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Re: Systematic review had no relevance to routine monitoring as it is undertaken in the UK

Dear Editor

As someone who is in the throes of writing a chapter on growth monitoring in primary care for the Royal College of General Practitioners I read Garner et al's article(1) as well as their original Cochrane review (2) with interest. Both Professor Davies commentary and Professor Marcovitch’s precis in "Archives this month" discuss the findings in relation to growth monitoring in the United Kingdom. Unfortunately the inclusion criteria used by Garner et al, charitably described as ‘strict’ by Davies, by their nature excluded anything that resembles what currently takes place in general practice in the UK.

The ‘types of participants’ considered for inclusion in their review were populations of children up to five years of age. The ‘selection criteria’ compared ‘routine growth monitoring’ defined as at least three monthly with no growth monitoring. In their Cochrane review (2) the authors highlight the lack of national guidelines regarding the frequency of growth monitoring but quote the Child Growth Foundation recommendations of five routine measurements between birth and five years. Thus this criteria by default excludes routine growth monitoring in the UK, particularly in the over 2 year olds.

Garner et al excluded ‘single population measures, such as height at one or more specific ages, which aim to screen for conditions such as growth hormone deficiency’. However Hall in his recent article stated that growth hormone deficiency was one of only two conditions that were the ‘primary justification for growth monitoring’ in under two year olds.(3)

Thus having read both articles,(1, 2) neither represent a systematic review of growth surveillance as it takes place in the UK and I am left none the wiser as to whether anyone has undertaken trials comparing growth monitoring in this country with any alternative.

Yours sincerely

Michael Perkin
Wellcome Research Fellow in Clinical Epidemiology

1. Garner P, Panpanich R, Logan S. Is routine growth monitoring effective? A systematic review of trials. Arch Dis Child 2000;82:197-201.

2. Panpanich R, Garner P. Growth monitoring in children. Cochrane Review 1999:issue 2. (Oxford: Update software.)

Send letter to journal:
Re: Growth monitoring

Garner, Panpanich and Logan (Arch Dis Child 2000;82:197-201) presented a much needed review of growth monitoring. This is a component of primary health care on which so much finance and health workers' time has and is being expended. No doubt this review will stimulate more necessary trials.

However, they did not touch on one important aspect of growth monitoring, that is whether health workers making use of growth charts comprehend the weight-for-age graph.

Piaget (1896-1980) considered the line graph to be one of the more difficult subjects to teach. Graphic representation of number is not taught in primary schools in developing countries and colleagues with knowledge of primary education suggest that primary school teachers would not be able to teach it. Experience with post graduate doctors in the 1970s suggested that a proportion could not complete a weight chart and even more would have problems in interpreting it (Morley 1984). A similar problem has arisen with midwives in the use and interpretation of the partograph to plot the progress of labour.

Fortunately, an alternative method of weighing may overcome this difficulty. This involves weighing in or near the home, not in the clinic, with a Direct Recording Scale. With this the mother sees a large spring stretching up her child's chart, located in the scale, as she releases her child's weight into the weighing trousers below the scale. She then with a ball pen creates the next point on her child's growth curve through a hole in the pointer at the top of the spring. In this way even unschooled mothers can themselves create their child's growth curve This in time leads them, the grandmother and their older daughters to understand the weight for age curve. (Meegan 1988, Meegan 1999). In one study among the pastoral Maasai in Kenya they took action when faltering occurred giving such children an additional drink of milk (Meegan 1999).

Anyone interested in this new approach to Growth Monitoring or who want copies of the above papers and details of the Direct Recording Scale should contact TALC on:
talcuk@btinternet.com

or by post to
TALC, POB 49
St Albans AL1 5TX, UK

References

Morley DC. Will growth monitoring continue to be part of primary health care? S Afr Med J 1994;84(suppl):25-16.

Meegan M, Morley D, et al. Child weighing by the unschooled; a report of a controlled study of growth monitoring over 12 months of Maasai children using a Direct Recording Scale. Trans R Soc Med Hyg 1994;88:635-637.

Meegan M, Morley D. Growth Monitoring: Family Participation: Effective Community Development Tropical Doctor 1999;29;23-27.

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Re: Re: Growth monitoring

Michael Perkin[1] is absolutely right. The initial protocol defined routine growth monitoring in the setting familiar to us in poorer countries as three monthly measurements. As we found so few studies in our first search, we extended the inclusion criteria to any trial where growth is routinely monitored twice or more in any two year period in children aged 0-5 years, but neglected to change the wording in the review. We excluded "single measures at one age"-that is screening policies where all children at a particular age are measured. However, assuming Hall[2] defines growth monitoring as "at least two measures in the period 0 to 5 years" we then sought trials in this area but found none. We thank Dr Perkin for pointing this out, and will correct the inclusion strategy on the Cochrane Library, and note the modification to the original protocol. He will note that even with the wider definition we found no more trials, so the review remains relevant to both poorer and richer countries.

We thank David Morley for his comments.[3] He notes we did not examine whether health workers comprehend the growth chart. In fact, we sought evidence that health workers understood charts and then took action by seeking studies that recorded referrals (see inclusion criteria). One study that met the inclusion criteria reported maternal comprehension following targeted explanations, although it is not entirely clear what the marks assigned in the test actually mean for the mother or infant. We would advocate future research examines things that happen as a result of growth monitoring, such as treatment of intercurrent illness or referral, rather than what people comprehend about weight charts.

Paul Garner
Ratana Panpanich
Stuart Logan

References

(1) Perkin M. Systematic review had no relevance to routine monitoring as it is undertaken in the UK. Arch Dis Child [Rapid Response] 20 May 2000

(2) Hall DMB. Growth monitoring. Arch Dis Child 2000;82:10- 15.