Protocol and registration

This review was conducted and reported in accordance with the PRISMA 2020 guidelines. The protocol was not registered prospectively in PROSPERO or any comparable registry, and this is acknowledged as a limitation. Our decision to undertake the review emerged from preliminary scoping work, which identified a notable gap: no existing synthesis had examined pre-hospital snakebite management specifically in the pediatric age group. To guard against post hoc methodological choices, eligibility criteria, data extraction procedures, and planned analyses were specified in an internal protocol before the database searches were run, and none of these decisions were altered after searching commenced. Readers are encouraged to keep this limitation in mind when weighing the findings, given that prospective registration is the accepted standard for limiting selective outcome reporting (S1 Fig).

Eligibility criteria

Studies were eligible if they involved children and adolescents (0–18 years) with snakebite envenomation and reported on first-aid or pre-hospital practices, including both appropriate and potentially harmful interventions, such as tourniquet use, incision and suction, herbal remedies, and consultations with traditional healers. Outcomes of interest included morbidity, mortality, complications, delays in care, appropriateness of first-aid, and healthcare-seeking behaviors, with secondary outcomes addressing knowledge, attitudes, and provider perspectives. Eligible designs included observational, interventional, and qualitative studies written in English. Single-case reports, reviews, editorials, conference abstracts, and non-English publications were excluded. Restricting eligibility to English-language publications was a pragmatic decision driven by the language expertise available within the research team; we recognise that this likely introduced some degree of language bias. Important literature from Latin America, sub-Saharan Africa, and South and Southeast Asia may consequently have been missed, and readers should bear this in mind when assessing the geographic scope of the evidence. Studies restricted to adult populations, those reporting only in-hospital management without a pre-hospital component, animal or laboratory research, duplicate cohorts, and papers with insufficiently described methods were all excluded.

Information sources

A comprehensive literature search was conducted across three major electronic databases: PubMed/MEDLINE, Scopus, and Lens.org. These databases were selected to ensure broad coverage of medical, scientific, and interdisciplinary literature relevant to snakebite envenomation. Trial registries and grey literature sources were not searched, and we consider this a meaningful limitation. Unpublished hospital audits, national health ministry reports, and program evaluations from high-burden countries could hold relevant data on community-level pre-hospital practices that simply do not appear in peer-reviewed journals. Reference list screening was not applied systematically, though pertinent citations encountered during full-text review were recorded and considered for inclusion.

Search strategy

The search strategy was developed iteratively with input from the research team and incorporated both Medical Subject Headings (MeSH) terms and free-text keywords. The strategy combined three main concept groups using Boolean operators: snakebite-related terms, first-aid and pre-hospital care terms, and pediatric population terms.

For PubMed/MEDLINE, the search utilized MeSH terms including “Snake Bites”[Mesh], “Snakes”[Mesh], “First Aid”[Mesh], “Emergency Medical Services”[Mesh], “Child”[Mesh], “Infant”[Mesh], and “Adolescent”[Mesh], combined with text words such as snakebite*, pre-hospital*, prehospital*, first-aid, traditional practice*, indigenous practice*, harmful practice*, child*, pediatric*, paediatric*, and related variants. For Scopus and Lens.org, adapted search strategies using TITLE-ABS-KEY fields and field-specific operators were employed to maintain consistency while accounting for database-specific syntax requirements.

Study selection

All retrieved records were imported into reference management software, and duplicate records were identified and removed using both automated and manual methods. The study selection process was conducted in two stages by two independent reviewers (initials blinded for review). In the first stage, titles and abstracts of all unique records were screened against the predefined eligibility criteria. Records that clearly did not meet the inclusion criteria were excluded at this stage. In cases of uncertainty, studies were advanced to full-text review. In the second stage, full-text articles of potentially eligible studies were retrieved and assessed independently by two reviewers against the complete set of inclusion and exclusion criteria. Disagreements between reviewers at both stages were resolved through discussion, and when consensus could not be reached, a third reviewer was consulted.

The study selection process and reasons for exclusion at each stage are documented in the PRISMA 2020 flow diagram (Fig 1). Reasons for exclusion of full-text articles were systematically recorded and categorized into not pediatric-specific, no first-aid or pre-hospital care data, wrong study design, insufficient data quality or unclear methodology, and duplicate data from the same cohort (S1 Table).

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Fig 1. PRISMA flow diagram illustrating the article selection and screening.

https://doi.org/10.1371/journal.pntd.0014508.g001

Data extraction process

Data from the included studies were systematically extracted by two independent reviewers using a standardized, pilot-tested Excel sheet that captured study and population characteristics, details of first-aid and pre-hospital practices, clinical outcomes, and methodological features. Variables recorded included demographics, snake species, severity of envenomation, types and prevalence of first-aid or harmful practices, delays in care, and healthcare-seeking behaviors, alongside outcomes such as complications, disability, and mortality. Methodological aspects, including diagnostic criteria, outcome measures, and potential biases, were also documented. Discrepancies were resolved through discussion, with attempts made to clarify missing or unclear data from the study authors; however, this was not always successful for older publications (S2 Table).

Risk of bias and quality assessment

The methodological quality and risk of bias of included studies were assessed independently by two reviewers using tools appropriate to each study design. For observational studies including cross-sectional, case-control, and cohort studies, the Newcastle–Ottawa Scale (NOS) was employed, which evaluates selection of study groups, comparability of groups, and ascertainment of exposure or outcome. For case series and descriptive studies without comparison groups, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series was utilized. Qualitative studies were assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist, which evaluates rigor, credibility, and relevance.

Each study was classified as having a low, moderate, or high risk of bias based on its overall assessment across the various domains. Disagreements in quality assessment were resolved through discussion, with arbitration by a third reviewer when necessary. The quality assessment results were used to contextualize findings during synthesis. Still, they were not used as exclusion criteria, as excluding studies based on quality might have resulted in loss of valuable information from resource-limited settings where methodological rigor may be constrained (S3 Table).

Data synthesis

Due to substantial heterogeneity in study designs, populations, interventions, outcomes, and measurement methods, a narrative synthesis was conducted instead of a meta-analysis. Findings were organized thematically around first-aid practices, harmful pre-hospital interventions, traditional healing methods, knowledge and attitudes, healthcare-seeking behaviors, and clinical outcomes. Data were described by region, practice type, and population characteristics, with subgroup analyses by geography, practice category, and setting. The strength of evidence was assessed qualitatively; however, quantitative pooling was avoided due to the diverse outcome measures, inconsistent reporting, variation in snake species, and differences in healthcare systems, which rendered meta-analysis inappropriate.

Study selection

The systematic search identified 1,310 records, of which 193 duplicates were removed, resulting in 1,117 records for screening. After title and abstract review, 367 records were excluded for reasons such as non-pediatric focus, unrelated topics, lack of pre-hospital data, inappropriate publication type, or animal studies. Ninety-three reports were sought for full-text review, but nine could not be retrieved. Of the 84 assessed, 42 were excluded due to mixed populations lacking pediatric data, a focus on in-hospital care only, an unsuitable study design, poor data quality, or duplication. Ultimately, 44 studies met all inclusion criteria and were incorporated into the systematic review, as detailed in the PRISMA flow diagram (Fig 1).

Characteristics of included studies

The 44 included studies were published between 1973 and 2025, with a notable increase in publication frequency observed after 2015, reflecting growing recognition of pediatric snakebite as a distinct clinical entity requiring specialized attention. Geographically, the included studies represented diverse snakebite-endemic regions, with the majority conducted in South Asia (particularly India, Sri Lanka, and Bangladesh), Sub-Saharan Africa (Nigeria, South Africa, Sudan), the Middle East (Saudi Arabia, Israel), South America (Brazil), and smaller numbers from Southeast Asia, Europe, and North America. This geographic distribution aligns with the global burden of pediatric snakebite envenomation in low- and middle-income countries, particularly in tropical and subtropical regions. The geographic distribution of included studies is illustrated in Fig 2.

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Fig 2. Geographic distribution of studies included in the systematic review.

Base map sourced from Natural Earth (http://www.naturalearthdata.com), public domain. Natural Earth data are free to use without restriction and are fully compatible with the CC BY 4.0 license.

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Study designs varied considerably across the included literature. The majority were retrospective cohort studies (n = 18) and prospective observational studies (n = 14), with additional contributions from cross-sectional surveys (n = 7), case series (n = 3), and mixed-methods studies (n = 2). Sample sizes ranged from small case series of fewer than 20 patients to large multicenter cohorts comprising more than 500 pediatric snakebite cases. The age range of the included populations generally encompassed children from birth through 18 years, although some studies focused specifically on younger age groups (under 5 years or under 12 years), while others included adolescents up to 15 or 16 years, based on local definitions of pediatric populations.

Study settings demonstrated considerable heterogeneity. Hospital-based studies examining pre-hospital practices through retrospective case note review or structured interviews with caregivers at the time of hospital presentation predominated (n = 28). Community-based studies employing household surveys, interviews with parents, and assessments of knowledge and practices in snakebite-endemic villages provided complementary perspectives (n = 12). Several studies employed mixed approaches, combining hospital surveillance data with community outreach and educational assessments (n = 4). Detailed characteristics of all included studies are presented in Table 1.

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Table 1. Characteristics of included studies in the systematic review.

https://doi.org/10.1371/journal.pntd.0014508.t001

Density visualization of thematic terms

Figure 3 presents a density visualization generated using VOS viewer, illustrating the co-occurrence and frequency of key terms extracted from the titles and abstracts of the 44 studies included in this systematic review. The heatmap reveals concentrated thematic clusters around terms such as “children,” “snake bite,” “envenomation,” “hospitalization,” “mortality,” and “first aid,” reflecting the dominant research focus on clinical outcomes and pre-hospital management in pediatric populations. Brighter regions indicate higher term density, signifying areas of intense scholarly attention. The visualization also highlights the prominence of terms like “venom,” “anti-snake venom,” “epidemiology,” and “toxicology,” underscoring the biomedical emphasis in existing literature (Fig 3).

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Fig 3. Bibliometric network visualization of included studies.

Constructed using VOS viewer (Visualization of Similarities viewer), a freely available software tool for constructing and visualizing bibliometric networks. VOSviewer enables mapping of co-authorship, co-citation, and keyword co-occurrence patterns. Reference: van Eck NJ, Waltman L. VOSviewer A computer program for bibliometric mapping. Scientometrics. 2010;84(2):523–538. https://doi.org/10.1007/s11192-009-0146-3.

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Peripheral clusters in the visualization reveal emerging themes such as “traditional medicine,” “indigenous practices,” “intensive care units,” and “World Health Organization,” suggesting growing interest in sociocultural and policy-related dimensions of pediatric snakebite care. Notably, demographic terms including “female,” “child,” and “pediatrics” form interconnected nodes, emphasizing the specificity of the affected population. This bibliometric mapping complements the narrative synthesis by visually demonstrating the thematic breadth and research intensity across domains. It also reinforces the need for targeted interventions addressing harmful pre-hospital practices and community education, particularly in resource-limited settings where traditional beliefs heavily influence health-seeking behavior.

First-aid and pre-hospital care practices

The synthesis of first-aid and pre-hospital care practices revealed substantial variation across geographic regions and cultural contexts. The most commonly reported first-aid measures included the application of tourniquets, which were reported in 32 studies, with a prevalence ranging from 15% to 78% of cases [10,12,13]. Immobilization of the affected limb, a recommended practice, was documented in 18 studies but demonstrated inconsistent application, with prevalence varying from 8% to 45% of cases [5,13]. Local incision or cutting at the bite site was reported in 24 studies, with particularly high frequencies observed in sub-Saharan African and South Asian contexts, reaching 35% to 60% [12,30,31].

The application of herbal or traditional medicines to bite sites was documented in 21 studies, reflecting the widespread integration of indigenous healing practices in pre-hospital snakebite management [10,13,14]. Suction of venom, either orally or using mechanical devices, was reported in 15 studies, with prevalence rates ranging from 10% to 40%. Less commonly documented practices included the application of ice or cold compresses (8 studies), the use of electric shock therapy (3 studies, primarily in South American contexts), and the administration of traditional oral remedies or animal-derived products (12 studies) [3,14].

Appropriate first-aid measures aligned with WHO and international guidelines were infrequently employed. Rapid transportation to healthcare facilities was reported as the primary response in only 8–35% of cases across most studies, with substantial delays observed between bite occurrence and hospital presentation [5,6,13]. Studies examining therapeutic itineraries revealed complex health-seeking pathways, with 40% to 75% of families consulting traditional healers before seeking hospital care in several settings [10,14,15]. Median time from bite to hospital presentation ranged from 2 to 8 hours across studies, with consultation with traditional healers identified as the primary factor contributing to delays exceeding 6 hours [3,5,31].

Parental knowledge of appropriate first-aid was assessed in 14 studies, revealing substantial deficits across all geographic regions examined. Studies reported that fewer than 20% of parents or caregivers could identify appropriate first-aid measures, while 60% to 85% endorsed at least one harmful practice as beneficial [23,29,50]. Educational interventions targeting school students and community members demonstrated improvements in knowledge, though sustained behavioral change remained difficult to assess due to short-term follow-up [27,29,50].

Harmful indigenous and traditional practices

Harmful indigenous and traditional practices were ubiquitous across included studies, with 41 of 44 studies reporting at least one category of potentially harmful pre-hospital interventions. Tourniquet application emerged as the most frequently reported harmful practice, documented in 32 studies. Several studies specifically examined complications associated with tourniquet use, including one detailed case report of a pediatric patient presenting with severe limb ischemia requiring emergency surgical intervention after prolonged tight tourniquet application [16]. Hospital-based studies reported that tourniquets were left in place for durations ranging from 30 minutes to over 24 hours, with longer durations associated with increased risk of compartment syndrome and tissue necrosis [8,16].

Incision and suction practices were documented in 24 studies, with reported complications including secondary bacterial infections, increased local tissue damage, bleeding, and delays in definitive care [12,31]. In some contexts, particularly rural Sub-Saharan Africa and South Asia, multiple incisions were made at and around the bite site using non-sterile instruments, occasionally accompanied by application of irritant substances [10,12,49]. Three studies documented use of fire or cauterization at bite sites, resulting in severe burns requiring additional medical management [10,31].

Traditional healer consultations and the administration of indigenous remedies were extensively reported, particularly in studies from Brazil, Nigeria, Sudan, Sri Lanka, and India [10,12,13,31]. The types of traditional remedies varied by region but commonly included herbal poultices, animal-derived products, and orally administered plant extracts. Six studies reported cases of adverse effects directly attributable to traditional remedies, including allergic reactions, gastrointestinal toxicity, and interference with subsequent antivenom administration [3,10]. Studies examining parental beliefs and attitudes have revealed that consultation with traditional healers is driven by multiple factors, including geographic proximity, cultural trust, perceived spiritual causation of snakebites, financial constraints, and prior negative experiences with formal healthcare systems [13,14].

Geographic variation in harmful practices was evident across included studies. Tourniquet application predominated in South Asian studies (60–78% of cases), while incision and suction were more commonly reported in Sub-Saharan African contexts (45–60% of cases) [12,13,25,31]. Electric shock therapy, though less common overall, was specifically reported in Brazilian and few South American contexts [3]. Application of traditional medicines demonstrated less geographic specificity, occurring across all endemic regions studied.

Outcomes associated with pre-hospital practices

Associations between pre-hospital practices and clinical outcomes were examined in 28 studies, though the quality and depth of analysis varied considerably. Thirteen studies employed multivariable analyses to identify independent predictors of adverse outcomes in pediatric snakebite envenomation. Pre-hospital tourniquet application was identified as an independent risk factor for severe local complications in five studies [4–6,8,16]. Specifically, tourniquet use was associated with increased rates of compartment syndrome, tissue necrosis requiring surgical intervention, and prolonged hospital stays.

Delays in hospital presentation, frequently attributed to consultation with traditional healers or application of indigenous remedies, were consistently associated with worse outcomes across multiple studies [3,5,6,10,31]. Studies reported that children presenting more than 6 hours after envenomation had significantly higher rates of severe envenomation syndrome, acute kidney injury, coagulopathy, and mortality compared to those presenting within 2 hours [5,6,49]. One study specifically quantified this relationship, finding that each hour of delay increased odds of severe envenomation by 1.4-fold [5].

Incision at bite sites was associated with increased risk of secondary bacterial infections and cellulitis in seven studies [3,4,10,12,31]. Studies examining traditional medicine application reported mixed findings; while most documented delays in care and interference with medical management, direct toxic effects were less commonly quantified [10,14,15].

Mortality rates in pediatric snakebite varied substantially across studies, ranging from 0% in some hospital-based series from high-resource settings to over 10% in resource-limited contexts [8,14,23,31,32]. While multiple factors influenced mortality including the species involved, severity of envenomation, availability of antivenom, harmful pre-hospital practices and delayed presentation were identified as modifiable risk factors in several multivariable analyses [5,6,31].

Risk of bias in included studies

Quality assessment of included studies revealed methodological heterogeneity and varying risk of bias across domains. Among observational cohort studies, the primary methodological concerns included retrospective data collection with potential for incomplete documentation of pre-hospital practices (documented in 18 of 32 cohort studies), lack of standardized definitions for first-aid practices leading to inconsistent categorization across studies, potential recall bias in studies relying on caregiver-reported pre-hospital practices during emergencies, and limited control for confounding variables in analyses examining associations between pre-hospital practices and outcomes.

Cross-sectional studies assessing knowledge, attitudes, and practices demonstrated varying sampling strategies, with concerns regarding representativeness in several community-based surveys [15,29,31,]. Selection bias was a concern in hospital-based studies that may have preferentially captured more severe cases or those accessing formal healthcare systems, potentially underestimating the true prevalence of traditional healer-only management pathways in communities.

Despite these limitations, most included studies (34 of 44) demonstrated adequate clarity in reporting of study populations, inclusion and exclusion criteria, and outcome definitions. Twelve studies were assessed as having low risk of bias across most domains, employing prospective data collection, standardized assessment tools, and appropriate statistical methods [3,5–7,9,13,15,26,30]. Overall, while methodological limitations must be considered when interpreting the findings, the consistency of results across diverse geographic contexts and study designs strengthens confidence in the key findings regarding the prevalence and harms of inappropriate pre-hospital practices in pediatric snakebite envenomation.