Changes

January 2026 — reviewed. A literature search was conducted in November 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There were no significant changes to the topic recommendations. Minor structural changes have been made to the topic to align the recommendations with the most recent literature.

Update

Goals

To support primary healthcare professionals to: 

• Make a diagnosis of childhood squint.
• Recognize and urgently refer children who have a serious underlying cause of squint.
• Arrange routine referral to the paediatric eye service for all other children with squint.
• Provide shared care for children who are being treated for squint in secondary care.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

NICE quality standards

What is it?

• A squint (strabismus) is a misalignment of the visual axis [RCO, 2012]. This means that the eyes are not directed at an object at the same time: while one eye is directed at an object, the other eye may turn in (esotropia), out (exotropia), up (hypertropia), or down (hypotropia) [Sawers, 2017]. This misalignment may be persistent or intermittent [Sawers, 2017]. 
• A pseudo squint (pseudostrabismus) is the impression of misaligned eyes when no squint is actually present. For example, prominent epicanthic folds may partially cover the nasal sclera to give the appearance of a squint. Alternatively, an abnormal interpupillary distance when short may simulate esotropia (where one or both eyes turn inwards), whereas a wide interpupillary distance may simulate exotropia (where one or both eyes turn outwards) [Bommireddy, 2020; Salmon, 2024].

How are squints classified?

• The classification of a squint is based on several features, including [Bommireddy, 2020]:
  • The age of onset:
    • Congenital/infantile — onset within the first 6 months of life (most commonly idiopathic in a child with otherwise normal health).
    • Acquired — onset after the first 6 months of life.
  • When it is present:
    • Constant — present all the time.
    • Intermittent — occurs at certain times or under certain conditions. Potentially worsening towards the end of the day or with fatigue.
  • The direction of the deviation:
    • Horizontal deviation — this can be further classified as esotropia (or esophoria), where one or both eyes turn inwards (convergent squint), and exotropia (or exophoria), where one or both eyes turn outwards (divergent squint).
    • Vertical deviation — this can be further classified as hypertropia, where one or both eyes turn upward (upward squint), and hypotropia, where one or both eyes turn downward (downward squint).
    • Cyclotorsional — rotation of an eye around its visual axis.
  • The fusional status:
    • Manifest squint (tropia) — seen when no fusional control is present. There is a deviation of one eye whilst the other eye takes up fixation, meaning that when one eye views the object of interest, the other eye is deviated.
    • Latent squint (phoria) — fusional control is present, and there is normal ocular alignment, but the squint occurs only when the use of the two eyes together is interrupted, for example, by covering one eye. 
  • The laterality:
    • Unilateral — there is a definite preference for fixation of vision with one eye; therefore, the squint always appears to be in the other eye. 
    • Alternating — there is an alternation of fixation of vision from one eye to the other; therefore, the squint can alternate from one eye to the other.
  • Variation with gaze position:
    • Comitant (concomitant) — typical of most childhood squints. The ocular deviation can be seen in all directions of gaze by an equal amount. There is no paralysis or limitation of eye movements, but the balance between the muscles in the two eyes has been lost.  
    • Incomitant (non-comitant) squint — the degree of deviation varies with the direction of gaze. This may indicate an acquired neurological or muscular disease, causing paresis or paralysis of one or more of the extraocular muscles, resulting in limitation of eye movements.
  • The relationship to accommodation:
    • Accommodative — occurs, or is more obvious, when the child is accommodating and focusing on an object. The child is typically hypermetropic (long-sighted), and the squint can be reduced or corrected if the refractive error is corrected with glasses.
    • Non-accommodative — either there is no significant hypermetropia, or if hypermetropia is present, there is no change in the angle of the squint with appropriate glasses.
• The common types of childhood squint include [Yeung, 2010b; RCO, 2012; Salmon, 2024]:
  • Congenital/infantile squint:
    • Convergent squint is much more common than divergent squint.
    • The angle of the squint is often large. 
    • Usually, there is no significant refractive error. 
    • Cross-fixation is frequent. That is, both eyes have good vision, and the child tends to use the right eye to look to the left and the left eye to look to the right. (This is sometimes mistaken for bilateral sixth nerve palsies.) 
    • Nystagmus may be present. 
  • Accommodative esotropia:
    • Generally, develops sometime between 6 months and 5 years of age, but by 3 years of age in the majority of cases.
    • It may begin as an intermittent esotropia, typically when the child is tired or when concentrating on objects close by, and in time becomes constant. 
    • A fully accommodative esotropia is fully correctable with glasses for hypermetropia (long-sightedness) and binocular function is present with the glasses on.
    • A partially accommodative esotropia is only partially corrected with glasses for hypermetropia and binocular function is not present.
  • Non-accommodative esotropia: 
    • Most commonly develops sometime between the ages of 2–5 years.
    • It may begin as an intermittent esotropia, typically when the child is tired or when concentrating on objects close by, and in time becomes constant. However, the onset may be acute. 
    • Hypermetropia may or may not be present, but the squint is not corrected by the correction of any refractive error. 
  • Intermittent distance exotropia (IDEX):
    • It often develops between the ages of 2–5 years, but there is a significant proportion that begin later, and onset can be at any age. 
    • The squint is intermittent and most commonly observed when the child is tired or in bright sunlight. 
    • Visual acuity is usually good, and the incidence of refractive errors is no greater than in the general population.
    • The control of the squint may be improved by correction of any refractive error, especially myopia and astigmatism.
    • The angle of the squint is often greater when looking at distant objects, and the squint may disappear when looking at a near object or when reading. 
  • Other types of squint that develop as a consequence of neurodevelopmental disorders, other eye diseases, neurological diseases, or diseases that affect the extraocular muscles.

How common is it?

• In the UK, the prevalence of squint in children is 2.1% [Pathai et al, 2010].
• The prevalence of squint may vary in different ethnic groups: 
  • A cross-sectional study of 2546 American children aged 6–71 months showed that a squint was present in 3.3% of white and 2.1% of African American children [Friedman, 2009a].
  • A prevalence of 5.7% was reported in pre-school children in eastern China [Chen, 2015]. 
• Esotropias are the most common type of squint in children. A series of population-based studies of children in the US [Govindan, 2005; Greenberg, 2007; Mohney, 2007] found that the overall prevalence of squint in children was just over 3%, and of squints detected: 
  • 60.1% were esotropias. Of these: 
    • 8.1% were infantile/congenital.
    • 36.4% were fully accommodative.
    • 10.1% were partially accommodative.
    • 16.6% were non-accommodative.
    • 11.4% were associated with a neurological disorder.
    • 6.5% were sensory.
    • 6.5% were paralytic.
    • 4.4% were undetermined and 'other'.
  • 32.7% were exotropias. Of these, most had intermittent distance exotropia. 
  • 6.7% were hypertropias.
• Young children diagnosed with a pseudo squint are at increased risk of developing a squint and undergoing surgery for a squint. In a population-based retrospective cohort study of 17,885 children [Ryu, 2020]:
  • Squint was diagnosed in 9.6% of children initially diagnosed with a pseudo squint compared with 1.7% of children in the control group. 
  • Esotropia was the most common type of squint in both groups (69.7% in the pseudo squint group and 62.1% in the control group).
  • A total of 377 children (21.9%) in the pseudo squint group underwent squint surgery compared with 12.1% of children in the control group.

What are the causes of childhood squint?

• A squint develops because there is a lack of coordination that prevents the gaze of both eyes from being focused on the same point in space. 
• Most squints are idiopathic, or the cause is not clearly defined, although there are certain risk factors that increase the risk of having a squint.
• Known causes of squint include:
  
  • Refractive errors in one or both eyes, especially hypermetropia (long-sightedness), which are strongly associated with accommodative esotropia. 
  • Other causes of poor visual acuity or blindness in one or both eyes (a so-called sensory squint), including:
    • Retinoblastoma.
    • Cataract.
    • Ocular malformations.
    • Optic neuropathy.
    • Amblyopia (lazy eye), which can also be a complication of a squint.
  • Neurodevelopmental conditions and syndromes, such as cerebral palsy and Down syndrome.
  • Congenital abnormalities of the extra-ocular muscles or their innervation, such as Brown’s syndrome and Duane's syndrome.
  • Diseases that can affect one or more of the extra-ocular muscles or their innervation, such as brain tumours, other brain lesions, head injury, post-viral problems, hydrocephalus, and muscle disorders (for example, myasthenia gravis).
    • These are rare in children but need to be considered when a child presents with a squint, particularly where there is a paralytic or incomitant element with reduced eye movements. 

[Tychsen, 2012; Bommireddy, 2020; Saxena, 2020; Khorrami-Nejad, 2024; Salmon, 2024]

What are the risk factors for developing a childhood squint?

• Significant risk factors for developing childhood squint include [Maconachie, 2013; Khorrami-Nejad, 2024; Salmon, 2024]:
  • Low birth weight and prematurity — a longitudinal cohort analysis of 38,055 otherwise healthy children who were born prematurely demonstrated that [Gulati, 2014a]:
    • Independent of gestational age, very low birth weight (less than 2 kg) conferred a large increase in squint risk among premature infants.
  • Maternal smoking during pregnancy [Yang, 2019].
  • Anisometropia (when the eyes have varying or unequal refractive power, causing them to focus unevenly).
  • Hypermetropia (long-sightedness).
  • Family history of squint (a strong hereditary link is present, particularly in accommodative forms of squint).
• Other risk factors include:
  • Assisted delivery (forceps or caesarean section) [Pathai et al, 2010; RCO, 2012].
  • Pseudo squint — children diagnosed with pseudo squint are at increased risk of developing squint and undergoing squint surgery [Sefi-Yurdakul, 2016] [Ryu, 2020].
  • Neurodevelopmental disorders — neurodevelopmental squint is independently associated with maternal smoking later in pregnancy, maternal illnesses in pregnancy, and low birth weight for gestational age [RCO, 2012].
  • Opioid use disorder, potentially including those on methadone substitution therapy [Hamilton, 2024].

What are the complications of childhood squint?

• Complications of untreated childhood squint include [Coats et al, 2000; Sabri, 2006; Durnian, 2011; Marsh, 2015a; Bommireddy, 2020; Salmon, 2024]:
  • Amblyopia (lazy eye) — this is a decrease in visual acuity caused either by blurred vision (anisometropic amblyopia); obstructed vision in one eye, such as from a congenital cataract (deprivation amblyopia); or by one eye being ignored in a child with a squint.
    
    • The visual cortex may suppress the image from a squinting eye to prevent double vision. Consequently, the development of the visual pathways and areas in the brain responsible for vision pertaining to that eye is impaired, and visual acuity is reduced. This is not immediately correctable by refraction.
    • Amblyopia is the most common cause of visual impairment in children, and squint is a major cause of amblyopia.
    • The visual loss will become permanent and irreversible if not treated early in childhood, whilst the visual pathways are still developing. In general, amblyopia should be treated by 7 years of age. Earlier treatment leads to better outcomes. 
  • Loss of, or failure to develop, binocular vision — this results in poor stereopsis (the perception of depth), which requires binocular vision to develop fully. 
  • Compensatory head postures — these can develop unconsciously in a child in an attempt to maintain binocular vision.
    • Abnormal head posture may include a face turn, a head tilt, or a chin in an elevated or depressed position, depending on the type and severity of the squint.
  • Poor eye contact — this is a particular issue in pre-verbal children, where eye contact is especially important for communication.
  • Social and psychological problems — children with a squint may be stigmatized in school and suffer from a loss of self-esteem [Sawers, 2017]. The presence of a manifest squint can adversely affect aspects of people's lives, including social integration at school, finding a partner, job prospects, and interaction with peers. Mental health impairments like anxiety and depression are highly prevalent among children with a squint. 
    • A population-based study found impaired health-related quality of life (physical well-being, emotional well-being, self-esteem, family, friends, and school) and mental health problems (hyperactivity/inattention) in children and adolescents with parental report of squint [Schuster, 2019].

What is the prognosis?

• An untreated childhood squint that is present after 3 months of age does not usually resolve without treatment.
  • Esotropias tend to deteriorate over time, with loss of binocular vision and the development of amblyopia (lazy eye).
  • Intermittent distance exotropias often remain intermittent, although the frequency of the squint may increase. 
  • Some squints may improve or resolve with time, but any associated amblyopia will be permanent if not treated early.
• With timely and appropriate treatment, especially if treatment is initiated soon after a squint develops, the outlook is good.
  • Treatment can prevent or limit the severity of amblyopia and correct misalignment of the eyes. 
  • Correction of misalignment of the eyes may improve binocular vision, which may also improve stereopsis (depth perception) in some cases. However, many children with squints never regain binocular function.
  • Even in later childhood or adulthood, in a person with a long-standing squint, correction of misalignment of the eyes is still an option for most people. Although in this situation it is relatively uncommon to recover binocular vision and stereopsis, it can significantly improve psychological and social problems related to the presence of a squint.

[Durnian, 2011; Kushner, 2011; RCO, 2012; Marsh, 2015a; Salmon, 2024]

How can I identify a child with a squint?

• Routine eye checks are offered to children to promptly identify reduced vision and other eye conditions.
  • Within 72 hours of birth, the child's eyes will be checked for any obvious physical problems as part of the newborn physical examination.
  • Between 6–8 weeks old, a follow-up physical examination is done to check for any obvious problems that were not picked up soon after birth.
  • At school entry (around 4 or 5 years of age), vision screening is offered to all children to identify common causes of reduced vision, including refractive error (long- or short-sightedness) and squint.
• Parents may also report any concerns they have about their child's eyesight at the 12- and 24-month health visitor-led health and development review.
• Also, a parent or carer may present with a concern that their child's eye is 'turning'. 
  • Any complaint of a 'turning eye' should be taken seriously, even if this cannot be reproduced in a consultation, as the squint may be intermittent.
  • Intermittent deviation of the eyes is common in healthy neonates and should not cause undue concern in an otherwise healthy baby, but a thorough assessment is still required. Any constant squint, even in neonates, is significant. Normal binocular coordination is established at about 3 months, and any squint after this age is significant.

How should I assess a child with a squint?

• Take a history to try to identify the cause of the squint and any red flags. Ask about:
  
  • The age of onset of the squint.
  • The nature of onset (sudden or gradual) and if related to recent infections, illnesses, or head injury.
  • Any associated symptoms.
    • Symptoms that may reflect underlying neurological or eye disease include diplopia, headaches, nausea, vomiting, or sensory or motor symptoms.
    • Double vision is more common in adults than in children,    as suppression is present in children.
  • Past medical history, including birth history.
    • Neurodevelopmental, neurological, and systemic conditions can cause squint.
    • A birth history can identify risk factors for developing squint, such as low birth weight, prematurity and assisted delivery (forceps or caesarean section).
  • Past ocular history.
    • Ask about the presence of a refractive error and whether glasses are worn.
    • Ask about any previous eye surgery, including squint surgery, or previous treatment for amblyopia (lazy eye).
  • Family history of eye problems.
    • There is a strong familial association with squint, and around 30% of people have other family members with squint.
    • Ask family members if they have had any previous treatment or surgery to correct a squint.
  • Child or parental concerns about vision. 
  • Psychological impact of the squint on the child.
• Perform the examinations to confirm the presence of a squint, including: 
  • General inspection of the eye.
    • Look for any asymmetry in eye position and for ocular abnormalities, including pupil asymmetry and ptosis. 
    • Examine for a full range of eye movements, particularly abduction in cases of esotropia.
    • Assess for nystagmus (involuntary, repetitive, side-to-side oscillation of the eyes). 
  • Corneal light reflex test (Hirschberg test):
    • Have the child fixate on a light (for example, a pen torch) held about 50 cm in front of their eyes.
    • Observe the light that reflects back from their corneas, which is normally in the same place on both corneas.
    • Any asymmetry of the reflected light suggests a squint.
  • Cover test to determine if a manifest squint is present:
    • Get the child to view an object, such as a toy, at 33 cm away from their eyes.
    • Whilst fixation is maintained (which may require lots of encouragement in young children), cover one eye with a piece of card or similar.
    • As the cover is introduced over one eye, watch the uncovered eye for any movement. Then repeat, covering the other eye.
    • In a manifest squint when the straight eye is covered, the squinting eye will have to move to align with the fixation objection. It is this movement that the examiner is looking for.
    • If no manifest squint is found, look for a latent squint. 
  • The cover/uncover test to determine if a latent squint is present:
    • As the child fixates on the toy, cover one eye for about 3 seconds, then quickly remove the cover and watch for any movement of that eye (rather than the uncovered eye, as in the test for manifest squint). Repeat, covering the other eye.
    • In latent squint, the eye will drift under the cover. On removing the cover, the eye will straighten to regain binocular vision, and the examiner will see this movement.
    • Instead of removing the cover, it may be easier to elicit a latent squint by moving the cover slowly back and forwards between the eyes and not letting the eyes regain use together until the test is finished (the alternate cover test).
    • Each time the cover is moved, the examiner looks at the eye that has just been uncovered to see if there is any movement.
• If a squint is found, check the range of eye movements to determine if it is a concomitant squint (typical of most childhood squints) or an incomitant squint (which is more likely to be related to a more serious cause). 
  • Aim to get the child to follow a toy or light, to each side and up and down to assess if the eyes can move fully in all directions.
  • For children with an esotropia, it may be necessary to test the movements uni-ocularly by covering one eye and encouraging the child to follow the toy with the uncovered eye.
  • This is because with both eyes open, the child may cross fixate to the sides (using the convergent right eye to look to the left and/or the convergent left eye to look to the right). 
• Perform a general clinical assessmentto identify a serious underlying condition presenting as a squint.
  
  • Assess for the presence of the red reflex and exclude leukocoria (white or grey pupil).
    • Absence of a red reflex suggests a potentially serious intraocular cause of a squint, such as retinoblastoma. 
  • Assess for any abnormal head posture.
    • Look at the child and see if they hold their head in an abnormal position. 
    • Hypertropia in the affected eye may be associated with a head tilt to the opposite side and depression of the chin. This may be due to weakness of the superior oblique muscle.
  • Assess for features that may suggest a neurological cause of squint.
    • Squint can be associated with neurological disorders, such as cerebral palsy and Möbius syndrome.
    • Finding abnormal neurological signs should prompt referral to a paediatrician. 
  • Check for dysmorphic features, especially craniofacial developmental abnormalities, that can be linked to a squint. These may include anomalies such as craniosynostosis, hydrocephalus, plagiocephaly or orbital defects.
  • If appropriate or possible (depending on the age of the child), consider fundoscopy and a test of visual acuity.
• Squints that may give rise to particular concern about the underlying cause include:
  • Constant unilateral exotropias.
  • Any acquired incomitant squint.
  • Sudden, late-onset (over 3–4 years) esotropia, particularly if there is no family history and no significant hypermetropia (long-sightedness).

Scenario: Management

From birth to 16 years.

Atropine eye drops

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews, and randomized controlled trials of primary care management of squint in children.

Search dates

January 2021 - November 2025

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Strabismus/ or squint.tw.
• (Tropia and phoria).tw.
• child/ or child, preschool/
• strabismus
• amblyopia

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.