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Re: Growth Monitoring

The articles by Grote et al (1) , and Fayter et al (2) , in the March and April issues of Archives, respectively, are important contributions to the thorny issue of growth monitoring as a community – wide screening tool. However the editorial on this theme in the April issue by Tam Fry, which criticises current UK policy developed at the “Coventry Consensus” on growth monitoring, and the “Atom” presented by the Editor, are misleading.

That Consensus meeting, contrary to what Fry implies, did indeed produce a consensus – as far as we know, just two out of over thirty members dissented. We have compared our recommendations with the evidence presented by Grote et al and Fayter et al. Grote et al found that length / height monitoring in children under the age of three performed poorly in identifying growth disorders; this is in keeping with the report of Mei et al (3) regarding the high incidence of centile crossing in very young children . They also observed that centile crossing (the “height deflection” rule in their paper) made little contribution to case finding. Fayter et al in their systematic review noted that virtually all the published studies were based on single measurements and were unable to identify evidence that serial measurements were significantly more productive. All these points support the views of the consensus group.

We do agree, however, that the issue of adjusting the school entry height measurement for parental height deserves to be re-visited, although the practical difficulties are downplayed by Grote et al. Estimated heights are unreliable (4), so actual measured heights are vital, but the parents are often unavailable. Even in the well documented series of girls with Turner’s syndrome (5), included in Grote et al’s analysis, parent heights were missing in over half the cases. The correction process, which looks easy to paediatricians, may be challenging to many of the staff who undertake screening unless we can automate it. Nevertheless, such an adjustment might improve the sensitivity of the screen with negligible reduction in specificity (6).

The Editor’s Atom comments that the yield of growth monitoring would actually be greater than reported in these two papers, because children with idiopathic short stature would be identified and referred for growth hormone treatment. Treating this group is controversial – the gains in height are modest, the health related quality of life may not be improved (7) - and the cost is estimated at 20,000 Euros per cm of height gained (8). Height monitoring for celiac disease was shown by Grote et al to be a poor tool for identifying cases – if we do want to screen for the “sub- clinical” cases that are more common in older children than in infancy, there are better ways of doing it (9).

Growth monitoring of all children is difficult in our health care system and becoming more so as primary care fragments. In the UK, coverage (% of eligible children measured) is often low and measuring is often badly done (though we hope not as badly as depicted on the cover of the April Archives). Quality assurance and clear referral pathways are vital, as in any screening programme. We have stated previously that it is better to do a few things well than many things badly.

Does the challenge of childhood obesity call for a change in the Coventry Consensus recommendations? Country-wide anonymised BMI data collection is a Government – led initiative that is expected to facilitate monitoring of the obesity “epidemic” and of public health interventions; but there is no evidence that the proposed feedback of individual BMI results to parents will have any impact on the obesity epidemic (10). The label of overweight or obese may indeed be harmful and stigmatising, particularly as interventions are unproven and treatment resources are inadequate.. Nevertheless, if political pressures demand that such a programme is to be introduced, the opportunity should be seized to implement the straightforward recommendation of the Coventry Consensus, to undertake an accurate school entry height measurement and act on it where appropriate.

Signed: David Hall (Institute of General Practice, University of Sheffield) (d.hall@shefield.ac.uk) Tim Cole (Institute of Child Health, University College London) David Elliman (Great Ormond Street Hospital) Penny Gibson (Surrey PCT) Stuart Logan (Peninsula Medical School) Jerry Wales (University of Sheffield and Sheffield Children’s Hospital)

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Re: I REPEAT, IF IT’S WORTH DOING – LET’S DO IT

I thank the ADC for affording me the right of reply to the above Rapid Response. As always, when given this courtesy, it is hard to know whether first to rebut my detractors’ final statement and work backwards or to begin from the top. Assuming that you’ve just read their challenge – and haven’t already yourself fallen for the appeal of the Response button - I’ll deal with the school entry issue first.

As all the signatories must know, even an accurate single growth screen at school entry is virtually worthless since it will confirm only how tall, short, fat or thin the child is on the day it is measured. The Coventry Consensus was, therefore, wrong not to recommend an appropriate second or third measurement to establish trend and the many people who disagreed with the single check decision [see below] were right. Unfortunately they didn’t insist enough that the staffing was available to do even the minimum well – and the facts speak for themselves. To-day, in some areas of the UK, the National Child Measurement Programme data confirms that 50% of children don’t get a routine growth check at any time in their schoolhood because of the shortfall in school nurses and many more PCTs fail to assess 1-in-4 primary pupils on their lists.

Growth monitoring should never be characterised as “ difficult “ – or even a “ thorny issue “ – by paediatricians who know that its assessment is a window on paediatrics and is, as Atoms emphasised, “ a time-honoured measurement ingrained in primary care “. It is high time that monitoring was given its due and instead of depressingly stating that “ in the UK is coverage is often low and measuring is often badly done “ the signatories should be using their influence to champion the need to increase the coverage and insist that health professionals are trained to do the job. Measuring is not only foreign territory to many doctors but to their staff as well. Growth training hardly ever appears as a topic on training college timetables and, therefore, is seen not to be important. Successive editions of Health For All Children have recognised this culture and repeatedly called for “ vital “ staff training. Unbelievably the calls have fallen on deaf ears. A day’s basic workshop and routine practice thereafter is, in truth, all that it might take to turn an interested student into a competent auxologist but medical establishment don’t bother to find the time.

Coventry did not produce a consensus – but I hope that its lack of achievement will soon be history. The Child Growth Foundation is delighted that a second meeting to discuss growth monitoring is shortly to be organised by the RCPCH and Department of Health and hopes that, this time around, a comprehensive policy is considered. Now that the General Secretary of the Royal College of Nursing has added his voice to the chorus recommending annual growth checks for our children from an early age, the Foundation will be astonished if such common sense is discarded.

For the avoidance of doubt – and to prove that the 1998 meeting was bad news for children – I have re-read my files on its single school entry screening conclusion. It is true that only one paediatrician spoke out against it on the day but others soon feared for its consequencies. One paediatrician on the way home agonised that the meeting had been

“ dominated by the gurus of evidence based medicine “ and several nurses concurred, feeling that “ the academics were not fully understanding of the full holistic benefit of growth monitoring “. A few more felt, simply, conned. One correspondent, a professor of child health and development, who copied his appraisal of Coventry to both Editors of Health For All Children, was “ appalled “ at their decision to interpret Coventry as a green light not to recommend earlier opportunistic measuring. His support at the meeting “ was based on a belief that good clinical practice, including measurement, would identify those children with disordered growth, severe enough to be recognised before 5 years. That was the Coventry Consensus. If children are not to be measured before 5 years then the whole edifice collapses “. [Names and addresses supplied]