Pediatric Clinical Practice Guidelines Pdf

[Carolina Schmalzried]

CPGsare developed by teams consisting of multidisciplinary clinicians and usually include clinical decision support personnel and informaticists. Most CPGs are associated with order sets that mirror guideline recommendations, thus making it easier to use the guideline at the point of care. Many CPGs have process and outcome metrics to monitor their impact on patient care. These metrics can be monitored over time to provide front line providers and leaders alike information on gaps in practice and foundation for clinical quality improvement initiatives to close those gaps.

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Importance: National clinical practice guidelines (CPGs) guide medical practice. The use of race in CPGs has the potential to positively or negatively affect structural racism and health inequities.

Evidence review: A literature search of PubMed, Medscape, Emergency Care Research Institute Guidelines Trust, and MetaLib.gov was performed for English-language clinical guidelines addressing patients younger than 19 years of age from January 1, 2016, to April 30, 2021. The study team systematically identified and evaluated all articles that used race and ethnicity terms and then used a critical race theory framework to classify each use according to the potential to either positively or negatively affect structural racism and racial inequities in health care.

Conclusions and relevance: In this systematic review of US-based pediatric CPGs, race was frequently used in ways that could negatively affect health care inequities. Many opportunities exist for national medical organizations to improve the use of race in CPGs to positively affect health care, particularly for racial and ethnic minoritized communities.

This clinical practice guideline (CPG), which is intended for all clinicians in any setting who interact with children aged 1 to 18 years who may be candidates for tonsillectomy, is an update of, and replacement for, the prior CPG that was published in 2011. The purpose of this multidisciplinary CPG is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections.

On Monday, January 9th, the American Academy of Pediatrics (AAP) published new clinical practice guidelines (CPGs) for evaluating and treating obesity in children and adolescents. These new guidelines have been five years in the making and are the result of comprehensive, evidence-based research and deliberative committee processes. The previous guidelines from 2007 were the result of expert committee recommendations and focused primarily on diet, physical activity, and lifestyle behaviors, such as screen-time, for treating children and adolescents with obesity. The new, evidence-based guidelines reflect significant progress in understanding obesity as a chronic disease with a multitude of medical treatment options.

Recent findings support the effectiveness of weight loss medications in children and adolescents. In December, 2022, the New England Journal of Medicine published a study on the effectiveness of once-weekly semaglutide use in adolescents with obesity. Participants, aged 12 to 18 years, were randomly assigned to receive once-weekly subcutaneous semaglutide or placebo for 68 weeks plus lifestyle intervention. For the 180 participants that completed the treatment plan, the mean change in BMI for those who received semaglutide was -16.8%, compared to +0.6% BMI units for participants who received the placebo. These results indicate the effectiveness of pharmacotherapy in addition to intensive behavioral therapy in reducing BMI for adolescents with obesity.

The updated recommendations have been criticized by media groups and individuals on social media platforms like Twitter. Some of the main criticisms are about the recommendation to treat obesity with pharmacotherapy and surgery. Critics have argued that the guidelines should instead advocate for diet and lifestyle changes and could increase the possibility of increasing eating disorders in adolescents. Solutions to obesity must be both lifestyle modification and options for more aggressive treatment if behavioral approaches fail. Rigorous trials of obesity therapy have not been associated with an increase in eating disorders. Many of the comments in response to the new CPGs fail to recognize obesity as a disease that should be treated with medical interventions but continue to view obesity as a personal failing resulting from poor lifestyle choices.

Throughout the updated guidelines, the AAP is clear in labeling obesity as a chronic disease resulting from a complex array of contributing factors. This indication is an important step forward in addressing the frequent stigma associated with obesity. By recognizing the systems-level factors that contribute to childhood obesity, the AAP emphasizes that there are social determinants of health that contribute to overweight and obesity in children, such as bullying and systemic racism.

While new guidelines and research reflect a promising future for the treatment of overweight and obesity in children and adolescents, significant challenges remain. The AAP acknowledged that it will be difficult for pediatric practices to absorb and implement all of the changes and recommendations provided in the new guidelines. Most pediatric practices lack the capacity to deliver the comprehensive, multi-component treatment necessary to meet the new guidelines. Finally, the lack of payment for obesity care remains a major barrier to the implementation of the new CPGs for child and adolescent obesity.

L Clifford McDonald, Dale N Gerding, Stuart Johnson, Johan S Bakken, Karen C Carroll, Susan E Coffin, Erik R Dubberke, Kevin W Garey, Carolyn V Gould, Ciaran Kelly, Vivian Loo, Julia Shaklee Sammons, Thomas J Sandora, Mark H Wilcox

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Summarized below are recommendations intended to improve the diagnosis and management of Clostridium difficile infection (CDI) in adults and children. CDI is defined by the presence of symptoms (usually diarrhea) and either a stool test positive for C. difficile toxins or detection of toxigenic C. difficile, or colonoscopic or histopathologic findings revealing pseudomembranous colitis. In addition to diagnosis and management, recommended methods of infection control and environmental management of the pathogen are presented. The panel followed a process used in the development of other Infectious Diseases Society of America (IDSA) guidelines, which included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system (Figure 1). A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found in the full text of the guidelines. The extent to which these guidelines can be implemented is impacted by the size of the institution and the resources, both financial and laboratory, available in the particular clinical setting.

Stratify data by patient location to target control measures when CDI incidence is above national and/or facility reduction goals or if an outbreak is noted (weak recommendation, low quality of evidence).

VII. What is the best-performing method (ie, in use positive and negative predictive value) for detecting patients at increased risk for clinically significant C. difficile infection in commonly submitted stool specimens?

X. Does detection of fecal lactoferrin or another biologic marker improve the diagnosis of CDI over and above the detection of toxigenic C. difficile? Can such a subset predict a more ill cohort?

Since completion of this guideline, a new therapeutic agent and a molecular diagnostic test platform have become available for CDI. Bezlotoxumab, a monoclonal antibody directed against toxin B produced by C. difficile, has been approved as adjunctive therapy for patients who are receiving antibiotic treatment for CDI and who are at high risk for recurrence [10]. Multiplex polymerase chain reaction (PCR) platforms that detect C. difficile as part of a panel of >20 different enteric pathogens have also become available [11]. These most recent innovations and other innovations that may become available in the near future will be covered in subsequent guideline updates.

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