Brain Trauma Foundation Updates Guidelines for Managing Pediatric Severe TBI

Recommendations for Temperature Control/Hypothermia

Clinicians suggest moderate (32-33°C) hypothermia may be used to control ICP; however, moderate hypothermia is not recommended over normothermia for the overall improvement of outcomes.

Safety recommendations for the use of hypothermia warn that rewarming should be carried out at a rate of 0.5 to 1.0°C every 12 to 24 hours or slower to avoid complications. Furthermore, if phenytoin is used during the rewarming period, researchers suggest monitoring and adjusting the dose to minimize toxicity.

With the addition of 2 new meta-analyses and 3 new randomized controlled trials, the evidence base for this topic supports a moderate recommendation strength.

Recommendations for Barbiturates

High-dose barbiturates are suggested to lower ICP in hemodynamically stable patients with refractory intracranial hypertension. However, safety recommendations require continuous arterial blood pressure monitoring and cardiovascular support to maintain cerebral perfusion pressure.

Although 2 new class 3 studies were added to the evidence base for this topic, the recommendation remains unchanged from the Second Edition. Overall, insufficient evidence was provided to support a level I or II recommendation.

Recommendations for Decompressive Craniectomy

Clinicians recommend decompressive craniectomy for ICP control in pediatric patients with clearly defined indications, including neurologic deterioration, herniation, or intracranial hypertension.

For this edition, the recommendation was specified for ICP control, and 14 new class 3 studies were added to the evidence base for this topic. However, a lack of high-quality evidence contributed to a level III recommendation strength.

Recommendations for Nutrition

Clinicians do not recommend use of an immune-modulating diet in children with severe TBI. However, initiating enteral nutritional support within 72 hours from injury is suggested to improve outcomes and decrease mortality.

The latter recommendation is new to this edition, provided by the addition of a new class 3 study to the evidence base. Overall, the strength of these recommendations is considered weak.

Recommendations for Corticosteroids

Clinicians do not recommend the use of corticosteroids to reduce ICP or improve overall outcomes. For patients with adrenal suppression, injury to the hypothalamic-pituitary steroid axis, or needing steroid replacement therapy, this recommendation is not meant to circumvent use of replacement corticosteroids.

These recommendations have been downgraded from a level II designation to level III in the newest edition.


Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: update of the brain trauma foundation guidelines. Pediatr Crit Care Med. 2019; 20(3S):S1-S82.