general update and restructure of the clinician section WIP

documentation/docs/clinician/clinical-faq.md

@@ -0,0 +1,58 @@
+---
+reviewers: Dr Marcus Baw, Dr Anchit Chandran
+audience: clinicians, health-staff
+---
+
+# Clinical FAQ
+
+The following are the original FAQs from previous (non-Digital) versions of RCPCH Growth Charts. We have included them in our dGC documentation to provide a comprehensive resource for clinicians, as most of the advice remains relevant.
+
+### When should babies be weighed?
+
+Babies should be weighed in the first week, as part of the assessment of feeding, and after as needed. Recovery of birthweight indicates that feeding is effective and the child is well. Once feeding is established, babies should usually be weighed at around 8, 12 and 16 weeks and 1 year at the time of routine immunisations.
+
+Weights measured too close together may be misleading, but if there are concerns about [faltering growth](https://pathways.nice.org.uk/pathways/faltering-growth#content=view-node%3Anodes-monitoring), weight should be measured more often, but usually no more often than:
+
+- daily if less than 1 month old.
+- weekly between 1–6 months old.
+- fortnightly between 6–12 months.
+- monthly from 1 year of age.
+
+### When should length or height be measured?
+
+Length or height should be measured whenever there are any worries about a child’s weight gain, growth or general health. Measure length until age 2, measure height after age 2.  A child’s height is usually slightly less than their length.
+
+### How should weight loss after birth be assessed?
+
+Weight gain in the early days varies a lot from baby to baby, however, by 2 weeks of age most babies will be on a centile close to their birth centile. Most babies lose some weight in the first 3-4 days after birth, but most have regained birth weight by 3 weeks of age. Careful clinical assessment and evaluation of feeding technique is indicated when weight loss exceeds 10% or recovery of birth weight is slow.
+
+Calculating the percentage weight loss is a useful way to identify babies who need assessment.
+Percentage weight loss can be calculated as follows:
+
+<div class="latex">
+<img src="https://latex.codecogs.com/svg.image?Percentage\;Weight\;loss = \frac{Birth\;weight - Current\;weight}{Birth\;weight} \times 100" />
+</div>
+
+For example, a child born at 3.500kg who drops to 3.150kg at 5 days has lost 350g or 10%; in a baby born at 3.000kg, a 300g loss is 10%.
+
+### What is a normal rate of weight gain and growth?
+
+Babies do not all grow at the same rate, so a baby’s weight often does not follow a particular centile line, especially in the first year. Weight is most likely to track within one centile space (the gap between two centile lines, see diagram). In infancy, acute illness can lead to sudden weight loss and a weight centile fall, but on recovery the child’s weight usually returns to its normal centile within 2–3 weeks. However, a sustained drop through 2 or more weight centile spaces is unusual (fewer than 2% of infants), and should be carefully assessed by the primary care team, including measuring length/height.
+
+Because it is difficult to measure length and height accurately in pre-school children, successive measurements commonly show wide variation. If there are worries about growth, it is useful to measure occasionally over time; most healthy children will show a stable average position over time.
+
+UK children have relatively large heads compared to the WHO standard, particularly after the age of 6 months. After the age of 6 weeks, a head circumference below the 2nd centile will be seen in only 1 in 250 children. A head circumference above the 99.6th centile, or crossing upwards through 2 centile spaces, should only cause concern if there is a continued rise after 6 months, or other signs or symptoms.
+
+### Why do the length/height centiles change at 2 years?
+
+The growth standards show length data up to 2 years of age, and height from age 2 onwards. When a child is measured standing up, the spine is squashed a little, so their height is slightly less than their length; the centile lines shift down slightly at age 2 to allow for this. It is important this difference does not worry parents; what matters is whether the child continues to follow the same centile after the transition.
+
+### When is further assessment required in school aged children?
+
+If any of the following occur:
+
+- Where weight or height or BMI is below the 0.4th centile, unless already fully investigated at an earlier age.
+- If the height centile is more than 3 centile spaces below the mid-parental centile.
+- A drop in height centile position of more than 2 centile spaces, as long as measurement error has been excluded.
+- Smaller centile falls or discrepancies between child’s and mid-parental centile, if seen in combination, or if associated with possible underlying disease.
+- If there are any other concerns about the child’s growth.

documentation/docs/clinician/date-age-calculations.md

@@ -1,10 +1,9 @@
 ---
-title: Date and Age Calculations
 reviewers: Dr Marcus Baw, Dr Anchit Chandran
 audience: clinicians, health-staff, statisticians
 ---
 
-# Date and Age Calculations
+# Growth Chart Nomenclature
 
 ## Decimal Age
 

documentation/docs/clinician/how-the-api-works.md → documentation/docs/clinician/how-the-calculations-work.md

@@ -3,13 +3,10 @@ title: How the API Works
 reviewers: Dr Marcus Baw, Dr Anchit Chandran
 audience: clinicians, health-staff, statisticians
 ---
-# How the API Works
+# How the calculations work
 
 Details for interested clinicians and statisticians. It is not necessary to understand this detail in order to use growth charts clinically, this is just for those interested in the technical details.
 
-## Growth Charting Introduction
-
-The UK-WHO 0-4 year old charts were officially launched on May 11th 2009. Any child born after that date should be plotted on a UK-WHO growth chart. Children born before May 11th 2009 are plotted on British 1990 (UK90) charts and subsequent measurements must be plotted using those charts. After age 4, the two charts are the same.
 
 ## The LMS Method
 

documentation/docs/clinician/faqs-for-clinicians.md → documentation/docs/clinician/implementation-faq.md

@@ -1,16 +1,13 @@
 ---
-title: FAQs for Clinicians
 reviewers: Dr Marcus Baw, Dr Anchit Chandran
 audience: clinicians, health-staff
 ---
 
-# Frequently Asked Questions for Clinicians
+# Implementation FAQ
 
-## Q: What are the main differences between the old paper or PDF Growth Charts and the dGC Project?
-
-**A**: Paper or PDF charts required a human to plot the measurement and then read off the Centile. Digital Growth Charts automatically calculate Centiles and SDS (Standard Deviation Score) from the measurements, and plot these on a digital chart for you.
+## Q: Can I try out the Digital Growth Charts APIs?
 
-Digital Growth Charts include recommended SNOMED-CT clinical terminology to guide persistence of the returned values.
+**A**: Yes, you can use the demo site at <https://growth.rcpch.ac.uk/> to evaluate the charts. Your EPR vendor will implement the API in your EPR, and you will be able to use the charts in your clinical workflow. The user interface implemented in your EPR may not look identical to our demo site, but the underlying data and calculations will be the same.
 
 ## Q: How do I get the RCPCH Digital Growth Charts in my EPR?
 
@@ -23,6 +20,12 @@ Many EPR suppliers have already started the process of integrating the RCPCH Dig
 !!! info
     We now have a section on the RCPCH Forum for supporting clinicians wanting to get Digital Growth Charts implemented in their EPR. To get access to this area sign up to the forum site and request access to our [Digital Growth Charts Clinicians](https://forum.rcpch.tech/g/dgc-clinicians)
 
+## Q: What are the main differences between the old paper or PDF Growth Charts and the dGC Project?
+
+**A**: Paper or PDF charts required a human to plot the measurement and then read off the Centile. Digital Growth Charts automatically calculate Centiles and SDS (Standard Deviation Score) from the measurements, and plot these on a digital chart for you.
+
+Digital Growth Charts include recommended SNOMED-CT clinical terminology to guide persistence of the returned values.
+
 ## Q: How much do the RCPCH Digital Growth Charts APIs cost?
 
 **A**: The APIs themselves are run on a sustainable non-profit basis by the RCPCH, which is a charitable organisation. The aim is for modest revenues from the API to be fed back into development of future APIs and new features.
@@ -33,19 +36,17 @@ Pricing depends on the volume of requests the vendor requires and the amount of
 
 The process of integrating the API into an existing EPR product is technically straightforward and the amount of work is modest. EPR suppliers may levy a fee for this additional integration work, however after being done once for a product, there should be zero to minimal additional work rolling out to other sites, so you should check whether the vendor has already deployed the dGC elsewhere.
 
-## Q: Can I try out the Digital Growth Charts APIs?
-
-**A**: Yes, you can use the demo site at <https://growth.rcpch.ac.uk/> to evaluate the service.
-
 ## Q: If we have a calculated centile from the API, then why do we need the traditional 'curved-lines' growth charts at all?
 
-**A**: Good question. Maybe, this style of chart will no longer be needed in the future. Perhaps they will be replaced by SDS charts, which would allow us to view height, weight, head circumference, and BMI all on one chart too!
+**A**: Good question! The traditional growth charts were actually a form of 'paper calculator' for the centile values. The clinician plotted the age, height/weight data, and then looked for which centile lines it was between: this was the data read off and recorded. We would also keep the charts for future plotting. This was the reason the lines were curved, we read off the centile from the curve.
+
+The Growth Charts API removes the need for this 'manual centile reading-off' step, since **we** calculate the centiles for you. However, even if the centile is calculated for us, we will always want to visualise **trends** in the growth.
 
-The traditional growth charts were actually a form of 'paper calculator' for the centile values. The clinician plotted the age, height/weight data, and then looked for which centile lines it was between: this was the data read off and recorded. We would also keep the charts for future plotting.
+We expect that, for the immediate future, clinical users will want to see the traditional growth chart, out of simple familiarity. But in time, one possibility for the future is that gradually we might start to make more use of Standard Deviation Score (SDS or z-score) Charts, which would allow us to view height, weight, head circumference, and BMI all on one chart
 
-The Growth Charts API removes the need for this step, since **we** calculate the centiles for you. However, another important function of the chart was to visualise **trends** in the growth. Our API does not do this, so there will be a need for some form of chart to visualise the trend.
+Researchers may develop even better visualisations of the trends which allow us as clinicians to focus on the trend. Research has already been done into ways to represent the concept of growth velocity, using thrive lines, and this is likely to be a feature in future versions of the API.
 
-Initially, we expect that clinical users will want to see the traditional growth chart, out of simple familiarity. But in time, researchers may develop better visualisations of the trend in centiles/SDS, which don't necessitate such confusing curvy charts. The future of displaying growth trends is entirely open to new ideas and innovation.
+The future of displaying growth trends is entirely open to new ideas and innovation. [Contact us on our forum](/contact) if you have ideas or suggestions.
 
 ## Q: Where can I see your clinical safety documentation?
 

documentation/docs/clinician/chart-information-health-staff.md → documentation/docs/clinician/uk-who-uk90-who.md

@@ -53,57 +53,7 @@ Anyone who measures a child, plots or interprets charts should be suitably train
 - Height: (from 2 years): position head and feet as illustrated, with child standing as straight as possible. Measure height recorded to the last millimetre. A correctly installed stadiometer, or approved portable measuring device rigid rule with T piece, is the only equipment that can be reliably used.
 - Head circumference: use a narrow plastic or paper tape to measure where the head circumference is greatest.
 
-## Frequently Asked Questions
 
-### When to weigh?
-
-Babies should be weighed in the first week, as part of the assessment of feeding, and after as needed. Recovery of birthweight indicates that feeding is effective and the child is well. Once feeding is established, babies should usually be weighed at around 8, 12 and 16 weeks and 1 year at the time of routine immunisations.
-
-Weights measured too close together may be misleading, but if there are concerns about [faltering growth](https://pathways.nice.org.uk/pathways/faltering-growth#content=view-node%3Anodes-monitoring), weight should be measured more often, but usually no more often than:
-
-- daily if less than 1 month old.
-- weekly between 1–6 months old.
-- fortnightly between 6–12 months.
-- monthly from 1 year of age.
-
-### When to measure length or height?
-
-Length or height should be measured whenever there are any worries about a child’s weight gain, growth or general health. Measure length until age 2; measure height after age 2.  A child’s height is usually slightly less than their length.
-
-### How to assess weight loss after birth?
-
-Weight gain in the early days varies a lot from baby to baby, however, by 2 weeks of age most babies will be on a centile close to their birth centile. Most babies lose some weight in the first 3-4 days after birth, but most have regained birth weight by 3 weeks of age. Careful clinical assessment and evaluation of feeding technique is indicated when weight loss exceeds 10% or recovery of birth weight is slow.
-
-Calculating the percentage weight loss is a useful way to identify babies who need assessment.
-Percentage weight loss can be calculated as follows:
-
-<div class="latex">
-<img src="https://latex.codecogs.com/svg.image?Percentage\;Weight\;loss = \frac{Birth\;weight - Current\;weight}{Birth\;weight} \times 100" />
-</div>
-
-For example, a child born at 3.500kg who drops to 3.150kg at 5 days has lost 350g or 10%; in a baby born at 3.000kg, a 300g loss is 10%.
-
-### What is a normal rate of weight gain and growth?
-
-Babies do not all grow at the same rate, so a baby’s weight often does not follow a particular centile line, especially in the first year. Weight is most likely to track within one centile space (the gap between two centile lines, see diagram). In infancy, acute illness can lead to sudden weight loss and a weight centile fall, but on recovery the child’s weight usually returns to its normal centile within 2–3 weeks. However, a sustained drop through 2 or more weight centile spaces is unusual (fewer than 2% of infants), and should be carefully assessed by the primary care team, including measuring length/height.
-
-Because it is difficult to measure length and height accurately in pre-school children, successive measurements commonly show wide variation. If there are worries about growth, it is useful to measure occasionally over time; most healthy children will show a stable average position over time.
-
-UK children have relatively large heads compared to the WHO standard, particularly after the age of 6 months. After the age of 6 weeks, a head circumference below the 2nd centile will be seen in only 1 in 250 children. A head circumference above the 99.6th centile, or crossing upwards through 2 centile spaces, should only cause concern if there is a continued rise after 6 months, or other signs or symptoms.
-
-### Why do the length/height centiles change at 2 years?
-
-The growth standards show length data up to 2 years of age, and height from age 2 onwards. When a child is measured standing up, the spine is squashed a little, so their height is slightly less than their length; the centile lines shift down slightly at age 2 to allow for this. It is important this difference does not worry parents; what matters is whether the child continues to follow the same centile after the transition.
-
-### When is further assessment required in school aged children?
-
-If any of the following occur:
-
-- Where weight or height or BMI is below the 0.4th centile, unless already fully investigated at an earlier age.
-- If the height centile is more than 3 centile spaces below the mid-parental centile.
-- A drop in height centile position of more than 2 centile spaces, as long as measurement error has been excluded.
-- Smaller centile falls or discrepancies between child’s and mid-parental centile, if seen in combination, or if associated with possible underlying disease.
-- If there are any other concerns about the child’s growth.
 
 ### How do SDS charts work?
 

documentation/mkdocs.yml

@@ -35,11 +35,13 @@ nav:
     - 'integrator/faqs-for-integrators.md'
     - 'integrator/whos-using-dgc.md'
   - Clinicians:
-    - 'clinician/how-the-api-works.md'
     - 'clinician/chart-information-health-staff.md'
+    - 'clinician/down-and-turner.md'
+    - 'clinician/clinical-faq.md'
+    - 'clinician/implementation-faq.md'
     - 'clinician/date-age-calculations.md'
     - 'clinician/growth-references.md'
-    - 'clinician/faqs-for-clinicians.md'
+    - 'clinician/how-the-calculations-work.md'
   - Parents:
     - 'parents/chart-information-families.md'
     - 'parents/faqs-parents.md'