AGREEⅡ评价9个儿童青少年维生素D临床实践指南及推荐意见共识和差异

目的 使用指南研究与评价工具Ⅱ（AGREEⅡ）评价儿童青少年维生素D（VD）临床实践指南（VD指南）,反映目前儿童青少年补充VD的基本共识和存在的争议。方法 制定VD指南的纳入标准和检索策略,检索PubMed、Web of Science、中国期刊全文数据库、万方数据库、维普中文科技期刊数据库、美国国立指南文库（NGC）、指南国际网络（G-I-N）等相关指南数据库,按纳入标准纳入有关儿童青少年VD指南,提取和描述VD指南AGREEⅡ评价信息,使用AGREEⅡ评价纳入指南质量,使用组内相关系数（ICC）进行评价员间一致性检验。分析比较不同VD指南推荐内容的共识和差异。结果 共纳入9篇VD指南,分别来自美国、中国、加拿大、法国、波兰和澳大利亚/新西兰。发表年度从2006至2012年。3篇为循证指南,其中2篇采用GRADE证据分级系统,1篇采用AHRQ证据分级系统;其余6篇为非循证指南。①指南质量经AGREEⅡ评分显示：6大领域的评分中,范围和目的、清晰性和应用性的总体平均得分均>50%,指南制定的参与人员、制定的严谨性和编辑的独立性有待加强（平均得分分别为48％、42％和28％）;循证指南在指南的参与人员、制定的严谨性、编辑的独立性方面优于非循证指南。②总体归纳不同VD指南之间在推荐内容上有5个方面的主要差异。VD预防建议：各指南基本认同的是0～1岁婴儿400 IU·d-1的VD缺乏预防量是安全的;VD治疗建议：美国（ES）指南推荐2 000 IU·d-1(1~18岁),维持6周;阳光照射：美国和澳大利亚/新西兰的指南持不同推荐意见;VD2或VD3：不同指南推荐意见不同;25羟维生素D(25OHD)水平：各指南基本认同25OHD水平<30 nmol·L-1时,佝偻病的患病率增加;孕妇及哺乳期妇女：各指南推荐这一人群要注意及时补充VD,或维持适宜的25OHD水平。结论 ①纳入VD指南整体质量仍有待提高。循证指南质量在指南的参与人员、制定的严谨性、编辑独立性方面优于非循证指南。②纳入VD指南推荐内容虽有一定的差异,但对于0～18岁人群400 IU·d-1的VD缺乏预防量被认为是安全的剂量。③中国VD指南推荐内容参考了国外高质量的指南,改编和制定国内高质量的指南迫在眉睫。     

Quality assessment of clinical practice guidelines for the prevention and treatment of childhood overweight and obesity

Background  The prevalence of childhood overweight and obesity is increasing at dramatic rates in children and adolescents worldwide. Clinical practice guidelines (CPGs) are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Their objective is to provide explicit recommendations for clinical practice based on current evidence for best practice in the management of diseases. Materials and methods  The aim of this study was to identify and assess the quality of CPGs for the prevention and treatment of obesity and overweight in childhood. We developed a search to identify CPGs published between January 1998 and August 2007. We considered for inclusion documents that provided recommendations for clinical practice referring to children and adolescents. Three independent appraisers assessed the quality of the1 CPGs using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument. We identified 376 references and selected 22 for further assessment. Results  The overall agreement among reviewers using the intraclass correlation coefficient was 0.856 (95% confidence interval [CI] 0.731–0.932). Six of the 22 initial guidelines were recommended and a further eight were recommended with conditions or provisos. We concluded that the number of documents with recommendations on the prevention and treatment of childhood obesity published during the 10-year study period was considerable, but only a few of them could be considered as high quality. CPGs were deficient in areas such as applicability, editorial independence and rigor in development. Conclusion  Due to the increasing burden of obesity among children and the potential for long-term comorbidities, clinicians need to be critical in assessing the rigor of how these are developed and their appropriateness for use in the clinician’s own practice. There is a need to improve the methodology and the quality of CPGs on childhood obesity to help clinicians and other decision-makers to tackle this disease. This project was funded with a grant (AE08_015) from CIBER de Epidemiología y Salud Pública (CIBERESP), Spain.     

Emergency department management of gastro-enteritis in Australia and New Zealand

Objective: Comparison of clinical practice guideline (CPG) recommendations and reported physician management of gastro‐enteritis at Paediatric Research in Emergency Departments International Collaborative (PREDICT) network sites as a baseline for further randomised controlled trials. Methods: Two part survey comprising: (i) review of CPGs from PREDICT sites for gastro‐enteritis; and (ii) survey of senior emergency department physicians regarding the management of gastro‐enteritis. Results: All 11 PREDICT sites participated. Nine CPGs were available with three sites using a common CPG. For moderate dehydration, eight CPGs advocated nasogastric (NG) rehydration in preference to intravenous (IV) rehydration. The IV route was reserved for severe dehydration or failed NG rehydration. In the second component of the survey, 78 of 83 (94%) physicians responded. In moderate dehydration, 82% of respondents used NG rehydration. In severe dehydration, 86% used IV fluids; 12% used NG and 3% an initial IV bolus followed by NG fluid. Serum electrolytes were measured universally with IV fluid use and by 22% using NG rehydration. The IV fluid bolus was with normal saline (86%). Fifty‐four per cent used anti‐emetics ‘rarely’ or ‘sometimes’. The commonest agents were ondansetron (60%) and metoclopramide (29%). Conclusions: CPG recommendations and physician practice for the management of gastro‐enteritis were similar across PREDICT sites with a focus on NG for moderate dehydration and IV for severe dehydration. A variety of fluids and administration rates were used. Anti‐emetics were used infrequently. The efficacy and safety of newer anti‐emetics should be explored in collaborative studies. Collaborative development of new CPGs should be considered to simplify fluid regimens.     

From Concept to Bedside: What Pediatricians Should Know about Synthesis of Clinical Practice Guidelines?

Clinical Practice guidelines (CPGs) have emerged as a potentially effective intervention in delivering a high quality, consistent, safe and evidence-based health care. CPGs can either be developed by de novo synthesis or by adaptation of existing guidelines formed in another organization. Guideline recommendations are formulated based on strength of the evidence, validity, clinical relevance and patient values. Support of the organization leadership, role modeling of senior staff and involvement of stakeholders is a key to the success of implementation of guidelines. This article aims to enhance a practicing pediatrician''s understanding of how guidelines are developed, disseminated, and potentially utilized.Key Words: Clinical Practice Guidelines, Development, Synthesis, Adaptation, Implementation     

Identifying clinical practice guidelines for the supportive care of children with cancer: A report from the Children's Oncology Group

Providing evidence‐based supportive care for children with cancer has the potential to optimize treatment outcomes and improve quality of life. The Children's Oncology Group (COG) Supportive Care Guidelines Subcommittee conducted a systematic review to identify current supportive care clinical practice guidelines (CPGs) relevant to childhood cancer or pediatric hematopoietic stem cell transplant. Only 22 papers met the 2011 Institute of Medicine criteria to be considered a CPG. The results highlight the paucity of CPGs available to pediatric oncology healthcare professionals and the pressing need to create CPGs using current methodological standards.     

Emergency management of paediatric status epilepticus in Australia and New Zealand: Practice patterns in the context of clinical practice guidelines

Aims:   To establish current acute seizure management through a review of clinical practice guidelines (CPGs) and reported physician management in the 11 largest paediatric emergency departments in Australia ( n = 9) and New Zealand ( n = 2) within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, and to compare this with Advanced Paediatric Life Support (APLS) guidelines and existing evidence.
Methods:   (i) Review of CPGs for acute seizure management at PREDICT sites. (ii) A standardised anonymous survey of senior emergency doctors at PREDICT sites investigating management of status epilepticus (SE).
Results:   Ten sites used seven different seizure CPGs. One site had no seizure CPG. First line management was with benzodiazepines (10 sites). Second line and subsequent management included phenytoin (10), phenobarbitone (10), thiopentone (9), paraldehyde (6) and midazolam infusion (5). Of 83 available consultants, 78 (94%) responded. First line management of SE without intravenous (IV) access included diazepam per rectum (PR) (49%), and midazolam intramuscular (41%) and via the buccal route (9%). First line management of SE with IV access included midazolam IV (50%) and diazepam IV (44%). The second line agent was phenytoin (88%); third line agents were phenobarbitone (33%), thiopentone and intubation (32%), paraldehyde PR (22%) and midazolam infusion (6%). Fourth line agents were thiopentone and intubation (60%), phenobarbitone (16%), midazolam infusion (13%) and paraldehyde (9%).
Conclusions:   Initial seizure management by CPG recommendations and reported physician practice was broadly similar across PREDICT sites and consistent with APLS guidelines. Practice was variable for second/third line SE management. Areas of controversy would benefit from multi-centred trials.     

Evidenced‐based clinical practice guideline for management of newborn pain

Aim: To facilitate the uptake of evidence and to reduce the evidence practice gap for management of newborn pain through the development of a clinical practice guideline. Method: An audit of practice and an appraisal of clinical practice guidelines were undertaken to establish current practices and guideline availability for the management of newborn pain in 23 hospitals in Australia. Guidelines were appraised using the Appraisal of Guidelines for Research and Evaluation instrument. A literature search was undertaken to acquire the evidence for best practice for management of newborn pain. Results: Neonatal units in 17 hospitals had clinical practice guidelines. Each was peer reviewed and assessed according to the domains of the Appraisal of Guidelines for Research and Evaluation instrument. There was lack of consistency across the guidelines. As a result, a best practice guideline was developed based on current best evidence and the Royal Australian College of Physicians recommendations. To facilitate an ongoing compliance with the guideline, an audit tool was included together with algorithms for procedural pain and pain assessment. Conclusion: The clinical practice guideline can be used by clinicians in varying settings such as the neonatal intensive care and special care unit. The document can be used to support existing practices or challenge clinicians to close the evidence practice gap for the management of newborn pain.     

USPSTF Perspective on Evidence-Based Preventive Recommendations for Children

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.     

Pediatricians' awareness of and attitudes about four clinical practice guidelines

BACKGROUND: The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics' "Practice Parameter for Hyperbilirubinemia in Newborns" (hyperbilirubinemia), "A Guideline for the Management of Febrile Infants" (fever), the Agency for Health Care Policy and Research's "Guideline for Otitis Media With Effusion" (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services (preventive care). OBJECTIVES: 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners' perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider's training or practice that are associated with changing practice as a result of guidelines? DESIGN: A national survey of 600 pediatricians selected at random from the American Medical Association master file. RESULTS: A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = "not at all helpful" and 10 = "extremely helpful") ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were "too cookbook," 6% to 19% reported that they were "too time-consuming," and 4% to 16% reported that they were "too cumbersome." Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change. CONCLUSION: In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them.     

临床实践指南的循证评价和应用

随着现代医学的发展,临床实践指南逐渐成为临床医师科学决策的依据。但不同的国家或学术组织针对同一种病症可能制定了不同的诊治指南,这些指南的质量良莠不齐,给临床决策带来极大困扰。现就如何循证评价临床实践指南及如何将指南应用于临床实践进行阐述。     

The role of clinical practice guidelines in enhancing quality and reducing racial/ethnic disparities in paediatrics

Paediatricians believe that clinical practice guidelines (CPGs) can improve patient care but only when the CPGs are flexible, rigorously tested, effective, not used punitively and are motivated by desires to improve quality, not reduce costs. Paediatricians may avoid using CPGs because few have been subjected to rigorous evaluation to demonstrate improved quality and reduced costs.Effective physician adherence to a CPG can be viewed as a multi-step process with potential barriers at each step. Barriers to adherence can be classified as internal (lack of awareness, familiarity, agreement, self-efficacy, outcome expectancy regarding a given CPG and inability to overcome the inertia of current practice) or external (deficits in the required CPG implementation infrastructure). Effective interventions for overcoming barriers to CPG adherence can include multiple modes of disseminating CPG information to practitioners, continuing medical education, feedback to physicians and establishing a solid infrastructure for CPG implementation.Adherence to evidence-based asthma CPGs may be a potentially powerful tool for reducing or eliminating racial/ethnic disparities in asthma treatment because CPGs consist of strict, explicit protocols based on symptoms, not race, ethnicity or socioeconomic status.     

Managing anorexia nervosa

Clinical confidence and coordinated multidisciplinary care can influence the course of anorexia nervosa in children and adolescents. Sicker and younger patients with anorexia nervosa often present first to a paediatrician, requiring early recognition and appropriate management. Paediatric knowledge and skills are also needed to manage the impact of eating disorders on growth and development. This review provides practical guidance on the management of anorexia nervosa for paediatricians, in the areas of assessment, acute management and re-feeding, and long-term monitoring. In the absence of a strong evidence base for some of these recommendations, local protocols based on best practice guidelines can reduce anxiety, increase cooperation and reduce risk.     

2016年中国大陆期刊发表临床实践指南的报告质量评价

目的：使用国际实践指南报告标准（RIGHT）评价2016年中国大陆期刊发表的临床实践指南的报告质量,为中国学者报告指南提供参考。方法：计算机检索中国生物医学文献服务系统（CBM）、中国知网（CNKI）和万方数据库（Wan Fang Data）,收集期刊公开发表的中国大陆临床实践指南,检索时限为2016年1月1日至2016年12月31日。由2位评价员独立筛选文献,提取资料并交叉核对,用Office Excel 2016软件处理数据。结果：共纳入指南79篇。领域1（基本信息）的报告率最高（52.7%）,领域5（评审和质量保证）和领域7（其他方面）的报告率最低（6.3%）。79篇指南均报告了条目1a（能否通过题目判断为指南）,均未报告条目9a-1（如何遴选参与指南制订的所有贡献者）、条目11b-1（已发表系统评价的检索与评价）、条目11b-2（是否对系统评价进行更新）、条目14a（是否考虑目标人群的价值观和偏好）、条目17（是否经过质量控制程序）和条目18b（推荐意见的传播和实施）。结论：2016年中国大陆期刊指南总体报告质量不佳,建议在以后指南制订过程中参考RIGHT规范对指南进行报告。     

Streptococcal pharyngitis in children: to treat or not to treat?

Controversy remains about the need for antibiotic therapy of group A streptococcal (GAS) pharyngitis in high-resource settings. Guidelines on the management of GAS pharyngitis differ considerably, especially in children. We performed a literature search on the diagnosis and treatment of GAS pharyngitis in children and compared different guidelines with current epidemiology and the available evidence on management. Some European guidelines only recommend antibiotic treatment in certain high-risk patients, while many other, including all American, still advise antimicrobial treatment for all children with GAS pharyngitis, given the severity and re-emerging incidence of complications. Empirical antimicrobial treatment in children with sore throat and a high clinical suspicion of GAS pharyngitis will still result in significant overtreatment of nonstreptococcal pharyngitis. This is costly and leads to emerging antibiotic resistance. Early differential diagnosis between viral and GAS pharyngitis, by means of a ‘rapid antigen detection test’ (RADT) and/or a throat culture, is therefore needed if ‘pro treatment’ guidelines are used. Conclusion: Large scale randomized controlled trials are necessary to assess the value of antibiotics for GAS pharyngitis in high-resource countries, in order to achieve uniform and evidence-based guidelines. The severity and the possibly increasing incidence of complications in school-aged children suggests that testing and treating proven GAS pharyngitis can still be beneficial.     

不同病原感染所致的重症社区获得性肺炎的临床表现

肺炎是5岁以下儿童死亡的首要原因,绝大部分儿童肺炎为社区获得性肺炎(community acquired pneumoni-a,CAP),其中的重症肺炎是造成儿童死亡和影响生命质量的重要原因.国内指南和规范都提出根据儿童年龄、临床及影像学资料等评估儿童社区获得性肺炎的严重程度;及早明确病原,尽快使经验治疗转为目标治疗,...     

Implementing the Becoming Breastfeeding Friendly initiative in Scotland

Despite strong policy support in Scotland, United Kingdom, key challenges to scaling up promotion, protection and support for breastfeeding remain. These include low breastfeeding rates and socioeconomic and regional inequalities. The Becoming Breastfeeding-Friendly (BBF) process was implemented to highlight actions that could address these challenges. The Scottish BBF committee employed an iterative process of documentary analysis and evidence reviews supplemented by 18 interviews with key informants. The data were mapped to BBF benchmarks and each gear was scored accordingly. Nineteen draft recommendations addressing policy and practice gaps were prioritised. Ten recommendations were grouped into eight themes, which cross-cut the BBF gears. The process took place from May 2018 to May 2019. The overall BBF Index score for Scotland was 2.4 indicating a strong scaling-up environment for breastfeeding. Five gears were assessed as strong gear strength, and the remaining three were judged as moderate gear strength. Three recommendation themes illuminate strengths and areas for development. The theme ‘reinforcing political will’ showed effective leadership, strong policies and significant investment in supporting breastfeeding and highlights actions to sustain this. The theme ‘strengthening and coordinating breastfeeding messages’ revealed a need for coordination between government, health services and the third sector. The theme ‘promoting a supportive return to work environment’ highlighted that, while employment legislation is not devolved to the Scottish government, action could be taken by employers to optimise an enabling environment for breastfeeding. The BBF process identified strengths and triggered actions to enhance breastfeeding promotion, protection and support in Scotland.     

Home oxygen therapy after hospital discharge

Home oxygen therapy is increasingly prescribed for various conditions in the neonatal period, particularly for infants with bronchopulmonary dysplasia. Due to limited evidence on indication, minimal target oxygen saturation, monitoring, application and discontinuation of home oxygen therapy clinical practice varies widely throughout the world. International guidelines provide recommendations mostly on the basis of nonsystematic clinical observations. Most relevant points for the clinical management of home oxygen therapy include a minimal target oxygen saturation of equal to or greater than 93%, the provision of a home monitoring of oxygen saturation ideally with a memory function, and the conduct of continuous overnight oximetry or polysomnography during weaning from supplemental oxygen. This review summarizes relevant literature as well as existing guidelines and recommendations on home oxygen therapy to aid clinicians in the management of these patients and identifies areas for future research.     

《国际指南：静脉注射免疫球蛋白在治疗Rh和ABO新生儿溶血病中的作用》解读

《国际指南：静脉注射免疫球蛋白在治疗Rh和ABO新生儿溶血病中的作用》由血液学家、新生儿科医生和输血科专家共同组成的国际专家小组起草,2022年3月16日发表于《英国血液学杂志》。该指南针对静脉注射免疫球蛋白（intravenous immunoglobulin,IVIG）用于Rh和ABO新生儿溶血病进行了循证证据总结并提出了推荐意见。该指南推荐IVIG不应常规应用于Rh和ABO新生儿溶血病以减少换血（exchange transfusion,ET）;在合并严重高胆红素血症（接近或超过ET阈值）或无法实施ET的情况下,IVIG的最佳使用时机尚不明确。该指南制定方法规范严谨,但现有的证据质量等级不高。