One-Half of GERD Clinical Practice Guidelines Rated “Low”

Patient Selection Crucial for Appropriate Endoscopic GERD Management


High-quality clinical practice guidelines can help pediatric gastroenterologists make evidence-based decisions when treating patients with GERD.


Gastroesophageal reflux (GER), in which gastric contents pass into the esophagus or oropharynx from the stomach, is a common and mostly benign occurrence in infants and younger children. However, it can become symptomatic of more serious gastroesophageal reflux disease (GERD), explains Karthik Rajasekaran, MD, FACS, and colleagues. “GERD can be difficult to diagnose, unpleasant, and concerning for both patients and parents, and untreated, can lead to long-term health morbidities,” Dr. Rajasekaran writes in Pediatric Gastroenterology, Hepatology & Nutrition. Although clinical practice guidelines (CPGs) have addressed diagnosis and management of pediatric GERD, there has been no all-inclusive review of guideline quality or methodological accuracy.

“Unfortunately, we don’t have any great data out there that says, ‘If this happens, you need to do this,’” he says. “But GERD is not that straightforward.  There’s a wide range of symptoms and disease severity. There are different sorts of guidelines and thought processes out there.”

As such, Dr. Rajasekaran and colleagues evaluated current pediatric GERD CPGs for quality and accuracy. They conducted a systematic literature search, identifying eight CPGs pertaining to pediatric GERD and performed an analysis via the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. An intraclass correlation coefficient (ICC) analysis was executed to measure the reliability between reviewers. ICC categories consisted of poor (<0.20), fair (0.21–0.41), moderate (0.41–0.60), good (0.61-0.80), and very good (0.81–1.00). “We first set out to determine how many guidelines exist that discuss this topic,” he says. “Then we needed to systematically review each item methodologically in the guidelines and finally, grade their quality.”

Importance of Differentiating GER from GERD

Of total CPGs, three were discovered to be “high” quality, with five of six domains scoring greater than 60%. There was one “average” quality CPG, with four of six domains meeting that threshold, and the remaining four CPGs were rated “low” quality. “[The ‘high quality’] recommendations emphasize the importance of differentiating GER from GERD, ruling out other diagnoses, understanding the variability in presenting symptoms at different ages, and the roles for various interventions (Table),” Dr. Rajasekaran and colleagues note.

While strong CPGs relating to the diagnosis and management of pediatric GERD exist, this analysis showed that many guidelines lack methodological accuracy and broad applicability, the study authors add. “Areas of strength among the CPGs included ‘Scope and Purpose’ (clearly states objective, highlights the health questions, and describes the target population), and ‘Clarity and Presentation’ (the language, structure, and format of the guidelines), as they tended to be well-written and easily understood. Areas in need of improvement were ‘Stakeholder Involvement’ (evaluates CPG authorship), ‘Rigor of Development’ (quantifies the evidentiary basis for published guidelines), and ‘Applicability’ (reflects the extent to which the guidelines are valid in settings with different resources and barriers to implementation) suggesting these CPGs may not be appropriate for all patients or providers.”

 CPGs Must Be Methodologically Rigorous & Offer High-Quality Guidance

Dr. Rajasekaran and colleagues acknowledge some limitations of their analysis and concur that further, more specific research is needed to confirm that the guidelines rated “high quality” are in fact indicated. In addition, they wrote, “the AGREE II tool weighs all domains equally, despite evidence that ‘Rigor of Development’ and ‘Editorial Independence’ are more strongly associated with effective clinical guidelines. The AGREE II tool also relies on subjective ratings from the reviewers; although statistical techniques were used to generate consensus ratings, these numbers reflect the opinions of four authors. Finally, the literature search could have missed applicable guidelines, particularly those in non-English languages, despite the potential significance of these internationally.”

CPGs can help pediatric gastroenterologists make evidence-based decisions when treating pediatric patients with GERD, the researchers note. “However, it is important that [CPGs] are methodologically rigorous and offer high-quality guidance,” they write. “Based on our analysis using the AGREE II instrument, only three of the eight (37.5%) identified CPGs pertaining to pediatric reflux are high quality. Areas for improvement include the domains of ‘Stakeholder Involvement,’ ‘Applicability,’ and ‘Editorial Independence.’”

Dr. Rajasekaran and colleagues would like to see more clinical trials and randomized controlled trials that address pediatric GERD. “This will help us better understand the best options for each patient,” he says.



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