TABLE 1-3

Evidence Grading System: Strength of Recommendations

Statement TypeDefinitionImplication
Strong recommendationThe expert panel believes that the benefits of the recommended approach clearly exceed the harms and that the quality of the supporting evidence is excellent (grade A or B). In some clearly defined circumstances, strong recommendations may be made on the basis of lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits clearly outweigh the harms.Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
RecommendationThe expert panel feels that the benefits exceed the harms but that the quality of the evidence is not as strong (grade B or C). In some clearly defined circumstances, recommendations may be made on the basis of lesser evidence when high-quality evidence is impossible to obtain and when the anticipated benefits clearly outweigh the harms.Clinicians should generally follow a recommendation but remain alert to new information and sensitive to patient preferences.
OptionalEither the quality of the evidence that exists is suspect (grade D) or well-performed studies (grade A, B, or C) have found little clear advantage to one approach versus another.Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set boundaries on alternatives; patient and family preference should have a substantial influencing role.
No recommendationThere is both a lack of pertinent evidence (grade D) and an unclear balance between benefits and harms.Clinicians should not be constrained in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient and family preference should have a substantial influencing role.
  • Adapted from American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Pediatrics. 2004;114(3):874–877.