Under-recognized or Under-reported? A Global Bibliometric Analysis (1994-2025) of Neurological Assessment in Pediatric Intensive Care Units

This global bibliometric analysis of 128 studies from 1994 to 2025 reveals a critical gap between the high neurological vulnerability of children in PICUs and the limited, inconsistent, and often underreported assessment strategies in the literature, highlighting an urgent need to expand structured neurological evaluations to all critically ill children regardless of their primary diagnosis.

The Gist

Imagine a hospital's Pediatric Intensive Care Unit (PICU) as a bustling, high-stakes control room for tiny, fragile engines (children's bodies). When these engines break down, the mechanics (doctors) work frantically to fix the heart, lungs, or kidneys. But there's a critical question this paper asks: Are they also checking the dashboard of the brain?

This research is a "detective story" about how much we actually study and report on checking the brains of sick children in the ICU. The authors didn't treat new patients; instead, they acted like librarians and data detectives, scanning thousands of scientific reports from 1994 to 2025 to see what the medical world has been saying about this topic.

Here is the story of their findings, broken down simply:

1. The "Library" Was Surprisingly Empty

The team looked for reports on how doctors check the brains of kids in the ICU. They found a massive library of 359 potential books, but only 128 were actually about the specific topic they wanted.

• The Analogy: Imagine looking for a recipe for "Chocolate Cake" in a library with 359 cookbooks, but only 128 of them actually have the recipe. The rest might be about "How to bake bread" or "History of ovens."
• The Takeaway: Even though brain injuries are a huge risk for sick kids, scientists haven't written much about how to check them properly. It's a "silent gap" in the research.

2. The "All-Star Team" vs. The Rest of the World

The paper found that the United States wrote more than half of these 128 reports.

• The Analogy: Think of this research field like a soccer league. The US team has a massive budget, fancy stadiums, and a super-team that scores 50% of all the goals. Countries like France, Turkey, and India are playing too, but they are scoring very few goals, and when they do, the rest of the world doesn't always hear about them.
• The Takeaway: Most of what we "know" comes from rich countries with high-tech hospitals. We might be missing out on brilliant ideas from other parts of the world because they aren't getting the same spotlight.

3. The "Focus Group" Problem

The doctors and researchers mostly studied kids who had Traumatic Brain Injuries (like car accidents) or Cardiac Arrest (heart stopping).

• The Analogy: Imagine a mechanic who only checks the brakes on cars that have crashed into a wall. They never check the brakes on cars that just have a flat tire or a broken engine, even though those cars might also need brake checks!
• The Takeaway: The research focuses heavily on kids who already have a broken brain. It ignores the thousands of other kids in the ICU who are there for pneumonia, sepsis, or surgery, even though their brains are also at risk from the stress, sedation, and lack of sleep.

4. The "Flashlight" vs. The "Map"

The study looked at how doctors check the brain. They found a mix of old-school tools and high-tech gadgets.

• The Tools:
  • The Flashlight (GCS): Doctors use the Glasgow Coma Scale (shining a light in eyes, asking simple questions). This is the most common tool, used at the start.
  • The X-Ray Machine (CT/MRI): Used to take pictures of the brain.
  • The Heart Monitor (EEG): Used to listen to the brain's electrical signals.
• The Problem: The study found that while everyone uses the "Flashlight" at the beginning, they often forget to check the brain again before the child leaves the hospital. It's like checking the oil when you buy a car, but never checking it again before you drive it home.
• The Takeaway: We check the brain when the child arrives, but we often fail to check if the brain has recovered or been damaged by the ICU stay itself before they go home.

5. The "Under-Reported" Mystery

The paper's title asks: "Under-recognized or Under-reported?"

• The Analogy: Imagine a chef who is actually cooking a delicious, complex meal every day but never writes down the recipe. If you ask the chef, "Do you know how to cook this?" they say, "I do it all the time!" But if you look at the cookbook, the recipe is missing.
• The Takeaway: The authors suspect that doctors are checking the brains of kids in the ICU every day (under-recognized in the data), but they aren't writing it down in scientific papers (under-reported). They might think it's "just routine work" and not "newsworthy science."

The Big Conclusion

The authors conclude that we are treating the "engine" (the body) very well, but we are neglecting the "dashboard" (the brain) for many children.

• The Metaphor: We are driving a race car with a broken dashboard. We know the engine is running, but we don't know if the navigation system is working.
• The Call to Action: The paper urges the medical world to stop only looking at kids with obvious brain injuries. Every child in the ICU, whether they have a broken leg or a bad infection, needs a "brain check-up" from the moment they arrive until the moment they leave. We need to write down these checks so we can learn how to protect the developing brains of our most vulnerable children.

In short: We know the brain is fragile, but our scientific "map" of how to protect it is full of holes. It's time to fill those holes so no child's brain health is left to chance.

Technical Summary

1. Problem Statement

Critically ill children in Pediatric Intensive Care Units (PICUs) face significant neurological risks, with brain complications accounting for up to 90% of deaths in previously healthy children admitted to PICUs in the US. Despite the known vulnerability of the developing brain to PICU environmental factors (noise, invasive procedures, sedation), it remains unclear whether neurological assessments are adequately integrated into routine clinical practice or if they are simply underreported in scientific literature. The authors hypothesize that neurological assessment in critically ill pediatric patients is either underemphasized in clinical research or underreported in the literature, creating a gap between patient vulnerability and the evidence base for care.

2. Methodology

The study employed a dual-layered approach combining bibliometric analysis with clinical-guided critical appraisal.

• Data Source: Web of Science Core Collection (WoS-CC).
• Search Period: 1994 to 2025 (Search conducted June 10, 2025).
• Search Strategy: Combined terms related to pediatric critical care (e.g., PICU, critically ill children) with neurological assessment terms (e.g., neurological examinations, neurodevelopmental outcomes).
• Inclusion Criteria: Original research articles explicitly focusing on neurological evaluation in critically ill children admitted to PICUs, covering the PICU stay or spanning admission to post-PICU periods.
• Exclusion Criteria: Reviews, editorials, letters, conference papers, studies assessing only post-PICU status, and survey-based studies.
• Analysis Tools:
  • Bibliometrics: VOSviewer (for co-authorship and keyword co-occurrence), Microsoft Excel, and MapChart.
  • Laws Applied: Lotka's Law (author productivity), Zipf's Law (keyword frequency), and Bradford's Law (journal scattering).
  • Clinical Mapping: A structured extraction of neurological assessment modalities (tools used), timing (admission, PICU stay, discharge), and clinical scenarios (diagnosis).

3. Key Contributions

• First Global Bibliometric Review: This is the first study to map the global scientific landscape specifically regarding neurological assessment in PICUs over a 31-year period.
• Dual-Layer Analysis: It moves beyond standard bibliometrics by integrating a clinical-guided critical analysis to map how and when assessments are performed, identifying specific gaps in practice reporting.
• Differentiation of "Under-recognized" vs. "Under-reported": The study provides evidence to distinguish whether neurological assessments are clinically neglected or merely absent from publication records.
• Identification of Research Gaps: It highlights the lack of standardized protocols, the dominance of retrospective studies, and the underrepresentation of non-neurological diagnoses in neuro-assessment literature.

4. Key Results

A. Bibliometric Landscape

• Volume: From 359 initial records, 128 articles met inclusion criteria, indicating a limited global literature base.
• Geographic Distribution: Highly skewed. The United States accounted for >50% of publications (n=70) and citations (n=1,965). Other contributors included France, Turkey, India, and Spain, but with significantly lower output and citation impact.
• Key Authors/Networks: The Berg-Nadkarni-Topjian network emerged as the most prolific and influential cluster. Other key corresponding authors included Fink, Lang, Appavu, and Au.
• Journals: Adhering to Bradford's Law, a core group of journals published the majority of articles: Pediatric Critical Care Medicine (n=20), Neurocritical Care (n=10), and Resuscitation (n=7).
• Study Designs: The field is dominated by observational studies (Retrospective: n=56; Prospective: n=20). Randomized controlled trials and interventional studies are virtually non-existent (n=1 each), limiting the ability to establish causality or standardized protocols.

B. Clinical Assessment Patterns

• Dominant Conditions: Research focuses heavily on Traumatic Brain Injury (TBI) and Cardiac Arrest. Other conditions like CNS infections, encephalopathies, and metabolic disorders are underrepresented.
• Tools and Timing:
  • Admission: The Glasgow Coma Scale (GCS) is the primary tool for TBI; however, for cardiac arrest and other conditions, admission assessments are often unspecified or rely on broad functional scales.
  • PICU Stay: Advanced neuromonitoring (EEG, ICP, MRI, CT) is used but inconsistently. ICP monitoring, a gold standard for severe TBI, was reported in fewer than half of relevant studies.
  • Discharge: The Pediatric Cerebral Performance Category (PCPC) is the most common outcome measure.
• Biomarkers: Only a minority of studies (n=7) utilized biomarkers (e.g., NSE, S100B, GFAP, NFL), despite their potential for early detection.
• Gaps:
  • Neurological assessments are rarely reported for non-neurological PICU admissions (e.g., sepsis, respiratory failure).
  • Delirium was entirely absent from the retrieved dataset, despite being a critical neurological manifestation.
  • Discharge assessments are frequently missing or lack detail.

5. Significance and Conclusion

The study concludes that there is a critical disconnection between the neurological vulnerability of PICU patients and the scientific strategies guiding their care.

• Under-reporting vs. Under-utilization: The authors suggest that while neurological assessments may occur in practice, they are underreported in literature, likely because they are embedded in broader protocols rather than reported as standalone outcomes.
• Geographic and Methodological Bias: The field is heavily reliant on data from high-income countries (specifically the US) and low-evidence study designs (retrospective observational), which hinders the development of global, standardized guidelines.
• Call to Action: The authors advocate for a conceptual shift: every PICU admission should be considered a potential neurological risk, regardless of the primary diagnosis.
• Future Directions: There is an urgent need for:
  1. Prospective, multicenter, randomized studies.
  2. Standardized reporting of neurological assessments across all PICU diagnoses.
  3. Integration of advanced biomarkers and multimodal monitoring.
  4. Inclusion of underrepresented regions in global research networks to ensure equitable neurocritical care standards.

This paper serves as a foundational call to action to move pediatric neurocritical care from a reactive, condition-specific approach to a proactive, universal standard of brain health protection.