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Journal Article
Do general practitioners influence the uptake of breast cancer screening?
FA Majeed, DG Cook, R Given-Wilson, P Vecchi, and J Poloniecki. J Med Screen 1995 2: 119-124.
OBJECTIVES--To investigate the relative importance of patient and general practice characteristics in explaining variations between practices in the uptake of breast cancer screening.
DESIGN--Ecological study examining variations in breast cancer screening rates among 131 general practices using routine data.
SETTING--Merton, Sutton, and Wandsworth Family Health Services Authority, which covers parts of inner and outer London.
MAIN OUTCOME MEASURE--Percentage of eligible women aged 50-64 who attended for mammography during the first round of screening for breast cancer (1991-1994).
RESULTS--Of the 43,063 women eligible for breast cancer screening, 25,826 (60%) attended for a mammogram. Breast cancer screening rates in individual practices varied from 12.5% to 84.5%. The estimated percentage list inflation for the practices was the variable most highly correlated with screening rates (r = -0.69). There were also strong negative correlations between screening rates and variables associated with social deprivation, such as the estimated percentage of the practice population living in households without a car (r = -0.61), and with variables that measured the ethnic make-up of practice populations, such as the estimated percentage of people in non-white ethnic groups (r = -0.60). Screening rates were significantly higher in practices with a computer than in those without (59.5% v 53.9%, difference 5.6%, 95% confidence interval 1.1 to 10.2%). There was no significant difference in screening rates between practices with and without a female partner; with and without a practice nurse; and with and without a practice manager. In a forward stepwise multiple regression model that explained 58% of the variation in breast cancer screening rates, four factors were significant independent predictors (at P = 0.05) of screening rates: list inflation and people living in households without a car were both negative predictors of screening rates, and chronic illness and the number of partners in a practice were both positive predictors of screening rates. The practice with the highest screening rate (84.5%) contacted all women invited for screening to encourage them to attend for their mammogram and achieved a rate 38% higher than predicted from the regression model. Breast cancer screening rates were on average lower than cervical cancer screening rates (mean difference 14.5%, standard deviation 12.0%) and were less strongly associated with practice characteristics.
CONCLUSIONS--The strong negative correlation between breast cancer screening rates and list inflation shows the importance of accurate age-sex registers in achieving high breast cancer screening rates. Breast cancer screening units, family health services authorities, and general practitioners need to collaborate to improve the accuracy of the age-sex registers used to generate invitations for breast cancer screening. The success of the practice with the highest screening rate suggests that practices can influence the uptake of breast cancer screening among their patients. Giving general practitioners a greater role in breast cancer screening, either by offering them financial incentives or by giving them clerical support to check prior notification lists and contact nonattenders, may also help to increase breast cancer screening rates.

Epidemiology of short stature due to growth failure.
A Macfarlane. J Med Screen 1995 2: 128-129.

Short stature: does it matter? A review of the evidence.
LD Voss. J Med Screen 1995 2: 130-132.
Short stature is widely regarded to be a liability, but despite the importance commonly ascribed to the psychological impact of physique, there is a paucity of methodologically sound research on the topic. The question of growth hormone therapy for a short, but otherwise normal child is still controversial. The justification for such treatment will depend not only on whether a marked improvement in height can be achieved but also on whether short stature can be shown to be an appreciable handicap, either in childhood or later in life. There is some evidence, though much is anecdotal, to suggest that the short statured adult is disadvantaged both socially and economically. There are no conclusive data as yet, however, to suggest that short statured children, either before or during early adolescence have significantly lower scores on conventional psychometric testing than children of average stature. Possibly, the problems associated with short stature will only emerge in the older adolescent, but for the present, alternative, less expensive forms of treatment should be considered for those children apparently unable to cope.

Genetic and environmental influences on growth
RJ Rona and S Chinn. J Med Screen 1995 2: 133-139.
OBJECTIVES--To provide an overview of the factors associated with growth in primary school children in England and Scotland and to provide information about the secular trend of growth in the last 20 years.
SETTING--Representative English and Scottish samples and an English inner city sample. METHODS--The study had a mixed longitudinal design from 1972 to 1994. Between 8000 and 10,000 children participated in each survey. Height was measured in at least 95% of the children in most surveys, and 75% to 85% of parents provided information about family background. Main results are based on published information. Multiple regression was used for most of the analyses.
RESULTS--Parents' height, child's birth weight, mother's age at child's delivery, ethnic background and, in white children, family size are the only factors markedly associated with height. Variables that have traditionally been used to assess the possible effect of social conditions were generally not associated with height. The height increase was more marked in Scotland than England over the period 1972 to 1990, and the differences in height of children in the two countries is now minimal.
CONCLUSIONS--Most factors cannot be neatly classified as purely genetic or environmental, but seem to indicate that genes are relatively more important. Social factors usually assessed in growth studies do not have an important effect on growth. The marked increase of height over time indicates that the environment and social conditions have allowed children to grow taller. Sibship size is the only factor that was shown to be related to the secular trend in growth.

Growth screening and urban deprivation.
E White, A Wilson, SA Greene, W Berry, C McCowan, A Cairns, and I Ricketts. J Med Screen 1995 2: 140-144.
OBJECTIVES--To assess the effect of urban deprivation on childhood growth in a modern British society by analysing data from a regional growth survey, the Tayside growth study.
SETTING--The Tayside Region in Scotland, which has three districts with distinct socioeconomic status: Dundee (D, urban city), Angus (A, rural), and Perth (P, rural and county town).
SUBJECTS AND METHODS--Height and weight of 23,046 children (> 90% of the regional childhood population) were measured as part of a child health surveillance programme, by community health care workers at 3, 5, 7, 9, 11, and 14 years. Height standard deviation score (calculated against Tanner) and body mass index (BMI-weight (kg)/height (m)2) were calculated for each child by a central computer program; mean height standard deviation score and BMI standard deviation score were calculated for each measuring centre (school, health clinic). A deprivation score for each centre was calculated from the prevalence of single parent families; families with more than three children; unemployment rate; the number of social class V individuals; the percentage of council houses.
RESULTS--Mean height standard deviation score for Tayside was 0.11. An intraregional difference was demonstrated: mean height standard deviation score (SD) D = 0.04 (1.0); A = 0.14 (1.1); P = 0.21 (1.1); P < 0.002. There was a positive association between short stature and increasing social deprivation seen throughout Tayside (P < 0.05), with a strong association in Dundee primary school children (r = 0.6; P < 0.001). Analysis by district showed that the association was significant only above the age of 8 (P < 0.004). There was no relation between BMI and social deprivation.
CONCLUSIONS--In an industrialised developed society, urban deprivation appears to influence height mostly in late childhood, and this association should be taken into consideration in the clinical management of short stature. Height seems to be a better physical indicator of urban deprivation, and hence an index of childhood health, than BMI.

Failure to thrive and the risk of child abuse: a prospective population survey.
DH Skuse, D Gill, S Reilly, D Wolke, and MA Lynch. J Med Screen 1995 2: 145-149.
OBJECTIVE--To identify the relative importance of failure to thrive during infancy as a risk factor for later abuse or neglect. DESIGN--Whole population birth cohort (1 January to 31 December 1986) studied prospectively over a four year period.
SETTING--An inner city health district in London, England. SUBJECTS--2609 births, of whom 47 were identified as having non-organic failure to thrive by first birthday.
MAIN OUTCOME MEASURES--Registration on Child Protection Register, or subject to investigation of suspected abuse or neglect without registration.
RESULTS--2.5% (64) of birth cohort had been placed on the Child Protection Register during the period 1986-1990, and a further 1.2% (32) had been a cause for concern. The relative risk attributable to non-organic failure to thrive was 4.3 (95% CI 1.65 to 11.94) and exceeded other measured risk factors, including birth weight < 2500 g, 1.96 (95% CI 1.01 to 3.82); gestation < 35 weeks, 3.26 (95% CI 1.32 to 3.75); ordinal position > or = 4, 1.53 (95% CI 0.72 to 3.23). A multiple logistic regression confirmed the independent contribution of non-organic failure to thrive to subsequent poor parenting warranting professional intervention.
CONCLUSIONS--Early postnatal non-organic failure to thrive is a risk factor for later serious parenting deficiencies, but previous research has overstated its importance. Within the community studied the nature of subsequent risk was (non-nutritional) neglect, rather than non-accidental injury. More than eight out of 10 cases do not give further cause for concern.

Common causes of short stature detectable by a height surveillance programme.
W Hyer, AM Cotterill, and MO Savage. J Med Screen 1995 2: 150-153.

United Kingdom community growth screening 1994: a survey of current practice. "Screening for Growth Towards 2000" Scientific Organising Committee.
JA Hulse and S Schilg. J Med Screen 1995 2: 154-156.
OBJECTIVE--To determine current policies, resources, and attitudes to community growth screening in the United Kingdom.
METHODS--A postal survey of community paediatricians and paediatric endocrinologists.
RESULTS--164 replies were received-most from senior clinical medical officers or community paediatricians-covering between 68 and 78% of the United Kingdom population. One hundred and thirty three (81%) trusts or districts had a written growth policy. Preschool and school age height screening took place in 75% and 81% of districts respectively, but most children were only measured once before school or at school. Policies for the age at which measurements were made and their frequency varied enormously. Seventy three per cent used standard equipment, the most popular being the Minimetre. A wide variety of charts were used, of which 23% were decimal age charts. A large number of referral criteria were used, including height, height velocity, and weight. Most children were referred to hospital outpatient clinics rather than specialist growth clinics.
CONCLUSIONS--Over 90% of respondents felt that growth screening was either extremely valuable or useful depending on resources. The survey showed a widespread lack of standardisation of equipment, charts, and policies. Referral criteria and objectives need to be clarified by research and audit, and growth monitoring integrated into a systematic programme of child health surveillance.

Setting up a height surveillance programme: recommendations based on the Hackney growth initiative.
S Hearn, W Majrowski, S Jenkins, M Savage, and AM Cotterill. J Med Screen 1995 2: 157-159.

The Oxford growth study: a district growth surveillance programme 1988-1994.
ML Ahmed, AD Allen, DB Dunger, and A Macfarlane. J Med Screen 1995 2: 160-163.
OBJECTIVES--To develop a method of community based growth assessment. SETTING--Oxford District, United Kingdom.
METHODS--A system of growth surveillance involving a community consultant paediatrician, a paediatric endocrinologist, a clinical auxologist, a project coordinator, and the many primary health care teams was started. Letters and meetings were arranged to introduce the programme to general practitioners and health visitors, emphasising the importance of growth assessment in normal child development. They were asked to measure all children as part of their routine developmental checks at 3 and 4.5 years of age. Community growth assessment clinics staffed by an experienced auxologist were established. Children whose heights were more than two standard deviation (SD) scores below the mean or whose height SD score decreased between the two ages were referred to the clinic. Any child whose height was more than 3 SD scores below the mean was referred directly to the paediatric endocrinologist. Those seen in the community clinics were followed up for a year and if their velocity was > 25th centile, karyotype normal, and bone age appropriately delayed, they were discharged to the general practitioner for further follow up. Any child with an annual velocity < 25th centile was referred to the endocrinologist.
RESULTS--Of 20,338 children monitored, 260 (1.3%) had heights > -2 SD scores. Seventy six were lost to follow up, 35 were measuring errors, 69 were already seeing a paediatrician, leaving 80 children to be evaluated. Of these, 69 were "short normals" and 11 were newly identified diagnoses.
CONCLUSIONS--This system of secondary referral keeps normal healthy children out of hospital, avoids unnecessary over-investigation, reduces travel and anxiety for families, avoids filling specialist clinics with normal children, and provides an inexpensive system of growth surveillance.

Can we measure growth?
LD Voss. J Med Screen 1995 2: 164-167.
Poor installation and maintenance of height measuring equipment is a serious problem in the community. With care, however, height can be measured with sufficient precision (+/- 0.5 cm) to identify unusually short or tall stature. Height velocity, on the other hand, is liable to misinterpretation. It cannot be estimated with sufficient precision to identify abnormal growth in the short term. There is no correlation between two successive 12 month velocities. When a trend towards poor velocity is beyond all doubt then it will be apparent on the height chart alone. In addition, "poor" or "excessive" growth is conditional on the height of the child: short children do not grow at the same rate as tall. A diagnosis of abnormal growth requires long term monitoring and is best seen as a series of height measurements crossing the centiles on the height chart. Given the correct equipment and training, height or length can be measured with a fair degree of precision in the youngest of children. The earlier measurements begin, the sooner an abnormal pattern of growth will become evident. The regular monitoring of height should be standard practice and available to each and every child.

Referral criteria for growth screening.
JA Hulse. J Med Screen 1995 2: 168-170.
Population height screening studies performed over the past 20 years have shown that between 17 and 21% of children with heights below the third centile have organic disease, of whom about 20% will be new diagnoses. The likelihood of organic disease increases to 50% for children with heights below -3 SDs. The age of screening will also influence the outcome as both acquired disease and disorders with progressive growth slowing, such as Turner's syndrome, are more likely to be detected by screening at an older age. Height velocity as a screening tool has evoked interest for many years as, despite technical problems, slowly growing children are thought more likely to have disease. Inclusion of height or height/weight relations may further improve screening sensitivity. It may assist in the early detection of coeliac disease or eating disorders in older children. A minimum of three measurements is required to define an individual's growth pattern and, preferably, five or six measurements spread over the preschool and primary school years. The value of extension of growth screening to the secondary school age group remains uncertain. Children should be screened for both height and weight and referred when there are major discrepancies between these two measurements (more than three centile bands). A two level system of referral with a community assessment for some children and a direct referral to a growth clinic for children with more severe growth disturbance may be the best use of resources.

An international perspective on height surveillance.
AM Cotterill. J Med Screen 1995 2: 171-173.

Growth monitoring: the next five years.
DM Hall. J Med Screen 1995 2: 174-178.

Congress
Screening for Growth Towards 2000. Proceedings of a conference.
London, United Kingdom, 14 December 1994. J Med Screen 1995 2: 127-178.

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