systematic review search date

Full search – results fully incorporated

Electronic search strategies run in full in all relevant databases AND all search results are assessed for eligibility as included, excluded, or ongoing studies. Only if all reasonable efforts to classify search results have failed should they be placed in ‘Studies awaiting classification.’*

Top-up search – results not fully incorporated 

Electronic search strategies run in full in all relevant databases BUT search results are not all assessed for eligibility, instead they are placed in 'Studies awaiting classification'.

Scoping search for updating

Electronic search strategies run in selected databases to determine if an update is required.

Select your preferred language for Cochrane Reviews and other content. Sections without translation will be in English.

Select your preferred language for the Cochrane Library website.

View search results / Select Trials tab > Under "Filter your results" (left column), enter date range ("Date added to CENTRAL trials database") as custom range 01/07/2019 to 01/05/2023

#x AND ("2019/07/01"[CRDT] : "3000"[CRDT] OR "2019/07/01"[EDAT] : "3000"[EDAT] OR "2019/07/01"[MHDA] : "3000"[MHDA]) 

(MHDA refers to the date that MeSH are added and may increase duplicates but can identify indexed records previously missed by textword searching)

.dt,ez,da. (Create Date, Entrez date; MeSH date)

(201907* OR 201908* OR 201909* OR 20191* OR 202*).dt,ez,da.

(da refers to the date that MeSH are added and may increase duplicates but can identify indexed records previously missed by textword searching)

limit x to dc=20190701-20230501

(EM 20190701- OR (ZD "in process" AND RD 20190701-))

Web of Science Core Collection (new Web of Science platform)

Select Index Date: 2019-07-01 to 2023-05-01

OR

From Advanced Search Query Builder > Query Preview:

LD=(2019-07-01/2023-05-01)

Determine if there is already a review on this topic

,   , or

If a systematic review already exists or is in process, then conducting an additional review may result in publication challenges.

Create and register a protocol

Checklist:
Where to register: , , or

Define your inclusion and exclusion criteria

Identify 3 to 10 “gold standard” articles (GSAs)

These are ideal articles that you want for your review.

Identify databases for search

Subject heading frequency analysis of gold standard articles

Use subject explosion when fitting.

Term Harvesting

or

Include synonyms and acronyms.

Create search string 1

Combine terms with Boolean operators and add in advanced searching features: truncation, proximity searching, field codes, and wild cards.

Test search string 1 against gold standard articles, if GSAs are not found modify the search string

Translate search string to remaining databases

, , or

Remember controlled vocabulary will and advanced search features may vary between databases.

Run all database searches on the same day

Note date ran and the number of results from each database.

Search for grey literature, hand searching, etc. (if applicable)

Deduplicate Results

, or

have the ability to detect duplicates. Note number of duplicates removed!

Title & Abstract Screening

, , or

Use a minimum of two independent reviewers.

Full text Screening

(if necessary)

Use a minimum of two independent reviewers.

Quality & Risk of Bias Assessment

, , , or

Document the Process

&

Extract data

or

Have two reviewers complete the data extraction and develop a plan for resolving conflicts. Determine the data you need to collect, ideal method to collect this data, and a tool to organize data. Finally run a pilot and adjust if necessary.

Synthesize findings (Qualitative or Quantitative)

Write & Publish Review

&

* Denotes required field.

Service information page

PROSPERO is currently prioritising registration of COVID-19 protocols and continues to receive a vast and increasing number of registrations. To allow the PROSPERO team to focus on COVID-19 and to avoid further delay, during the pandemic all submissions that have been waiting for registration for more than 30 days and which pass a basic automated check will be published automatically . The PROSPERO team will not check these submissions; this will be stated clearly on the published record. Records will be published exactly as submitted; therefore extra care should be taken to ensure that submitted information is accurate. Submissions which do not pass the basic automated check will be automatically rejected.

Due to technical issues, you will not receive an email notification if your record is automatically published. Please check your account after 30 days to confirm registration

For records that are within 30 days of submission, registrations from the UK will continue to be prioritised because PROSPERO is funded by the National Institute of Health Research (NIHR).

We are receiving a huge volume of emails enquiring about progress. Answering these takes time away from processing records, so we ask that you only email should it be absolutely necessary. If your enquiry is related to a review on COVID-19 registration please add #COVID-19 to your subject line.  For other reviews please allow at least 34 days from submission before enquiring about progress. We thank you for your understanding in advance.

Previous changes With effect From 1st October 2019, PROSPERO only accepts reviews provided that data extraction has not yet started. This is intended to reduce potential for bias by reducing the opportunity for (conscious or subconscious) selection or manipulation of data during extraction to shape a review so that it reaches a desired conclusion. PROSPERO will continue to accept registrations if formal screening of search results against the review’s eligibility criteria is complete, because we understand that the steps of a review up to that point do not always follow a strictly sequential manner. We also recognise that registration before then may be challenging for reviews being done to a short timeline or strict deadline. Records are now date stamped to show initial submission date and date of receipt of revised records (for those returned to authors for amendment), as well as registration date.

Authors should have written a full protocol before they register and provide full and specific details on their methods in the PROSPERO registration record. Generic ‘cut and paste’ statements should not be used.

STUDENTS doing mini-reviews or other training exercises should NOT register

PROSPERO has limited resource and is unable to process student work done as part of their training these (handling them takes time away from full projects intended for publication). Students may use the system to create and store a record by saving but please do not submit. Substantial reviews done for dissertations or theses may be registered but will require email confirmation by supervisors.

PROSPERO has temporarily suspended the automatic uploading of Cochrane protocols because of technical issues. We are working to resolve these and hope to resume the automatic registration of Cochrane protocols over the coming months.

NIHR Survey

We have been asked by NIHR to investigate if and how PROSPERO is helping to reduce unintended duplication of systematic reviews. This information will be used in support of our forthcoming application for renewed funding for PROSPERO.

Please help us by agreeing to participate in a short on-line survey that should take no more than 15 minutes to complete.

At this stage we just need your permission to send you a link to the survey in June.

Yes please, send me the link No thanks

PRIVACY STATEMENT - Information about you: how we use it and with whom we share it

We will add your email address to a list that we will use to send you a link to the above survey. By agreeing to participate in the survey, you give your consent for us to do so. We will not hold or use this information for any other purpose and we will not share with any third party. We do not use profiling or automated decision-making processes.

Thank you for helping us to secure future funding for PROSPERO.

Your code has expired. Please contact us by email using the details on the contact page to get a new code

Thank you. We will send you a link to the survey when it is launched in June

Thank you. We have recorded your preference not to be sent a link to the survey

If you have an issue you can contact us...

Systematic reviews of humans

Email: [email protected]

Tel: +44 (0)1904 321049

Systematic reviews of animals

Email: [email protected]

This field uses answers to initial screening questions. It cannot be edited until after registration.

Tick the boxes to show which review tasks have been started and which have been completed.

Update this field each time any amendments are made to a published record.

Give the working title of the review, for example the one used for obtaining funding. Ideally the title should state succinctly the interventions or exposures being reviewed and the associated health or social problems. Where appropriate, the title should use the PI(E)COS structure to contain information on the Participants, Intervention (or Exposure) and Comparison groups, the Outcomes to be measured and Study designs to be included.

Acronyms may be included in titles, but should not be used alone without expansion unless they are regarded as more usual than the expansion (e.g. HIV).

The title in this field must be in English. If the original title is in a different language the English version must be entered here, with the non-English version entered into the field labelled “Original Language Title”.

If the final title of the review differs, this can be displayed in the Publication of Final Report Field.

Example: Systematic review and meta-analysis of recurrence and survival following pre- versus post-operative radiation in localized, resectable soft-tissue sarcoma.

For reviews in languages other than English, this field should be used to enter the title in the language of the review. This will be displayed together with the English language title.

Example: Revisión sistemática y meta-análisis de la recurrencia y la supervivencia tras la fase de radiación en comparación con post-operatorio en el sarcoma localizados resecables de tejido blando.

Give the date when the systematic review commenced, or is expected to commence.

For the purposes of PROSPERO, the date of commencement for the systematic review can be defined as any point after completion of a protocol but before formal screening of the identified studies against the eligibility criteria begins.

A protocol can be deemed complete when it is approved by a funder or the person commissioning the review; when peer review is complete; when the protocol is published or when the authors decide that it is complete and they do not anticipate any major revisions to the design of the systematic review.

This field may be edited at any time. All edits to published records will appear in the record audit trail. A brief explanation of the reason for changes should be given in the Revision Notes facility.

Example:  01 June 2011

Give the date by which the review is expected to be completed. In the absence of an agreed contractual date, a realistic anticipated date for completion should be set. It can be modified should the schedule change. When this date is reached, the named contact will receive an automated email to ask them to provide an update on  progress.

This field may be edited at any time. All edits will appear in the record audit trail. A brief explanation of the reason for changes should be given in the Revision Notes facility.

Indicate the stage of progress of the review by ticking the relevant Started and Completed boxes. Additional information may be added in the free text box provided.

Please note: Reviews that have progressed beyond the point of completing data extraction at the time of initial registration are not eligible for inclusion in PROSPERO. Should evidence of incorrect status and/or completion date being supplied at the time of submission come to light, the content of the PROSPERO record will be removed leaving only the title and named contact details and a statement that inaccuracies in the stage of the review date had been identified.

This field should be updated when any amendments are made to a published record and on completion and publication of the review.

Example:  Preliminary searches ticked as completed, pilot of the study selection process ticked as started.

The named contact acts as the guarantor for the accuracy of the information presented in the register record. This should be the lead reviewer or a representative of the review team. This person is also responsible for submitting details of any amendments while the review is ongoing and publication details after the review is completed. The named contact is the person to whom users of PROSPERO would send questions or comments.

This field is automatically populated from the named contact’s signing in details. The named contact’s name will be displayed in the public record.

Example:  Dr Joseph Bloggs N.B. To change the named contact for a published record, send details of the existing and new contact to [email protected]

Give the electronic mail address of the named contact. This may be a generic email address to which the named contact has access.

This field is automatically populated from the named contact’s joining details, but can be changed if required. The email address supplied here will be displayed in the public record.

Examples:  [email protected] or [email protected]

Give the full postal address for the named contact. (N.B. This field is automatically populated from the named contact’s joining details.)

This address will be displayed in the public record. If you do not wish it to appear in the public record delete the content of this field.

Example:  Alcuin B Block,University of York, York, YO10 5DD, UK

Give the telephone number for the named contact, including international dialling code.  (N.B. This field is automatically populated from the named contact’s joining details.)

This number will be displayed in the public record. If you do not wish it to appear in the public record delete the content of this field.

Example:  +44 (0)10904 321040

Full title of the organisational affiliations for this review and website address if available. This field may be completed as ‘None’ if the review is not affiliated to any organisation.

Example:  Andalusian Agency for Health Technology Assessment (AETSA)

Give the personal details and the organisational affiliations of each member of the review team. Affiliation refers to groups or organisations to which review team members belong. NOTE: email and country are now mandatory fields for each person. . Affiliation refers to groups or organisations to which review team members belong.

Review team members will be listed ‘manuscript’ style in the order entered in this list. The named contact will be automatically added to this field, but can be deleted if not a member of the review team. To place the named contact somewhere other than first in order, delete the automatic entry and enter members’ details in the required order.

Membership of the review team and details of affiliations can be updated at any time. All edits will appear in the record audit trail.

Example:  Mr Joseph Bloggs, Centre for Reviews and Dissemination, University of York, UK. Dr Jane Smith, Department of Health Sciences, University of York, UK. Prof. Steven Jones, Centre for Health Statistics, Medical Research Centre, Canada.

Give details of the individuals, organizations, groups or other legal entities who take responsibility for initiating, managing, sponsoring and/or financing the review. Include any unique identification numbers assigned to the review by the individuals or bodies listed.

Examples:  NIHR HTA Programme (Project ref 09/13/02). The Terry Fox New Frontiers Program in Cancer (Ref 201006TFL). Funding provided by Amgen, Merck, Roche, and Sanofi-aventis.

List any conditions that could lead to actual or perceived undue influence on judgements concerning the main topic investigated in the review. The conflicts of interest listed should cover the review team as a whole, as well as individuals in the team.

Conflicts of interest arise when a team member or the team as a whole (e.g. because of the team’s institution) has financial or personal relationships that may inappropriately influence (bias) their actions (such relationships are also known as dual commitments, competing interests, or competing loyalties).These relationships vary from being negligible to having great potential for influencing judgement. Not all relationships represent true conflict of interest.

On the other hand, the potential for conflict of interest can exist regardless of whether a person believes that the relationship affects his or her scientific judgement. Financial relationships (such as employment, consultancies, stock ownership, honoraria, and paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the review.

However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion. For the purposes of disclosure, the term “competing interest” should be considered synonymous with conflict of interest. 1

Example:  The lead reviewer (JB) has given talks on this topic at workshops, seminars, and conferences for which travel and accommodation has been paid for by the organisers. The other authors declare that they have no known conflicts of interest.

Give the name and affiliation of any individuals or organisations who are working on the review but who are not listed as review team members. NOTE: email and country are now mandatory fields for each person.

Example:  Dr Eric Porter, Oncologist, University Hospital, Brighton, UK. Clinical advisor.

State the question(s) to be addressed by the review, clearly and precisely. Review questions may be specific or broad. It may be appropriate to break very broad questions down into a series of related more specific questions. Questions may be framed or refined using PI(E)COS where relevant.

Example:  How does pre-operative chemotherapy impact on survival of early stage non-small cell lung cancer compared to surgery alone?

State the sources that will be searched. Give the search dates, and any restrictions (e.g. language or publication period). Do NOT enter the full search strategy (it may be provided as a link or attachment.)

The search strategy reported in systematic review protocols should:

• Name all sources that will be used to identify studies for the systematic review.

Sources include (but are not limited to) bibliographic databases, reference lists of eligible studies and review articles, key journals, conference proceedings, trials registers, Internet resources and contact with study investigators, experts and manufacturers.

Systematic reviews typically use more than one database. Examples of electronic bibliographic databases include MEDLINE, EMBASE, PsycINFO. Other database sources include The Cochrane Library, Health Technology Assessment Database, and Web of Science.

• Search dates (from and to)
• Restrictions on the search including language and publication period
• Whether searches will be re-run prior to the final analysis

It is considered good practice for searches to be re-run just before the final analyses and any further studies identified, retrieved for inclusion. 

• Whether unpublished studies will be sought

Give a link to the search strategy or an example of a search strategy for a specific database if available (including the keywords that will be used in the search strategies). Alternatively, an electronic file could be supplied which will be linked to from the Register record. This will be made publicly available from the published record immediately, or it can be held in confidence until the review has been completed, at which time it will be made publicly available.

Example:  http://www.biomedcentral.com/1756-0500/3/250

Give a short description of the disease, condition or healthcare domain being studied. This could include health and wellbeing outcomes.

Examples:  Type 2 diabetes. Physical activity in children.

Give summary criteria for the participants or populations being studied by the review. The preferred format includes details of both inclusion and exclusion criteria.

Example: Inclusion: Adults with schizophrenia (as diagnosed using any recognised diagnostic criteria). Exclusion: Adolescents (under 18 years of age) and elderly people (over 70).

Give full and clear descriptions or definitions of the nature of the interventions or the exposures to be reviewed. This is particularly important for reviews of complex interventions (interventions involving the interaction of several elements). If appropriate, an operational definition describing the content and delivery of the intervention should be given.

Ideally, an intervention should be reported in enough detail that others could reproduce it or assess its applicability to their own setting. The preferred format includes details of both inclusion and exclusion criteria.

For reviews of qualitative studies give details of the focus of the review.

Example:  Population-level tobacco control interventions are defined as those applied to populations, groups, areas, jurisdictions or institutions with the aim of changing the social, physical, economic or legislative environment to make them less conducive to smoking. These are approaches that mainly rely on state or institutional control, either of a link in the supply chain or of smokers' behaviour in the presence of others.

Examples include tobacco crop substitution or diversification, removing subsidies on tobacco production, restricting trade in tobacco products, measures to prevent smuggling, measures to reduce illicit cross-border shopping, restricting advertising of tobacco products, restrictions on selling tobacco products to minors, mandatory health warning labels on tobacco products, increasing the price of tobacco products, restricting access to cigarette vending machines, restricting smoking in the workplace, and restricting smoking in public places. Such approaches could also form part of wider, multifaceted interventions in schools, workplaces or communities. 3

Where relevant, give details of the alternatives against which the main subject/topic of the review will be compared (e.g. another intervention or a non-exposed control group). The preferred format includes details of both inclusion and exclusion criteria.

Control or comparison interventions should be described in as much detail as the intervention being reviewed. If the comparator is ‘treatment as usual’ or ‘standard care’, this should be described, with attention being paid to whether it is ‘standard care’ at the time that an eligible study was done, or at the time the review is done.

Systematic reviews of qualitative studies rarely have a comparator or control; stating ‘Not applicable’ is therefore acceptable.

Examples:  Placebo. A group of hospital in-patients who were not exposed to the infectious agent.

Give details of the types of study (study designs) eligible for inclusion in the review. If there are no restrictions on the types of study design eligible for inclusion, or certain study types are excluded, this should be stated. The preferred format includes details of both inclusion and exclusion criteria.

If different study designs are needed for different parts of the review, this should be made clear. Where qualitative evidence will be incorporated in or alongside a review of quantitative data, this should be stated.

Example:  We will include randomised trials to assess the beneficial effects of the treatments, and will supplement these with observational studies (including cohort and case–control studies) for the assessment of harms.

Give summary details of the setting and other relevant characteristics which help define the inclusion or exclusion criteria.

Include relevant details if these form part of the review’s eligibility criteria but are not reported elsewhere in the PROSPERO record.

Examples:  Studies in hospital accident and emergency departments. Research in low- and middle-income countries only will be included.

Give the pre-specified primary (most important) outcomes of the review, including details of how the outcome is defined and measured and when these measurement are made, if these are part of the review inclusion criteria.

For systematic reviews of qualitative studies give details of what the review aims to achieve.

Examples: Change in depression score from baseline to the last available follow-up, measured using the Beck Depression Inventory. Five year progression-free survival (measured from randomisation). Establishing the barriers and facilitators to smoking cessation in pregnancy.

List the pre-specified secondary (additional) outcomes of the review, with a similar level of detail to that required for primary outcomes. Where there are no secondary outcomes please state ‘None’ or ‘Not applicable’ as appropriate to the review

Example: Apgar scores for the baby at 1 and 5 minutes after birth.

Describe how studies will be selected for inclusion. State what data will be extracted or obtained. State how this will be done and recorded.

Data extraction methods reported in systematic review protocols should include:

Study selection

• The number of reviewers applying eligibility criteria and selecting studies for inclusion in the systematic review (good practice suggests more than one individual) and how this will be done (e.g. whether two people will independently screen records for inclusion or whether one will screen and an other check decisions) and whether researchers will be blinded to each other’s’ decisions.
• How disagreements between individual judgements will be resolved
• The software system or mechanism for recording decisions
• List which data will be extracted from study documents, including information about study design and methodology, participant demographics and baseline characteristics, numbers of events or measures of effect (where applicable). Alternatively, state how this information will obtained from study investigators.
• The number of people extracting or checking received data (good practice suggests more than one individual) and how this will be done (e.g. whether two people will independently extract data or whether one will extract data and an other person check the extracted data).
• How missing data will be handled including whether study investigators will be contacted for unreported data or additional details.
• The means of recording data (e.g. in an excel spreadsheet, in a software system such as Eppi Reviewer)
• Another relevant detail that should be included is the software or tool, if any, that will be used for data extraction and management. An example of such a software tool is the Systematic Review Data Repository-Plus

Describe the method of assessing risk of bias or quality assessment. State which characteristics of the studies will be assessed and any formal risk of bias tools that will be used.

Methods for assessing risk of bias reported in systematic review protocols should include:

• Which characteristics will be assessed (e.g. methods of randomisation, treatment allocation, blinding).
• Whether assessment will be done at study or outcome level
• The criteria used to assess internal validity, if formal a risk of bias assessment is planned (e.g. the Cochrane risk of bias tool, ROBINS, QUADAS). 
• How the results of the assessment will inform data synthesis (where applicable).
• The number of reviewers that will be involved in the quality assessment
• How disagreements between reviewers judgements will be resolved

Provide details of the planned synthesis including a rationale for the methods selected. This must not be generic text but should be specific to your review and describe how the proposed analysis will be applied to your data.

Data synthesis methods reported in systematic review protocols should be specific about how they apply to the review and data in question and include:

• Criteria under which the data will be synthesised (e.g. the minimum number of studies or level of consistency required for synthesis)
• Which data will be synthesised including outcomes and summary effect measures (e.g. risk ratios for progression free survival at 2 years)
• The formal method of combining individual study data including, as applicable, information about statistical models that will be fitted (e.g. risk ratios for individual studies will be combined using a random effects meta-analysis) or methods of synthesising qualitative data.

State any planned investigation of ‘subgroups’. Be clear and specific about which type of study or participant will be included in each group or covariate investigated. State the planned analytic approach.

Planned ‘subgroup’ analysis or investigation of potential effect modifiers in reported in systematic review protocols should include:

• The rationale for the investigation (why are differences anticipated, or why is it important to look separately at different types of study or individual)
• Clear definitions of which types of study or individual will be included in each group (e.g. study design such as randomised/ non-randomised trial, intervention type such as high dose/low dose drug, setting such as hospital/ home care, participant characteristics such as male/female, stage III/stage IV tumour, <18 years/ ≥18 years)
• Details of the planned analytic approach (e.g. meta-regression, tests of interaction between groups, logistic regression using individual-level data). Where applicable this should include details of statistical models to be used.

Select the type of review and the review method from the lists below. Select the health area(s) of interest for your review.

N.B. The information required here relates to the topic and outcome of the systematic review rather than the methods to be used. It is used to facilitate accurate searching of the database.

Select each country individually to add it to the list below, use the bin icon to remove any added in error.

The entry will default to English if no other selection is made. For languages other than English, registrants are asked to indicate whether a summary or abstract will be made available in English.

Example:  English, French.

Select the country in which the review is being carried out from the drop down list. For multi-national collaborations select all the countries involved.

Example:  England, Canada.

Give the name of any organisation where the systematic review title or protocol is registered (such as with The Campbell Collaboration, or The Joanna Briggs Institute) together with any unique identification number assigned. (N.B. Registration details for Cochrane protocols will be automatically entered). If extracted data will be stored and made available through a repository such as the Systematic Review Data Repository (SRDR), details and a link should be included here. If none, leave blank.

Example:  The title for this review and the review protocol are recorded in the Campbell Library as Project 27

Give the citation and link for the published protocol, if there is one. This may be to an external site such as a journal or organisational website. Alternatively an unpublished protocol may be deposited with CRD in pdf format. A link to this will be automatically added.

Example:  Free C, Phillips G, Felix L, Galli L, Patel V, Edwards P. The effectiveness of M-health technologies for improving health and health services: a systematic review protocol. BMC Research Notes 2010, 3:250 doi:10.1186/1756-0500-3-250 http://www.biomedcentral.com/1756-0500/3/250 .

Give brief details of plans for communicating essential messages from the review to the appropriate audiences. Any knowledge transfer or implementation activities beyond publication of the final report that are planned should be included.

Example:  In addition to producing a report for the funders of this review, which will be made available free of charge on their website, a paper will be submitted to a leading journal in this field. Furthermore, should the findings of the review warrant a change in practice, a one page summary report will be prepared and sent to lead clinicians and healthcare professionals in the National Health Service.

Give words or phrases that best describe the review. Keywords will help users find the review in the Register (the words do not appear in the public record but are included in searches). Be as specific and precise as possible. Avoid acronyms and abbreviations unless these are in wide use.

The addition of keywords is particularly important for non-effectiveness reviews. These records are likely to contain fewer relevant terms in other fields such as comparators and outcomes.

Information specialists at the Centre for Reviews and Dissemination (CRD) will assign MeSH terms, which will appear in the public record.

Example:  Systematic review; meta-analysis; recurrence; survival; radiation; resectable; soft-tissue; sarcoma.

Give details of earlier versions of the systematic review if an update of an existing review is being registered, including full bibliographic reference if possible.

Example:  This review is an update of our earlier systematic review and economic model and is being undertaken in the light of the publication of significant new research which will assist in developing our model. The citation for the existing review is Fayter D, Nixon J, Hartley S, Rithalia A, Butler G, Rudolf M, Glasziou P, Bland M, Stirk L, Westwood M. A systematic review of the routine monitoring of growth in children of primary school age to identify growth-related conditions.  Health Technol Assess . 2007;11(22):1-87.

Select from drop down list to indicate the current status of the review:

Review status should be updated when the review is completed and when it is published.

Select from the list below to indicate the current status of the review.

Use the free text box to provide an explanation of the status of the review.

Example:  Discontinued: This review has been abandoned as we have been unable to secure adequate funding to proceed.

Provide any other information the review team feel is relevant to the registration of the review.

Example:  This review is being undertaken as part of the planning for a randomised trial to compare all different types of radiotherapy for localised, resectable soft-tissue sarcoma.

This field should be left empty until details of the completed review are available OR you have a link to a preprint.

Give the full citation for the preprint or final report or publication of the systematic review, including the URL where available.

This field may also be used to record the availability of an un-published final report, summary results etc.

Example:  Toulis KA, Goulis DG, Venetis CA, Kolibianakis EM, Negro R, Tarlatzis BC, Papadimas I. Risk of spontaneous miscarriage in euthyroid women with thyroid autoimmunity undergoing IVF: a meta-analysis. Eur J Endocrinol. 2010 Apr;162(4):643- 52. Epub 2009 Dec 2. http://eje-online.org/cgi/content/full/162/4/643

Give the working title of the review. This must be in English. The title should have the interventions or exposures being reviewed and the associated health or social problems.

Where appropriate, the title should use the PI(E)CO structure to contain information on the Population, Intervention (or Exposure) and Comparison groups, and the Outcomes to be measured. Acronyms may be included in titles, but should not be used alone without expansion unless they are regarded as more usual than the expansion (e.g. HIV). If the original title is in a different language, the English version must be entered here, with the non-English version entered into Field #2 (Original language title). If the final title of the (published) review differs from the one entered here, this can be recorded in Field #40 (Details of the final report/publication(s)). 

Example: Efficacy of ischemic postconditioning against renal ischemia-reperfusion injury in animal models, a systematic review and meta-analysis.

For the purposes of PROSPERO, the date of commencement for the systematic review can be defined as any point after completion of a protocol, but before formal screening of the identified studies against the eligibility criteria begins. A protocol can be deemed complete when it is approved by a funder or the person commissioning the review, when peer review is complete, when the protocol is published, or when the authors decide that it is complete and they do not anticipate any major revisions to the design of the systematic review.

Give the date by which the review is expected to be completed.

In the absence of an agreed contractual date, a realistic anticipated date for completion should be set. It can be modified should the schedule change. When this date is reached, the named contact will receive an automated email to ask them to provide an update on progress.

This field should be updated when any amendments are made to a published record and on completion and publication of the review. Example: “ Preliminary searches” ticked as completed, “Piloting of the study selection process” ticked as started.

The named contact acts as the guarantor for the accuracy of the information presented in the register record.

This should be the lead reviewer or a representative of the review team. This person is also responsible for submitting details of any amendments while the review is ongoing and publication details after the review is completed. The named contact is the person to whom users of PROSPERO would send questions or comments. This field is automatically populated from the named contact’s signing in details. The named contact will be displayed in the public record.

Example:  Dr Joseph Bloggs

Enter the electronic mail address of the named contact.

This may be a generic email address to which the named contact has access. This field is automatically populated from the named contact’s signing in details, but can be changed if required. The email address supplied here will be displayed in the public record.

Examples:  [email protected]; [email protected]

Enter the full postal address for the named contact.

This field is automatically populated from the named contact’s signing in details. This address will be displayed in the public record. If you do not wish it to appear in the public record delete the content of this field.

Example:  Alcuin B Block, University of York, York, YO10 5DD, UK

Enter the telephone number for the named contact, including international dialling code. 

This field is automatically populated from the named contact’s signing in details. This number will be displayed in the public record. If you do not wish it to appear in the public record delete the content of this field.

Example:  +44 (0)10904 32104

Full title of the organisational affiliations for this review and website address if available. This field may be completed as ‘none’ if the review is not affiliated to any organisation.

Example:  Radboud university medical center (Radboudumc)

Give the personal details and the organisational affiliations of each member of the review team. NOTE: email and country are now mandatory fields for each person. .

Affiliation refers to groups or organisations to which review team members belong. The named contact will be automatically added to this field, but can be deleted if not a member of the review team. To place the named contact somewhere other than first in order, delete the automatic entry and enter members’ details in the required order. Membership of the review team and details of affiliations can be updated at any time. All edits will appear in the record audit trail.

Examples:  Mr Joseph Bloggs, Centre for Reviews and Dissemination, University of York, UK. Dr Jane Smith, Department of Health Sciences, University of York, UK. Prof. Steven Jones, Centre for Health Statistics, Medical Research Centre, Canada.

Give details of the individuals, organisations, groups or other legal entities who take responsibility for initiating, managing, sponsoring and/or financing the review. Any unique identification numbers assigned to the review by the individuals or bodies listed should be included.

List any conditions that could lead to actual or perceived undue influence on judgements concerning the main topic investigated in the review.

The conflicts of interest listed should cover the review team as a whole, as well as individuals in the team. Conflicts of interest arise when a team member or the team as a whole (e.g. because of the team’s institution) has financial or personal relationships that may inappropriately influence (bias) their actions (such relationships are also known as dual commitments, competing interests, or competing loyalties). These relationships vary from being negligible to having great potential for influencing judgement. Not all relationships represent true conflict of interest. On the other hand, the potential for conflict of interest can exist regardless of whether a person believes that the relationship affects his or her scientific judgement. Financial relationships (such as employment, consultancies, stock ownership, honoraria, and paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the review. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion. For the purposes of disclosure, the term “competing interest” should be considered synonymous with conflict of interest.

Example:  The lead reviewer (JB) has given talks on this topic at workshops, seminars, and conferences for which travel and accommodation has been paid for by the organisers. The other authors declare that they have no known conflicts of interest.

Give the name, affiliation and role of any individuals or organisations who are working on the review but who are not listed as review team members.

Give details of the question to be addressed by the review, clearly and precisely. This should be clearly and precisely defined, but may be specific or broad. The question may be framed or refined using PI(E)COS where relevant. Further guidance is available in e.g. the step by step search guide.

Example:  Does analgesic treatment reduce the number or incidence of metastasis in animal cancer models?

Give details of the sources to be searched, and any restrictions (e.g. language or publication period). The full search strategy is not required, but may be supplied as a link or attachment.

A step by step search guide , as well as animal search filters for Pubmed and EMBASE , are available to facilitate the search process. List all sources that will be used to identify studies for the review. Sources include (but are not limited to) bibliographic databases, reference lists of eligible studies and review articles, key journals, trials registers, conference proceedings, internet resources and contact with experts and manufacturers.

Example:  We will search the following electronic bibliographic databases: MEDLINE, EMBASE, and Web of Science. The full search strategy (see pdf) is based on the search components “animal” (using Pubmed and EMBASE search filters [ref, ref]), “laparoscopic surgery” and “renal function”. No publication date or language restrictions will be applied. We will screen the reference lists of included studies for additional eligible studies not retrieved by our search. The searches will be re-run just before the final analyses to retrieve the most recent studies eligible for inclusion.

Give a link to the search strategy or an example of a search strategy for a specific database if available (including the keywords that will be used in the search strategies).

Alternatively, an electronic file could be supplied which will be linked to from the Register record. This will be made publicly available from the published record immediately, or it can be held in confidence until the review has been completed, at which time it will be made publicly available. Example:  http://www.biomedcentral.com/1756-0500/3/250

Give a short description of the disease, condition or healthcare domain being modelled.

This could include health and wellbeing outcomes.

Example:  Type 2 diabetes; Myocardial infarction; Physical activity in the elderly.

Give summary criteria for the animals being studied by the review, e.g. species, sex, details of disease model. Please include details of both inclusion and exclusion criteria.

Example: Inclusion criteria: all animal models with experimental cancer in which metastasis can develop (all species, all sexes). Exclusion criteria: animals with co-morbidities; ex vivo, in vitro and in silico models; experimental cancer without metastasis

Give full and clear descriptions of the nature of the interventions or the exposures to be reviewed (e.g. dosage, timing, frequency). Please include details of both inclusion and exclusion criteria.

For reviews of pre-clinical animal studies, the intervention would be e.g. treatment with a drug, or a therapeutic intervention such as exercise. For reviews of animal exposure studies, e.g. in toxicology, the intervention would be exposure to a certain compound. For reviews aiming to provide an overview of animal models for a certain health problem or disease, this would be the intervention(s) used to induce the disease model (e.g. high-fat diet to induce obesity, or transverse aortic constriction to induce heart failure). See also Field #30 for additional information on review types.

Example:  Inclusion criteria: analgesic treatment with compounds registered for use in clinical practice, including pre-treatment of tumor cells with analgesics before injection. All timings, frequencies and dosages of treatment are eligible for inclusion. Exclusion criteria: treatment with analgesics not registered for use in clinical practice.

Where relevant, give details of the type(s) of control interventions against which the experimental condition(s) will be compared (e.g. another intervention or a non-exposed control group). Please include details of both inclusion and exclusion criteria.

Control or comparison interventions should be described in as much detail as the intervention being reviewed. A “control group” may refer to vehicle-treated animals, sham-treated animals, animals undergoing no treatment at all, baseline measurements, etc. Indicate which of these control conditions are eligible for inclusion.

If the review aims to provide an overview of available animal models for a certain health problem / disease (animal model review, see Field #30), the comparator would generally be a healthy, naive animal”.

Example:  Inclusion criteria: vehicle-treated control animals. Exclusion criteria: all other control conditions (e.g. no treatment, saline-treated if vehicle is not saline).

Give details of the types of study (study designs) eligible for inclusion in the review. If there are no restrictions on the types of study design eligible for inclusion, or certain study types are excluded, this should be stated. Please include details of both inclusion and exclusion criteria.

Example:  Inclusion criteria: controlled studies with a separate control group. Exclusion criteria: case studies, cross-over studies, studies without a separate control group.

Give details of any other inclusion and exclusion criteria (e.g. publication date or language restrictions).

Examples:  Inclusion criteria: all languages, all publication dates. Exclusion criteria: none.

Give details of the outcome measures to be considered for inclusion in the review. Please include details of both inclusion and exclusion criteria.

Example:  Inclusion criteria: tumor number and/or tumor incidence reported. Exclusion criteria: no relevant outcomes reported (e.g. tumor weight only).

This question does not apply to systematic reviews of animal studies for human health submissions

Give the procedure for selecting studies for the review and extracting data, including the number of researchers involved and how discrepancies will be resolved. List the data to be extracted.

Other relevant details could include whether study selection and/or data extraction will be blinded (researchers unaware of author/journal details) and whether and how authors of eligible studies will be contacted to provide missing or additional data.

For reviews of individual participant data, this field should include the data to be sought and how this will be collected.

A description of any other manipulation or transformation of the extracted data that is planned may be included.

Example: Titles and/or abstracts of studies retrieved using the search strategy and those from additional sources will be screened independently by two review authors to identify studies that potentially meet the inclusion criteria outlined above. The full text of these potentially eligible studies will be retrieved and independently assessed for eligibility by two review team members. Any disagreement between them over the eligibility of particular studies will be resolved through discussion with a third reviewer.

A standardised, pre-piloted form will be used to extract data from the included studies for assessment of study quality and evidence synthesis. Extracted information will include: study setting; study population and participant demographics and baseline characteristics; details of the intervention and control conditions; study methodology; recruitment and study completion rates; outcomes and times of measurement; indicators of acceptability to users; suggested mechanisms of intervention action; information for assessment of the risk of bias. Two review authors will extract data independently, discrepancies will be identified and resolved through discussion (with a third author where necessary). Missing data will be requested from study authors.

Example for IPD: Those responsible for the included studies will be asked to supply line by line individual participant data comprising: de-identified patient reference; allocated treatment, date of randomisation; date of birth, gender, tumour stage, tumour histology, survival status, date of last follow up or death.

State whether and how risk of bias and/or study quality will be assessed. Assessment tools specific for pre-clinical animal studies include SYRCLE’s risk of bias tool and the CAMARADES checklist for study quality.

SYRCLE’s risk of bias tool is used to perform an assessment of internal validity, addressing selection, performance, detection, attrition, and other types of bias. The CAMARADES checklist is used to perform a combined assessment of the reporting of a number of measures to reduce bias, and several indicators of external validity and study quality. Both tools may be adapted by adding or removing items. If this is planned, specify which adaptations have been made. “No risk of bias and/or quality assessment planned” is acceptable only if the aim of the review is limited to providing an overview of available animal models, without presenting any outcome data.

Give the planned general approach to synthesis, e.g. whether aggregate or individual participant data will be used and whether a quantitative or narrative (descriptive) synthesis is planned. It is acceptable to state that a quantitative synthesis will be used if the included studies are sufficiently homogenous.

Where appropriate, the planned analytical approaches (e.g. Bayesian or frequentist (classical), fixed or random effects; categorising studies within a narrative synthesis) should be outlined. Whether and how statistical heterogeneity will be explored and how any observed heterogeneity will impact on or modify the planned approach to analysis should be stated, along with any planned sensitivity analyses.

Example:  We will provide a narrative synthesis of the findings from the included studies, structured around the type of intervention, target population characteristics, type of outcome and intervention content. We will provide summaries of intervention effects for each study by calculating risk ratios (for dichotomous outcomes) or standardised mean differences (for continuous outcomes).

We anticipate that there will be limited scope for meta-analysis because of the range of different outcomes measured across the small number of existing trials. However, where studies have used the same type of intervention and comparator, with the same outcome measure, we will pool the results using a random-effects meta-analysis, with standardised mean differences for continuous outcomes and risk ratios for binary outcomes, and calculate 95% confidence intervals and two sided P values for each outcome. In studies where the effects of clustering have not been taken into account, we will adjust the standard deviations for the design effect. Heterogeneity between the studies in effect measures will be assessed using both the χ2 test and the  I 2 statistic. We will consider an  I 2 value greater than 50% indicative of substantial heterogeneity. We will conduct sensitivity analyses based on study quality. We will use stratified meta-analyses to explore heterogeneity in effect estimates according to: study quality; study populations; the logistics of intervention provision; and intervention content. We will also assess evidence of publication bias.

Example for IPD:  Individual data from all randomised participants will be included in the analyses, which will be performed on an intention to treat basis. A two-stage approach to synthesis will be used. For time to event outcomes, the individual times to event will be used in the stratified (by trial) logrank test to produce hazard ratio estimates of the effect of treatment for individual trials. These hazard ratios will then be combined across studies using a fixed effect model to give combined hazard ratios. For dichotomous outcomes, the number of events and the number of patients will be used to calculate Peto odds ratio estimates of treatment effect. These will be generated for individual trials and then combined across trials using a fixed effect model. For all outcomes, trial results will also be combined using a random effects model to test robustness to model choice.

Give details of any plans for the separate presentation, exploration or analysis of different types of participants (e.g. by age, disease status, ethnicity, socioeconomic status, presence or absence or co-morbidities); different types of intervention (e.g. drug dose, presence or absence of particular components of intervention); different settings (e.g. country, acute or primary care sector, professional or family care); or different types of study (e.g. randomised or non-randomised).

The approach to be taken should be stated, e.g. whether subgroup analyses, meta-regression or modelling of covariates is planned and, where appropriate, details of categorisation (e.g. BMI <25, 25-30,>30) should be given. Where it is not possible or appropriate to specify subgroups or subsets in advance, for example in a qualitative synthesis, please make a statement to this effect.

Example:  If the necessary data are available, subgroup analyses will be done for people with stage I and stage II disease separately. Within each stage, and overall, we also plan to do a subgroup analysis by age (<20, 20-30, 30-40, >40 years).

This is a qualitative synthesis and while subgroup analyses may be undertaken it is not possible to specify the groups in advance

Pre-clinical animal intervention reviews have a review question in the PICO format and concern pre-clinical testing of intervention(s) in animal models of disease. Animal model reviews aim to provide an overview of animal models for a certain health problem or disease (area) and do not investigate the efficacy of treatment. They may still have a PICO review question where the intervention is the induction of a disease model. Experimental animal exposure reviews have a review question in PECO format and concern the effect of exposure to certain compounds in experimental animals, e.g. safety studies in toxicology.

Select each country individually to add it to the list below, use the bin icon to remove any added in error. The entry will default to English if no other selection is made. For languages other than English, registrants are asked to indicate whether a summary or abstract will be made available in English.

List other places where the systematic review protocol is registered. The name of the organisation and any unique identification number assigned to the review by that organisation should be included.

Example:  All Wales Systematic Review Register (AWSRR2 Sciaticax)

Example:  G.P.J. van Hout, S.J. Jansen of Lorkeers, K.E. Wever, E.S. Sena, W.W. van Solinge, P.A. Doevendans, G. Pasterkamp, S.A.J. Chamuleau and I.E. Hoefer. Anti-inflammatory compounds to reduce infarct size in large-animal models of myocardial infarction: A meta-analysis (pages 4–10). Version of Record online: 20 JAN 2015 | DOI: 10.1002/ebm2.4

Give words or phrases that best describe the review. Keywords will help users find the review in the Register. Be as specific and precise as possible. Avoid acronyms and abbreviations unless these are in wide use.

Information specialists at the Centre for Reviews and Dissemination (CRD) will assign MeSH terms. When the review is published, NLM assigned MeSH terms will be added where these are available.

Example:  This is an update of our earlier systematic review and is being undertaken in the light of the publication of significant new research. The citation for the existing review is Hypothermia in animal models of acute ischaemic stroke: a systematic review and meta-analysis. Van der Worp HB, Sena ES, Donnan GA, Howells DW, Macleod MR. Brain. 2007 Dec;130(Pt 12):3063-74.

Review status should be updated when the review is completed and when it is published

• Animal review
• Narrative synthesis
• Synthesis of qualitative studies

Loading metrics

Open Access

Peer-reviewed

Research Article

Magnitude and clinical characteristics of cerebral palsy among children in Africa: A systematic review and meta-analysis

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Assistant Professor in Pediatrics and Child Health Nursing, College of Health Science, Woldia University, Weldiya, Ethiopia

Affiliation MSc in Psychiatry, College of Health Science, Woldia University, Weldiya, Ethiopia

Affiliation MSc in Pediatrics and Child Health Nursing, College of Health Science, Woldia University, Weldiya, Ethiopia

Affiliation MSc in Emergency Medicine and Critical Care Nursing, College of Health Science, Woldia University, Weldiya, Ethiopia

Roles Conceptualization, Formal analysis, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation MSc in Adult Health Nursing, College of Health Science, Woldia University, Weldiya, Ethiopia

• Biruk Beletew Abate, 
• Kindie Mekuria Tegegne, 
• Alemu Birara Zemariam, 
• Addis Wondmagegn Alamaw, 
• Mulat Awoke Kassa, 
• Tegene Atamenta Kitaw, 
• Gebremeskel Kibret Abebe, 
• Molla Azmeraw Bizuayehu

• Published: June 21, 2024
• https://doi.org/10.1371/journal.pgph.0003003
• Peer Review
• Reader Comments

Cerebral palsy (CP) is the most common motor disability in childhood which causes a child’s behavioral, feeding, and sleep difficulties. It remains a poorly studied health problem in Africa. The main aim of this study was assessing the pooled prevalence of Cerebral Palsy (CP) and its clinical characteristics in Africa context. Systematic review and meta-analysis were conducted using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search articles from electronic databases (Cochrane library, Ovid platform) (Medline, Embase, and Emcare), Google Scholar, CINAHL, PubMed, Maternity and Infant Care Database (MIDIRS). The last search date was on 12/05/ 2023 G. C. A weighted inverse variance random-effects model was used to estimate the pooled estimates of cerebral palsy and its types. The subgroup analysis, publication bias and sensitivity analysis were done. Studies on prevalence and clinical characteristics of cerebral palsy were included. The primary and secondary outcomes were prevalence and clinical characteristics of cerebral palsy respectively. A total of 15 articles with (n = 498406 patients) were included for the final analysis. The pooled prevalence of cerebral palsy in Africa was found to be 3·34 (2·70, 3·98). The most common type is spastic cerebral palsy accounting 69·30% (66·76, 71·83) of all cases. The second one is quadriplegic cerebral palsy which was found to be 41·49% (33·16, 49·81). Ataxic cerebral palsy accounted 5·36% (3·22, 7·50). On the other hand, dyskinetic cerebral palsy was found to be 10.88% (6·26, 15·49). About 32·10% (19·25, 44.95) of cases were bilateral while 25·17% (16·84, 33·50) were unilateral. The incidence of cerebral palsy in Africa surpasses the reported rates in developed nations. Spastic and quadriplegic subtypes emerge as the most frequently observed. It is recommended to channel initiatives toward the strategic focus on preventive measures, early detection strategies, and comprehensive management protocols.

Citation: Abate BB, Tegegne KM, Zemariam AB, Wondmagegn Alamaw A, Kassa MA, Kitaw TA, et al. (2024) Magnitude and clinical characteristics of cerebral palsy among children in Africa: A systematic review and meta-analysis. PLOS Glob Public Health 4(6): e0003003. https://doi.org/10.1371/journal.pgph.0003003

Editor: Julia Robinson, PLOS: Public Library of Science, UNITED STATES

Received: November 15, 2023; Accepted: May 22, 2024; Published: June 21, 2024

Copyright: © 2024 Abate et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data are available in the manuscript and supporting files .

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Cerebral palsy (CP) is a group of permanent disorders of development that affect different body parts and result in activity limitations with the manner of walking, muscle tone, posture, and coordination of movement. This is attributed to a non-progressive disturbance that occurs in the development of the fetal or infant brain [ 1 ]. There are various forms of cerebral palsy, each distinguished by the area of the brain that is injured. This occurs when signals are not correctly sent from the brain to the muscle. Despite the fact that numerous studies show that CP can result from a wide range of conditions, such as early birth, illnesses, injuries, and medical issues, the pathophysiology of this issue is unclear [ 2 ]. Cerebral palsy movement abnormalities are frequently accompanied with sensory, perception, cognition, communication, and behavior issues, seizures, and subsequent musculoskeletal problems [ 3 ]. Children with CP are present with certain characteristics/types which include spasticity, hypotonia, diplegia, hemiplegia, and dystonia [ 4 ]. Usually, motor disorders are more common and accompanied by perception cognition, sensation, communication and behavior due to epilepsy and secondary musculoskeletal problems [ 1 ]. CP greatly affects the childhood characteristics such as behavioral difficulties, feeding difficulties, social skills, and sleep [ 5 ].

CP is the most common neurologic problem causing motor disability in children [ 6 , 7 ]. According to the World Health Organization(WHO) report globally, there were 10% of children (approximately 200 million) suffer from physical disability, mental deficiencies or developmental delay, and impaired learning abilities [ 8 ]. Furthermore, more than three fourth of the world’s disabled population live in low-income countries, many of these in Africa [ 9 ]. Recent population-based studies from around the world reported that the prevalence of CP was ranging from 1 to nearly 4 per 1,000 live births [ 4 ]. The prevalence of CP is variably reported across different countries which are 1.89 per 1,000 live births in Norway [ 10 ], and 2.2 per 1,000 live births in Denmark [ 11 ]. Furthermore, a population-based study in Bangladesh reported that 3.4 per 1,000 children [ 12 ].

In Africa, the prevalence of CP is also compared to developed nations. Evidently, studies on hospital clinical samples suggest prevalence ranging from 2 to 10 cases per 1000 live births from Egypt, Uganda, South Africa, and South Egypt, respectively [ 13 – 18 ]. Moreover, a population-based study in Uganda revealed that the prevalence of CP was 2.9 per 1,000 children in 2017 [ 19 ]. In line with the global trend, CP places a heavy burden of disease on children, families, and society in both developed and developing countries [ 4 , 11 ]. The previous studies done in different countries showed that several factors were associated with CP. Among these factors, asphyxia at birth, low birth weight, intrauterine infections and multiple gestations were the most important determinants for CP [ 20 – 22 ]. Cases of CP varies in presentation, etiology, evolution, severity, medical and rehabilitation needs, comorbidities, and outcomes [ 23 ]. Furthermore, compared to younger ages, older children with cerebral palsy (CP) were substantially less prevalent, and this tendency was reflected in the decline in prevalence. These results implied that a substantial death rate existed among children with cerebral palsy, especially in the most severely impacted children. The paucity of information on the epidemiology of cerebral palsy (CP) in low- and middle-income countries (LMICs) highlights the maltreatment of and shortage of resources for children with CP in these countries, which lowers their survival rate for consecutive birth dates [ 19 ]. It might be appreciated at early or later age. Cerebral palsy was diagnosed in 43.4% of children after the first year of life, 32.4% after the second half of life, and 24.1% before the age of six months [ 24 ]. This figure shows there is time delay in the diagnosis of CP.

Globally, several strategies and interventions have been tried to reduce the prevalence and adverse sequels of CP among children [ 7 , 9 ]. It was anticipated that advancements in these areas would lead to lower rates of cerebral palsy because prenatal events are thought to account for about 75% of all cases of cerebral palsy. These include electronic fetal monitoring, cesarean sections, and generally improving obstetric and neonatal care [ 4 , 8 , 25 ]. Beyond these efforts, the problem has still a public concern, particularly in developing nations [ 26 ], because their obstetric and neonatal advanced medical care is limited [ 27 ]. Few rigorous population-based studies have recently been published from Uganda [ 19 ], and Bangladesh [ 12 ] revealing large discrepancy in prevalence between them and studies from high income countries. Large differences in the prevalence of CP were found between studies conducted in high-income countries and those conducted in African nations. These investigations unequivocally showed that the data from these disparate pieces of evidence or from research conducted in wealthy nations, and they suggested the necessity of a thorough evaluation of CP from low- and middle-income nations [ 28 ]. There is a lack of structured and consistent screening policy for developmental disabilities amongst children in Africa [ 18 ]. Due to this circumstance and delayed presentation, many children with disabilities have gone undiagnosed and consequently have not received the necessary assistance. Consequently, the severity and impact of CP in Africa are understated. Because of stigma, families with disabled children in African nations often find themselves shut out of society. Because they are frequently denied access to the necessities of recognition, education, health care, and socialization, the majority of these children thereafter face numerous social, economic, and political obstacles [ 29 ].

In Africa different studies have been conducted regarding the magnitude and clinical characteristics of cerebral palsy, however findings from these small studies lack consistency and results are variable making it challenging to recommend actions. To date, a rigorous systematic review and meta-analysis of the overall prevalence of CP are lacking in resource-poor settings despite the fact that large burden of the disease. Hence, this study is intended to assess the pooled prevalence of CP and its clinical characteristics among children in Africa. The result of this systematic review and meta-analysis will provide a pooled data on the burden of cerebral palsy which can be used as a baseline in designing strategies for prevention and control of cerebral palsy.

Search strategy

This systematic review and meta-analysis review assessed studies that provide data on the magnitude and clinical characteristics of cerebral palsy in the Africa context. We searched these articles from the following databases: Cochrane library, Ovid platform (Medline, Embase, and Emcare), Google Scholar, CINAHL, PubMed, Maternity and Infant Care Database (MIDIRS), and institutional repositories in Africa countries on 12/05/ 2023 G. C. The search in all database included keywords that are the combinations of population, condition/outcome, and context. A snowball searching for the references of relevant papers for linked articles was also performed.

The following search map was applied: (prevalence OR magnitude) AND (Children [MeSH Terms] OR infant OR child OR childhood) AND (cerebral palsy [MeSH Terms] OR “developmental disabilities”, OR “neurological impairment,” OR “childhood disability”) AND (ataxia OR dyskinesia OR spastic) AND (“clinical characteristics [MeSH Terms]” OR type) AND (Africa OR “developing countries”) on PubMed database ( S1 Table ). These search terms were further paired with the names of African countries. Thus, the key searching terms were considering Africa countries that compose of Ethiopia, Djibouti, Somalia, Egypt, Eritrea, Sudan, Tanzania, Kenya, Nigeria, Uganda etc. Using those key terms, we used the Boolean operator "OR" (to connect key terms/phrases within the same concept), "AND" (to connect key terms /phrases between two concepts), and "NOR" to filter out. In addition, we used truncation (*), adjacency searching ( ADJn) , and wildcard symbols to find variations in spelling and variant word endings on the Ovid databases. Moreover, we applied relevant limits (filters) such as a limit to human studies only. The sample search strategy for Medline is provided in S1 Table .

Study selection and screening

The retrieved studies were exported to Endnote version 8 reference managers to remove duplicate studies. Two investigators (BB and KM) independently screened the selected studies using article’s title and abstracts before retrieval of full-text papers. We used pre-specified inclusion criteria to further screen the full-text articles. Disagreements were discussed during a consensus meeting with other reviewers (AB and AW) for the fin selection of studies to be included in the systematic review and meta-analysis. The retrieved studies were imported in covidence platform to remove duplicate studies and to do the whole screening process.

Inclusion and exclusion criteria

Studies that assess the magnitude and clinical characteristics of cerebral palsy among children under the age of 18 were considered. Citations without abstract and/or full text, anonymous reports, editorials, and qualitative studies were excluded from the analysis. The Prevalence of cerebral palsy was considered as the proportion of children with cerebral palsy among 1000 risk population.

Studies conducted among children under the age of 18 were considered.

Intervention

Not applicable.

Studies conducted in Africa context.

Study design

All observational studies.

Prevalence of cerebral palsy and its clinical characteristics/type.

Quality assessment

The authors appraised the quality of the studies by using the Joanna Briggs Institute (JBI) quality appraisal checklist [ 17 , 30 ]. There was a team of four reviewers and the papers were split amongst the team. Each paper was then assessed by two reviewers and any disagreements were discussed with the third and the fourth reviewers. Studies were considered as low risk or good quality when it scored 4 and above for all designs (cross-sectional, and cohort) [ 19 ], whereas the studies scored 3 and below were considered as high risk or poor quality and excluded ( S2 Table ). Furthermore, we thoroughly extract adjusted confounders and main findings from all included studies ( Table 1 ). Similar methodology has been used in previously published works [ 17 , 18 , 31 – 37 ].

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pgph.0003003.t001

Data extraction

The authors developed a data extraction form on the excel sheet and the following data were extracted for eligible studies: year of publication, country, and study design, the definition of cerebral palsy, and clinical characteristics / type of cerebral palsy. The data extraction sheet was piloted using 4 papers randomly, and it was adjusted after piloted the template. Two of the authors (BB and KM) extracted the data using the extraction form in collaboration. The third and fourth (MA and AB) authors checked the correctness of the data independently. Any disagreements between reviewers were resolved through discussions with third and fourth reviewers when required. The mistyping of data was resolved through crosschecking with the included papers.

Synthesis of results

The authors transformed the data to STATA 17 for analysis after it was extracted in an excel sheet considering prevalence, and type/characteristics reported. We pooled the overall prevalence estimates of cerebral palsy by a random effect meta-analysis model. We examined the heterogeneity of effect size using the Q statistic and the I 2 statistics. In this study, the I 2 statistic value of zero indicates true homogeneity, whereas the value 25%, 50%, and 75% represented low, moderate and high heterogeneity, respectively [ 38 – 41 ]. Subgroup analysis was done by the study country, study design, and year of publication. Sensitivity analysis was employed to examine the effect of a single study on the overall estimation. Publication bias was checked by the funnel plot and more objectively through Egger’s regression test.

A total of 5394 studies were identified; 5380 from different databases and 14 from other sources. After duplication removed, a total of 2,431 articles remained (2963 removed by duplication). Finally, 206 studies were screened for full-text review, and 15 articles with (n = 498406 patients) were included for the final analysis ( Fig 1 , and S2 Table ).

https://doi.org/10.1371/journal.pgph.0003003.g001

Characteristics of included studies

Fifteen studies were included in this systematic review and meta-analysis [ 14 , 16 , 19 , 42 – 52 ]. Two studies were from Ethiopia [ 42 , 47 ], two from Uganda [ 19 , 43 ], two from Tanzania [ 44 , 45 ], three from Egypt [ 16 , 46 , 50 ], one from Cameroon [ 51 ], one from Nigeria [ 52 ], two from South Africa [ 14 , 48 ], and one from Sudan [ 49 ] ( Table 1 ).

Prevalence of cerebral palsy in Africa

Most of the included studies (n = 11) have reported the prevalence of cerebral palsy per 1000 live births [ 14 , 16 , 19 , 45 , 46 , 50 – 52 ]. The prevalence of cerebral palsy was ranged from 1(95% CI: 0·96, 1·04) to 17·77 (95% CI: 10·93, 24·61). The random-effects model analysis from those studies revealed that, the pooled prevalence of cerebral palsy in Africa was found to be 3·34 (95% CI: 2·70, 3·98) (95% CI: I 2 = 99·4%; p < 0·001) ( Fig 2 ).

https://doi.org/10.1371/journal.pgph.0003003.g002

Subgroup analysis

S ubgroup analysis was done through stratified by country, and sample size. Based on this, the prevalence of cerebral palsy was found to be 2·90(2·72–3·08) in Uganda, 13·68(6·08–21·28) in Tanzania, 2·12 (1·37, 2·88) in Egypt, 4·86 (4·20, 5·52), 2·30 (2·23, 2·37) in Nigeria and 10·00 (8·70,11·30) in South Africa ( Fig 3 ).

https://doi.org/10.1371/journal.pgph.0003003.g003

Publication bias

A funnel plot showed asymmetrical distribution. The Egger’s regression test-value was 0·009, which indicated that, the presence of publication bias. Due to the presence of publication bias ( S1 Fig ), we employed a trim and fill analysis and one study was added and the prevalence of cerebral palsy becomes 3·193 ( S2 Fig ).

Sensitivity analysis

We also employed a leave-one-out sensitivity analysis to identify the potential source of heterogeneity in the analysis of the prevalence of cerebral palsy in Africa. The results of this sensitivity analysis showed that the findings were not dependent on a single study. Our pooled estimated prevalence of cerebral palsy varied from 2·76 (2·12–3·39) to 3·55 (2·84–4·25) after the deletion of a single study ( S3 Fig ).

Clinical characteristics of cerebral palsy in Africa

Spastic cerebral palsy..

Pooled prevalence . Spastic cerebral palsy is the most common type of cerebral palsy in Africa. It is characterized by jerky movements, muscle tightness and joint stiffness. Six of the included studies have reported the magnitude of spastic cerebral palsy in percentage [ 16 , 19 , 42 , 43 , 46 , 52 ]. The prevalence of spastic cerebral palsy was ranged from 23·00%(95% CI: 15·90, 30·10) to 88·90 (95% CI: 85·83, 91·97). The random-effects model analysis from those studies revealed that, the pooled prevalence of spastic cerebral palsy in Africa was found to be 69·30% (95% CI: 66·76, 71·83) (95% CI: I 2 = 99·5%; p < 0·001) ( Fig 4 ).

https://doi.org/10.1371/journal.pgph.0003003.g004

Subgroup analysis . The subgroup analysis was done through stratified by country, and sample size. Based on this, the prevalence of spastic cerebral palsy was found to be 23·00%(95% CI: 15·90, 30·10) in Uganda, 70·13% (65·54,74·72) in Egypt, 69·90%(69·68, 70·12) in Nigeria, and 88·9%(85·83, 91·97) in Ethiopia ( S4 Fig ).

Publication bias . A funnel plot showed symmetrical distribution. The Egger’s regression test-value was 0·468, which indicated that, the absence of publication bias. As a result, we didn’t conduct trim and fill analysis ( S5 Fig ).

Quadriplegic cerebral palsy in Africa.

Pooled prevalence . Dyskinetic CP is characterized by involuntary, uncontrolled, and recurring movements with fluctuating muscle tone [ 3 , 28 ]. Most of the included studies (n = 5) have reported the magnitude of quadriplegic cerebral palsy in percentage from total cerebral palsy cases [ 16 , 19 , 42 , 46 , 48 , 49 ]. The prevalence of unilateral cerebral palsy was ranged from 27.60% (95% CI: 18.56, 36.64) to 62·50 (95% CI: 57·77, 67·23). The random-effects model analysis from those studies revealed that, the pooled prevalence of quadriplegic cerebral palsy in Africa was found to be 41·49% (95% CI: 33·16, 49·81) (95% CI: I 2 = 99·7%; p < 0·001) ( Fig 5 ).

https://doi.org/10.1371/journal.pgph.0003003.g005

Subgroup analysis . The subgroup analysis was done through stratified by country. Based on this, the prevalence of quadriplegic unilateral cerebral palsy was found to be 36·40% (24·44–48·35) in Egypt, 62·5% (57·77, 67·23) in Ethiopia, 27·60% (18·56, 36·64) in South Africa, and 43·50% (34·15, 52·85) in Sudan ( S6 Fig ).

Publication bias . A funnel plot showed symmetrical distribution. The Egger’s regression test-value was 0·360, which indicated that, the absence of publication bias. As a result, we didn’t conduct trim and fill analysis ( S7 Fig ).

Ataxic cerebral palsy in Africa.

Pooled prevalence . Ataxic cerebral palsy characterized by trouble with balance and coordination [ 53 ]. Most of the included studies (n = 11) have reported the prevalence of ataxic cerebral palsy per 1000 [ 16 , 19 , 42 , 43 , 45 – 49 , 52 ]. The prevalence of cerebral palsy was ranged from 1·4(95% CI: 0·25, 2·55) to 9·80 (95% CI: 9·66, 9·94). The random-effects model analysis from those studies revealed that, the pooled prevalence of cerebral palsy in Africa was found to be 5·36 (95% CI: 3·22, 7·50) (95% CI: I 2 = 99·8%; p < 0·001) ( Fig 6 ).

https://doi.org/10.1371/journal.pgph.0003003.g006

Subgroup analysis . The subgroup analysis was done through stratsified by country, and sample size. Based on this, the prevalence of ataxic cerebral palsy was found to be 5·38(2·02–12·78) in Uganda, 9·00(3·39–14·61) in Tanzania, 4·90 (2·46, 7·35) in Egypt, 2·09 (0·23, 3·96) in Ethiopia, 9·60 (3·64, 15·56) in South Africa and 10·00 (8·70,11·30) in Sudan ( S8 Fig ).

Publication bias . A funnel plot showed symmetrical distribution. The Egger’s regression test-value was 0·633, which indicated that, the absence of publication bias. Due to the absence of publication bias, we did not employ a trim and fill analysis ( Fig 7 ).

https://doi.org/10.1371/journal.pgph.0003003.g007

Dyskinestic cerebral palsy in Africa.

Pooled prevalence . Dyskinetic cerebral palsy is characterized by dystonia, athetosis, and chorea [ 54 ]. Most of the included studies (n = 8) have reported the magnitude of ataxic cerebral palsy [ 16 , 19 , 42 , 43 , 46 – 48 , 52 ]. The prevalence of ataxic cerebral palsy was ranged from 3·80% (95% CI: 3·57, 4·03) to 29·80 (95% CI: 20·55, 39·05). The random-effects model analysis from those studies revealed that, the pooled prevalence of unilateral cerebral palsy in Africa was found to be 10·88% (95% CI: 6·26, 15·49) (95% CI: I 2 = 100%; p < 0.001) ( Fig 8 ).

https://doi.org/10.1371/journal.pgph.0003003.g008

Subgroup analysis . The subgroup analysis was done through stratified by country, and sample size. Based on this, the prevalence of unilateral cerebral palsy was found to be 9·67%(6·92–12·42) in Uganda, 9·90% (2·06, 21·86) in Egypt, 4·60%(4·50, 4·70) in Nigeria, 8·51%(5·94, 11·06) in Ethiopia, and 29·80% (20·55, 39·05) in South Africa ( S10 Fig ).

Publication bias . A funnel plot showed symmetrical distribution. The Egger’s regression test-value was 0·728, which indicated that, the absence of publication bias. As a result, we didn’t conduct trim and fill analysis ( S11 Fig ).

Bilateral cerebral palsy in Africa.

Pooled prevalence . Bilateral cerebral palsy is a problem with movement, co-ordination and development which affects both sides of the body [ 55 ]. Most of the included studies (n = 10) have reported the magnitude of bilateral cerebral palsy in percentage from total cerebral palsy cases [ 16 , 19 , 42 , 43 , 46 – 48 , 52 ]. The prevalence of unilateral cerebral palsy was ranged from 9·60% (95% CI: 9·24, 9·96) to 60·40 (95% CI: 53·74, 67·06). The random-effects model analysis from those studies revealed that, the pooled prevalence of bilateral cerebral palsy in Africa was found to be 32·10% (95% CI: 19·25, 44·95) (95% CI: I 2 = 100%; p < 0·001) ( Fig 9 ).

https://doi.org/10.1371/journal.pgph.0003003.g009

Subgroup analysis . The subgroup analysis was done through stratified by country, and sample size. Based on this, the prevalence of unilateral cerebral palsy was found to be 41·40%(36·48–46·31) in Uganda, 20·00% (12·16–27·84) in Tanzania, 28·94% (8·96, 66·83) in Egypt, 60·20%(59·97, 60·43) in Nigeria, 34·96 (14·73, 84·4) in Ethiopia, 16·00% (8·59, 23·41) in South Africa, and 13·9% (7·38, 20·42) in Sudan ( S12 Fig ).

Publication bias . A funnel plot showed symmetrical distribution. The Egger’s regression test-value was 0·529, which indicated that, the absence of publication bias. As a result, we didn’t conduct trim and fill analysis ( S13 Fig ).

Unilateral cerebral palsy in Africa.

Pooled prevalence . Unilateral Cerebral Palsy is characterized by hemiplegia and hemiparesis, is a condition that affects muscle control and function on one side of the body [ 56 ]. Most of the included studies (n = 10) have reported the magnitude of unilateral cerebral palsy in percentage from total cerebral palsy cases [ 16 , 19 , 42 , 43 , 45 – 49 , 52 ]. The prevalence of unilateral cerebral palsy was ranged from 13·50% (95% CI: 13·08, 13·92) to 23·70 (95% CI: 16·53, 30·87). The random-effects model analysis from those studies revealed that, the pooled prevalence of unilateral cerebral palsy in Africa was found to be 25·17% (95% CI: 16·84, 33·50) (95% CI: I 2 = 100%; p < 0·001) ( Fig 4 ).

Subgroup analysis . The subgroup analysis was done through stratified by country. Based on this, the prevalence of unilateral cerebral palsy was found to be 35·15%(13·30–56·99) in Uganda, 15%(8·00–22·00) in Tanzania, 17·45% (9·71, 25·19) in Egypt, 39·8%(39·57, 40·03) in Nigeria and 10·00 (8·70,11·30), 24·76%(19·61, 29· 92) in Ethiopia, 16·00% (8·59,23·41) in South Africa, and 25·9% (17·64, 34·16) in Sudan ( S14 Fig ).

Publication bias . A funnel plot showed symmetrical distribution. The Egger’s regression test-value was 0·903, which indicated that, the absence of publication bias. As a result, we didn’t conduct trim and fill analysis ( S15 Fig ).

Mixed type cerebral palsy in Africa.

Pooled prevalence . Mixed cerebral palsy occurs when a child exhibits symptoms of more than one type of cerebral palsy [ 57 ]. Most of the included studies (n = 10) have reported the magnitude of mixed cerebral palsy in percentage [ 19 , 42 , 43 , 45 – 49 , 52 ]. The prevalence of mixed cerebral palsy in Africa was ranged from to 2·00%(1·85, 2·15) to 26·9% (95% CI: 26·36, 27·44). The random-effects model analysis from those studies revealed that, the pooled prevalence of mixed cerebral palsy in Africa was found to be 8·58% (95% CI: 4·06, 13·11) (95% CI: I 2 = 99·9%; p < 0·001) ( Fig 10 ).

https://doi.org/10.1371/journal.pgph.0003003.g010

Subgroup analysis . The subgroup analysis was done through stratified by country. Based on this, the prevalence of unilateral cerebral palsy was found to be 4·60%(1·31–10·51) in Uganda, 5·0%(0·73–9·27) in Tanzania, 25·21% (21·88, 28·54) in Egypt, 8·3%(8·17, 8·43) in Nigeria and 2·70 (0·97, 4·42) in Ethiopia, 2·10% (0·80, 5·00) in South Africa, and 2·80% (0·31, 6·59) in Sudan ( S16 Fig ).

Publication bias . A funnel plot showed symmetrical distribution. The Egger’s regression test-value was 0·468, which indicated that, the absence of publication bias. As a result, we didn’t conduct trim and fill analysis ( S17 Fig ).

The most prevalent form of motor disability that affects children is cerebral palsy (CP). The brain may malfunction during fetal or prenatal development due to insufficient oxygenation, or it may result from damage to the developing infant’s brain during the postpartum period. In this systematic review and meta-analysis, we aimed to assess the magnitude and clinical characteristics of CP among children in Africa. Accordingly, the pooled prevalence of cerebral palsy was found to be 3·3 per 1000 live births (2·69,3·92). This finding is in line with the study done in USA [ 58 ]. This might be because African descendants were surveyed in that study. However, this finding is higher than CP prevalence in most other countries in United State and Europe which is estimated to be 2–2·5 of 1000 [ 59 – 61 ]. Compared to some studies conducted in Arabic-speaking countries, 1·8 [ 7 ], Europe, 2·25 [ 62 ], India, 2·27 [ 63 ], Canada, 2·57 [ 64 ], and Japan 1·88 [ 65 ], the pooled prevalence of cerebral palsy is greater in Africa. This discrepancy might be because of the high magnitude of perinatal complications such as birth asphyxia and neonatal infections in Africa [ 66 ]. In addition, this might be due to the fact that in Africa, there are challenges to manage cerebral palsy due to: inaccessibility of basic care, limited availability of diagnostic facilities, limited number of trained and expertise personal in managing cerebral palsy and exacerbated by lack of appropriate intervention, medication, surgical procedure and regular physical care [ 67 ]. In fact, these improper managements might have contributed to the prevalence of cerebral palsy. Furthermore, prematurity, low birthweight, kernicterus, asphyxia and neonatal infections are among the main causes of cerebral palsy, and they are more common in Africa than in western nations [ 67 ]. This implies there may be a greater proportion of children with more severe disability in resource-poor countries because of delayed presentation of a range of disorders and absence of early intervention services. Moreover, the clinical spectrum of CP differs from that of affluent countries in resource-poor, developing nations. The discrepancy probably explained by the multifactorial causes of CP and difference in quality of health care delivery between the two regions, low- and middle-income countries and developed countries [ 19 , 68 ]. The burden difference might also be due to absence or inadequacy of inter-disciplinary team approach in developing countries [ 24 ]. On the other hand, most studies done in developing countries were institution based and at referral hospitals. Since referral hospitals receive CP patients from different district hospitals, health center and regional hospitals where there are few experts and facilities hence the number of CP patients’ data might be aggregated to the referral hospitals [ 44 , 69 ]. In addition, the high prevalence may be due to improvement in health seeking behavior of the community in developing countries where previously people in Africa believed that having CP patient at home is a curse and tried to hide them at their homes. Tanzania had a higher prevalence of cerebral palsy, at 13·68/1000 (6·08–21·28) compared to studies from other African countries. This might be due to the small sample size included in studies from Tanzania. It is also higher than that of other countries study, Norway 2·1 [ 70 ], Thailand 1·0 [ 71 ]. This difference might be advance technology used, utilization of advance treatment modalities, regular follow up of antenatal care and sample size difference in other countries like Norway and Thailand.

The results of the current review revealed that the spastic type of cerebral palsy affected the majority of children in Africa which accounts 63·4% of all form cerebral palsy. This finding is in line with different studies done in other regions such as north east Italy, Bangladesh and Nepal [ 58 , 72 , 73 ]. During assessment of perinatal factors, studies identified that those children with spastic subtype of CP had higher rate of fetal distress and PROM during the perinatal period, higher rate of language and speech difficulty and worse functional impairment while those with Dyskinetic and Ataxic CP were found to have higher rate of precipitated labor and deep jaundice during the neonatal period [ 74 ]. These findings may indicate that spastic subtype of CP might be related with the high rate of perinatal hypoxic insult in Africa as in cases of fetal distress, while dyskinetic and ataxic forms may be associated with bleeding and injuries to the deep grey matters of the brain that can happen in cases of precipitated labor. Children with severe forms of CP were shown to have lower levels of communication function, according to a study from Sweden that demonstrated the relationship between communication function and gross and fine motor and cognitive function [ 75 ]. Numerous severe (quadriplegic) bilateral spastic type of CP arises from injuries to the full-term brain due to complications during the birth process such as birth asphyxia or acquired central nervous system infections like meningitis [ 76 ]. Study done in Misurata Hospital -LIBYA around 50% of cases had malnutrition and anemia [ 77 ]. In Greece study, nearly one-third of patients suffered from iron deficiency anemia [ 78 ]. Children with disabilities and their families in African countries are frequently excluded from society because of stigmatization. Most of these children consequently confront many challenges socially, economically, and politically because they are often denied the basics of health care, education, socialization, and recognition.

This systematic review and meta-analysis have limitations. There is variation between African countries in terms of culture, the economic profile, political stability, research funding and infrastructure, and health care systems. This makes it very difficult to generalize the results of this review across all countries. Besides, although we have tried to extensively search articles from all countries in Africa, we able to found 15 articles with from few countries; this may also affect the generalizability of the pooled findings. Furthermore, differences in methodology, including hospital versus community sittings, in the included studies also contributed to high levels of heterogeneity. Despite these limitations, these meta-analyses provide a picture of CP and its types among children in Africa.

Conclusions and recommendations

The overall prevalence of cerebral palsy in Africa found to be high (3·34 /1000) (95% CI: 2·70, 3·98). Compared to findings from developed countries spastic, and quadriplegic cerebral palsy were found to be the most common with pooled prevalence of 69·30% (95% CI: 66·76, 71·83) and 41·49% (95% CI: 33·16, 49·81) respectively. Governmental and non-governmental organizations should target their effort on the prevention, early detection and management of cerebral palsy in Africa. Large multicenter studies, qualitative or mixed-methods studies assessing patient and family understanding of CP, access to resources, and barriers to care are virtually absent in Africa to address recent evidence gap. In addition, there is a need for longitudinal studies that would assess outcomes over time for patients with CP as well as for randomized controlled trials of community-based treatment strategies that would be appropriate in an African setting.

Supporting information

S1 table. search strategy used for one of the databases..

https://doi.org/10.1371/journal.pgph.0003003.s001

S2 Table. Quality appraisal result of included studies in Africa, using Joanna Briggs Institute (JBI) quality appraisal checklist [ 16 ].

https://doi.org/10.1371/journal.pgph.0003003.s002

S1 Fig. Shows test of publication bias for prevalence of cerebral palsy among children in by sample size in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s003

S2 Fig. Trim and fill analysis for prevalence of cerebral palsy among children in by sample size in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s004

S3 Fig. Sensitivity analysis for prevalence of cerebral palsy among children in by sample size in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s005

S4 Fig. Subgroup analysis for prevalence of spastic cerebral palsy among children by countries in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s006

S5 Fig. Publication bias for prevalence of spastic cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s007

S6 Fig. Subgroup analysis for prevalence of quadriplegic cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s008

S7 Fig. Publication bias for prevalence of quadriplegic cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s009

S8 Fig. Subgroup analysis for prevalence of ataxic cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s010

S9 Fig. Publication bias for prevalence of ataxic cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s011

S10 Fig. Subgroup analysis for prevalence of dyskinetic cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s012

S11 Fig. Publication bias for prevalence of dyskinetic cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s013

S12 Fig. Subgroup analysis for prevalence of bilateral cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s014

S13 Fig. Publication bias for prevalence of bilateral cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s015

S14 Fig. Subgroup analysis for prevalence of unilateral cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s016

S15 Fig. Publication bias assessment for prevalence of unilateral cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s017

S16 Fig. Subgroup analysis for prevalence of mixed type cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s018

S17 Fig. Publication bias for prevalence of mixed type cerebral palsy among children in Africa.

https://doi.org/10.1371/journal.pgph.0003003.s019

https://doi.org/10.1371/journal.pgph.0003003.s020

• View Article
• PubMed/NCBI
• Google Scholar
• 2. Florin T., Netter’s pediatrics. 2011: Elsevier Health Sciences. https://www.elsevierhealth.com.au/
• 23. Shevell M.,Miller S.P., Scherer S.W. Yager J.Y. Fehlings M. G. The Cerebral Palsy Demonstration Project: A multidimensional research approach to cerebral palsy. in Seminars in Pediatric Neurology. 2011. Elsevier. https://pubmed.ncbi.nlm.nih.gov/21575839/
• 43. Kakooza-Mwesige A., Cerebral palsy in Mulago hospital, Uganda: comorbidity, diagnosis and cultural adaptation of an assessment tool. 2016: Karolinska Institutet (Sweden). https://openarchive.ki.se/xmlui/handle/10616/45094
• 44. Ngassa E.A., Assessment of prevalence and risk factors for cerebral palsy: A case of Mbeya zonal referral hospital. 2018, The Open University of Tanzania. http://repository.out.ac.tz/2330/
• 54. Albright A.L., Spasticity and movement disorders in cerebral palsy. 1996, SAGE Publications Sage CA: Thousand Oaks, CA. p. S1–S4. https://pubmed.ncbi.nlm.nih.gov/24224163/

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• J Med Libr Assoc
• v.106(4); 2018 Oct

A systematic approach to searching: an efficient and complete method to develop literature searches

Associated data.

Creating search strategies for systematic reviews, finding the best balance between sensitivity and specificity, and translating search strategies between databases is challenging. Several methods describe standards for systematic search strategies, but a consistent approach for creating an exhaustive search strategy has not yet been fully described in enough detail to be fully replicable. The authors have established a method that describes step by step the process of developing a systematic search strategy as needed in the systematic review. This method describes how single-line search strategies can be prepared in a text document by typing search syntax (such as field codes, parentheses, and Boolean operators) before copying and pasting search terms (keywords and free-text synonyms) that are found in the thesaurus. To help ensure term completeness, we developed a novel optimization technique that is mainly based on comparing the results retrieved by thesaurus terms with those retrieved by the free-text search words to identify potentially relevant candidate search terms. Macros in Microsoft Word have been developed to convert syntaxes between databases and interfaces almost automatically. This method helps information specialists in developing librarian-mediated searches for systematic reviews as well as medical and health care practitioners who are searching for evidence to answer clinical questions. The described method can be used to create complex and comprehensive search strategies for different databases and interfaces, such as those that are needed when searching for relevant references for systematic reviews, and will assist both information specialists and practitioners when they are searching the biomedical literature.

INTRODUCTION

Librarians and information specialists are often involved in the process of preparing and completing systematic reviews (SRs), where one of their main tasks is to identify relevant references to include in the review [ 1 ]. Although several recommendations for the process of searching have been published [ 2 – 6 ], none describe the development of a systematic search strategy from start to finish.

Traditional methods of SR search strategy development and execution are highly time consuming, reportedly requiring up to 100 hours or more [ 7 , 8 ]. The authors wanted to develop systematic and exhaustive search strategies more efficiently, while preserving the high sensitivity that SR search strategies necessitate. In this article, we describe the method developed at Erasmus University Medical Center (MC) and demonstrate its use through an example search. The efficiency of the search method and outcome of 73 searches that have resulted in published reviews are described in a separate article [ 9 ].

As we aimed to describe the creation of systematic searches in full detail, the method starts at a basic level with the analysis of the research question and the creation of search terms. Readers who are new to SR searching are advised to follow all steps described. More experienced searchers can consider the basic steps to be existing knowledge that will already be part of their normal workflow, although step 4 probably differs from general practice. Experienced searchers will gain the most from reading about the novelties in the method as described in steps 10–13 and comparing the examples given in the supplementary appendix to their own practice.

CREATING A SYSTEMATIC SEARCH STRATEGY

Our methodology for planning and creating a multi-database search strategy consists of the following steps:

• Determine a clear and focused question
• Describe the articles that can answer the question
• Decide which key concepts address the different elements of the question
• Decide which elements should be used for the best results
• Choose an appropriate database and interface to start with
• Document the search process in a text document
• Identify appropriate index terms in the thesaurus of the first database
• Identify synonyms in the thesaurus
• Add variations in search terms
• Use database-appropriate syntax, with parentheses, Boolean operators, and field codes
• Optimize the search
• Evaluate the initial results
• Check for errors
• Translate to other databases
• Test and reiterate

Each step in the process is reflected by an example search described in the supplementary appendix .

1. Determine a clear and focused question

A systematic search can best be applied to a well-defined and precise research or clinical question. Questions that are too broad or too vague cannot be answered easily in a systematic way and will generally result in an overwhelming number of search results. On the other hand, a question that is too specific will result into too few or even zero search results. Various papers describe this process in more detail [ 10 – 12 ].

2. Describe the articles that can answer the question

Although not all clinical or research questions can be answered in the literature, the next step is to presume that the answer can indeed be found in published studies. A good starting point for a search is hypothesizing what the research that can answer the question would look like. These hypothetical (when possible, combined with known) articles can be used as guidance for constructing the search strategy.

3. Decide which key concepts address the different elements of the question

Key concepts are the topics or components that the desired articles should address, such as diseases or conditions, actions, substances, settings, domains (e.g., therapy, diagnosis, etiology), or study types. Key concepts from the research question can be grouped to create elements in the search strategy.

Elements in a search strategy do not necessarily follow the patient, intervention, comparison, outcome (PICO) structure or any other related structure. Using the PICO or another similar framework as guidance can be helpful to consider, especially in the inclusion and exclusion review stage of the SR, but this is not necessary for good search strategy development [ 13 – 15 ]. Sometimes concepts from different parts of the PICO structure can be grouped together into one search element, such as when the desired outcome is frequently described in a certain study type.

4. Decide which elements should be used for the best results

Not all elements of a research question should necessarily be used in the search strategy. Some elements are less important than others or may unnecessarily complicate or restrict a search strategy. Adding an element to a search strategy increases the chance of missing relevant references. Therefore, the number of elements in a search strategy should remain as low as possible to optimize recall.

Using the schema in Figure 1 , elements can be ordered by their specificity and importance to determine the best search approach. Whether an element is more specific or more general can be measured objectively by the number of hits retrieved in a database when searching for a key term representing that element. Depending on the research question, certain elements are more important than others. If articles (hypothetically or known) exist that can answer the question but lack a certain element in their titles, abstracts, or keywords, that element is unimportant to the question. An element can also be unimportant because of expected bias or an overlap with another element.

Schema for determining the optimal order of elements

Bias in elements

The choice of elements in a search strategy can introduce bias through use of overly specific terminology or terms often associated with positive outcomes. For the question “does prolonged breastfeeding improve intelligence outcomes in children?,” searching specifically for the element of duration will introduce bias, as articles that find a positive effect of prolonged breastfeeding will be much more likely to mention time factors in their titles or abstracts.

Overlapping elements

Elements in a question sometimes overlap in their meaning. Sometimes certain therapies are interventions for one specific disease. The Lichtenstein technique, for example, is a repair method for inguinal hernias. There is no need to include an element of “inguinal hernias” to a search for the effectiveness of the Lichtenstein therapy. Likewise, sometimes certain diseases are only found in certain populations. Adding such an overlapping element could lead to missing relevant references.

The elements to use in a search strategy can be found in the plot of elements in Figure 1 , by following the top row from left to right. For this method, we recommend starting with the most important and specific elements. Then, continue with more general and important elements until the number of results is acceptable for screening. Determining how many results are acceptable for screening is often a matter of negotiation with the SR team.

5. Choose an appropriate database and interface to start with

Important factors for choosing databases to use are the coverage and the presence of a thesaurus. For medically oriented searches, the coverage and recall of Embase, which includes the MEDLINE database, are superior to those of MEDLINE [ 16 ]. Each of these two databases has its own thesaurus with its own unique definitions and structure. Because of the complexity of the Embase thesaurus, Emtree, which contains much more specific thesaurus terms than the MEDLINE Medical Subject Headings (MeSH) thesaurus, translation from Emtree to MeSH is easier than the other way around. Therefore, we recommend starting in Embase.

MEDLINE and Embase are available through many different vendors and interfaces. The choice of an interface and primary database is often determined by the searcher’s accessibility. For our method, an interface that allows searching with proximity operators is desirable, and full functionality of the thesaurus, including explosion of narrower terms, is crucial. We recommend developing a personal workflow that always starts with one specific database and interface.

6. Document the search process in a text document

We advise designing and creating the complete search strategies in a log document, instead of directly in the database itself, to register the steps taken and to make searches accountable and reproducible. The developed search strategies can be copied and pasted into the desired databases from the log document. This way, the searcher is in control of the whole process. Any change to the search strategy should be done in the log document, assuring that the search strategy in the log is always the most recent.

7. Identify appropriate index terms in the thesaurus of the first database

Searches should start by identifying appropriate thesaurus terms for the desired elements. The thesaurus of the database is searched for matching index terms for each key concept. We advise restricting the initial terms to the most important and most relevant terms. Later in the process, more general terms can be added in the optimization process, in which the effect on the number of hits, and thus the desirability of adding these terms, can be evaluated more easily.

Several factors can complicate the identification of thesaurus terms. Sometimes, one thesaurus term is found that exactly describes a specific element. In contrast, especially in more general elements, multiple thesaurus terms can be found to describe one element. If no relevant thesaurus terms have been found for an element, free-text terms can be used, and possible thesaurus terms found in the resulting references can be added later (step 11).

Sometimes, no distinct thesaurus term is available for a specific key concept that describes the concept in enough detail. In Emtree, one thesaurus term often combines two or more elements. The easiest solution for combining these terms for a sensitive search is to use such a thesaurus term in all elements where it is relevant. Examples are given in the supplementary appendix .

8. Identify synonyms in the thesaurus

Most thesauri offer a list of synonyms on their term details page (named Synonyms in Emtree and Entry Terms in MeSH). To create a sensitive search strategy for SRs, these terms need to be searched as free-text keywords in the title and abstract fields, in addition to searching their associated thesaurus terms.

The Emtree thesaurus contains more synonyms (300,000) than MeSH does (220,000) [ 17 ]. The difference in number of terms is even higher considering that many synonyms in MeSH are permuted terms (i.e., inversions of phrases using commas).

Thesaurus terms are ordered in a tree structure. When searching for a more general thesaurus term, the more specific (narrower) terms in the branches below that term will also be searched (this is frequently referred to as “exploding” a thesaurus term). However, to perform a sensitive search, all relevant variations of the narrower terms must be searched as free-text keywords in the title or abstract, in addition to relying on the exploded thesaurus term. Thus, all articles that describe a certain narrower topic in their titles and abstracts will already be retrieved before MeSH terms are added.

9. Add variations in search terms (e.g., truncation, spelling differences, abbreviations, opposites)

Truncation allows a searcher to search for words beginning with the same word stem. A search for therap* will, thus, retrieve therapy, therapies, therapeutic, and all other words starting with “therap.” Do not truncate a word stem that is too short. Also, limitations of interfaces should be taken into account, especially in PubMed, where the number of search term variations that can be found by truncation is limited to 600.

Databases contain references to articles using both standard British and American English spellings. Both need to be searched as free-text terms in the title and abstract. Alternatively, many interfaces offer a certain code to replace zero or one characters, allowing a search for “pediatric” or “paediatric” as “p?ediatric.” Table 1 provides a detailed description of the syntax for different interfaces.

Field codes in five most used interfaces for biomedical literature searching

Searching for abbreviations can identify extra, relevant references and retrieve more irrelevant ones. The search can be more focused by combining the abbreviation with an important word that is relevant to its meaning or by using the Boolean “NOT” to exclude frequently observed, clearly irrelevant results. We advise that searchers do not exclude all possible irrelevant meanings, as it is very time consuming to identify all the variations, it will result in unnecessarily complicated search strategies, and it may lead to erroneously narrowing the search and, thereby, reduce recall.

Searching partial abbreviations can be useful for retrieving relevant references. For example, it is very likely that an article would mention osteoarthritis (OA) early in the abstract, replacing all further occurrences of osteoarthritis with OA . Therefore, it may not contain the phrase “hip osteoarthritis” but only “hip oa.”

It is also important to search for the opposites of search terms to avoid bias. When searching for “disease recurrence,” articles about “disease free” may be relevant as well. When the desired outcome is survival , articles about mortality may be relevant.

10. Use database-appropriate syntax, with parentheses, Boolean operators, and field codes

Different interfaces require different syntaxes, the special set of rules and symbols unique to each database that define how a correctly constructed search operates. Common syntax components include the use of parentheses and Boolean operators such as “AND,” “OR,” and “NOT,” which are available in all major interfaces. An overview of different syntaxes for four major interfaces for bibliographic medical databases (PubMed, Ovid, EBSCOhost, Embase.com, and ProQuest) is shown in Table 1 .

Creating the appropriate syntax for each database, in combination with the selected terms as described in steps 7–9, can be challenging. Following the method outlined below simplifies the process:

• Create single-line queries in a text document (not combining multiple record sets), which allows immediate checking of the relevance of retrieved references and efficient optimization.
• Type the syntax (Boolean operators, parentheses, and field codes) before adding terms, which reduces the chance that errors are made in the syntax, especially in the number of parentheses.
• Use predefined proximity structures including parentheses, such as (() ADJ3 ()) in Ovid, that can be reused in the query when necessary.
• Use thesaurus terms separately from free-text terms of each element. Start an element with all thesaurus terms (using “OR”) and follow with the free-text terms. This allows the unique optimization methods as described in step 11.
• When adding terms to an existing search strategy, pay close attention to the position of the cursor. Make sure to place it appropriately either in the thesaurus terms section, in the title/abstract section, or as an addition (broadening) to an existing proximity search.

The supplementary appendix explains the method of building a query in more detail, step by step for different interfaces: PubMed, Ovid, EBSCOhost, Embase.com, and ProQuest. This method results in a basic search strategy designed to retrieve some relevant references upon which a more thorough search strategy can be built with optimization such as described in step 11.

11. Optimize the search

The most important question when performing a systematic search is whether all (or most) potentially relevant articles have been retrieved by the search strategy. This is also the most difficult question to answer, since it is unknown which and how many articles are relevant. It is, therefore, wise first to broaden the initial search strategy, making the search more sensitive, and then check if new relevant articles are found by comparing the set results (i.e., search for Strategy #2 NOT Strategy #1 to see the unique results).

A search strategy should be tested for completeness. Therefore, it is necessary to identify extra, possibly relevant search terms and add them to the test search in an OR relationship with the already used search terms. A good place to start, and a well-known strategy, is scanning the top retrieved articles when sorted by relevance, looking for additional relevant synonyms that could be added to the search strategy.

We have developed a unique optimization method that has not been described before in the literature. This method often adds valuable extra terms to our search strategy and, therefore, extra, relevant references to our search results. Extra synonyms can be found in articles that have been assigned a certain set of thesaurus terms but that lack synonyms in the title and/or abstract that are already present in the current search strategy. Searching for thesaurus terms NOT free-text terms will help identify missed free-text terms in the title or abstract. Searching for free-text terms NOT thesaurus terms will help identify missed thesaurus terms. If this is done repeatedly for each element, leaving the rest of the query unchanged, this method will help add numerous relevant terms to the query. These steps are explained in detail for five different search platforms in the supplementary appendix .

12. Evaluate the initial results

The results should now contain relevant references. If the interface allows relevance ranking, use that in the evaluation. If you know some relevant references that should be included in the research, search for those references specifically; for example, combine a specific (first) author name with a page number and the publication year. Check whether those references are retrieved by the search. If the known relevant references are not retrieved by the search, adapt the search so that they are. If it is unclear which element should be adapted to retrieve a certain article, combine that article with each element separately.

Different outcomes are desired for different types of research questions. For instance, in the case of clinical question answering, the researcher will not be satisfied with many references that contain a lot of irrelevant references. A clinical search should be rather specific and is allowed to miss a relevant reference. In the case of an SR, the researchers do not want to miss any relevant reference and are willing to handle many irrelevant references to do so. The search for references to include in an SR should be very sensitive: no included reference should be missed. A search that is too specific or too sensitive for the intended goal can be adapted to become more sensitive or specific. Steps to increase sensitivity or specificity of a search strategy can be found in the supplementary appendix .

13. Check for errors

Errors might not be easily detected. Sometimes clues can be found in the number of results, either when the number of results is much higher or lower than expected or when many retrieved references are not relevant. However, the number expected is often unknown, and very sensitive search strategies will always retrieve many irrelevant articles. Each query should, therefore, be checked for errors.

One of the most frequently occurring errors is missing the Boolean operator “OR.” When no “OR” is added between two search terms, many interfaces automatically add an “AND,” which unintentionally reduces the number of results and likely misses relevant references. One good strategy to identify missing “OR”s is to go to the web page containing the full search strategy, as translated by the database, and using Ctrl-F search for “AND.” Check whether the occurrences of the “AND” operator are deliberate.

Ideally, search strategies should be checked by other information specialists [ 18 ]. The Peer Review of Electronic Search Strategies (PRESS) checklist offers good guidance for this process [ 4 ]. Apart from the syntax (especially Boolean operators and field codes) of the search strategy, it is wise to have the search terms checked by the clinician or researcher familiar with the topic. At Erasmus MC, researchers and clinicians are involved during the complete process of structuring and optimizing the search strategy. Each word is added after the combined decision of the searcher and the researcher, with the possibility of directly comparing results with and without the new term.

14. Translate to other databases

To retrieve as many relevant references as possible, one has to search multiple databases. Translation of complex and exhaustive queries between different databases can be very time consuming and cumbersome. The single-line search strategy approach detailed above allows quick translations using the find and replace method in Microsoft Word (<Ctrl-H>).

At Erasmus MC, macros based on the find-and-replace method in Microsoft Word have been developed for easy and fast translation between the most used databases for biomedical and health sciences questions. The schema that is followed for the translation between databases is shown in Figure 2 . Most databases simply follow the structure set by the Embase.com search strategy. The translation from Emtree terms to MeSH terms for MEDLINE in Ovid often identifies new terms that need to be added to the Embase.com search strategy before the translation to other databases.

Schematic representation of translation between databases used at Erasmus University Medical Center

Dotted lines represent databases that are used in less than 80% of the searches.

Using five different macros, a thoroughly optimized query in Embase.com can be relatively quickly translated into eight major databases. Basic search strategies will be created to use in many, mostly smaller, databases, because such niche databases often do not have extensive thesauri or advanced syntax options. Also, there is not much need to use extensive syntax because the number of hits and, therefore, the amount of noise in these databases is generally low. In MEDLINE (Ovid), PsycINFO (Ovid), and CINAHL (EBSCOhost), the thesaurus terms must be adapted manually, as each database has its own custom thesaurus. These macros and instructions for their installation, use, and adaptation are available at bit.ly/databasemacros.

15. Test and reiterate

Ideally, exhaustive search strategies should retrieve all references that are covered in a specific database. For SR search strategies, checking searches for their recall is advised. This can be done after included references have been determined by the authors of the systematic review. If additional papers have been identified through other non-database methods (i.e., checking references in included studies), results that were not identified by the database searches should be examined. If these results were available in the databases but not located by the search strategy, the search strategy should be adapted to try to retrieve these results, as they may contain terms that were omitted in the original search strategies. This may enable the identification of additional relevant results.

A methodology for creating exhaustive search strategies has been created that describes all steps of the search process, starting with a question and resulting in thorough search strategies in multiple databases. Many of the steps described are not new, but together, they form a strong method creating high-quality, robust searches in a relatively short time frame.

Our methodology is intended to create thoroughness for literature searches. The optimization method, as described in step 11, will identify missed synonyms or thesaurus terms, unlike any other method that largely depends on predetermined keywords and synonyms. Using this method results in a much quicker search process, compared to traditional methods, especially because of the easier translation between databases and interfaces (step 13). The method is not a guarantee for speed, since speed depends on many factors, including experience. However, by following the steps and using the tools as described above, searchers can gain confidence first and increase speed through practice.

What is new?

This method encourages searchers to start their search development process using empty syntax first and later adding the thesaurus terms and free-text synonyms. We feel this helps the searcher to focus on the search terms, instead of on the structure of the search query. The optimization method in which new terms are found in the already retrieved articles is used in some other institutes as well but has to our knowledge not been described in the literature. The macros to translate search strategies between interfaces are unique in this method.

What is different compared to common practice?

Traditionally, librarians and information specialists have focused on creating complex, multi-line (also called line-by-line) search strategies, consisting of multiple record sets, and this method is frequently advised in the literature and handbooks [ 2 , 19 – 21 ]. Our method, instead, uses single-line searches, which is critical to its success. Single-line search strategies can be easily adapted by adding or dropping a term without having to recode numbers of record sets, which would be necessary in multi-line searches. They can easily be saved in a text document and repeated by copying and pasting for search updates. Single-line search strategies also allow easy translation to other syntaxes using find-and-replace technology to update field codes and other syntax elements or using macros (step 13).

When constructing a search strategy, the searcher might experience that certain parentheses in the syntax are unnecessary, such as parentheses around all search terms in the title/abstract portion, if there is only one such term, there are double parentheses in the proximity statement, or one of the word groups exists for only one word. One might be tempted to omit those parentheses for ease of reading and management. However, during the optimization process, the searcher is likely to find extra synonyms that might consist of one word. To add those terms to the first query (with reduced parentheses) requires adding extra parentheses (meticulously placing and counting them), whereas, in the latter search, it only requires proper placement of those terms.

Many search methods highly depend on the PICO framework. Research states that often PICO or PICOS is not suitable for every question [ 22 , 23 ]. There are other acronyms than PICO—such as sample, phenomenon of interest, design, evaluation, research type (SPIDER) [ 24 ]—but each is just a variant. In our method, the most important and specific elements of a question are being analyzed for building the best search strategy.

Though it is generally recommended that searchers search both MEDLINE and Embase, most use MEDLINE as the starting point. It is considered the gold standard for biomedical searching, partially due to historical reasons, since it was the first of its kind, and more so now that it is freely available via the PubMed interface. Our method can be used with any database as a starting point, but we use Embase instead of MEDLINE or another database for a number of reasons. First, Embase provides both unique content and the complete content of MEDLINE. Therefore, searching Embase will be, by definition, more complete than searching MEDLINE only. Second, the number of terms in Emtree (the Embase thesaurus) is three times as high as that of MeSH (the MEDLINE thesaurus). It is easier to find MeSH terms after all relevant Emtree terms have been identified than to start with MeSH and translate to Emtree.

At Erasmus MC, the researchers sit next to the information specialist during most of the search strategy design process. This way, the researchers can deliver immediate feedback on the relevance of proposed search terms and retrieved references. The search team then combines knowledge about databases with knowledge about the research topic, which is an important condition to create the highest quality searches.

Limitations of the method

One disadvantage of single-line searches compared to multi-line search strategies is that errors are harder to recognize. However, with the methods for optimization as described (step 11), errors are recognized easily because missed synonyms and spelling errors will be identified during the process. Also problematic is that more parentheses are needed, making it more difficult for the searcher and others to assess the logic of the search strategy. However, as parentheses and field codes are typed before the search terms are added (step 10), errors in parentheses can be prevented.

Our methodology works best if used in an interface that allows proximity searching. It is recommended that searchers with access to an interface with proximity searching capabilities select one of those as the initial database to develop and optimize the search strategy. Because the PubMed interface does not allow proximity searches, phrases or Boolean “AND” combinations are required. Phrase searching complicates the process and is more specific, with the higher risk of missing relevant articles, and using Boolean “AND” combinations increases sensitivity but at an often high loss of specificity. Due to some searchers’ lack of access to expensive databases or interfaces, the freely available PubMed interface may be necessary to use, though it should never be the sole database used for an SR [ 2 , 16 , 25 ]. A limitation of our method is that it works best with subscription-based and licensed resources.

Another limitation is the customization of the macros to a specific institution’s resources. The macros for the translation between different database interfaces only work between the interfaces as described. To mitigate this, we recommend using the find-and-replace functionality of text editors like Microsoft Word to ease the translation of syntaxes between other databases. Depending on one’s institutional resources, custom macros can be developed using similar methods.

Results of the method

Whether this method results in exhaustive searches where no important article is missed is difficult to determine, because the number of relevant articles is unknown for any topic. A comparison of several parameters of 73 published reviews that were based on a search developed with this method to 258 reviews that acknowledged information specialists from other Dutch academic hospitals shows that the performance of the searches following our method is comparable to those performed in other institutes but that the time needed to develop the search strategies was much shorter than the time reported for the other reviews [ 9 ].

CONCLUSIONS

With the described method, searchers can gain confidence in their search strategies by finding many relevant words and creating exhaustive search strategies quickly. The approach can be used when performing SR searches or for other purposes such as answering clinical questions, with different expectations of the search’s precision and recall. This method, with practice, provides a stepwise approach that facilitates the search strategy development process from question clarification to final iteration and beyond.

SUPPLEMENTAL FILE

Acknowledgments.

We highly appreciate the work that was done by our former colleague Louis Volkers, who in his twenty years as an information specialist in Erasmus MC laid the basis for our method. We thank Professor Oscar Franco for reviewing earlier drafts of this article.

• Systematic Review
• Open access
• Published: 28 June 2024

Poor glycemic control impairs oral health in children with type 1 diabetes mellitus - a systematic review and meta-analysis

• Zsuzsanna Triebl 1 , 2   na1 ,
• Bulcsú Bencze 1 , 3   na1 ,
• Dorottya Bányai 1 , 2 ,
• Noémi Rózsa 2 ,
• Péter Hermann 3 &
• Dániel Végh 1 , 3  

BMC Oral Health volume  24 , Article number:  748 ( 2024 ) Cite this article

34 Accesses

Metrics details

There are more than one million children and adolescents living with type 1 diabetes mellitus, and their number is steadily increasing. Diabetes affects oral health through numerous channels, including hyposalivation, immune suppression, and the inflammatory effect of glycation end-products. However, patients with type 1 diabetes must follow a strict sugar free diet that is proven to be carioprotective. Therefore, the aim of this systematic review and meta-analysis is to investigate whether children with type 1 diabetes have a difference in Decayed, Missing, Filled Teeth index (DMFT), salivary function, and periodontal status than children without diabetes, with an emphasis on glycemic control.

Materials and Methods

PubMed, Embase and Cochrane libraries were screened for articles, using predefined search keys without any language or date restrictions. Two independent authors performed the selection procedure, extracted data from the eligible articles, carried out a manual search of the reference lists, and assessed the risk of bias using the Newcastle-Ottawa scale. Meta-analysis was performed in R using the random-effects model. Effect sizes were mean differences; subgroup analysis was performed on glycemic control.

33 studies satisfied the eligibility criteria. 22 studies did not show a significant difference regarding the DMFT index between the diabetes and non-diabetes groups; six studies found that children living with diabetes had higher DMFT scores, compared to five studies that found significantly lower scores. Meta-analysis found no statistically significant differences in plaque, gingival, and calculus indexes, however it found significant differences in pooled DMFT indexes, and salivary flow rate. Subgroup analysis on glycemic control using DMFT values found significant differences in children with good and poor glycemic control with results of 0.26 (CI95%=-0.50; 1.03) and 1.46 (CI95%=0.57; 2.35), respectively.

Conclusions

Children with poor glycemic control face higher risk of developing caries compared to good control and non-diabetes children. Regular dental check-ups and strict control of glycemic levels are highly advised for children living with type 1 diabetes, further emphasizing the importance of cooperation between dentists and diabetologists.

Peer Review reports

Introduction

Diabetes Mellitus (DM) is a disorder that is caused by either the lack of insulin secretion or the insufficient effect of the hormone [ 1 ], that leads to a chronically increased blood glucose level, which harms human health in several ways [ 2 ].

DM has four main types: type 1 is caused by an autoimmune response against the beta-cells of the pancreas; type 2 can develop on a multifactorial basis, mainly by an unhealthy lifestyle with the addition of bad diet and obesity; gestational diabetes develops and usually recedes within the gestational period; and lastly secondary diabetes that is either caused by certain medications or other illnesses [ 3 ]. There is still some uncertainty on the exact reason behind the development of type 1 DM; numerous causes are mentioned in the current literature including genetic (HLA proteins) and nongenetic factors (viral infections such as Coxsackievirus B) [ 4 , 5 ].

It was estimated that the number of people affected by DM to be at 536,3 million in 2021, and projected to reach 783 million by 2045 [ 6 ]. A significant portion of the affected individuals consists of children and adolescents and approximately 1.2 million of them have type 1 DM [ 6 ]. According to Chobot et al., the incidence of type 1 DM increased from 5.36 to 22.74 per 100 000 capita in 24 years’ time [ 7 ]. Several studies showed that there is a consistent increase in the number of affected children, approximately 3%, per year [ 8 ].

Hyperglycemia is the main cause of the clinical symptoms: elevated blood sugar levels can cause polyuria, weight loss despite heightened appetite, blurred vision, excessive thirst, constant tiredness and diabetic ketoacidosis [ 9 ]. Diagnosis relies on symptoms alongside an oral glucose tolerance test (OGTT), although evaluating metabolic control can also be achieved through measuring the HbA1c level; furthermore, the presence of autoantibodies associated with diabetes can be examined [ 10 ].

Dental caries is widespread all around the world [ 11 ]. Facilitated by biofilms and various factors, leads to localized demineralization of teeth [ 12 ]. Additionally, there were studies that reported on the harmful effects of DM on oral health, namely higher caries rate in children with type 1 DM, significantly higher plaque accumulation, gingivitis and calculus deposition [ 13 , 14 , 15 ].

According to Nederfors, salivary dysfunctions can be classified into three main groups: xerostomia, hyposalivation and changes in the composition of saliva [ 16 ]. Xerostomia is known to be the subjective complaint of oral dryness [ 17 ], whereas hyposalivation means the decrease in salivary outflow, that can be objectively measured [ 18 ]. Hyposalivation can go together with xerostomia, but that’s not always the case – on the other hand, sometimes xerostomia is present without real salivary gland dysfunction [ 19 ].

DM is considered to cause lower salivary flow rate [ 2 ], which can also induce harmful complications such as caries [ 20 ] and oral candidiasis [ 21 ]. Hyposalivation, poor immune defense, and high blood sugar levels are the main risk factors of developing oral candidiasis [ 21 , 22 ]. A suppressed immune system does not only make the human body susceptible to infections [ 22 ], but it also has a negative effect on wound healing [ 23 ].

DM has a bidirectional relationship with periodontal health, namely because DM promotes periodontal inflammation through various pathophysiological pathways that influence immune cells, collagen and lipid metabolism [ 11 , 12 , 24 ], while periodontitis can have serious adverse effects on glycemic control [ 25 ]. High blood sugar levels can lead to the formation of advanced glycation end-products, which enhance the production of inflammatory cytokines. In this manner the speed of periodontal bone resorption increases rapidly [ 26 ].

There is still debate on the overall effect of type 1 DM on oral health; on one hand, lower salivary functions and higher salivary glucose levels shift the oral environment towards a more cariogenic milieu, on the other hand patients with DM should follow a strict sugar-free diet, that has a serious carioprotective effect [ 27 ]. The relationship between type 2 DM and oral health is more certain, however, the impact of type 1 DM is still contradictory. There is data in the literature that type 1 DM decreases [ 28 ], or has no significant effect on caries prevalence [ 29 ], and also that it increases calculus and gingival indices [ 30 ].

There is no previous analysis in the literature that investigates the effect of different glycemic controls on oral health in children with type 1 DM. Therefore, we decided to investigate the effect of type 1 DM and glycemic control on caries prevalence, salivary flow rate and periodontal indices.

Materials and methods

This review was created according to the standards of the PRISMA® (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement. The PICO (P, population/patient/problem; I, intervention; C, comparison; O, outcome) question we investigated in this review was formed according to the rules of PRISMA®:

“Do children (P) living with Type 1 Diabetes Mellitus (I), compared to healthy children (C), have worse caries and periodontal indexes? (O)

The protocol of the review was preregistered on PROSPERO (CRD42023449223).

Inclusion and exclusion criteria

Studies were included, if they (1) were cross-sectional and case-control studies; (2) included patients under the age of 19; (3) included only type 1 DM. Studies were excluded if they (1) did not report on any of the predefined outcomes; (2) were about other fields of dentistry; (3) were animal studies; (4) were inadequate article types, such as notes, reviews, letters, conference abstracts or randomized controlled studies; (5) had high risk of bias.

Information sources, search strategy and the selection process

An extensive search strategy was employed to identify eligible studies through the following electronic databases: Pubmed, Cochrane Library, and Embase. The complete search key used was the following: ((diabetes OR DM OR diabetes mellitus OR diabetic) AND (type 1 OR type-1 OR type one OR insulin dependent OR IDDM)) AND (children OR child) AND (caries OR decay OR oral health status OR DMF OR gingival index OR calculus index OR salivary flow rate OR plaque index). The keywords were linked with the help of Boolean operators. The databases were screened on May 30, 2024.

The results were exported to Endnote [ 31 ]. After duplicate removal, which was done with the help of the automatic duplicate finder in Endnote, two calibrated independent authors searched for articles according to the predefined inclusion and exclusion criteria with the help of Rayyan.ai [ 32 ], where the title and abstract selection was conducted. Disagreements were solved by consensus. If no consensus was achieved a third reviewer helped with the decision. The final pool of included studies was decided upon completing the full-text selection procedure under similar conditions. Agreements between the reviewers were calculated by Cohen’s Kappa. A manual search of the included papers reference list was conducted using the online Citation chaser tool [ 33 ].

Quality assessment and data extraction

The quality assessment of the included studies was done by the same two independent reviewers based on the guidelines of the Newcastle-Ottawa scale for case-control and cross-sectional studies.

Two authors have extracted the necessary data independently using Excel (Microsoft) forms. The following data were extracted: first, the year the article was published; second, the names of the authors; and third, the title of the study. The number and type of different case and control groups were recorded, the parameters they examined, the number of the examined children in their respective groups, ages, and sex distributions were recorded. Data on Decayed, Missing due to caries, and Filled Teeth (DMFT) index (categorical outcomes) and the parameters of the saliva, including salivary flow rate (continuous outcomes) and the quantity of the saliva (continuous outcomes were recorded). Some studies recorded the results of the Oral Hygiene Index-Simplified (OHI-S), the Plaque Index (PI) (Silness-Löe), the Calculus Index (CI) (Greene and Vermilion), and the Gingival Index (GI) (Löe-Silness) which were also extracted.

The results and conclusions of each study were summarized to make the comparison more easily manageable and the results straightforwardly accessible.

Publication bias and certainty of evidence

Publication bias was assessed by funnel plots when at least 10 studies were available.

Certainty of evidence was assessed by one reviewer with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

Data Synthesis and Analysis

For the analysis, a random-effects model was chosen based on the assumption of significant between-study heterogeneity. The predefined included outcomes were all continuous, therefore the effect size measure was the difference between the means (MD) with 95% CI. A result that didn’t contain the null value was considered statistically significant. Subgroup analysis was performed based on the glycemic control of the patients; differentiation was made between well-, and poorly controlled patients based on their HbA1c values; for standardization purposes patients with lower than 7,5–8% HbA1c were allocated to the well-controlled, and higher than 7,5–8% were allocated to the poorly controlled group. Furthermore, between-study heterogeneity was calculated with the I2 statistics. Descriptive statistics were used to show the results of the meta-analysis with forest plots. Subgroup analyses were performed using the glycemic control data of the patient groups. All statistical analyses were carried out with R (version 4.3.0) using the meta (version 6.2.1) package for basic meta-analysis calculations and plots.

Result of the systematic search and quality assessment

From the systematic search 1723 articles were retrieved, after the duplication removal 1499 articles were assessed by title and abstract selection (κ = 0.81). Conducting the full text selection, 34 eligible articles were identified for further analysis (κ = 1). The databases were screened on May 30, 2024. No additional eligible studies were found at the manual searches of the reference lists. The detailed selection procedure can be found in Fig. 1 .

Prisma flowchart (2020), detailed explanation of the selection procedure

For the included studies it was required to have transparent inclusion and exclusion criteria, measurements of outcomes, adequate statistical analysis and consistent reporting of outcomes. To increase the certainty of the evidence, studies with low to moderate risk of bias (above a score of five) were included, whereas studies with high risk (below a score of five) were excluded from further analysis. The risk of bias assessment of studies is shown in Table 1 .

The study of Al-Mutari et al. has received high risk of bias due to the contradictions in the abstract and in the full text of the article. They had conflicting outcomes in the Results section compared to the conclusion in the main text [ 34 ].

General aspects of the included studies

All in all, the included articles were from 14 countries. There were five studies from India [ 35 , 36 , 37 , 38 , 39 ], four from Iran [ 27 , 40 , 41 , 42 ],two from Saudi Arabia [ 43 , 44 ], two from Egypt [ 45 , 46 ], two from Greece [ 47 , 48 ], one from Kuwait [ 14 ], one from The United States [ 49 ] one from Poland [ 50 ], one from Portugal [ 51 ], one from Montenegro [ 52 ], one from Kosovo [ 53 ], one from Turkey [ 54 ], one from Brazil [ 55 ], one from Iraq [ 56 ], one from Libya [ 57 ], one from Sweden [ 58 ], one from Belgium [ 29 ], one from Romania [ 59 ], one from Italy [ 60 ], one from Hong Kong [ 61 ], one from Finland [ 62 ], one from Lithuania [ 63 ] and one from Hungary [ 64 ].

The youngest child in the cohort was two-year-olds, while the oldest one was eighteen years old. Altogether, 5048 children were examined: 2547 children living with type 1 DM and 2501 non-DM children.

The included articles analyzed the oral health of children with DM in comparison with their sex and age-matched controls without DM. The parameters under investigation included the following: DMFT, DMFS (Decayed, Missing due to caries, and Filled Surface), dmft (decayed, missing, and filled primary teeth) indexes, ICDAS (International Caries Detection and Assessment System), stimulated or unstimulated salivary flow rate, buffer capacity, viscosity and glucose level of the saliva, CI, PI, GI (Table 2 ).

Glycemic control

Several articles differentiated between the quality of glycemic control. Ten study divided the DM study group into further groups according to their metabolic control [ 27 , 29 , 40 , 46 , 47 , 48 , 50 , 59 , 60 , 63 ]; five articles defined good glycemic control (GGC) and poor glycemic control (PGC) [ 47 , 48 , 50 , 60 , 63 ]. Whereas five articles included a third group called intermediate glycemic control (IGC) [ 27 , 40 , 46 , 29 , 59 ]. The HbA1c values used to define the sub-groups are shown in Table 3 .

Seven articles examined the buffer capacity in relation to the prevalence of caries [ 14 , 44 , 47 , 48 , 52 , 53 , 63 ], two reported significantly worse buffer capacity in children living with DM [ 43 , 53 ], and one of these two have reported significantly higher scores on DMFT index [ 53 ]. From the three article reporting no significant differences between the study and the control group with respect to buffer capacity, two did not find a significant difference concerning the DMFT index either [ 48 , 63 ] and one found significantly higher DMFT [ 14 ]. Two articles have reported higher buffer capacity, though not significantly higher values, while there was no significant difference between the DMFT indexes either [ 47 , 52 ] (Table  4 ).

Caries indexes

The included studies exhibited a high degree of heterogeneity with respect to the analysis of DMFT index, which stands for the number of decayed, missing due to caries, and filled teeth [ 65 ].

Twenty-two studies did not find statistically significant differences between the study group and the control group [ 27 , 29 , 38 , 41 , 42 , 43 , 44 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 54 , 55 , 57 , 59 , 60 , 61 , 62 , 64 ]. There were six studies revealing higher DMFT values in the DM groups [ 14 , 35 , 40 , 45 , 53 , 56 ]; and five studies found that children living with type 1 DM had lower DMFT values, which means a better caries prevalence [ 36 , 37 , 39 , 58 , 63 ].

All those studies that found the DMFT index significantly worse revealed poorer results in many other aspects, such as higher PI and GI [ 45 ], lower buffer capacity and salivary flow rate [ 53 ].

Interestingly, the study conducted by Elheeny et al. reported higher DMFT index in the DM group, even though they brushed their teeth significantly more [ 45 ]. Babu et al. reported that the DMFT index was higher in children with DM, however their GI was comparable [ 35 ]. The study of Geetha et al. disclosed that the DMFT index in children with DM was significantly lower, while their CI were significantly higher [ 36 ]. One other study stated that the study group had better DMFS and PI indexes despite having a lower salivary flow rate and a higher salivary glucose level [ 37 ].

All the other studies revealed that there was no statistically significant difference between the study and control groups regarding the DMFT or DMFS indexes. From these 22 articles, twelve showed a higher DMFT value in DM groups, but these differences were not significant [ 27 , 38 , 44 , 46 , 29 , 42 , 49 , 51 , 55 , 57 , 62 , 64 ], and there were five studies in which children with DM had better DMFT values than healthy controls [ 41 , 43 , 52 , 54 , 61 ]. The remaining five articles did not report on the comparison of healthy and DM individuals, only comparing the groups divided by metabolic control [ 47 , 48 , 50 , 59 , 60 ].

There were 17 studies included in the meta-analysis [ 14 , 27 , 29 , 35 , 36 , 38 , 40 , 41 , 42 , 44 , 46 , 49 , 52 , 55 , 56 , 61 , 62 ]. Statistically significant differences were found between the groups, with a result of 0.41 (CI95%=0.03; 0.78). The between study heterogeneity was considered very high and significant I2=98% (Fig. 2 ).

Meta-analysis of the pooled DMFT values compared in children with and without DM

After dividing children living with DM into groups according to their metabolic control, there were a few articles that did not find statistically significant differences between the groups [ 27 , 40 , 46 , 47 , 29 , 59 , 60 ]. Three articles found significant differences between different metabolic controls [ 48 , 50 , 63 ]. Pachonski et al. reported that there was a significant difference between children with PGC and GGC regarding the DMFT index, and children with GGC had the best DMFT values among the groups, including the healthy controls, while children with PGC had the worst values [ 50 ]. According to the study of Pappa et al., even though there was no significant difference between children with GGC and no DM in terms of DMFT, there was a significant difference between the GGC and PGC groups and a significant difference between the PGC and control group [ 48 ]. Babatzia reported that children with PGC had higher DMFS values, although not significant [ 47 ]. According to the study of Siudikiene, children living with DM had significantly lower DMFS score compared to non-DM children, patients with well-controlled DM had significantly less decayed surface, to poorly controlled individuals [ 63 ].

There were five studies included in the meta-analysis of DMFT with subgroup analysis based on their glycemic control [ 27 , 29 , 40 , 48 , 50 ]. There was a statistically significant difference between poorly controlled patients and non-DM patients with a result of 1.46 (CI95%=0.57; 2.35). The between study heterogeneity was considered very high and statistically significant I2=92%; there was no difference between the well-controlled and non-DM patients (Fig. 3 ).

Subgroup Meta-analysis of DMFT index in well- and poorly controlled children compared with children without DM

Salivary parameters

Seven articles investigated the buffer capacity of children with DM [ 14 , 44 , 47 , 48 , 52 , 53 , 62 ]. Two articles showed statistically significantly worse buffer capacity [ 44 , 53 ], three articles did not find significant differences between the study and control group [ 14 , 48 , 62 ], and two studies reported better results in the DM group, while the buffer capacity of these children was not significantly higher compared to children without DM [ 47 , 52 ].

Eleven study examined salivary flow rate, from which five studies examined stimulated salivary flow rate [ 44 , 47 , 52 , 53 , 62 ], four study examined the unstimulated flow rate [ 37 , 39 , 51 , 55 ], and two examining both the stimulated and the resting salivary flow rate [ 14 , 48 ]. Five of them have reported significantly worse results [ 37 , 39 , 52 , 53 , 55 ], five studies revealed no significant difference between the study and control groups [ 14 , 44 , 48 , 51 , 62 ], and lastly, one study reported comparable outcomes in children with DM to non-DM children [ 47 ].

Out of the three articles where they found the flow rate significantly worse in the study group than in the control group [ 37 , 39 , 52 , 53 , 55 ], there was one article that reported significantly higher DMFT scores [ 53 ], two with no significant difference [ 52 , 55 ], and two with significantly lower DMFT index [ 37 , 39 ]; whereas the five articles where they found no significant difference in the salivary flow rate, four of them also showed no significant difference in the DMFT scores [ 44 , 48 , 51 , 62 ], except for the study of Akpata, where the DMFT index was significantly higher in DM children [ 14 ] (Table 3 ).

Seven articles examined the buffer capacity in relation to the prevalence of caries [ 14 , 44 , 47 , 48 , 52 , 53 , 62 ], two reported significantly worse buffer capacity in children living with DM [ 43 , 53 ], and one of these two have reported significantly higher scores on DMFT index [ 53 ]. From the three article reporting no significant differences between the study and the control group with respect to buffer capacity, two did not find a significant difference concerning the DMFT index either [ 48 , 62 ] and one found significantly higher DMFT [ 14 ]. Two articles have reported higher buffer capacity, though not significantly higher values, while there was no significant difference between the DMFT indexes either [ 47 , 52 ] (Table 4 ).

There were seven studies included in the meta-analysis of salivary flow rate [ 14 , 44 , 52 , 53 , 62 , 63 ]. There were statistically significant differences between the groups with a result of -0.21 (CI95%=-0.36; -0,07). The between study heterogeneity was considered very high and significant I2=97% (Fig. 4 ).

Meta-analysis of stimulated salivary flow rate compared in children with and without DM

Only three of the seven articles recorded data about metabolic control and salivary parameters. Pappa et al. reported that salivary flow rate and pH values were significantly lower in the PGC group than in the GGC group and controls [ 48 ], while others found that the flow rate of all children was normal with sufficient capacity [ 47 ]. Siudikiene et al. found that there were no significant differences between the groups in terms of salivary flow rate and buffering capacity [ 63 ].

Periodontal indexes

Considering periodontal indexes, GI, PI, and CI were examined.

There were nine studies reporting on GI scores. Four articles showed higher GI scores in children living with DM [ 40 , 42 , 45 , 46 ], and five articles did not find significant differences [ 35 , 38 , 47 , 50 , 61 ]. There were no data about significantly better GI scores; however, in one study the gingival conditions of DM children were considered healthy [ 35 ].

Seven studies were included in the quantitative analysis of GI that was comparable and used the Löe and Silness index [ 35 , 39 , 40 , 46 , 49 , 50 , 54 , 61 ]. There were no statistically significant differences between the groups with a result of 0.05 (CI95%=-0.01; 0.11). The between study heterogeneity was considered low and statistically non-significant I2=44% (Fig. 5 ).

Meta-analysis of Löé & Silness gingival index values compared in children with and without DM

Regarding CI, two out of five studies have reported significantly higher scores in children living with DM [ 36 , 51 ], and three did not find statistically significant differences between the groups [ 40 , 47 , 61 ]. Just as in the case of GI scores, there was not a significantly better CI score recorded in the DM group.

Meta-analysis was conducted on three studies regarding CI that used Greene and Vermilion indexes [ 40 , 52 , 61 ]. There were no statistically significant differences between the groups with a result of 0,04 (CI95%=-0,00; 0,09). The between study heterogeneity was considered very low and non-significant I2=0% (Fig. 6 ).

Meta-analysis of Greene and Vermilion calculus index values compared in children with and without DM

Nine articles reported on PI, from which five articles found significantly higher PI scores in the DM group [ 40 , 45 , 46 , 51 ]. Among these four articles, one applied this observation only to children with poor metabolic control [ 47 ]. There were two studies with non-significant differences between the groups [ 42 , 50 ], while two studies have reported lower PI scores in the DM group [ 37 , 54 ].

There were seven studies included in the meta-analysis of PI [ 37 , 40 , 46 , 50 , 52 , 54 , 61 ]. There were no statistically significant differences between the groups with a result of 0.17 (CI95%=-0.40; 0.74). The between study heterogeneity was considered very high and statistically significant I2=95% (Fig. 7 ).

Meta-analysis of Silness & Löé plaque index values compared in children with and without DM

Three studies that examined DM children according to different metabolic controls did not find significant differences between the groups regarding the conditions of the periodontium and oral hygiene (PI, GI, and CI) [ 40 , 46 , 50 ]. Even though Babatzia et al. have reported that there was no significant difference between GI and CI scores, they found that children with PGC had significantly more dental plaque [ 47 ].

With analyses containing at least 10 studies, publication bias was assessed by generating funnel plots. DMFT outcomes have provided symmetrical funnel plots, hence the probability of the existence of publication bias is low (Fig. 8 ).

Funnel plotof publication bias in DMFT outcomes

Outcomes DMFT, GI, and CI have received low certainty of evidence, whereas outcomes salivary flow rate and PI have received very low certainty of evidence (Fig. 9 ).

Assessment of the certainty of evidence with GRADE tool

The results of our meta-analysis regarding the pooled values of DMFT differences between patients with and without DM are in line with current state of the literature, however we only found a small difference between the groups, that is even though statistically significant, also clinically irrelevant, therefore a more complex approach is necessary to identify the connections more accurately [ 66 ].

The measurement of metabolic values in children holds significant importance as it facilitates early diagnosis and timely intervention. This approach enables full understanding of the potential consequences of DM, especially the effects of elevated blood glucose levels.

For instance, certain studies did not report statistically significant differences between the study and control groups. However, taking into account the differences in metabolic control, significant differences are found. For instance, Pachonski et al. reported no significant differences between DM and non-DM children concerning DMFT values. However, they observed statistically significant differences between PGC and non-DM children. [ 50 ]. Differences in metabolic control within the populations could give an explanation for some of the differences between the included studies, that may be responsible for some of the between study heterogeneity.

The most recent meta-analysis in the topic have found similar results regarding the differences in pooled DMFT values, however it did not investigate the effect of different glycemic controls on DMFT values [ 20 ]. Therefore, this meta-analysis sought to fill this gap in the literature.

The study of Elheeny et al. did not group the children with DM according to their quality of metabolic control, despite that, the study can be informative in this aspect. The frequency of children with PGC was higher in the age group between 8 and 10, than 11 and 14 with percentages of 93,6% and 76,3%, respectively – which means, especially for the early adolescent group, that they basically examined children with poorly controlled DM. They found significantly higher caries scores in both of these age groups [ 45 ]. However, in some cases, even when they examined more children with PGC, they did not observe significant differences between the study groups and the control groups. In the study of Lai, 70.6% of the children living with DM had PGC; in the study of Sadeghi, 40% of the DM children had PGC; and in the study of Mesaro S., 66.7% of the study group had high HbA1c values [ 40 , 59 , 60 ]. However, these percentages are significantly lower than those previously mentioned.

Most of the articles showed no significant differences between the study groups and the control groups. Some even reported significantly better DMFT indexes in children living with DM type I [ 36 , 37 , 39 , 58 , 63 ]. There could be several factors behind these results. Lower caries prevalence corresponds with the lower plaque scores, which could mean that DM children have better oral health routines than healthy children [ 37 ]. We have found no significant difference in PI between children with and without DM, that is in line with other studies [ 67 ]. Dental plaque is the strongest risk factor of developing caries, and the fact that PI is similar in the two population elevates the evidence of the impact of DM on caries risk [ 68 ]. It is said that children living with type 1 DM represent a more health-conscious and motivated group of society, due to the fact that these children are diagnosed with a metabolic disease at a young age and their parents are willing to cooperate with doctors and dentists to provide better life circumstances for their children [ 64 ]. This is confirmed in few studies; children with GGC had the best results not only compared to children with PGC but also to healthy controls [ 48 , 50 ]. Lai et al. have reported that children with GGC are counted as patients with lower caries risk in contrast to children living with PGC. They did not observe a significant difference between the study and the control group, but there were significantly more caries-free children in the GGC group compared to the PGC group, and there was a statistically significant difference concerning many cariogenic bacteria [ 60 ].

Another reason for the outstanding DMFT values of DM patients are their strict, sucrose-restricted diet and frequent monitoring, which might answer the question of why children with GGC represent the lowest DMFT values [ 37 , 48 ].

Furthermore, an important factor that could influence the results is the selection of patients in each group. For example, in the study of Iscan et al. 2020, control patients were children who sought treatment at the faculty, which could be a reason for an elevated value of DMFT score among them [ 54 ]. In another case, data of children with DM were collected at events organized to promote health-conscious lifestyles. Therefore, it may not represent the average DM population, hence parents that bring their children to such events are usually more health-conscious [ 64 ].

There is already evidence in the literature, that poor glycemic control in patients with type 2 DM elevates the risk of caries, periodontitis and peri-implantitis, however there were no previous analysis in the matter that investigated children with type 1 DM [ 69 , 70 , 71 ]. In order to fill this gap, we conducted the necessary analyses and found statistically significant, and clinically relevant differences between GGC and PGC children.

To have good glycemic control, it is essential to attend regular meetings with a diabetologist, who helps with motivation, cooperation, and education of health. Therefore, when examining the effects of DM, not only the presence of the illness is the most relevant factor, but the quality of metabolic control. In a few studies, the children living with type 1 DM had better parameters than the controls [ 36 , 37 , 39 , 58 , 63 ]. In other cases, only the children with GGC had better scores [ 60 ]. There was not a single case where children with PGC had better oral health parameters than controls or the GGC group.

We have found significantly lower salivary flow rate in children with DM, that could also provide a possible explanation for higher caries indices, that is in line with other studies conducted in the topic [ 72 ]. There was no article showing significantly better salivary flow rate in the DM group compared to the control groups’ scores. Pappa et al. examined not only the measurable salivary flow rate but the subjective feeling of xerostomia as well. Although they did not find a significant difference between the healthy and the DM groups, they found statistically significantly more children living with PGC suffering from xerostomia and lower salivary flow rate [ 48 ]. Children with GGC did not have significantly lower flow rates than the control patients; however, they reported xerostomia more often. According to Pappa et al., that could be a consequence of the frequent changes in blood sugar levels [ 48 ].

Also, we have found similar results regarding GI and CI parameters, that are closely connected with dental plaque induced inflammation, that further strengthens the connections of DM and caries [ 73 , 74 ]. However, in the study of Babatzia et al., they found elevated amounts of plaque in the group of PGC children, there were no significantly higher GI index associated with it [ 47 ]. Additionally, some studies did not find significantly different values in CI either. However, it is important to note, that the formation of calculus and the induction of gingival inflammation could be affected by individual characteristics as well, not only the presence or absence of DM and dental plaque [ 40 ].

According to the results of our analysis, it is possible to conclude that PGC leads to higher prevalence of caries. There are many tools that enable dentists to measure their patients HbA1c levels without blood taking, pain, and with a relatively good cost- and time-efficient method, in the dental office [ 75 ]. Therefore, we suggest HbA1c measurements in the dental office for patients with DM, to check their quality of glycemic control, and to suggest diabetologist consultation when poor control is found.

Due to the nature of our research question, we could only include observational studies. Therefore, our certainty in our evidence is limited. Some included studies have not used the same indexes to report on periodontal condition, so it was not possible to include them in the quantitative analysis. The results for the meta-analysis have shown very high heterogeneity, which affects the certainty of the evidence. The strength of our study is, that to the best of our knowledge, there is no up-to-date analysis in the available literature on the topic that also investigates the impact of glycemic control on caries and periodontal outcomes. Hence, we could provide important insight in the topic.

According to our results, our implication for practice is that HbA1c measurements are highly advised among children with DM to screen for poor glycemic control and to prevent any possible further damage on oral and systemic health. The strive for good glycemic control, by improving patient compliance and encouraging good cooperation with diabetologists and dentists would benefit the oral and systemic health of children with type 1 DM.

Furthermore, we highly suggest more studies with rigorous protocols to compare children with different qualities of glycemic control according to their HbA1c levels to non-DM children, with cohorts matched for oral hygiene values.

Children living with poorly controlled type 1 DM have higher DMFT values, while well-controlled children have comparable or better DMFT values to children with no DM. Chairside HbA1c measurement is highly suggested at dental checkups in order to identify underlying DM and verify the quality of glycemic control with close cooperation with diabetologist specialists.

Availability of data and materials

The datasets used in this study can be found in the full-text articles included in the systematic review and meta-analysis.

Reference list

Guthrie RA, Guthrie DW. Pathophysiology of diabetes mellitus. Crit Care Nurs Q. 2004;27(2):113–25.

Article   PubMed   Google Scholar  

Hoseini A, et al. Salivary flow rate and xerostomia in patients with type I and II diabetes mellitus. Electron Physician. 2017;9(9):5244–9.

Article   PubMed   PubMed Central   Google Scholar  

Committee ADAPP. 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes—2024. Diabetes Care. 2023;47(Supplement1):S20–42.

Google Scholar  

Novotna M, Podzimek S, Broukal Z, Lencova E, Duskova J. Periodontal diseases and dental caries in children with type 1 diabetes mellitus. Mediators Inflamm. 2015;2015:379626. https://doi.org/10.1155/2015/379626 .

Hober D, Alidjinou EK. Enteroviral pathogenesis of type 1 diabetes: queries and answers. Curr Opin Infect Dis. 2013;26(3):263–9.

Article   CAS   PubMed   Google Scholar  

Federation ID. IDF Diabetes Atlas, 10th edn. Brussels, Belgium: International Diabetes Federation. 2021; https://www.diabetesatlas.org .

Chobot A, et al. Updated 24-year trend of Type 1 diabetes incidence in children in Poland reveals a sinusoidal pattern and sustained increase. Diabet Med. 2017;34(9):1252–8.

Patterson CC, et al. Trends and cyclical variation in the incidence of childhood type 1 diabetes in 26 European centres in the 25 year period 1989–2013: a multicentre prospective registration study. Diabetologia. 2019;62:408–17.

Association AD. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2009;32(Suppl 1):S62.

Article   Google Scholar  

Neu A, et al. Diagnosis, Therapy and Follow-Up of Diabetes Mellitus in Children and Adolescents. Exp Clin Endocrinol Diabetes. 2019;127:01.

Dicembrini I, et al. Type 1 diabetes and periodontitis: prevalence and periodontal destruction-a systematic review. Acta Diabetol. 2020;57(12):1405–12.

Kumar M, et al. Diabetes and gum disease: the diabolic duo. Diabetes Metab Syndr. 2014;8(4):255–8.

Ismail AF, McGrath CP, Yiu CK. Oral health of children with type 1 diabetes mellitus: a systematic review. Diabetes Res Clin Pract. 2015;108(3):369–81.

Akpata ES, et al. Caries experience among children with type 1 diabetes in Kuwait. Pediatr Dent. 2012;34(7):468–72.

PubMed   Google Scholar  

del López LM, Ocasio-López C. Comparing the oral health status of diabetic and non-diabetic children from Puerto Rico: a case-control pilot study. P R Health Sci J. 2011;30(3):123–7.

Nederfors T. Xerostomia and hyposalivation. Adv Dent Res. 2000;14:48–56.

Rayman S, Dincer E, Almas K. Xerostomia. Diagnosis and management in dental practice. N Y State Dent J. 2010;76(2):24–7.

Thakkar JP, Lane CJ. Hyposalivation and Xerostomia and Burning Mouth Syndrome: Medical Management. Oral Maxillofac Surg Clin North Am. 2022;34(1):135–46.

López-Pintor RM, et al. Xerostomia, hyposalivation, and salivary flow in diabetes patients. J Diabetes Res. 2016;2016:4372852.

Liu T, et al. Caries status and salivary alterations of type-1 diabetes mellitus in children and adolescents: a systematic review and meta-analysis. J Evid Based Dent Pract. 2021;21(1):101496.

Patel PN, et al. Oral candidal speciation, virulence and antifungal susceptibility in type 2 diabetes mellitus. Diabetes Res Clin Pract. 2017;125:10–9.

Mauri-Obradors E, et al. Oral manifestations of diabetes mellitus. a systematic review. Med Oral Patol Oral Cir Bucal. 2017;22(5):e586–94.

CAS   PubMed   PubMed Central   Google Scholar  

Baltzis D, Eleftheriadou I, Veves A. Pathogenesis and treatment of impaired wound healing in diabetes mellitus: new insights. Adv Ther. 2014;31(8):817–36.

Zheng M, et al. Prevalence of periodontitis in people clinically diagnosed with diabetes mellitus: a meta-analysis of epidemiologic studies. Acta Diabetol. 2021;58(10):1307–27.

Baeza M, et al. Effect of periodontal treatment in patients with periodontitis and diabetes: systematic review and meta-analysis. J Appl Oral Sci. 2020;28:e20190248.

Graves DT, Ding Z, Yang Y. The impact of diabetes on periodontal diseases. Periodontol 2000. 2020;82(1):214–24.

Kamran S, Moradian H, Yazdan E, Bakhsh. Comparison of the mean DMF index in type i diabetic and healthy children. J Dent (Shiraz). 2019;20(1):61–5.

Singh-Hüsgen P, et al. Investigation of the oral status and microorganisms in children with phenylketonuria and type 1 diabetes. Clin Oral Invest. 2016;20:841–7.

Tagelsir A, et al. Dental caries and dental care level (restorative index) in children with diabetes mellitus type 1. Int J Pediatr Dent. 2011;21(1):13–22.

Siudikiene J, et al. Oral hygiene in children with type I diabetes mellitus. Stomatologija. 2005;7(1):24–7.

The EndNote Team. EndNote. Philadelpia, PA: Clarivate Analytics; 2013.

Ouzzani M, et al. Rayyan—a web and mobile app for systematic reviews. Syst Reviews. 2016;5(1):210.

Haddaway NR, Grainger MJ, Gray CT. citationchaser: an R package for forward and backward citations chasing in academic searching. 2021.

AlMutairi FFJ, et al. Relationship between type-I diabetes mellitus and oral health status and oral health-related quality of life among children of Saudi Arabia. J Family Med Prim Care. 2020;9(2):647–51.

Babu KLG, Subramaniam P, Kaje K. Assessment of dental caries and gingival status among a group of type 1 diabetes mellitus and healthy children of South India - a comparative study. J Pediatr Endocrinol Metab. 2018;31(12):1305–10.

Geetha S, et al. Oral health status and knowledge among 10-15years old type 1 diabetes mellitus children and adolescents in Bengaluru. Indian J Dent Res: Off Publ Indian Soc Dent Res. 2019;30(1):80–6.

CAS   Google Scholar  

Manjushree R, et al. Evaluation of salivary components and dental plaque in relation to dental caries status in type 1 diabetes mellitus. Int J Clin Pediatr Dent. 2022;15(Suppl 2):S121–5.

Govindaraju L, Gurunathan D. Comparison of the oral hygiene status in children with and without juvenile diabetes - a comparative study. Indian J Dent Res. 2023;34(4):410–2.

Rai K, et al. Dental caries and salivary alterations in Type I Diabetes. J Clin Pediatr Dent. 2011;36(2):181–4.

Sadeghi R, et al. The effect of diabetes mellitus type I on periodontal and dental status. J Clin Diagn Res. 2017;11(7):ZC14–7.

PubMed   PubMed Central   Google Scholar  

Bassir L, et al. Relationship between dietary patterns and dental health in type I diabetic children compared with healthy controls. Iran Red Crescent Med J. 2014;16(1):e9684.

Rafatjou R, et al. Dental health status and hygiene in children and adolescents with Type 1 diabetes mellitus. J Res Health Sci. 2016;16(3):122–6.

Al-Badr AH, et al. Dental caries prevalence among Type 1 diabetes mellitus (T1DM) 6- to 12-year-old children in Riyadh, Kingdom of Saudi Arabia compared to non-diabetic children. Saudi Dent J. 2021;33(5):276–82.

Assiri SA, et al. Assessment of dental caries and salivary characteristics among type 1 diabetic Saudi children. J Dent Sci. 2022;17(4):1634–9.

Elheeny AAH. Oral health status and impact on the oral health-related quality of life of Egyptian children and early adolescents with type-1 diabetes: a case-control study. Clin Oral Invest. 2020;24(11):4033–42.

El-Tekeya M, et al. Caries risk indicators in children with type 1 diabetes mellitus in relation to metabolic control. Pediatr Dent. 2012;34(7):510–6.

Babatzia A, et al. Clinical and microbial oral health status in children and adolescents with type 1 diabetes mellitus. Int Dent J. 2020;70(2):136–44.

Pappa E, Vastardis H, Rahiotis C. Chair-side saliva diagnostic tests: an evaluation tool for xerostomia and caries risk assessment in children with type 1 diabetes. J Dent. 2020;93:103224.

Goteiner D, et al. Periodontal and caries experience in children with insulin-dependent diabetes mellitus. J Am Dent Assoc. 1986;113(2):277–9.

Pachonski M, et al. Dental caries and periodontal status in children with type 1 diabetes mellitus. Pediatr Endocrinol Diabetes Metabolism. 2020;26(1):39–44.

Coelho A, et al. Oral health of Portuguese children with Type 1 Diabetes: a multiparametric evaluation. J Clin Pediatr Dent. 2018;42(3):231–5.

Djuričkovic M, Ivanovic M. Dental health status in children with type 1 diabetes mellitus in Montenegro. Vojnosanit Pregl. 2021;78(2):171–8.

Ferizi L, et al. The influence of Type 1 diabetes mellitus on dental caries and salivary composition. Int J Dent. 2018;2018:p5780916.

Iscan TA, Ozsin-Ozler C, Ileri-Keceli T, Guciz-Dogan B, Alikasifoglu A, Uzamis-Tekcicek M. Oral health and halitosis among type 1 diabetic and healthy children. J Breath Res. 2020;14(3):036008. https://doi.org/10.1088/1752-7163/ab8d8b .

Alves C, Menezes R, Brandão M. Salivary flow and dental caries in Brazilian youth with type 1 diabetes mellitus. Indian J Dent Res. 2012;23(6):758–62.

Amer Y, Saeed LM, Naser N. Biochemical evaluation of saliva in insulin dependent diabetes mellitus children in hilla city-iraq. J Pharm Sci Res. 2019;11(2):627–30.

Arheiam A, Omar S. Dental caries experience and periodontal treatment needs of 10- to 15-year old children with type 1 diabetes mellitus. Int Dent J. 2014;64(3):150–4.

Matsson L, Koch G. Caries frequency in children with controlled diabetes. Scand J Dent Res. 1975;83(6):327–32.

CAS   PubMed   Google Scholar  

MesaroS AS, et al. Does Diabetes Influence Oral Health in Children?. Rom J Diabetes Nutr Metabolic Dis. 2019;26(1):65–71.

Lai S, et al. Evaluation of the difference in caries experience in diabetic and non-diabetic children-a case control study. PLoS ONE. 2017;12(11):e0188451.

Ismail AF, McGrath CP, Yiu CKY. Oral health status of children with type 1 diabetes: a comparative study. J Pediatr Endocrinol Metab. 2017;30(11):1155–9.

Swanljung O, et al. Caries and saliva in 12-18-year-old diabetics and controls. Scand J Dent Res. 1992;100(6):310–3.

Siudikiene J, et al. Dental caries and salivary status in children with type 1 diabetes mellitus, related to the metabolic control of the disease. Eur J Oral Sci. 2006;114(1):8–14.

Banyai D, Vegh D, Vegh A, Ujpal M, Payer M, Biczo Z, et al. Oral health status of children living with type 1 diabetes mellitus. Int J Environ Res Public Health. 2022;19(1):545. https://doi.org/10.3390/ijerph19010545 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Pitts NB, et al. Dental caries. Nat Rev Dis Primers. 2017;3:17030.

Taylor GD. Children with type 1 diabetes and caries - are they linked?. Evid Based Dent. 2020;21(3):94–5.

Duda-Sobczak A, Zozulinska-Ziolkiewicz D, Wyganowska M. Better gingival status in patients with comorbidity of type 1 diabetes and thyroiditis in comparison with patients with type 1 diabetes and no thyroid disease-A preliminary study. Int J Environ Res Public Health. 2023;20(4):3008. https://doi.org/10.3390/ijerph20043008 .

Figuero E, et al. Mechanical and chemical plaque control in the simultaneous management of gingivitis and caries: a systematic review. J Clin Periodontol. 2017;44:S116–34.

de Lima AKA, et al. Diabetes mellitus and poor glycemic control increase the occurrence of coronal and root caries: a systematic review and meta-analysis. Clin Oral Investig. 2020;24(11):3801–12.

Wu CZ, et al. Epidemiologic relationship between periodontitis and type 2 diabetes mellitus. BMC Oral Health. 2020;20(1):204.

Bencze B, et al. Prediabetes and poorly controlled type-2 diabetes as risk indicators for peri-implant diseases:a systematic review and meta-analysis. J Dent. 2024;146:105094.

Shimazaki Y, et al. Stimulated salivary flow rate and oral health status. J Oral Sci. 2017;59(1):55–62.

Murakami S, et al. Dental plaque-induced gingival conditions. J Periodontol. 2018;89(Suppl 1):S17–27.

Velsko IM, et al. Microbial differences between dental plaque and historic dental calculus are related to oral biofilm maturation stage. Microbiome. 2019;7(1):102.

Masiero S, Alberti A, Corbella S, Francetti L. Chairside screening for undiagnosed diabetes and prediabetes in patients with periodontitis. Int J Dent. 2022;2022:9120115. https://doi.org/10.1155/2022/9120115 .

Download references

Acknowledgements

Financial interest.

The authors have no relevant financial or non-financial interests to disclose.

Open access funding provided by Semmelweis University. The authors did not receive support from any organization for the submitted work

Author information

Zsuzsanna Triebl and Bulcsú Bencze should be considered joint first authors.

Authors and Affiliations

Diabetes-Dental Workgroup, Semmelweis University, Szentkirályi 47, Budapest, 1088, Hungary

Zsuzsanna Triebl, Bulcsú Bencze, Dorottya Bányai & Dániel Végh

Department of Paediatric Dentistry and Orthodontics, Semmelweis University, Szentkirályi 47, Budapest, 1088, Hungary

Zsuzsanna Triebl, Dorottya Bányai & Noémi Rózsa

Department of Prosthodontics, Semmelweis University, Szentkirályi 47, Budapest, 1088, Hungary

Bulcsú Bencze, Péter Hermann & Dániel Végh

You can also search for this author in PubMed   Google Scholar

Contributions

ZS.T.:, methodology, formal analysis, writing – original draft; writing - review & editing; visualization; data curation B.B.: methodology, formal analysis, writing – original draft; writing - review & editing; visualization; data curation; statistical analyses; P.H., N.R.: conceptualization, writing – review & editing; V.D., B.D.: methodology; formal analysis; conceptualization; supervision; writing – original draft.; writing review & editing All authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript.

Corresponding author

Correspondence to Dániel Végh .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent to publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Triebl, Z., Bencze, B., Bányai, D. et al. Poor glycemic control impairs oral health in children with type 1 diabetes mellitus - a systematic review and meta-analysis. BMC Oral Health 24 , 748 (2024). https://doi.org/10.1186/s12903-024-04516-y

Download citation

Received : 29 March 2024

Accepted : 21 June 2024

Published : 28 June 2024

DOI : https://doi.org/10.1186/s12903-024-04516-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Type 1 diabetes mellitus
• Salivary flow rate
• Periodontal health

BMC Oral Health

ISSN: 1472-6831

• Submission enquiries: [email protected]
• General enquiries: [email protected]

An official website of the Department of Health & Human Services

• Search All AHRQ Sites
• Email Updates

1. Use quotes to search for an exact match of a phrase.

2. Put a minus sign just before words you don't want.

3. Enter any important keywords in any order to find entries where all these terms appear.

• The PSNet Collection
• All Content
• Perspectives
• Current Weekly Issue
• Past Weekly Issues
• Curated Libraries
• Clinical Areas
• Patient Safety 101
• The Fundamentals
• Training and Education
• Continuing Education
• WebM&M: Case Studies
• Training Catalog
• Submit a Case
• Improvement Resources
• Innovations
• Submit an Innovation
• About PSNet
• Editorial Team
• Technical Expert Panel

Preventable or potentially inappropriate psychotropics and adverse health outcomes in older adults: systematic review and meta-analysis.

Corvaisier M, Brangier A, Annweiler C, et al. Preventable or potentially inappropriate psychotropics and adverse health outcomes in older adults: systematic review and meta-analysis. J Nutr Health Aging. 2024;28(4):100187. doi:10.1016/j.jnha.2024.100187.

Older adults who take potentially inappropriate medications (PIM) are at increased risk of adverse events such as falls. This review focuses specifically on potentially inappropriate psychotropic (PIP) use in older adults. These studies investigated the association with PIP use association of falls , mortality, negative impact on ability to participate in activities of daily living, and unplanned hospitalizations; the use of a PIP increased the risk of all four outcomes.

Drug related problems and pharmacist interventions in a geriatric unit employing electronic prescribing. November 20, 2013

Overnight stay in the emergency department and mortality in older patients. November 29, 2023

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation. October 20, 2021

Error in intensive care: psychological repercussions and defense mechanisms among health professionals. October 29, 2014

Feelings of trust and of safety are related facets of the patient's experience in surgery: a descriptive qualitative study in 80 patients. August 24, 2022

Guidelines on Human Factors in Critical Situations 2023. August 9, 2023

Overview of adverse events related to invasive procedures in the intensive care unit. May 30, 2012

Accuracy of emergency department clinical findings for diagnosis of coronavirus disease 2019. July 29, 2020

Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial. October 13, 2021

Clinical reasoning in dire times- analysis of cognitive biases in clinical cases during the COVID-19 pandemic. February 23, 2022

Identification of warning signs during selection of surgical trainees. January 16, 2019

When do supervising physicians decide to entrust residents with unsupervised tasks? September 8, 2010

Agreement of expert judgment in causality assessment of adverse drug reactions. May 4, 2005

Error disclosure in neonatal intensive care: a multicentre, prospective, observational study. May 10, 2023

Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. March 1, 2011

Medication errors at hospital admission and discharge: risk factors and impact of medication reconciliation process to improve healthcare. October 20, 2021

Crossover of the patient satisfaction surveys, adverse events and patient complaints for continuous improvement in radiotherapy department. April 20, 2022

Anticoagulation-associated adverse drug events in hospitalized patients across two time periods. July 26, 2023

The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. December 2, 2009

Effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from the hospital. August 19, 2009

Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation. April 13, 2011

Influence of shift duration on cognitive performance of emergency physicians: a prospective cross-sectional study. August 29, 2018

Operating room organization and surgical performance: a systematic review. March 20, 2024

Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework. November 13, 2019

The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. April 15, 2009

Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. October 1, 2008

Reliability of the assessment of preventable adverse drug events in daily clinical practice. April 2, 2008

Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. September 2, 2020

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs. August 23, 2023

Success in hospital-acquired pressure ulcer prevention: a tale in two data sets. December 12, 2018

Managing competing organizational priorities in clinical handover across organizational boundaries. January 21, 2015

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge. December 17, 2014

Impact of including readmissions for qualifying events in the Patient Safety Indicators. April 22, 2015

Use of maternal early warning trigger tool reduces maternal morbidity. April 6, 2016

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. May 12, 2010

Identifying organizational cultures that promote patient safety. November 18, 2009

Inappropriate medications in elderly ICU survivors: where to intervene? June 29, 2011

Clinical care checklists: salvations or frustrations? June 1, 2011

Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. March 12, 2014

Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis. September 19, 2012

Patient safety culture and the association with safe resident care in nursing homes. April 18, 2012

Errors in electronic health record–based data query of statin prescriptions in patients with coronary artery disease in a large, academic, multispecialty clinic practice. May 2, 2018

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. May 17, 2017

Simulation-based assessment of the management of critical events by board-certified anesthesiologists. September 13, 2017

The development and implementation of checklists in obstetrics. September 27, 2017

An innovative collaborative model of care for undiagnosed complex medical conditions. May 31, 2017

Relationship of safety climate and safety performance in hospitals. April 1, 2009

Patient safety climate in 92 US hospitals: differences by work area and discipline. February 4, 2009

Patient safety climate in US hospitals: variation by management level. November 12, 2008

Effects of work hour reduction on residents' lives: a systematic review. September 28, 2005

Quality improvement implementation and hospital performance on patient safety indicators. January 31, 2006

Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey. September 26, 2007

Will my patient fall? January 17, 2007

Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. November 22, 2006

Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. November 23, 2005

Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. October 19, 2005

Systematic review: effects of resident work hours on patient safety. September 28, 2005

Differences in the reporting of care-related patient injuries to existing reporting systems. March 6, 2005

Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. June 12, 2024

Physician antipsychotic overprescribing letters and cognitive, behavioral, and physical health outcomes among people with dementia: a secondary analysis of a randomized clinical trial. May 29, 2024

Managers' perceptions of the factors affecting resident and patient safety work in residential settings and nursing homes: a qualitative systematic review. May 1, 2024

Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. January 24, 2024

Patient safety in nursing homes from an ecological perspective: an integrated review. January 17, 2024

Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization. November 15, 2023

Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review. November 1, 2023

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings. October 4, 2023

STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. September 27, 2023

Do not PIMP my nursing home ride! The impact of Potentially Inappropriate Medications Prescribing on residents' emergency care use. September 20, 2023

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals. September 13, 2023

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults. September 6, 2023

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data. August 30, 2023

American Geriatrics Society 2023 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. August 16, 2023

Value assessment of deprescribing interventions: suggestions for improvement. August 16, 2023

The spectrum of hospitalization-associated harm in the elderly. July 26, 2023

Association of polypharmacy and potential drug-drug interactions with adverse treatment outcomes in older adults with advanced cancer. July 19, 2023

Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. July 5, 2023

Drug-related problems among older people with dementia: a systematic review. July 5, 2023

Family conferences to facilitate deprescribing in older outpatients with frailty and with polypharmacy: the COFRAIL cluster randomized trial. May 10, 2023

Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review. May 3, 2023

A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. April 26, 2023

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial. March 1, 2023

A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges. February 8, 2023

Long-Term Trends of Psychotropic Drug Use in Nursing Homes. February 1, 2023

Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool. January 25, 2023

Interventions to increase patient safety in long-term care facilities-umbrella review. January 25, 2023

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. October 5, 2022

Potentially inappropriate prescribing for adults living with diabetes mellitus: a scoping review. October 5, 2022

Factors associated with potentially harmful medication prescribing in nursing homes: a scoping review. September 28, 2022

Connect With Us

Sign up for Email Updates

To sign up for updates or to access your subscriber preferences, please enter your email address below.

Agency for Healthcare Research and Quality

5600 Fishers Lane Rockville, MD 20857 Telephone: (301) 427-1364

• Accessibility
• Disclaimers
• Electronic Policies
• HHS Digital Strategy
• HHS Nondiscrimination Notice
• Inspector General
• Plain Writing Act
• Privacy Policy
• Viewers & Players
• U.S. Department of Health & Human Services
• The White House
• Don't have an account? Sign up to PSNet

Submit Your Innovations

Please select your preferred way to submit an innovation.

Continue as a Guest

Track and save your innovation

in My Innovations

Edit your innovation as a draft

Continue Logged In

Please select your preferred way to submit an innovation. Note that even if you have an account, you can still choose to submit an innovation as a guest.

Continue logged in

New users to the psnet site.

Access to quizzes and start earning

CME, CEU, or Trainee Certification.

Get email alerts when new content

matching your topics of interest

in My Innovations.