In this month’s issue of Pediatrics, Armand Antommaria MD, PhD, and colleagues from the University of Cincinnati review the “Quality of Evidence and Strength of Recommendations in American Academy of Pediatrics’ Guidelines” (10.1542/peds.2024-067836).
This article and accompanying video abstract provide fascinating insight into the quality of evidence supporting the 236 recommendations contained in the 14 current clinical practice guidelines (CPGs) developed by the American Academy of Pediatrics (AAP).
Dr. Antommaria and his co-authors describe the evolution of the AAP’s methodology in determining strength of recommendations in these CPGs, and how the AAP’s process is unique when compared to that from organizations in other specialties.
The accompanying commentary by Steven Downs, MD, from Wake Forest University gives an insider view into the process of AAP CPG development and gives new appreciation for the challenges CPG committees face when developing clinical guidance (10.1542/peds.2024-069341). There is a tightrope to be walked between being precise enough to be clinically useful, without crossing into the realm of being too prescriptive. The AAP’s Partnership for Policy Implementation is charged with helping these committees seek optimal levels of clarity.
When reading these articles, it is easy to get caught up in the primary finding that only 10% of recommendations in these CPGs are based upon “highest quality evidence,” such as well-conducted controlled trials and meta-analyses. This certainly leaves a feeling that many of our treatment recommendations are based on weaker evidence than we would like, and it is only moderately reassuring that this statistic is not an outlier when compared to CPG development within other specialties. We are in good company, with only 12% of CPG recommendations from the American College of Cardiology and 15% of those from the Infectious Diseases Society of America being based upon highest-quality evidence.
So, how is a practicing clinician supposed to interpret, and convey to patients and families, the 90% of AAP CPG recommendations that are based upon lesser quality evidence? Or the multitude of recommendations in Bright Futures and AAP policy statements where the strength of evidence is not delineated? In these cases, it is important to recognize the distinction between the goal of guideline development as compared to the goal of providing care for individual patients. Strong recommendations in these CPGs are based upon data that describe comparisons between groups of subjects. Although this is important information, it does not directly inform the best choice for any given patient.
Optimal medicine is practiced when knowledge of the science is combined with knowledge of the patient (and family) to develop a productive collaboration determining the next step forward. The 14 current CPGs from the AAP cover a broad spectrum of “bread and butter” topics in pediatric care, ranging from neonatal hyperbilirubinemia to children and adolescents with obesity.
Taking a moment to familiarize yourself with the “key action statements” in these CPGs is a high-yield endeavor that can inform your clinical judgment but is not a substitute for it.
