Quality of Evidence and Strength of Recommendations in American Academy of Pediatrics' Guidelines

Summarize the quality of the evidence and the strength of recommendations in the American Academy of Pediatrics' (AAP) current clinical practice guidelines.

We identified the AAP's current clinical practice guidelines from its website. Three independent reviewers abstracted each recommendation, the quality of evidence supporting it, and its strength from every guideline. We resolved discrepancies by consensus and analyzed results using descriptive statistics.

We identified 14 current clinical practice guidelines. Individual guidelines make between 1 and 39 recommendations (mean 16.9, median 15), and the guidelines make a total of 236 recommendations. Twenty-five (10.6%) recommendations are based on Level A evidence (well-designed and -conducted trials, meta-analyses), 112 (47.5%) Level B (trials with minor limitations; consistent findings from multiple observational studies), 64 (27.1%) Level C (single or few observational studies or multiples studies with inconsistent findings or major limitations), 15 (6.4%) Level D (expert opinion, case reports, reasoning from first principles), and 20 (8.5%) Level X (exceptional situations in which validating studies cannot be performed and there is a clear preponderance of benefit or harm). Eighty-two (34.7%) recommendations are Strong, 117 (49.6%) Moderate, and 37 (15.7%) Weak. Fifty of the 117 (42.7%) Moderate Recommendations are based on Level C evidence, and 10 of the 80 (13%) Strong Recommendations are based on Level X evidence.

A minority of recommendations in the AAP's current clinical practice guidelines (10.6%) are based on the highest-quality evidence. Additional research is needed to improve the quality of evidence supporting pediatric clinical practice guidelines.