Association between adherence to pediatric traumatic brain injury guidelines and clinical outcomes: a retrospective cohort study from lebanon

Traumatic Brain Injury (TBI) is a major cause of death and long-term disability in children worldwide. Implementing evidence-based pediatric TBI guidelines can significantly improve outcomes, yet gaps exist in practice, especially in resource-limited areas. In Lebanon, data on guideline adherence and its effects are scarce. This study assesses adherence to pediatric TBI guidelines and its link to clinical outcomes. A retrospective cohort study was conducted at Rafik Hariri University Hospital enrolling 120 pediatric patients aged 0–14 years diagnosed with TBI between 2014 and 2025. Adherence was assessed across fourteen clinical indicators derived from Pediatric Guidelines, yielding an overall adherence score (0–100%). Associations with in-hospital mortality and Glasgow Outcome Scale (GOS) at discharge were analyzed using multivariable logistic regression analysis ( p < 0.05). Most children presented with mild TBI (62.2%) predominantly from falls (71.7%). In-hospital mortality was 7.5% (9/120), while 85.6% of patients with available GOS data achieved a good recovery (101/118). Mean overall adherence was 74.23 ± 19.00%. Indicator-specific adherence varied across TBI care processes, ranging from 0% for invasive intracranial pressure monitoring within four hours (0/27 eligible patients) to 100% for timely treatment of documented hypoxia (22/22 eligible patients). Adherence to early nutritional support was 81.2% (95/117 evaluable patients). Higher guideline adherence was associated with lower odds of poor functional outcome, although this association did not reach statistical significance (ORa = 0.953, 95% CI: 0.906–1.003; p = 0.065), and was not significantly associated with in-hospital mortality (ORa = 0.967, 95% CI: 0.917–1.019; p = 0.213). Sensitivity analysis showed a consistent association between adherence and poor functional outcome across GCS severity groups (mild/moderate: adjusted OR = 0.912, 95% CI: 0.832–1.000; severe: adjusted OR = 0.931, 95% CI: 0.862–1.007). A similar, non-significant direction was observed for in-hospital mortality. Guideline adherence was moderate and varied substantially across clinical indicators. Guideline adherence was not significantly associated with poor functional outcome or in-hospital mortality. These findings highlight important gaps in TBI care and the need for strategies to improve adherence to evidence-based guidelines.