title: Assessment of controversial pediatric asthma management options using GRADE.
abstract: OBJECTIVE
  To develop explicit and transparent recommendations on controversial asthma management issues in children and to illustrate the usefulness of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach in rating the quality of evidence and strength of recommendations.
  
  
  METHODS
  Health care questions were formulated for 3 controversies in clinical practice: what is the most effective treatment in asthma not under control with standard-dose inhaled corticosteroids (ICS; step 3), the use of leukotriene receptor antagonist for viral wheeze, and the role of extra fine particle aerosols. GRADE was used to rate the quality of evidence and strength of recommendations after performing systematic literature searches. We provide evidence profiles and considerations about benefit and harm, preferences and values, and resource use, all of which played a role in formulating final recommendations.
  
  
  RESULTS
  By applying GRADE and focusing on outcomes that are important to patients and explicit other considerations, our recommendations differ from those in other international guidelines. We prefer to double the dose of ICS instead of adding a long-acting β-agonist in step 3; ICS instead of leukotriene receptor antagonist are the first choice in preschool wheeze, and extra fine particle ICS formulations are not first-line treatment in children with asthma. Recommendations are weak and based on low-quality evidence for critical outcomes.
  
  
  CONCLUSIONS
  We provide systematically and transparently developed recommendations about controversial asthma management options. Using GRADE for guideline development may change recommendations, enhance guideline implementation, and define remaining research gaps.
authors.affiliation: Department of Pediatrics, Emma Children’s Hospital, Academic Medical Center, Amsterdam, Netherlands. n.boluyt@amc.uva.nl
authors.forename: Nicole
authors.initials: N
authors.lastname: Boluyt
authors.forename: Bart L
authors.initials: BL
authors.lastname: Rottier
authors.forename: Johan C
authors.initials: JC
authors.lastname: de Jongste
authors.forename: Rob
authors.initials: R
authors.lastname: Riemsma
authors.forename: Elianne J L E
authors.initials: EJ
authors.lastname: Vrijlandt
authors.forename: Paul L P
authors.initials: PL
authors.lastname: Brand
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D000318:Adrenergic beta-Agonists / Q000008:administration & dosage; D018927:Anti-Asthmatic Agents / Q000008:administration & dosage*; D001249:Asthma / Q000188:drug therapy*; D002648:Child; D002675:Child, Preschool; D019317:Evidence-Based Medicine; D005938:Glucocorticoids / Q000008:administration & dosage*; D006801:Humans; D020024:Leukotriene Antagonists / Q000008:administration & dosage*; D017410:Practice Guidelines as Topic
chemical_list: D000305:Adrenal Cortex Hormones; D000318:Adrenergic beta-Agonists; D018927:Anti-Asthmatic Agents; D005938:Glucocorticoids; D020024:Leukotriene Antagonists