Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Monitoring for Growth Problems
B - All children who have survived childhood cancer should have their height measured regularly until they reach final adult height. Sitting height should also be measured in children who have received craniospinal irradiation.
C - Children with impaired growth velocity should be referred to a paediatric endocrinologist for growth hormone level measurement.
B - Causes of poor growth, other than growth hormone deficiency, including potential deficiencies of other pituitary hormones or problems related to early or delayed puberty, should be considered and treated as necessary.
B - Children with craniopharyngioma should be tested at presentation for growth and other pituitary hormone deficiencies and at regular intervals thereafter.
B - Prepubertal girls receiving cranial radiotherapy should be closely monitored for clinical signs of precocious puberty (see section 4 of the original guideline document).
Obesity
C - Regular growth monitoring should include evaluation of body mass index and be related to growth charts.
Treatment with Growth Hormone
Effectiveness
B - On confirmation of growth hormone deficiency, growth hormone replacement therapy is indicated. For children with craniopharyngioma, the need for growth hormone replacement may be from presentation.
C - If the cause of growth impairment is unclear, a trial of growth hormone treatment may be appropriate.
Safety
B - Survivors of childhood cancer should be informed that current evidence indicates that there is no increased risk of cancer recurrence from growth hormone replacement therapy.
Dental and Facial Problems
D - Children undergoing cancer treatment and their parents/carers should be advised about the possible effects on orofacial and dental development. Specialist paediatric dentists should have a role in the care of these children.
Female Puberty and Fertility
C - Girls treated with cranial irradiation should have their pubertal status assessed three to four times a year from the end of treatment as part of a routine clinical assessment.
C - Women who have evidence of impaired fertility should be referred for specialist assessment as they could benefit from assisted reproductive technology.
Cardiac Problems
C - Healthcare professionals should be aware that effective doses of anthracyclines for the treatment of childhood cancer may cause congestive cardiac failure later in life. These problems should be assessed during regular review.
C - Healthcare professionals should be aware that mediastinal irradiation over 30 Gy is a risk factor for cardiac disease in later life and monitoring is necessary.
Thyroid Dysfunction
B - Survivors of childhood cancer who received radiotherapy to the neck, spine, or brain should have thyroid function checked after completion of treatment and regularly thereafter. Survivors are likely to require lifetime surveillance.
Cognitive Structure and Neurological Function
D - Healthcare and education professionals should be aware that the treatment of childhood cancer may have an impact on neurological function in later life, particularly if irradiation of the brain occurs at a young age.
- Regular review of neurological function should be part of normal follow up.
- If a problem is suspected, the patient should be referred to a psychologist for a cognitive assessment.
D: Healthcare and education professionals should be aware that the treatment of childhood cancer may have an impact on educational and social function in later life.
- Regular review for possible educational and psychosocial dysfunction or morbidity should take place.
- If a problem is suspected, the patient should be referred appropriately.
Definitions:
Grades of Recommendations
A: At least one meta-analysis, systematic review of randomised controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies; high quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies, e.g. case reports, case series
4: Expert opinion