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Original articles: D Fayter, J Nixon, S Hartley, A Rithalia, G Butler, M Rudolf, P Glasziou, M Bland, L Stirk, and M Westwood Effectiveness and cost-effectiveness of height-screening programmes during the primary school years: a systematic review Arch Dis Child 2008; 93: 278-284 [Abstract] [Full text] [PDF]

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Response to Fayter et al

Graham V Vimpani, Anne F Vimpani, Community child health medical officer, Kaleidoscope Children's Health Network, Newcastle, Australia   (25 March 2008)

Growth monitoring

David M hall, Tim Cole, David Elliman, Penny Gibson, Stuart Logan and Jerry Wales   (12 May 2008)

Response to Fayter et al 25 March 2008
Graham V Vimpani, Consultant paediatrician Professor of Community Child and Family Health, University of Newcastle, NSW, Australia, Anne F Vimpani, Community child health medical officer, Kaleidoscope Children's Health Network, Newcastle, Australia Send letter to journal: Re: Response to Fayter et al graham.vimpani{at}hnehealth.nsw.gov.au Graham V Vimpani, et al.	Congratulations to the authors on an interesting systematic review. The authors' first point in discussion is that none of the published reports was able to distinguish the value added by height screening in terms of increased diagnostic yield. This is not strictly true. Our work indicated that only 4 children with growth hormone deficiency had been identified and in some cases begun treatment by the time screening was undertaken when the 48,000 children were aged between 6 and 9 years. Screening by Harpenden anthropometer followed up by accurate height measurement using a wall mounted stadiometer in a specially constructed mobile clinic and exercise induced growth hormone measurements identified a further 9 children. It is inconceivable that all of these would have been found, in the absence of screening, over the 6-12 months follow up period between initial screen and full assessment. Most of the short stature appeared to be a result of poverty and familial factors (which may have been intergenerational poverty) with short stature rates in different geographical areas showing very strong correlation with socioeconomic circumstances.
Growth monitoring 12 May 2008
David M hall, paediatrician emeritus Professor, dept of General Practice, Univ of Sheffield, Tim Cole, David Elliman, Penny Gibson, Stuart Logan and Jerry Wales Send letter to journal: Re: Growth monitoring d.hall{at}sheffield.ac.uk David M hall, et al.	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) 1. Grote FK, van Dommelen P, Oostdijk W et al. Developing evidence-based guidelines for referral for short stature. Arch Dis Child 2008;93:212–217. 2 Fayter D, Nixon J, Hartley S et al. Effectiveness and cost- effectiveness of height screening programmes during the primary school years: a systematic review. Arch Dis Child 2008;93:278–284. 3 Mei Z, Grummer-Strawn LM, Thompson D, Dietz WH. Longitudinal Data From the California Child Health and Development Study. 2004; Pediatrics 113: e-617-e627. 4 Cizmecioglu F, Doherty A, Paterson WF, et al. Measured versus reported parental height. Arch. Dis. Child. 2005;90;941-942 5 van Buuren S, van Dommelen P, Zandwijken GRJ, et al. Towards evidence based referral criteria for growth monitoring. Arch Dis Child 2004;89:336–341. 6 Cole TJ. A simple chart to identify non-familial short stature. Arch. Dis. Child. 2000;82;173-176. 7 Bryant J, Baxter L, Cave CB, Milne R. Recombinant growth hormone for idiopathic short stature in children and adolescents. Cochrane Database of Systematic Reviews 2007, Issue 3. 8 Lee JM, Davis MM, Clark SJ, et al. Estimated cost-effectiveness of growth hormone therapy for idiopathic short stature. Arch Pediatr Adolesc Med. 2006; 160: 263-9. 9 Korponay-Szabó IR, Szabados K, Pusztai J, et al. Population screening for coeliac disease in primary care by district nurses using a rapid antibody test: diagnostic accuracy and feasibility study. BMJ 2007;335;1244-1247; 10 Westwood M, Fayter D, Hartley S et al. Childhood obesity: should primary school children be routinely screened? A systematic review and discussion of the evidence. Arch Dis Child 2007;92:416–422.