Poor Growth-Monitoring Practices Need Overhaul

Becky McCall

January 29, 2016

There is a lack of consensus over the optimal choice of growth charts, priority target conditions, and validated algorithms to define abnormal growth and detect underlying disorders, a new systematic review indicates.

As a result, diagnosis of severe growth disorders is delayed and inappropriate referrals of disease-free children who have normal variants of growth are being made, with associated high healthcare costs, conclude the authors.

"Right now, nobody knows the answer to which growth charts should be used or how to define abnormal growth," said lead researcher Pauline Scherdel, from INSERM, Paris, France.

Senior author Martin Chalumeau, PhD, of University Paris Descartes, France, added, "Advanced parameters such as distance to target height, growth velocity, and [body mass index] BMI should be used during regular growth monitoring to detect abnormal growth early on in pediatric patients."

The systematic review evaluated studies reporting algorithms for growth monitoring in children, as well as studies comparing the performance of the new World Health Organization (WHO) growth charts (2006) with that of other growth charts.

It also explored which conditions should be targeted and how abnormal growth should be defined.

The paper was published online January 14 in Lancet Diabetes and Endocrinology, and according to the authors, it is the first review to examine a combination of growth monitoring in relation to both target conditions and algorithms that define abnormal growth.

No Consensus on Priority Conditions, Algorithms Poor

Of the studies included in the review, 11 were related to target conditions of growth monitoring, 15 reported on algorithms that define abnormal growth, two studies assessed the performance of WHO growth charts for early detection of target conditions, and 49 compared WHO growth charts with other growth charts.

One study from the Netherlands reported that no real pathology was seen in as many as 95% of referrals, emphasizing the need "to minimize unnecessary procedures in disease-free children within normal variants of growth," the authors note.

Meanwhile six main target conditions — Turner syndrome, growth-hormone deficiency, celiac disease, cystic fibrosis, renal tubular acidosis, and small for gestational age with no catch-up after 2 or 3 years — were the subject of the algorithms studied, explained Mrs Scherdel, although she emphasized that over 100 diseases are classified as potential causes of abnormal growth, notably by the European Society of Pediatric Endocrinology.

Hence, "these results suggest a lack of consensus on priority target conditions."

The researchers found the level of validation of the seven algorithms that define abnormal growth proposed in the literature to be low and incomplete.

However, among them, the Grote clinical decision rule (Arch Dis Child. 2008;93:212-217) and the Saari clinical decision rules (J Clin Endocrinol Metab. 2012;97:E2125-E2132) seemed the most promising.

But "clinicians should keep in mind that an algorithm is a decision-making companion that will never replace their own clinical assessment and judgment," the authors write.

Use of Growth Charts Complicated

Mrs Scherdel explained why they felt it was necessary to investigate use of the WHO growth charts in their analysis. "Since the publication of new WHO growth charts, we have observed concerns on the use of these…charts in several countries."

In the two studies assessing the performance of WHO growth charts for early detection of target conditions, detection would have been earlier and more frequent with national growth charts than WHO ones, the researchers note.

However, which charts will be better for growth monitoring is not obvious, because performance depends on the goal, measurement, and age group of children studied, they say.

And most studies comparing WHO growth charts with others showed that height, weight, and BMI of contemporary children were closer to the WHO growth charts than others used, which are often based on cohorts of children born in the 1960s and 1970s.

However, whether national growth charts should be replaced "greatly depends on the main objective of the user," the researchers say.

Much Future Work Needed

Overall, evidence supporting existing growth-monitoring practices is low, and there is a lack of consensus on which conditions should be targeted and on the standardization of detection tools.

Mrs Scherdel said that general agreement is needed on reducing the number of priority target conditions for growth-monitoring algorithms, as well as a complete validation with head-to-head comparison of all algorithms.

Internationally validated clinical decision rules are also needed to define abnormal growth, including the selection of appropriate growth charts.

Asked to comment, Antti Saari, MD, of the University of Eastern Finland and Kuopio University Hospital, Finland, noted that the paper was a "good and detailed review" and in particular highlights the fact that evidence on effectiveness of growth monitoring is still lacking.

A substantial amount of future research is required to obtain a consensus on how to monitor children's growth, Dr Saari noted.

"For example, currently, we don't know how often, at what age, or what kind of investigations should be performed if abnormal growth is detected," he said. It is also unknown whether systematic growth monitoring is cost-effective.

"We really need further studies in this field," he concluded.

The study authors and Dr Saari declare no relevant financial relationships.

Lancet Diabetes Endocrinol. Published online January 14, 2016. Abstract

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