Written by Hannah Harp
Spoon Feed
Only 10.2% of the AAP’s clinical practice guidelines and recommendations are based on the highest-quality evidence. This is low but on par with many other specialties.
Making the grade
Many medical specialties have evaluated the quality of evidence and strength of recommendations, with 5-30% of recommendations based on the highest category of evidence. The American Academy of Pediatrics (AAP) guidelines can be characterized on two scales – the quality of its supporting evidence (Levels A, B, C, D, and X) and the strength of the recommendation (strong, moderate, weak, or no recommendation). Ideally, strong recommendations would be based on Level A (well designed and conducted trials, meta-analyses) or Level B (trials with minor limitations, consistent findings from multiple observational studies) evidence, while weak recommendations would be based on Level C (single or few observational studies with inconsistent findings or major limitations) or D (expert opinions, case reports) quality data.
Importantly, these two grades can be discordant, which is much more common than you’d think (across all specialties). This descriptive study analyzed 236 recommendations from 14 current AAP clinical practice guidelines to assess evidence quality and recommendation strength. Only 10.6% of recommendations were supported by Level A evidence, while 47.5% were Level B and 27.1% Level C. Most recommendations were Moderate (49.6%) or Strong (34.7%). Notably, 42.7% of Moderate recommendations relied on Level C evidence, and 13% of Strong recommendations on Level X evidence (validating studies cannot be performed and clear preponderance of benefit or harm). The major limitation for this study is that the AAP revamped its scales for grading quality of evidence and strength of recommendation in 2019. Some of the same terminology was preserved, but definitions were starkly different after the revision.
How will this change my practice?
The fact that 10.6% of recommendations are based on Level A evidence (RCT with minimal limitations) isn’t so bad when you think about how few well-designed RCTs can get funded, approved, and fully enrolled in pediatrics. Still, it would be nice if strong recommendations really were always based on Level A or B evidence.
Source
Quality of Evidence and Strength of Recommendations in American Academy of Pediatrics’ Guidelines. Pediatrics. 2025 Apr 1;155(4):e2024067836. doi: 10.1542/peds.2024-067836. PMID: 40064313
