Research article

Referral patterns of children with poor growth in primary health care

Floor K Grote¹ , Wilma Oostdijk¹ , Sabine MPF De Muinck Keizer-Schrama² , Friedo W Dekker³ , Paula van Dommelen⁴ , Stef van Buuren^4,5 , Adry M Lodder-van der Kooij⁶ , Paul H Verkerk⁷ and Jan Maarten Wit¹

¹Dept. of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands

²Dept. of Paediatrics, Erasmus MC – Sophia Children's Hospital, Rotterdam, The Netherlands

³Dept of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands

⁴Dept. of Statistics, TNO Quality of life, Leiden, The Netherlands

⁵Dept. of Methodology & Statistics, University of Utrecht, The Netherlands

⁶Dept. Child Health Care, Regional Public Health Service Hollands Midden, Leiden, The Netherlands

⁷Dept. of Child Health, TNO Quality of life, Leiden, The Netherlands

author email corresponding author email

BMC Public Health 2007, 7:77doi:10.1186/1471-2458-7-77

Published:	11 May 2007

Abstract

Background

To promote early diagnosis and treatment of short stature, consensus meetings were held in the mid nineteen nineties in the Netherlands and the UK. This resulted in guidelines for referral. In this study we evaluate the referral pattern of short stature in primary health care using these guidelines, comparing it with cut-off values mentioned by the WHO.

Methods

Three sets of referral rules were tested on the growth data of a random sample (n = 400) of all children born between 01-01-1985 and 31-12-1988, attending school doctors between 1998 and 2000 in Leiden and Alphen aan den Rijn (the Netherlands): the screening criteria mentioned in the Dutch Consensus Guideline (DCG), those of the UK Consensus Guideline (UKCG) and the cut-off values mentioned in the WHO Global Database on Child growth and Malnutrition.

Results

Application of the DCG would lead to the referral of too many children (almost 80%). The largest part of the referrals is due to the deflection of height, followed by distance to target height and takes primarily place during the first 3 years. The deflection away from the parental height would also lead to too many referrals. In contrast, the UKCG only leads to 0.3% referrals and the WHO-criteria to approximately 10%.

Conclusion

The current Dutch consensus guideline leads to too many referrals, mainly due to the deflection of length during the first 3 years of life. The UKCG leads to far less referrals, but may be relatively insensitive to detect clinically relevant growth disorders like Turner syndrome. New guidelines for growth monitoring are needed, which combine a low percentage of false positive results with a good sensitivity.