The grades of recommendation (1A, 1B, 1C, 2A, 2B, 2C) and the approach to rating the quality of evidence are defined at the end of the "Major Recommendations" field.
Antithrombotic Therapy in Pediatric Patients
The expert panel suggests that where possible, pediatric hematologists with experience in thromboembolism (TE) manage pediatric patients with TE (Grade 2C). When this is not possible, the expert panel suggests a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C).
Heparin in Neonates and Children
The expert panel suggests that therapeutic unfractionated heparin (UFH) in children is titrated to achieve a target range of anti-Xa activity of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). The expert panel suggests that when initiating UFH therapy, UFH boluses be no greater than 75 to 100 units/kg and that boluses be withheld or reduced if there are significant bleeding risks (Grade 2C). The expert panel suggests avoiding long-term use of therapeutic UFH in children (Grade 2C).
Low-Molecular-Weight Heparin (LMWH) in Neonates and Children
The expert panel suggests, for neonates and children receiving either once- or twice-daily therapeutic LMWH that the drug be monitored to a target anti-Xa activity range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous (SC) injection or 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after SC injection (Grade 2C).
Vitamin-K Antagonists (VKAs) in Neonates and Children
The expert panel suggests, for children receiving VKAs, that the drug be monitored to a target international normalized ratio (INR) of 2.5 (range, 2.0-3.0), except in the setting of prosthetic cardiac valves where the expert panel suggests adherence to the adult recommendations outlined in the National Guideline Clearinghouse (NGC) summary of the American College of Chest Physicians (ACCP) guideline Antithrombotic and thrombolytic therapy for valvular disease (Grade 2C). The expert panel suggests that INR monitoring with point-of-care monitors be made available where resources make this possible (Grade 2C).
Aspirin
The expert panel suggests that when aspirin is used for antiplatelet therapy in children, it is used in doses of 1 to 5 mg/kg per day (Grade 2C).
Recommendations for Antithrombotic Therapy in Specific Clinical Situations
Venous Thromboembolism (VTE) in Neonates
The expert panel suggests that central venous access devices (CVADs) or umbilical venous catheters (UVCs) associated with confirmed thrombosis be removed after 3 to 5 days of therapeutic anticoagulation rather than left in situ (Grade 2C). The expert panel suggests either initial anticoagulation or supportive care with radiologic monitoring for extension of thrombosis rather than no follow-up (Grade 2C); however, in previously untreated patients, the expert panel recommends the start of anticoagulation if extension occurs (Grade 2C). The expert panel suggests that anticoagulation should be with either (1) LMWH or (2) UFH followed by LMWH. The expert panel suggests a total duration of anticoagulation of between 6 weeks and 3 months rather than shorter or longer durations (Grade 2C). If either a CVAD or a UVC is still in place on completion of therapeutic anticoagulation, the expert panel suggests a prophylactic dose of anticoagulation until such time as the CVAD or UVC is removed (Grade 2C). The expert panel suggests against thrombolytic therapy for neonatal VTE unless major vessel occlusion is causing critical compromise of organs or limbs (Grade 2C). The expert panel suggests if thrombolysis is required, tissue plasminogen activator (tPA) is used rather than other lytic agents (Grade 2C), and the expert panel suggests plasminogen (fresh frozen plasma) administration prior to commencing therapy (Grade 2C).
Renal Vein Thrombosis in Neonates
For unilateral renal vein thrombosis (RVT) in the absence of renal impairment or extension into the inferior vena cava (IVC), the expert panel suggests either (1) supportive care with radiologic monitoring for extension of thrombosis (if extension occurs the expert panel suggests anticoagulation) or (2) anticoagulation with UFH/LMWH or LMWH in therapeutic doses rather than no therapy. If anticoagulation is used, the expert panel suggests a total duration of between 6 weeks and 3 months rather than shorter or longer durations of therapy (Grade 2C). For unilateral RVT that extends into the IVC, the expert panel suggests anticoagulation with UFH/LMWH or LMWH for a total duration of between 6 weeks and 3 months (Grade 2C).
For bilateral RVT with evidence of renal impairment, the expert panel suggests anticoagulation with UFH/LMWH or initial thrombolytic therapy with tissue plasminogen activator (tPA) followed by anticoagulation with UFH/LMWH (Grade 2C).
Central Venous Access Device (CVAD) Prophylaxis in Neonates
For neonates with CVADs, the expert panel recommends to maintain CVAD patency with UFH continuous infusion at 0.5 units/kg per h over no prophylaxis (Grade 1A) or intermittent local thrombolysis (Grade 2C). For neonates with blocked CVADs, the expert panel suggests local thrombolysis after appropriate clinical assessment (Grade 2C).
Thromboprophylaxis for Blalock-Taussig Shunts and Modified Blalock-Taussig Shunts (MBTS)
For neonates and children having modified MBTS, the expert panel suggests intraoperative UFH therapy (Grade 2C). For neonates and children after MBTS surgery, the expert panel suggests either aspirin or no antithrombotic therapy as compared with prolonged LMWH or VKAs (Grade 2C).
Therapy for Femoral Artery Thrombosis in Neonates and Children
For neonates and children with acute femoral artery thrombosis, the expert panel recommends therapeutic doses of intravenous (IV) UFH as initial therapy compared with aspirin or no therapy (Grade 1B) or LMWH (Grade 2C). The expert panel suggests subsequent conversion to LMWH, or else continuation of UFH, to complete 5 to 7 days of therapeutic anticoagulation as compared with a shorter or longer duration (Grade 2C).
For neonates and children with limb-threatening or organ-threatening (via proximal extension) femoral artery thrombosis who fail to respond to initial UFH therapy and who have no known contraindications, the expert panel recommends thrombolysis (Grade 1C). For neonates and children with femoral artery thrombosis, the expert panel recommends surgical intervention compared with UFH therapy alone when there is a contraindication to thrombolytic therapy and organ or limb death is imminent (Grade 1C).
Prophylaxis for Peripheral Arterial Catheters in Neonates and Children
For neonates and children with peripheral arterial catheters in situ, the expert panel recommends UFH continuous infusion at 0.5 units/mL at 1 mL/h compared with normal saline (Grade 1A).
Therapy for Peripheral Artery Thrombosis Secondary to Peripheral Artery Catheters in Neonates and Children
For neonates and children with a peripheral arterial catheter-related TE, the expert panel suggests immediate removal of the catheter (Grade 2B). For neonates and children with a symptomatic peripheral arterial catheter-related TE, the expert panel suggests UFH anticoagulation with or without thrombolysis or surgical thrombectomy and microvascular repair with subsequent heparin therapy (Grade 2C).
Prophylaxis of Umbilical Arterial Catheters in Neonates
For neonates with umbilical arterial catheters (UACs), the expert panel suggests UAC placement in a high rather than a low position (Grade 2B).
For neonates with UACs, the expert panel suggests prophylaxis with a low-dose UFH infusion via the UAC (heparin concentration of 0.25-1 unit/mL, total heparin dose of 25-200 units/kg per day) to maintain patency (Grade 2A).
Prophylaxis for Cardiac Catheterization (CC) in Neonates and Children
For neonates and children requiring CC via an artery, the expert panel recommends administration of IV UFH as thromboprophylaxis over no prophylaxis (Grade 1A) or aspirin (Grade 1B). For neonates and children requiring cardiac catheterization via an artery, the expert panel recommends the use of UFH doses of 100 units/kg as a bolus compared with a 50-unit/kg bolus (Grade 1B). In prolonged procedures, the expert panel suggests further doses of UFH rather than no further therapy (Grade 2B).
Cerebral Sinovenous Thrombosis in Neonates
For neonates with cerebral sinovenous thrombosis (CSVT) without significant intracranial hemorrhage (ICH), the expert panel suggests anticoagulation, initially with UFH or LMWH and subsequently with LMWH, for a total therapy duration between 6 weeks and 3 months rather than shorter or longer treatment duration (Grade 2C). For neonates with CSVT with significant hemorrhage, the expert panel suggests either (1) anticoagulation or (2) supportive care with radiologic monitoring of the thrombosis at 5 to 7 days and anticoagulation if thrombus extension is noted as compared with no therapy (Grade 2C).
Arterial Ischemic Stroke in Neonates
For neonates with a first arterial ischemic stroke (AIS), in the absence of a documented, ongoing cardioembolic source, the expert panel suggests supportive care over anticoagulation or aspirin therapy (Grade 2C).
For neonates with a first AIS and a documented cardioembolic source, the expert panel suggests anticoagulation with UFH or LMWH (Grade 2C).
For neonates with recurrent AIS, the expert panel suggests anticoagulant or aspirin therapy (Grade 2C).
Neonates with Purpura Fulminans
For neonates with clinical presentations of homozygous protein C deficiency, the expert panel recommends administration of either 10 to 20 mL/kg of fresh frozen plasma every 12 h or protein C concentrate, when available, at 20 to 60 units/kg until the clinical lesions resolve (Grade 1A). For neonates with homozygous protein C deficiency, after initial stabilization, the expert panel recommends long-term treatment with VKA (Grade 1C), LMWH (Grade 1C), protein C replacement (Grade 1B), or liver transplantation (Grade 1C) compared with no therapy.
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in Children
In children with first VTE (CVAD and non-CVAD related) the expert panel recommends acute anticoagulant therapy with either UFH or LMWH (Grade 1B). The expert panel recommends initial treatment with UFH or LMWH for at least 5 days (Grade 1B). For ongoing therapy, the expert panel suggests LMWH or UFH. For patients in whom clinicians will subsequently prescribe VKAs, the expert panel recommends beginning oral therapy as early as day 1 and discontinuing UFH/LMWH on day 6 or later than day 6 if the INR has not exceeded 2.0 compared with no therapy (Grade 1B).
The expert panel suggests that children with idiopathic VTE receive anticoagulant therapy for 6 to 12 months compared with no therapy (Grade 2C).
Underlying values and preferences: Families who place a high value on avoiding the unknown risk of recurrence in the absence of an ongoing risk factor and a lower value on avoiding the inconvenience of therapy or potential impact of therapy on growth and development and bleeding risk associated with antithrombotic therapy are likely to choose to continue anticoagulant therapy beyond 6 to 12 months.
In children with secondary VTE (i.e., VTE that has occurred in association with a clinical risk factor) in whom the risk factor has resolved, the expert panel suggests anticoagulant therapy be administered for 3 months (Grade 2C) as compared with no further therapy. In children who have ongoing, but potentially reversible, risk factors, such as active nephrotic syndrome or ongoing asparaginase therapy, the expert panel suggests continuing anticoagulant therapy beyond 3 months in either therapeutic or prophylactic doses until the risk factor has resolved (Grade 2C).
In children with recurrent idiopathic VTE, the expert panel recommends indefinite treatment with VKAs (Grade 1A).
In children with recurrent secondary VTEs with an existing reversible risk factor for thrombosis, the expert panel suggests anticoagulation until resolution of the precipitating factor but for a minimum of 3 months as compared with no further therapy (Grade 2C).
In children with a CVAD in place who have a VTE, if a CVAD is no longer required or is nonfunctioning, the expert panel recommends it be removed (Grade 1B). The expert panel suggests at least 3 to 5 days of anticoagulation therapy prior to its removal rather than no anticoagulation prior to removal (Grade 2C). If CVAD access is required and the CVAD is still functioning, the expert panel suggests that the CVAD remain in situ and the patient given anticoagulants (Grade 2C). For children with a first CVAD-related VTE, the expert panel suggests initial management as for secondary VTE as previously described.
In children with CVAD in place who have a VTE and in whom the CVAD remains necessary, the expert panel suggests, after the initial 3 months of therapy, that prophylactic doses of VKAs (INR range, 1.5-1.9) or LMWH (anti-Xa level range, 0.1-0.3 units/mL) be given until the CVAD is removed (Grade 2C). If recurrent thrombosis occurs while the patient is receiving prophylactic therapy, the expert panel suggests continuing therapeutic doses until the CVAD is removed and for a minimum of 3 months following the VTE (Grade 2C).
Thrombolysis in Pediatric Patients with DVT
In children with VTE, the expert panel suggests that thrombolysis therapy be used only for life- or limb-threatening thrombosis (Grade 2C). If thrombolysis is used in the presence of physiologically low levels or pathologic deficiencies of plasminogen, the expert panel suggests supplementation with plasminogen (Grade 2C). In children with VTE in whom thrombolysis is used, the expert panel suggests systemic thrombolysis or catheter-directed thrombolysis, depending on institutional experience and, in the latter case, technical feasibility.
Thrombectomy and IVC Filter Use in Pediatric Patients with DVT
In children with life-threatening VTE, the expert panel suggests thrombectomy (Grade 2C). In children who have had a thrombectomy, the expert panel suggests anticoagulant therapy as per the recommendations above under "DVT and PE in Children"(Grade 2C). In children >10 kg body weight with lower-extremity VTE and a contraindication to anticoagulation, the expert panel suggests placement of a retrievable IVC filter (Grade 2C). In children who receive a filter, the expert panel suggests that the filter be removed as soon as possible if thrombosis is not present in the basket of the filter and when contraindication to anticoagulation is resolved (Grade 2C). In children who receive an IVC filter, the expert panel recommends appropriate anticoagulation for VTE as soon as the contraindication to anticoagulation is resolved (Grade 1C).
DVT in Children with Cancer
In children with cancer, the expert panel suggests that management of VTE follow the general recommendations for management of VTE in children. The expert panel suggests the use of LMWH in the treatment of VTE for a minimum of 3 months until the precipitating factor has resolved (e.g., use of asparaginase) (Grade 2C).
Remarks: The presence of cancer, the need for surgery, chemotherapy, or other treatments may modify the risk-benefit ratio for treatment of VTE, and clinicians should consider these factors on an individual basis.
Children with Antiphospholipid Antibodies (APLAs) and DVT
For children with VTE in the setting of APLAs, the expert panel suggests management as per general recommendations for VTE management in children.
Children with DVT and Positive Inherited Thrombophilia Testing
For children with VTE, independent of the presence or absence of inherited thrombophilic risk factors, the expert panel suggests that the duration and intensity of anticoagulant therapy as per the recommendations above under "DVT and PE in Children."
Children with VTE and Structurally Abnormally Venous Systems
For children with first VTE secondary to structural venous abnormalities, the expert panel suggests anticoagulation as per other "spontaneous" VTE (see recommendations above under "DVT and PE in Children") and consideration of subsequent percutaneous or surgical interventions, depending on patient factors and institutional experience. For children with recurrent VTE secondary to structural venous abnormalities, the expert panel suggests indefinite anticoagulation unless successful percutaneous or surgical interventions can be performed (Grade 2C).
Children with Right Atrial Thrombosis
For children with right atrial thrombosis related to CVAD, the expert panel suggests removal of the CVAD with or without anticoagulation, depending on the individual risk factors, compared with leaving the CVAD in situ (Grade 2C). For children with large (>2 cm) mobile right atrial thrombosis, the expert panel suggests anticoagulation, with appropriately timed CVAD removal, and consideration of surgical intervention or thrombolysis based on individualized risk-benefit assessment compared with no anticoagulation therapy (Grade 2C).
Children with CVADs
For CVADs, the expert panel suggests flushing with normal saline or heparin or intermittent recombinant urokinase to maintain patency as compared with no therapy (Grade 2C). For blocked CVADs, the expert panel suggests tPA or recombinant urokinase to restore patency (Grade 2C). If after at least 30 min following local thrombolytic instillation CVAD patency is not restored, the expert panel suggests a second dose be administered. If the CVAD remains blocked following two doses of local thrombolytic agent, the expert panel suggests radiologic imaging to rule out a CVAD-related thrombosis (Grade 2C).
For children with short- or medium-term CVADs, the expert panel recommends against the use of routine systemic thromboprophylaxis (Grade 1B).
For children receiving long-term home total parenteral nutrition, the expert panel suggests thromboprophylaxis with VKAs (Grade 2C).
Glenn Procedure or Bilateral Cavopulmonary Shunt (BCPS)
For children who have a BCPS, the expert panel suggests postoperative UFH (Grade 2C).
Fontan Surgery
For children after Fontan surgery, the expert panel recommends aspirin or therapeutic UFH followed by VKAs over no therapy (Grade 1C).
Endovascular Stents
For children having endovascular stents inserted, the expert panel suggests administration of UFH perioperatively (Grade 2C).
Dilated Cardiomyopathy
For pediatric patients with cardiomyopathy, the expert panel suggests VKAs no later than their activation on a cardiac transplant waiting list (Grade 2C).
Underlying values and preferences: Parents who place a high value on avoiding the inconvenience, discomfort, and limitations of anticoagulant monitoring and a lower value on the uncertain reduction in thrombotic complications are unlikely to choose VKA therapy for their children who are eligible for transplant.
Primary Pulmonary Hypertension
For children with primary pulmonary hypertension, the expert panel suggests starting anticoagulation with VKAs at the same time as other medical therapy (Grade 2C).
Biologic and Mechanical Prosthetic Heart Valves
For children with biologic or mechanical prosthetic heart valves, the expert panel recommends that clinicians follow the relevant recommendations from the adult population (see the NGC summary of the ACCP guideline Antithrombotic and thrombolytic therapy for valvular disease).
Ventricular Assist Devices (VADs)
For children with VADs the expert panel suggests administration of UFH (Grade 2C). The expert panel suggests starting UFH between 8 and 48 h following implantation (Grade 2C). In addition, the expert panel suggests antiplatelet therapy (either aspirin or aspirin and dipyridamole) to commence within 72 h of VAD placement (Grade 2C). For children with VAD, once clinically stable, the expert panel suggests switching from UFH to either LMWH or VKA (target INR 3.0 range, 2.5-3.5) until transplanted or weaned from VAD (Grade 2C).
Primary Prophylaxis for Venous Access Related to Hemodialysis
For patients undergoing hemodialysis via an arteriovenous fistula, the expert panel suggests routine use of VKAs or LMWH as fistula thromboprophylaxis as compared with no therapy (Grade 2C).
For patients undergoing hemodialysis via CVAD, the expert panel suggests routine use of VKAs or LMWH for thromboprophylaxis as compared with no therapy (Grade 2C).
Use of UFH or LMWH during Hemodialysis
For children having hemodialysis, the expert panel suggests the use of UFH or LMWH during hemodialysis to maintain circuit patency independent of type of vascular access (Grade 2C).
Kawasaki Disease
For children with Kawasaki disease, the expert panel recommends aspirin in high doses (80-100 mg/kg per day during the acute phase for up to 14 days) as an antiinflammatory agent, then in lower doses (1-5 mg/kg per day for 6 to 8 weeks) as an antiplatelet agent (Grade 1B). For children with Kawasaki disease, the expert panel recommends IV γ-globulin (2 g/kg, single dose) within 10 days of the onset of symptoms (Grade 1A).
For children with moderate or giant coronary aneurysms following Kawasaki disease, the expert panel suggests that warfarin in addition to low-dose aspirin be given as primary thromboprophylaxis (Grade 2C).
For children with Kawasaki disease who have giant aneurysms and acute coronary artery thrombosis, the expert panel suggests thrombolysis or acute surgical intervention (Grade 2C).
CSVT in Children
For children with CSVT without significant intracranial hemorrhage, the expert panel recommends anticoagulation initially with UFH or LMWH and subsequently with LMWH or VKA for a minimum of 3 months relative to no anticoagulation (Grade 1B). In children who after 3 months of therapy still experience occlusion of CSVT or ongoing symptoms, the expert panel suggests administration of a further 3 months of anticoagulation (Grade 2C). For children with CSVT with significant hemorrhage, the expert panel suggests initial anticoagulation as for children without hemorrhage or radiologic monitoring of the thrombosis at 5 to 7 days and anticoagulation if thrombus extension is noted at that time (Grade 2C). In children with CSVT and potentially recurrent risk factors (e.g., nephrotic syndrome, asparaginase therapy), the expert panel suggests prophylactic anticoagulation at times of risk factor recurrence (Grade 2C). The expert panel suggests thrombolysis, thrombectomy, or surgical decompression only in children with severe CSVT in whom there is no improvement with initial UFH therapy (Grade 2C).
AIS in Children
For children with acute AIS, with or without thrombophilia, the expert panel recommends UFH or LMWH or aspirin as initial therapy until dissection and embolic causes have been excluded (Grade 1C). For children with acute AIS, the expert panel suggests, once dissection and cardioembolic causes are excluded, daily aspirin prophylaxis for a minimum of 2 years as compared with no antithrombotic therapy (Grade 2C). For children receiving aspirin who have recurrent AIS or transient ischemic attacks (TIAs), the expert panel suggests changing to clopidogrel or anticoagulant therapy with LMWH or VKA (Grade 2C). For children with AIS, the expert panel recommends against the use of thrombolysis (tPA) or mechanical thrombectomy outside of specific research protocols (Grade 1C).
Embolic Stroke
For AIS secondary to cardioembolic causes, the expert panel suggests anticoagulant therapy with LMWH or VKAs for at least 3 months (Grade 2C). For AIS secondary to cardioembolic causes in children with demonstrated right-to-left shunts (e.g., PFO), the expert panel suggests surgical closure of the shunt (Grade 2C).
Dissection
For AIS secondary to dissection, the expert panel suggests anticoagulant therapy with LMWH or VKAs for at least 6 weeks (Grade 2C). Ongoing treatment will depend on radiologic assessment of degree and extent of stenosis and evidence of recurrent ischemic events.
Cerebral Vasculopathies
For children with acute AIS secondary to non-Moyamoya vasculopathy, the expert panel recommends UFH or LMWH or aspirin for 3 months as initial therapy compared with no treatment (Grade 1C). For children with AIS secondary to non-Moyamoya vasculopathy, the expert panel suggests ongoing antithrombotic therapy should be guided by repeat cerebrovascular imaging.
Moyamoya Disease
For children with acute AIS secondary to Moyamoya, the expert panel suggests aspirin over no treatment as initial therapy (Grade 2C).
For children with Moyamoya, the expert panel suggests they be referred to an appropriate center for consideration of revascularization.
Definitions:
Grading of Recommendations Assessment, Development and Evaluation (GRADE) Approach to Rating Quality of Evidence
Study Design |
Quality of Evidence |
Lower if |
Higher if |
Randomized Trial →
|
High
|
Risk of bias
-1 Serious
-2 Very serious
Inconsistency
-1 Serious
-2 Very serious
Indirectness
-1 Serious
-2 Very serious
Imprecision
-1 Serious
-2 Very serious
Publication bias
-1 Likely
-2 Very likely
|
Large effect
+1 Large
+2 Very large
Dose response
+1 Evidence of a gradient
All plausible confounding
+1 Would produce a demonstrated effect or
+1 Would suggest a spurious effect when result show no effect
|
|
Moderate
|
Observational Study →
|
Low
|
|
Very Low
|
Strength of the Recommendations Grading System
Grade of Recommendation* |
Benefit vs. Risk and Burdens |
Methodologic Quality of Supporting Evidence |
Implications |
Strong recommendation, high-quality evidence, Grade 1A |
Benefits clearly outweigh risk and burdens or vice versa |
Consistent evidence from randomized controlled trials (RCTs) without important limitations or exceptionally strong evidence from observational studies |
Recommendation can apply to most patients in most circumstances. Further research is very unlikely to change confidence in the estimate of effect |
Strong recommendation, moderate-quality evidence, Grade 1B |
Benefits clearly outweigh risk and burdens or vice versa |
Evidence from RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence from observational studies |
Recommendation can apply to most patients in most circumstances. Higher quality research may well have an important impact on confidence in the estimate of effect and may change the estimate |
Strong recommendation, low- or very-low-quality evidence, Grade 1C |
Benefits clearly outweigh risk and burdens or vice versa |
Evidence for at least one critical outcome from observational studies, case series, or from RCTs with serious flaws or indirect evidence |
Recommendation can apply to most patients in many circumstances. Higher-quality research is likely to have an important impact on confidence in the estimate of effect and may well change the estimate |
Weak recommendation, high-quality evidence, Grade 2A |
Benefits closely balanced with risks and burden |
Consistent evidence from RCTs without important limitations or exceptionally strong evidence from observational studies |
The best action may differ depending on circumstances or patient or society values. Further research is very unlikely to change confidence in the estimate of effect |
Weak recommendation, moderate-quality evidence, Grade 2B |
Benefits closely balanced with risks and burden |
Evidence from RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or very strong evidence from observational studies |
Best action may differ depending on circumstances or patient or society values. Higher-quality research may well have an important impact on confidence in the estimate of effect and may change the estimate |
Weak recommendation, low- or very-low-quality evidence, Grade 2C |
Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced |
Evidence for at least one critical outcome from observational studies, case series, or RCTs, with serious flaws or indirect evidence |
Other alternatives may be equally reasonable. Higher-quality research is likely to have an important impact on confidence in the estimate of effect and may well change the estimate |
*The guideline developers use the wording recommend for strong (Grade 1) recommendations and suggest for weak (Grade 2) recommendations.