To compare the efficacy and safety of mannitol versus hypertonic saline (HTS) for pediatric elevated intracranial pressure (ICP).

A systematic review and meta-analysis was conducted according to PRISMA guidelines. Studies comparing mannitol and HTS in children with elevated ICP were identified through major databases up to September 2025. Pooled odds ratios (ORs) and mean differences (MDs) were calculated using fixed or random effects models as appropriate.

Five studies (four RCTs, one cohort) covering 631 children (264 mannitol, 367 HTS) met inclusion. The pooled mean difference in duration of mechanical ventilation was 2.35 days longer for mannitol (95% CI: -2.24 to 6.94; p = 0.32; I² = 89%). Mortality was 16% with mannitol and 13% with HTS (OR 1.12, 95% CI 0.56 to 2.21; I² = 42%). PICU stay averaged 2.00 days longer with mannitol (95% CI: -2.72 to 6.73; p = 0.41; I² = 89%). Hospital stay was 1.10 days longer with mannitol (95% CI: -1.87 to 4.06; p = 0.47; I² = 0%). Subarachnoid haemorrhage rates were similar between agents (OR 1.14, 95% CI 0.64 to 2.04). Favourable neurological outcomes by Glasgow Outcome Scale were numerically higher with mannitol (OR 1.41, 95% CI 0.83 to 2.41; I² = 0%). No comparisons reached statistical significance.

Mannitol and hypertonic saline demonstrated clinical equivalence for pediatric ICP management. HTS showed slightly higher numerical advantages in ventilation, ICU/hospital stay, and mortality, though non-significant. Both agents remain reasonable first-line options. Further large-scale trials are required to clarify optimal therapy.