Clinical practice guidelines (CPGs) are statements that include recommendations for improving patient care. High-quality evidence-based CPGs are of value to support the clinical decisions of relevant healthcare providers and to improve patient outcomes.36, 37.
As defined by the Guidelines International Network (GIN) (and the former ADAPTE Collaboration), adaptation is “the systematic approach to the modification of a guideline(s) or recommendation(s) produced in one cultural and organizational setting for application in a different context. Adaptation may be used as an alternative to de novo guideline development (e.g., for customizing (an) existing guideline/s to suit the local context)”.17, 38.
The EPG committee marks the first national and collaborative initiative for the generation of Pediatric CPGs using an evidence-based methodology in Egypt.
The EPG committee decided to use the CPG adaptation methodology, specifically the ‘Adapted ADAPTE’ methodological framework, because it is clearly structured and easy to follow with a set of tools to support the process.39
Given the lack of relevant high-quality systematic reviews and randomized controlled trials from the Egyptian context, the adaptation of CPG recommendations is a good and valid alternative to developing de-novo CPG for children with ID/IDA. The ID/IDA guideline adaptation project marks the first for the EPG Hematology Group as part of the first wave of the EPG.39
The strategic plan for national pediatric evidence-based CPGs includes identifying the national healthcare priorities (high-priority health topics for CPGs) in the field of pediatrics and child health. ID, and specifically IDA, remains one of the most severe and important nutritional deficiencies in the world today. Every age group is vulnerable. Iron deficiency impairs the cognitive development of children from infancy to adolescence. It damages immune mechanisms and is associated with increased morbidity rates.40
Generally, the panel has chosen the recommendations with clearly presented evidence that were common in the three source guidelines and that represent the current acceptable and applicable practice of primary health care physicians at MOH, general practitioners, family medicine specialists, pediatricians, neonatologists and specialists from related disciplines, nurses and rural social health workers, medical students, dentists, pharmacists, parents, and caregivers.
This CPG is not intended to be explained or to serve as a standard of medical care. Adherence to the CPG recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgment should only be arrived following discussion of the options with the patient/caregiver, in light of the diagnostic and treatment choices available. However, it is advised that significant departures from the national CPG or any local CPGs derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken.
With the establishment of the Egyptian Health Council41, the authors hope the EPG CPGs in general and the EPG Hematology Group CPGs in particular will be properly disseminated, implemented, and audited throughout different sectors of the Egyptian health system that provide healthcare services for children with hematological diseases and disorders to improve quality and safety.
The ID/IDA EPG group included a comprehensive implementation tools set (e.g. tables for cut-off values for hemoglobin, microcytosis, dietary reference for adequate iron intake, factors that increase or decrease iron absorption, etc…) to facilitate successful uptake of the adapted recommendations.
Barriers to implement the guidelines could be lack of awareness of the magnitude of this national health problem which necessitates further efforts to shed light on it through campaigns, media, schools and health care centers. Another barrier could be shortage of heme-iron rich diet which could be solved by mixing several iron containing plants and cereals. Nutritional advice to improve bioavailability should include avoidance of excess milk, tea, coffee and fast foods. Moreover, availability of iron supplements in different forms and concentrations and with minimal side effects should be a master key in treating iron deficiency anemia.
There are several limitations to the application of this CPG. The panel chose not to discuss the issue of delayed cord clamping in neonates, as this may vary in different institutions according to the local practice guidelines. The chosen adapted guidelines did not differentiate between doses of iron supplementation in preterm and term infants. The current CPG focused on dietary ID/IDA, and excluded patients with comorbidities like parasitic infestations, inflammatory conditions, chronic kidney disease and other conditions that have multiple pathogenetic mechanisms with specific modes of treatment. However, with future revisions, these objectives could be revisited, and other objectives may be sought in view of the most recent evidence in the coming years.