David Beattie ST7 General Paediatrics RHSC Edinburgh
Guideline overview What are we auditing? Results What can we take from this? Questions/ discussion
Dr Lizzie Bayman – proposed guideline to be used locally To guide identification and assessment of short stature ◦ Primary care and general paediatrics ◦ Tertiary paediatric endocrinologists considering start of GH therapy When to refer to tertiary services for short stature ◦ If meet any of 5 criteria Framework of preliminary investigations for short stature
Severe short stature – height <0.4 th centile Height 2 centiles or more below mid-parental height Height below 2 nd centile and a height velocity over 1 year less than 25 th centile 2 years of age or more and crossing more than 1 height centile in a year In absence of short stature, a height velocity less than 3 rd centile over 1 year or less than 10 th centile sustained over 2 years
FBC U and E LFT Ferritin Vitamin D Coeliac screen IGF-1 Karyotype Bone age x-ray If pubertal age/ signs of puberty: LH, FSH Females - Oestradiol Males - Testosterone
Aim – To establish what our currently practice is and whether children requiring growth hormone would be picked up using this proposed new guideline Method ◦ Retrospective analysis of 25 insulin tolerance tests (ITT) performed in NHS Lothian Lothian – in context of blood glucose <2.2 or 50% reduction from baseline: Peak GH >5ug/L: pass ITT Peak GH 2-5ug/L: growth hormone deficiency Peak GH <2ug/L: severe growth hormone deficiency ◦ Height, height velocity and MPH were calculated and compared against guideline criteria of when to refer ◦ Which investigations had been performed prior to ITT
25 ITT ◦ 17 male ◦ 8 female ◦ 2 excluded as not GH naive Data from 23 patients analysed ◦ NHS Lothian n= 20 ◦ NHS Fife n = 1 ◦ NHS Tayside n = 1 ◦ NHS Highland n = 1 ◦ NHS D&G n = 2
4 3 2 1 0 Number of criteria
HV <10th centile for 2 years/ <3rd centile for 1 year >2 years of age and crossing >1 height centile in 1 year <2nd centile and HV (1 year) <25th centile >2 centiles below MPH <0.4th centile 0 2 4 6 8 10 12 14 16 Number of patients
4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Height<0.4th centile >2 centiles below MPH Height <2nd centile + HV (1 year) <25th centile >2 years of age and crossing >1 height centile in 1 year HV 10th centile for 2 years/ <3rd centile for over 1 year (in absence of short stature)
4 3 2 1 0 1 2 3 4 5 6 7 8 Height<0.4th centile >2 centiles below MPH Height <2nd centile + HV (1 year) <25th centile
6 5 4 3 2 1 0 >+2 SD +1+2 SD 0+1 SD 0-1 SD -1-2 SD >-2 SD Passed ITT Failed ITT
20 15 10 5 0
Results suggests that children who had ITT and needed GH would have been picked up using this guideline ◦ All 15 needing growth hormone met at least 1 criteria ◦ 11 of 15 had only 1 criteria suggesting the differing criteria are worthwhile 0 patients met “crossing >1 height centile in 1 year” Baseline investigations already being done (Vitamin D, coeliac, ferritin and karyotype less regular) Difficulty in availability of karyotype results
Retrospective audit: Extract data from CAS on last 50 referrals for short stature/ slow growth against same criteria/ investigations Prospective audit using guideline: primary care/ general paediatric clinic referrals to tertiary endocrine services for short stature
Lizzie Bayman Jennifer Roach Mike Crane Louise Bath Clare Webster Anthony Tasker Stuart Henderson Raj Shyam
Any questions?
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