The diagnostic work up of growth failure in secondary health care; an evaluation of consensus guidelines.
BACKGROUND
As abnormal growth might be the first manifestation of undetected diseases, it is important to have accurate referral criteria and a proper diagnostic work-up. In the present paper we evaluate the diagnostic work-up in secondary health care according to existing consensus guidelines and study the frequency of underlying medical disorders.


METHODS
Data on growth and additional diagnostic procedures were collected from medical records of new patients referred for short stature to the outpatient clinics of the general paediatric departments of two hospitals (Erasmus MC - Sophia Children's Hospital, Rotterdam and Spaarne Hospital, Haarlem) between January 1998 and December 2002. As the Dutch Consensus Guideline (DCG) is the only guideline addressing referral criteria as well as diagnostic work-up, the analyses were based on its seven auxological referral criteria to determine the characteristics of children who are incorrectly referred and the adequacy of workup of those who are referred.


RESULTS
Twenty four percent of children older than 3 years were inappropriately referred (NCR). Of the correctly referred children 74-88% were short corrected for parental height, 40-61% had a height SDS <-2.5 and 21% showed height deflection (Delta HSDS < -0.25/yr or Delta HSDS < -1). In none of the children a complete detailed routine diagnostic work up was performed and in more than 30% no routine laboratory examination was done at all. Pathologic causes of short stature were found in 27 children (5%).


CONCLUSIONS
Existing guidelines for workup of children with suspected growth failure are poorly implemented. Although poorly implemented the DCG detects at least 5% pathologic causes of growth failure in children referred for short stature. New guidelines for referral are required with a better sensitivity and specificity, wherein distance to target height should get more attention. The general diagnostic work up for short stature should include testing for celiac disease in all children and for Turner syndrome in girls.
Grote
Floor K
FK
Dept. of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands. fk.grote@planet.nl
Oostdijk
Wilma
W
De Muinck Keizer-Schrama
Sabine Mpf
SM
van Dommelen
Paula
P
van Buuren
Stef
S
Dekker
Friedo W
FW
Ketel
Arnoldus G
AG
Moll
Henriette A
HA
Wit
Jan M
JM
D000293:Adolescent; D001827:Body Height; D002446:Celiac Disease / Q000150:complications / Q000175:diagnosis; D002648:Child; D002675:Child, Preschool; D019411:Clinical Laboratory Techniques / Q000706:statistics & numerical data; D004393:Dwarfism, Pituitary / Q000150:complications / Q000175:diagnosis; D005260:Female; D006130:Growth Disorders / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D019983:Guideline Adherence; D006769:Hospitals, General; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D008297:Male; D009426:Netherlands; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000592:standards* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014424:Turner Syndrome / Q000150:complications / Q000175:diagnosis