Paediatric traumatic brain injury: unique population and unique challenges.

Paediatric traumatic brain injury (pTBI) remains a leading cause of death and disability in children around the world. The evidence to support pTBI management in children notably lags that in adult populations with a lack of data available to inform management. Injury mechanisms and physiologic responses vary considerably across the developmental spectrum of childhood, bringing unique challenges to the management of pTBI. This is compounded further by complexity of neurodevelopmental changes influencing long-term outcomes. The foundation of current understanding of pTBI is laid on the innovative work done over the turn of the century. Incremental progress in the last few years has furthered our understanding of mechanisms, disease pathophysiology, recovery pathways and consequences from pTBI. There are developments in identification of biomarkers that can help diagnosis as well as predict outcomes more accurately to guide clinical decision making and track long-term outcomes. However, this progress has been slow, and more work is required to translate the large body of observational work into interventions to help improve outcomes from pTBI. This review aims to synthesise recent findings, evaluate existing evidence, and propose future research directions. Structured to first address key epidemiological and pathophysiological differences in the paediatric population with associated clinical challenges, followed by the potential role of physiological, blood and imaging biomarkers, this review seeks to provide a comprehensive update. Additionally, it addresses current evidence gaps in therapeutic strategies, rehabilitation needs and comprehensive systems of care, integrating insights from high and low resource settings. Finally, it reviews current research with a view to offer recommendations to reduce the evidence gaps in pTBI.