Statistics from Altmetric.com
After waiting 20 years for the evidence that growth monitoring is not only effective but also cost effective, you will understand how much I welcome the papers by Fayter et al1 and Grote et al.2 Both have declared, yet again, that the early identification and referral of children with abnormal growth is beneficial and that a good monitoring system is required. If only the papers had been available in 1998 when a meeting of health professionals took place in Coventry and virtually dismantled any form of monitoring system in the United Kingdom. Having considered that growth hormone deficiency and Turner syndrome were the only two conditions worth measuring for in the absence of evidence to the contrary, the meeting concluded with a “consensus” that routinely measuring children was not worth it. This month’s papers have turned that on its head, with Grote’s study specifying at least four groups of patients with growth disorders and Fayter confirming that new cases of a number of other conditions may be identified as a consequence of height screening. In fact, the Coventry Consensus – as the gathering is now famously called – heard of 14 conditions for which monitoring was a diagnostic aid but ignored the majority of them.3
We will never know how many children – abnormally tall as well as abnormally short – may have had their futures permanently compromised by the Consensus but now, having the evidence, we should make sure that the minimalist monitoring protocol arrived at in Coventry is replaced. The protocol is enshrined in Health for all children 4e and the National service framework for children and is not worth the paper it is written on.4 5 Neither document believes that checking stature has any importance prior to a school entry growth screen and both state that weight need be assessed only in the first year of life. Neither recognises, either, that more than a single check is required to identify a growth trend – be it healthy or unhealthy; Grote’s reference groups had three if not four height measurements with which to work.
The challenge now is for at least three or four height measurements to be put back on the UK agenda. Fortuitously, today’s childhood obesity epidemic and the Health and Social Care Bill currently progressing through Parliament may provide the opportunity.6 Clauses in the bill, intended to be part of the plan to tackle obesity led jointly by the Departments of Health (DH) and Children, Schools and Families (DCSF), provide not only for more height and weight measurements at public and independent primary schools but also for measurements in the early years. I nurse the hope that it was the Health Select Committee of the House of Commons who prompted the clauses pertaining to schools to be introduced having seen its advice dumped by the DH in 2005. Following an unprecedented year-long inquiry into obesity, the MPs recommended annual body mass index (BMI) assessment.7 It would afford me additional comfort to believe that the new DH obesity team had also thought “outside the box” and added clauses to include measurements from infancy. There is little question that this is where many of the problems of obesity start.
I admit that the above is proposed as a public health measure and heights and weights must be taken anonymously, but there is an implicit responsibility clinically to identify each child at risk. Since 2002 the Royal College of Paediatrics and Child Health (RCPCH) and the National Obesity Forum (NOF) have called for any progressively or severely obese child to be in the hands of a paediatrician by the age of 2 (certainly implying that BMI should be measured at an earlier age) and England’s Chief Medical Officer called in 2003 for health professionals to identify the early signs of obesity in children and intervene at an early stage.8 9 The child harbouring a condition specifically related to stature should also be identified from the same data.
It would be nice to think that the Health and Social Care Bill’s measures were ground-breaking, but they are not. You have only to look across the Atlantic to see that measuring BMI annually was not only first considered in the USA in 2003 but has since been re-affirmed.10 In a special supplement to the December 2007 issue of Pediatrics, the American Academy of Pediatrics (AAP) made measurement its first priority in the identification and management of obesity.11 It reminded every doctor working with children to perform, at a minimum, a yearly assessment of weight status for all children. It further recommended that the assessment should include plotting and interpreting the child’s BMI curve on a standard growth chart. As a matter of policy the AAP recommends serially monitoring growth from infancy.12 The UK should follow that policy too.
Perspective on the paper by Grote et al2 and Fayter et al1 (see p 278)
Incidentally, if the Health and Social Care Bill gets on to the Statute Book unamended it will also fulfil the parliamentarians’ wish that BMI measurements are automatically given to parents together, where appropriate, with lifestyle advice. For the life of me I find it difficult to comprehend why an act of parliament is required to ensure that doctors provide such information and, furthermore, I fail to understand the aversion that many doctors have to explaining to parents anything about BMI. The DH wishes that they would but the doctors seem to believe that a little knowledge is a dangerous thing. Releasing BMI figures, they fear, might spark mass hysteria and children’s descent into anorexia. A fear indeed – but no evidence to support it.
The raw BMI data must of course be recorded and interpreted and here another initiative from Westminster, The children’s plan: building brighter futures, might do the trick.13 When announced in Parliament by the DCSF in December, it heralded the possibility that the personal child health record (PCHR) might be extended to cover primary school health. This is the record that most doctors believe is superfluous to requirements by the time a child is aged 5 but already contains height and weight centiles up to age 18. Whatever plans the DCSF has for its development, it would be sensible (for reasons explained below) if every PCHR also featured BMI charts to accompany the distance charts.
Giving parents the means to keep a permanent BMI record of their children would be logical considering the work that the DH is already undertaking to develop an online BMI calculator.14 Its objective is to show any family where on a BMI chart their children’s index lies and what the healthy BMI range is, but this detail is lost to the parents once they log off. Having a paper chart in the PCHR on which everybody could record and serially assess BMIs would be a distinct advantage. Indeed, a relevant amount of space in the record could contain all the information parents need to understand BMI.
Before you reach for your Rapid Response button to remonstrate that the above is going over the top, let me remind you where we are. For over a generation we have allowed a good third of our children insidiously and progressively to become unhealthily fat and have failed them by not using growth assessment to catch those at risk of obesity in time for intervention. That cannot be allowed to continue. If you tell me there is no point to the assessment because intervention doesn’t work, I will suggest you read the latest paper on successful community-based efforts.15
We must now do everything we can to prevent obesity in even one more than the 1 million children predicted to be obese by 2010. The DH has already had to ditch its 2010 target to halt obesity in favour of a new target for 2020. Its hope is that by then obesity will be back to its 2000 levels, but the predictions made in the Foresight report back in October make even that look remote.16 We need a sea change in our thinking about how to prevent the epidemic escalating and, overall, it might not be cheap. The cost of growth monitoring, however, will be peanuts in comparison and now that we have the evidence that it works, we should get on and practice it. The bonus will be that the UK will have comprehensive clinically useful growth and public health data for the first time ever. That must be cost effective in anybody’s book.
Competing interests: None.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.