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ST7 General Paediatrics RHSC Edinburgh Guideline overview What are - - PowerPoint PPT Presentation
ST7 General Paediatrics RHSC Edinburgh Guideline overview What are - - PowerPoint PPT Presentation
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
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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
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Severe short stature – height <0.4th centile Height 2 centiles or more below mid-parental height Height below 2nd centile and a height velocity over 1
year less than 25th 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
3rd centile over 1 year or less than 10th centile sustained over 2 years
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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
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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
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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
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1 2 3 4 Number of criteria
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2 4 6 8 10 12 14 16 <0.4th centile >2 centiles below MPH <2nd centile and 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 1 year Number of patients
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1 2 3 4 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)
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1 2 3 4 1 2 3 4 5 6 7 8 Height<0.4th centile >2 centiles below MPH Height <2nd centile + HV (1 year) <25th centile
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1 2 3 4 5 6 >+2 SD +1+2 SD 0+1 SD 0-1 SD
- 1-2 SD
>-2 SD
Passed ITT Failed ITT
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5 10 15 20
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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
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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
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Lizzie Bayman Jennifer Roach Mike Crane Louise Bath Clare Webster Anthony Tasker Stuart Henderson Raj Shyam
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