Classification of Recommendations In pediatrics, there are not likely to be any randomized con- trolled trials for treatment of IE, which posed a challenge for the writing group in compiling recommendations. Therefore, many of the indications are based on consensus. In cases of strong consensus that an intervention be considered as standard-of- care practice with scientific evidence, interventions were des- ignated as Class I indications. Where the wording of treatments indicates a recommendation, the standard classification is used. Strength of the recommendation is according to the ACC/AHA classification system for recommendations (Table 1). Epidemiology and Clinical Findings of IE in Children In a previous report, IE occurred less often in children than in adults and accounted for approximately 1 in 1280 (0.78 per 1000) pediatric admissions per year from 1972 to 1982 at a In a recent multicenter report,5 the annual incidence rate in the United States was between approximately 0.05 and 0.12 cases per 1000 pediatric admissions from 2003 to 2010, without a significant trend. Although the reported hos- pitalization rates for IE vary considerably among published series, both the overall frequency of endocarditis among chil- dren and a shift toward those with previous cardiac surgery appear to have increased in recent years in some reports.5 8 This may be related to improved survival among children who are at risk for endocarditis, such as those with CHD (with or without surgery) and hospitalized newborn infants. 2015 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0000000000000298 TheAmerican HeartAssociation makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. 