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Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review
Natalie Yanchar1, Pier-Alexandre Tardif, Gabrielle Freire
1From the Department of Surgery (N.Y.), University of Calgary, Calgary; Population Health and Optimal Health Practices Research Unit (P.-A.T., M.B., S.B., A.F.T., F.L., L.M.), Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus); Department of Social and Preventative Medicine (L.M.), Université Laval, Quebec City, Quebec; Division of Emergency Medicine, Department of Paediatrics (G.F.), University of Toronto, Toronto; Faculty of Nursing (M.Bérubé), Université Laval, Quebec City, Quebec; Departments of Critical Care Medicine (H.T.S.), Medicine (H.T.S.), and Community Health Sciences (H.T.S.), O'Brien Institute for Public Health, University of Calgary, Calgary; Department of Paediatric Surgery (M.Beaudin), Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec; Pediatrics, Emergency Medicine, and Community Health Sciences (A.S.), Cumming School of Medicine, University of Calgary, Calgary, Alberta; Division of Emergency Medicine (S.B.), Hospital for Sick Children, University of Toronto, Toronto, Ontario; Centre Mère-Enfant Soleil du CHU de Québec (M.W.), Transplant Quebec, Quebec City, Quebec; Division of Emergency Medicine, Department of Pediatrics (M.L.), CHU Sainte-Justine, Université de Montréal, Montreal; Department of Pediatrics (R.Z.), Children's Hospital of Eastern Ontario, Ottawa; Division of Pediatric Emergency Medicine (I.J.G.), McGill University Health Centre, Montreal Children's Hospital, Montréal; Département de Pédiatrie (E.B.), Faculté de Médecine, Centre Hospitalier Universitaire de Québec, and Department of Anesthesiology and Critical Care Medicine (A.F.T., F.L.), Division of Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada; and School of Public Health and Preventive Medicine (B.G.), Monash University, Melbourne, Victoria, Australia.
Insights
Clinical practice guidelines for pediatric solid organ injuries (SOIs) vary. This review found few strong recommendations, highlighting the need for improved guideline development and more research for better pediatric SOI management.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Clinical Practice Guidelines
Background:
- Variations in managing pediatric solid organ injuries (SOIs) may stem from fragmented and methodologically diverse clinical practice guidelines (CPGs).
- Difficulty in accessing and integrating recommendations complicates standardized care for pediatric SOIs.
Purpose of the Study:
- To systematically review and synthesize recommendations from CPGs for the management of pediatric SOIs.
- To assess the quality of existing CPGs and the evidence base for their recommendations.
Main Methods:
- Systematic review of CPGs targeting pediatric SOI populations.
- Data extraction and quality appraisal using the Appraisal of Guidelines Research and Evaluation II tool.
- Synthesis of recommendations from moderate to high-quality CPGs using a recommendations matrix.
Main Results:
- Eight CPGs were identified, with three rated as moderate or high quality.
- Methodological limitations included lack of diverse stakeholder involvement and unclear population definitions.
- Only one-third of recommendations from high-quality CPGs were based on moderate evidence or rated as strong.
Conclusions:
- Fifteen recommendations for pediatric SOI management were identified from 3 high-quality CPGs, but evidence quality was often low.
- Future CPGs should involve multidisciplinary teams, patients, and families, and include implementation support.
- There is an urgent need for more robust research to strengthen evidence-based recommendations for pediatric SOI care.
Background:
Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs.
Methods:
We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria.
Results:
We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries.
Conclusion:
We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population.
Level Of Evidence:
Systematic Review/Meta-analysis; Level III.
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