's
target users. Domain three determines whether the body of evidence leading to the
recommendations in the guidelines, was systematically searched and included for review based on clear
selection criteria. Furthermore, this domain determines whether the strengths and weaknesses
of the body of evidence were assessed, whether the link between recommendations and the
evidence was well delineated in the guideline, if the method(s) for formulating the
recommendations was clear and if the recommendations reflect an evaluation of pertinent health
benefits, risks and side effects. Lastly, domain three assesses the involvement of an external expert
review of the guideline before publication and if there is a method to update the guideline.
Domain four which examines the clarity of presentation of the CPGs evaluates whether
the recommendations are specific and unequivocal, present different options for
management and if the most important recommendations can be easily identified. Domain five
delves into the applicability of the CPG. This domain considers the facilitators and barriers
that impact the use of the guideline. Additionally, it evaluates the availability of tools and
resources to implement the guidelines, information on the resource utilization cost and
economic consideration pertaining to guideline as well as the presence of audit criteria. The
editorial independence of the guideline is addressed in the sixth domain, where the potential
competing interests of the guideline development group and the influence of the funding
body's views are assessed. [
Subsequently, a global assessment of the guideline was performed with an overall
sevenpoint scale quality rating. Here, appraisers also determined whether they would recommend
the CPG for use by indicating ªyesº, ªyes with modificationsº or ªnoº. [
The individual scores for the 23 items were summed within each respective domain, according
to the AGREE II user's manual to determine the overall domain scores for each CPG.
Afterwards, the individual domain scores are scaled according to the following formula:
Maximum possible score
Minimum possible score
Minimum possible score
The highest possible scaled score for a domain is equivalent to 100% while 0% equates to
the lowest possible scaled score. The percentage scores were calculated for the six domains of
each guideline. A descriptive analysis of the CPGs was performed and an assessment for the
CPGs according to the respective domains is provided. An intraclass correlation coefficient
(ICC) was calculated using R for statistical computing to assess the consistency of appraisers'
evaluations across each domain. A criteria of 0.7 was used an acceptable inter-rater reliability
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Fig 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram.
The initial search strategy produced 2824 titles and abstracts resulting in 2,372 unique records
for review after the removal of 452 duplicates (Fig 1). Subsequently, 1755 abstracts were
exempted from further review based on the eligibility criteria. A reference and citation analysis
was performed to retrieve an additional 15 manuscripts. Altogether, 632 full texts with CPGs
were reviewed according to the eligibility criteria of which 17 were retained for data extraction
and guideline appraisal. We contacted authors to find English versions of 37 non-English
texts; of the responses we received none that fit inclusion and exclusion criteria were found.
The systematic review of the literature resulted in the appraisal of 17 CPGs (Table 1) for the
acute management of pediatric TBI. Although the CPGs originated from 5 different continents
namely Asia, South America, Europe and North America, Australia, 10 were developed in
North America [18, 33±41]; of these 8 were from USA. [18, 33±35, 37±40] Apart from one
], all the CPGS were developed in predominantly high income countries or by an
international committee representative of a consortium of high income countries. [18, 33±41,
6 / 17
7 / 17
43±48]The 17 guidelines were created by a variety of guideline development groups namely,
four professional organizations [33±35, 45], two academic institutions [
nonprofit organizations [
18, 36, 37, 48
], two national institutes [
], two regional or state
], two international committees [
]and one from a collaboration
of an academic and professional institute. The target of 10 of the CPGs included both the
adult and pediatric population [18, 34, 37, 38, 42±46, 48] while 7 were restricted primarily to
the pediatric population. [
18, 33, 35, 36, 39, 40, 47
] Altogether, the CPGs spanned the full
spectrum of TBI severity. Here, 7 CPGs addressed all levels of severity [33, 38, 41±44, 48]
while 6 focused on mild or minor TBI. [34±36, 39, 40, 46] Furthermore, 3 CPGs specifically
highlighted the management of severe TBI [
18, 37, 45
] and a remaining CPG focused on both
minor and moderate TBI. [
] The focus of the CPGs varied broadly with one CPG primarily
addressing prehospital care [
], seven focused on early management of acute TBI [
35, 38, 39,
41, 43, 46, 47
] and one CPG [
] specifically addressed imaging in the acute setting. In
addition, two guidelines focused on early management and rehabilitation [
], two early
management and ICU care [
], two early management and subsequent evaluation or more
specifically return to play evaluation in the setting of a concussion. [
] Two guidelines
addressed a broader spectrum of care including prehospital care, early management, surgical
or specialist care and ICU or neurosurgical unit care. [
The AGREE II evaluation of CPGs with the scaled scores and appraisers' comments are
highlighted by domain and the overall assessment is also addressed. The domain specific
results are provided in Table 2 while the overall assessment of the CPGs are described in
Table 3. The consistency of raters' appraisal for each domain, which was determined with the
interrater reliability is presented in Table 4.
Domain oneÐScope and purpose
Evaluation and Management of Children Younger than Two Years Old with Apparently
Minor Head Trauma: Proposed Guidelines (AAP, 2001) received the highest score of 97.62%
in this domain. The lowest score of 65.08% was for the Guidelines for Neurosurgical Trauma
in Brazil (USP/BSN, 2001).
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Domain two-Stakeholder involvement
The highest score of 89.68% was from the Early Management of Patients with a Head Injury
(SIGN, 2009) while the Guidelines for Neurosurgical Trauma in Brazil (USP/BSN, 2001), with
a core of 35.71%, received the lowest score in the domain.
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Domain three-Rigor of development
Guidelines for Neurosurgical Trauma in Brazil (USP/BSN, 2001) received the lowest score of
20.24%. Early Management of Patients with a Head Injury (SIGN, 2009) scored the highest in
this domain with 89.58%
Domain four-Clarity of presentation
Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation (NZGG, 2006)
received the highest score of 95.24%. Guidelines for the Management of Severe Head Injury,
2nd Edition guidelines from the Guidelines Committee on the Management of Severe Head
Injury, the Japan Society of Neurotraumatology (JSN, 2012) received 66.67% as the lowest.
Early Management of Patients with a Head Injury (SIGN, 2009) received the highest score of
79.17% in this domain. The lowest score of 18.45% was for mild traumatic brain injury in
children: just another bump on the head? (CCH 2006)
Domain six-Editorial independence
The highest score was 88.10% which was for the Traumatic Brain Injury: Diagnosis, Acute
Management and Rehabilitation (NZGG, 2006). Guidelines for Neurosurgical Trauma in
Brazil (USP/BSN, 2001) received the lowest score of 20.24%.
Overall guideline assessment
New Zealand's Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation
(NZGG, 2006) received the best overall assessment with 46 out of the maximum 49 points.
The Scandinavian guidelines for initial management of minor and moderate head trauma in
children (SNC 2016) with 45 out of the maximum 49 points received the next highest overall
score. Subsequently, the Early Management of Patients with a Head Injury (SIGN, 2009) and
Guidelines for the acute medical management of severe traumatic brain injury in infants,
children, and adolescents-second edition (BTF 2012) both received 44 out of 49 points for overall
At 27 out of 49 points, Mild traumatic brain injury in children: just another bump on the
head? (CCH 2006) and Guidelines for Neurosurgical Trauma in Brazil (USP/BSN 2001)
received the lowest scores for overall guideline assessment. With a score of 29 out of 49 points,
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the American College of Radiology's Appropriateness Criteria Head TraumaÐChild (ACR
2014) received the next lowest score.
While the level of recommendation varied for each CPG, all the guidelines were
recommended for use. However, Traumatic Brain Injury: Diagnosis, Acute Management and
Rehabilitation (NZGG, 2006) received the highest recommendation for use from all appraisers
(100%). Subsequently, the Scandinavian guidelines for initial management of minor and
moderate head trauma in children (SNC 2016) and the Evaluation and Management of Children
Younger than Two Years Old with Apparently Minor Head Trauma: Proposed Guidelines
(AAP, 2001) received the next highest recommendation for use; both CPGs were individually
recommended by 85.71% of appraisers for use without modification. In contrast, 42.86% of
appraisers would not recommend either Mild traumatic brain injury in children: just another
bump on the head? (CCH 2003) or the Guidelines for Neurosurgical Trauma in Brazil (USP/
BSN 2001) for use.
Interrater reliability for four domains namely, Stakeholder involvement, Rigor of
Development, Applicability, Editorial Independence and Overall Guideline Assessment were above
0.70 demonstrating an acceptable consistency. [
] The domains for Scope and Purpose and
Clarity of Presentation, which were lower in consistency, resulted in intraclass correlation
values of 0.65 and 0.56 respectively.
To the best of our knowledge, this is the first systematic review and guideline appraisal of
CPGs for the acute management of pediatric TBI. Of the 17 CPGs evaluated in this study, ten
were developed for both the pediatric and adult population while the remaining guidelines
were specifically created for the pediatric population. On average, the domains for scope and
purpose and clarity of presentation received the highest scaled scores across the CPGs in
contrast to the domains for applicability and editorial independence which received the lowest
scores. In this study, the CPGs with the best overall assessments include two guidelines
restricted to the pediatric population, namely the Scandinavian guidelines for initial
management of minor and moderate head trauma in children (SNC 2016) and the Guidelines for the
acute medical management of severe traumatic brain injury in infants, children, and
adolescents (BTF 2012). Furthermore, guidelines appraised as the best quality were created by
professional guideline development groups with broad expertise and the experience of creating
previous versions of these guidelines. Only one CPG was created by a guideline development
group from an upper middle income country (UMIC); majority of the guidelines were
developed in high income countries (HICs). Our findings suggest that future acute pediatric TBI
guidelines may benefit in quality when the guideline is population specific and recognized as
an adaptive process with the advantage of being developed with the expertise of a dedicated
guideline development body. The missing perspectives of LMICs in the process of guideline
creation is essential in TBI care.
The guidelines with the highest overall assessment were developed by the Scandinavian
Neurotrauma Committee, Scottish Intercollegiate Guidelines Network, the Brain Trauma
Foundation and the now dissolved New Zealand Guideline Group. Moreover, the CPGs, SNC
2016, SIGN 2009, BTF 2012 and NZGG 2006 received the highest scores for rigor of
development. This domain evaluates whether the CPG uses a robust systematically searched evidence
base that is critically appraised by a development team with broad clinical and technical
expertise to directly inform CPG recommendations. The four guidelines shared two overarching
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factors: not only were the CPGs developed by professional guideline groups, but the members
of these groups had clinical, research and methodological expertise well suited to the endeavor
and the CPGs with the exception of SNC 2016, had undergone iterations with previous
pediatric editions. However, SNC 2016 was borne out of the experience of creating multiple TBI
guidelines. [51±53]. As such the process of CPG is best viewed as progressively adaptive and
the quality is significantly informed by the composition and expertise of the group creating the
In this study, two guidelines limited to the pediatric population emerged among the
appraised guidelines with the highest overall quality. These CPGs are specifically The
Scandinavian guidelines for initial management of minor and moderate head trauma in children
(SNC, 2016) and the Guidelines for the acute medical management of severe traumatic brain
injury in infants, children, and adolescents (BTF, 2012) [
18, 44, 47, 48
] In contrast, NZGG
2006, SIGN 2009 and NICE 2007 which address both adult and pediatric TBI received the
highest overall assessment and received the highest recommendation for use in previous CPG
25, 44, 48, 55, 56
] Our findings suggest that the quality of TBI guideline
development may significantly benefit from addressing a specific population; Moreover, AAP 2001, a
pediatric specific guideline, was appraised as the highest quality CPG in the domain for scope
and purpose, the most highly scored domain. Notably, the domain for scope and purpose
addresses the central impetus for the development of a guideline: the health questions
pertinent to the guideline endeavor, the population of interest and the overall guideline objective.
Targeted guideline development around a population serves to streamline evidence and
prioritize recommendations, all details that are crucial to improving the quality of the guideline. [
The dearth of CPGs from LMICs in the context of the multiple CPG and CPG updates
from HIC highlights a missing perspective in TBI guideline development. One of several issues
inherent in using CPGs developed in HIC in LMIC is the recommendations may not result in
the same outcome. This situation was best demonstrated in the South American trials:
Treatment of Intracranial Pressure (BEST Trip) trials where following ICP monitoring
recommendations resulted in no significant difference between patients treated by ICP monitoring
protocol and patients whose treatment was based on imaging and clinical examination.[
Current efforts by the Global Neurotrauma Research group are underway to create guidelines
for the management of severe TBI for LMIC by determine whether intracranial hypertension
in severe TBI patients can be managed without ICP monitoring. Not only must a CPG be
adaptable to a local context but the evidence base for recommendations must be interpreted
within that context as well. AGREE II indirectly addresses the potential for adaptation as a
guideline strategy or direct implementation of a guideline by evaluating the quality of the
applicability domain. However, similar to previous TBI CPG appraisals, this was the weakest
domain in our review. Improving the quality of CPGs in addressing how well the guidelines
translate from published material into actual clinical practice tools can potentially impact the
adaptation of CPGs for resource limited settings. The World Health Organization's Guidelines
for Essential Trauma Care has demonstrated efforts to create guidelines that can be adapted
across a range of resource settings and along with guideline adaptation tools, good quality TBI
CPGs can be adapted in LMICs. [
Despite the extensive search of databases with access to both English and non-English texts, it
is possible that we may have missed CPGs from countries with unpublished or non-English
TBI guidelines. To the best of our efforts, we contacted authors of non-English texts with
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potential abstracts for English versions of the guidelines. Furthermore, we contacted Chinese
medical schools and medical centers with online publications on acute TBI for local CPGs but
such guidelines within our scope were unavailable. Additionally, AGREE II guideline is
inherently a subjective tool with a potential for bias. However, based on the moderate to high
interrater reliability, the increased number of appraisers and diverse clinical experience of the
appraisers the potential for bias was minimized significantly.
CPGs for the acute management of pediatric TBI, as tools for evidence-based medicine, have
the capacity to inform the development of trauma care systems and improve the quality of
health care delivery. Targeted guideline creation for this specific population has the potential
to improve the quality of acute pediatric TBI CPGs. Moreover, considering the guideline
development process as adaptive over the long term creates the opportunity to build expertise
in guideline development which in turn informs the quality of the CPG. It is crucial to address
the applicability of a guideline to translate the CPG from a publication into a clinically relevant
local practice tools and for resource limited practice settings.
S1 Table. Search strategy for MEDLINE.
S2 Table. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
S1 Text. PROSPERO registration.
Meetings: Interim analysis has been presented at Duke University School of Medicine's Alpha
Omega Alpha Medical Society 47th Annual Scientific Research Symposium. August 4th, 2017
in Durham, NC, USA.
Conceptualization: Roselyn Appenteng, Emily Smith, Joao Ricardo Nickenig Vissoci,
Data curation: Roselyn Appenteng, Taylor Nelp, Jihad Abdelgadir, Nelly Weledji.
Formal analysis: Roselyn Appenteng, Taylor Nelp, Jihad Abdelgadir, Nelly Weledji, Oscar
Obiga, Francis M. Sakita, Edson A. Miguel, Carolina M. Vissoci.
Methodology: Roselyn Appenteng, Joao Ricardo Nickenig Vissoci, Catherine Staton.
Project administration: Roselyn Appenteng.
Supervision: Catherine Staton.
Validation: Joao Ricardo Nickenig Vissoci, Catherine Staton.
Writing ± original draft: Roselyn Appenteng, Catherine Staton.
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Writing ± review & editing: Roselyn Appenteng, Taylor Nelp, Jihad Abdelgadir, Nelly
Weledji, Michael Haglund, Emily Smith, Oscar Obiga, Francis M. Sakita, Edson A. Miguel,
Carolina M. Vissoci, Henry Rice, Joao Ricardo Nickenig Vissoci, Catherine Staton.
15 / 17
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