Pediatrics · Medical Literature
First-aid, pre-hospital care, and harmful indigenous practices in pediatric snakebite envenomation: A systematic review of global evidence from 1973 to 2025.
Abstract
Snakebite envenomation is a neglected tropical disease that disproportionately affects children in low- and middle-income countries. Pediatric patients are uniquely vulnerable due to smaller body mass, increased venom-to-body-weight ratios, and behavioral risk factors such as outdoor play. The pre-hospital phase is critical in determining outcomes, yet inappropriate first-aid and harmful indigenous practices often characterize it. Despite the recognized importance of early interventions, global evidence on pediatric-specific pre-hospital care remains fragmented. This systematic review synthesizes available literature on first-aid measures, pre-hospital interventions, and harmful traditional practices in pediatric snakebite envenomation. Following PRISMA 2020 guidelines, a comprehensive search was conducted in PubMed/MEDLINE, Scopus, and Lens.org, covering publications from 1973 to December 2025. Eligible studies included children and adolescents (0-18 years) with snakebite envenomation, reporting first-aid or pre-hospital practices and associated outcomes. Observational, interventional, and qualitative designs were included, while case reports, reviews, and non-English publications were excluded. Risk of bias was assessed using the Newcastle-Ottawa Scale, Joanna Briggs Institute checklist, and CASP qualitative tool. Due to heterogeneity, findings were synthesized narratively. Forty-four studies were included, representing South Asia, Sub-Saharan Africa, Latin America, the Middle East, Europe, and North America. Harmful practices were most prevalent in South Asia and Africa, where tourniquet use ranged from 38-78%, incision and suction from 22-64%, and herbal remedies from 28-58%. Consultation with traditional healers was frequent, reported in 40-73% of cases. Median delays in hospital presentation were longest in Africa and South Asia, often exceeding 6-18 hours, and each hour of delay increased severity odds by 1.4‑fold. Mortality varied regionally, from 0.06% in North America to 8-10% in Africa, with inappropriate first‑aid identified as an independent predictor of poor outcomes. Knowledge gaps were consistent across regions, with fewer than 20% of parents able to identify appropriate first‑aid and 67% of healthcare providers reporting inadequate training. This review demonstrates that harmful indigenous practices remain pervasive in pediatric snakebite management worldwide, contributing to preventable morbidity and mortality. Evidence underscores the urgent need for standardized, evidence-based pre-hospital guidelines, culturally sensitive community education, and targeted training for healthcare providers. Addressing these gaps through policy development and educational interventions is essential to reduce the global burden of pediatric snakebite envenomation.
Clinical relevance
Pediatric snakebite envenomation remains a critically underaddressed neglected tropical disease, with children disproportionately affected due to lower body mass and higher venom-to-body-weight ratios that amplify toxicity relative to adults. This systematic review addresses a significant evidence gap by synthesizing 52 years of global data (1973–2025) on pre-hospital care specifically in the pediatric population across six world regions. Clinicians caring for children in endemic or travel-medicine contexts must recognize that harmful pre-hospital practices — not envenomation severity alone — are independent predictors of poor outcomes, making provider awareness and community-level intervention urgent priorities.
Key findings
1. Harmful indigenous practices were highly prevalent across South Asia and Sub-Saharan Africa: tourniquet application was reported in 38–78% of pediatric cases, incision and suction in 22–64%, and herbal remedy use in 28–58% of cases. 2. Consultation with traditional healers prior to hospital presentation occurred in 40–73% of pediatric snakebite cases across included studies, reflecting the dominant role of non-biomedical care-seeking in high-burden regions. 3. Median pre-hospital delays were most pronounced in Africa and South Asia, frequently exceeding 6–18 hours from time of bite to hospital arrival. 4. Each additional hour of delay in hospital presentation was associated with a 1.4-fold increase in the odds of severe envenomation outcomes, underscoring the time-critical nature of the pre-hospital phase. 5. Regional mortality varied dramatically, ranging from 0.06% in North America to 8–10% in Sub-Saharan Africa, with inappropriate first-aid independently identified as a predictor of mortality and morbidity. 6. Knowledge deficits were pervasive across all regions: fewer than 20% of parents could identify appropriate first-aid measures, and 67% of healthcare providers reported receiving inadequate training in snakebite management.
Practice implications
Pediatric emergency and primary care providers in endemic regions should actively screen for pre-hospital interventions (tourniquet use, incision/suction, herbal applications) at triage, as these independently worsen outcomes and may require targeted management such as wound care, limb reassessment for ischemia, or accelerated antivenom administration. Given that presentation delays of 6–18 hours are common and each hour increases severity odds 1.4-fold, clinical protocols should prioritize rapid severity stratification and early antivenom eligibility assessment upon arrival rather than awaiting full symptom progression. Institutions and health ministries should invest in culturally sensitive community education programs targeting caregivers — given that fewer than 20% can identify correct first-aid — and in structured snakebite training for frontline healthcare providers, where a 67% self-reported training inadequacy rate represents a critical, modifiable gap in the care continuum.