Differences in clinical outcomes and resource utilization in pediatric traumatic brain injury between countries of different sociodemographic indices
Authors: Liang Keith Wei Han , Lee Jan Hau , Qadri Syeda K. , Nadarajan Janani , Caporal Paula , Roa G Juan D. , González-Dambrauskas Sebastián , Abbas Qalab , Kazzaz Yasser , Chong Shu-Ling , _ _ , Turina Deborah M. , Domínguez-Rojas Jesús A. , Pilar-Orive Francisco J. , Gan Chin Seng , Abbas Qalab , Villalobos Willmer E. Diaz , Ardila Ivan J. , Samransamruajkit Rujipat , Yock-Corrales Adriana , Fonseca Marisol , Aparicio Gabriela , Jaramillo-Bustamante Juan C. , Lee Pei-Chuen , Teran Thelma E. , Monteverde-Fernandez Nicolas , Rodríguez María Miñambres , Roa G Juan D. , Liu Chunfeng , Zhang Tao , Ming Meixiu , Dang Hongxing , Kurosawa Hiroshi , Chamorro Freddy Israel Pantoja , Noguera Deiby Lasso , Cerón Esteban , Arriola Natalia Gómez , Palomino Ruben Eduardo Lasso , Antar Mohannad 
Published: April 2024

OBJECTIVE
The burden of traumatic brain injury (TBI) is disproportionately high in low- and middle-income countries (LMICs). This study aimed to compare clinical outcomes and healthcare utilization for children with moderate to severe TBIs between LMICs and non-LMICs in Asia and Latin America.

METHODS
The authors performed an observational multicenter study from January 2014 to February 2023 among children with moderate to severe TBIs admitted to participating pediatric intensive care units (PICUs) in the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) and Red Colaborativa Pediátrica de Latinoamérica (LARed Network). They classified sites according to their 2019 sociodemographic index (SDI). Low, low-middle, and middle SDI sites were considered LMICs, while high-middle and high SDI sites were considered non-LMICs. The authors documented patient demographics and TBI management. Accounting for death, they recorded 14-day PICU-free and 28-day hospital-free days, with fewer free days indicating poorer outcome. The authors compared children who died and those who had poor functional outcomes (defined as Pediatric Cerebral Performance Category [PCPC] level of moderate disability, severe disability, or vegetative state or coma) between LMICs and non-LMICs and performed a multivariable logistic regression analysis for predicting poor functional outcomes.

RESULTS
In total, 771 children with TBIs were analyzed. Mortality was comparable between LMICs and non-LMICs (9.6% vs 12.9%, p = 0.146). Children with TBIs from LMICs were more likely to have a poor PCPC outcome (31.0% vs 21.3%, p = 0.004) and had fewer ICU-free days (median [IQR] 6 [0–10] days vs 8 [0–11] days, p = 0.004) and hospital-free days (median [IQR] 9 [0–18] days vs 13 [0–20] days, p = 0.007). Poor functional outcomes were associated with LMIC status (adjusted OR [aOR] 1.53, 95% CI 1.04–2.26), a lower Glasgow Coma Scale score (aOR 0.83, 95% CI 0.78–0.88), and the presence of multiple trauma (aOR 1.49, 95% CI 1.01–2.19). Children with TBIs in LMICs required greater resource utilization in the form of early intubation and mechanical ventilation (81.6% vs 73.2%, p = 0.006), use of hyperosmolar therapy (77.7% vs 63.6%, p < 0.001), and use of antiepileptic drugs (73.9% vs 53.1%, p < 0.001).

CONCLUSIONS
Within Asia and Latin America, children with TBIs in LMICs were more likely to have poor functional outcomes and required greater resource utilization. Further research should focus on investigating causal factors and developing targeted interventions to mitigate these disparities.