Global gaps in the quality and credibility of clinical practice guidelines for pediatric postinfectious bronchiolitis obliterans: a systematic appraisal using AGREE II and AGREE-REX

Postinfectious bronchiolitis obliterans (PIBO) is a rare but severe chronic lung disease in children, associated with long-term morbidity, impaired quality of life, and substantial healthcare utilization. Despite increasing scientific output, uncertainty persists regarding optimal diagnosis and management, and the quality of existing clinical practice guidelines (CPGs) remains unclear. A systematic search of MEDLINE, EMBASE, and grey literature was conducted through October 2024, with a 2025 update search. Eligible documents were appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) and the AGREE–Recommendations Excellence (AGREE-REX) instruments. Four CPGs or expert consensus documents published between 2009 and 2025 were included. AGREE II assessments showed acceptable performance only for Domain 1 (scope and purpose; 65–78%). All other domains—including stakeholder involvement, rigor of development, applicability, and editorial independence—scored below 50% across all documents. AGREE-REX evaluations demonstrated low credibility and limited implementability of recommendations, with modest improvement in clinical applicability in the most recent Chinese consensus. Current guidance for pediatric PIBO is scarce and predominantly consensus-based, with substantial methodological limitations. Future guideline development should prioritize transparent, structured methodologies, integration of patient perspectives, and explicit implementation strategies to reduce clinical variability and improve outcomes in this vulnerable population.