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Examining growth monitoring practices for children in primary care
  1. Sarah Carsley1,2,3,
  2. Catherine S Birken1,4,
  3. Karen Tu1,5,6,
  4. Eleanor Pullenayegum2,3,
  5. Patricia C Parkin1,4
  1. 1 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  2. 2 Division of Paediatric Medicine, Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
  3. 3 Division of Paediatric Medicine, Pediatric Outcomes Research Team (PORT), The Hospital for Sick Children, Toronto, Ontario, Canada
  4. 4 Department of Pediatric Medicine, University of Toronto, Toronto, Ontario, Canada
  5. 5 Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6 Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Dr Patricia C Parkin, Division of Paediatric Medicine, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, ON M5G 0A4, Canada; patricia.parkin{at}

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Growth monitoring is the long-standing practice used to identify children who fall outside healthy growth parameters. It has been proposed as a key activity for childhood obesity prevention.1 Accurate growth monitoring requires specific techniques and equipment and plotting measurements on a growth chart. The objective of this study was to determine if primary care providers follow recommended growth monitoring practices, including measurement techniques, standardised equipment and use of appropriate growth charts at all health visits.

An electronic survey was distributed between December 2016 and February 2017. The sampling frame was health professionals (physicians, dietitians, nurses) most responsible for growth measurement in primary care practices in the province of Ontario, Canada. The survey assessed the following: measurement equipment, technique, growth chart use and timing (scheduled and/or unscheduled visits). Respondent practice discipline was collected. Descriptive statistics were performed. χ2 and Fisher’s exact test were used to assess differences between practitioner discipline.

Seventy-three surveys were completed from physicians (36%), nurses (26%) and dietitians (38%). To measure weight, a digital scale was used by 93.2% for infants <2 years and 68.5% for children ≥2 years (table 1). To measure supine length in infants <2 years, 21% reported using a length board and 60% reported using the ‘paper and pencil’ method with a tape measure (table 2). For children <2 years able to stand, 31.5% reported using the ‘paper and pencil’ method and 32.9% used a stadiometer. Differences between professional disciplines were not statistically significant; however, dietitians had the highest adherence to recommendations (table 2). Growth was measured ‘always’ at scheduled well-child visits by 80.8% (height) and 86.3% (weight) and at unscheduled sick visits by 9.6% (height) and 34.3% (weight). Reported growth chart use was 85.0%, predominately the WHO chart (80.0%).

Table 1

Reported current practices for measurement of weight and child dress by age

Table 2

Reported current practices for measurement of length and height by age and professional designation

In this study, we found that adherence to recommendations for use of appropriate equipment and technique for measuring infant and child weight was adequate to high, but for measuring infant length was low. Growth chart use was high, but measurement at unscheduled visits was low. A survey of Primary Care Trusts in the UK found that more than 50% of children under 5 years had both weight and height/length measured, almost always by a health visitor; however, equipment, technique and growth chart use were not examined.2 A survey of primary care practices in the USA showed that correct equipment was used in 22% for height and 12% for length.3

Limitations of our study include the small number of survey respondents, use of a survey rather than direct observation and the possibility that the findings may not be generalisable to practices throughout the region. These limitations may have resulted in a bias towards higher rates of adherence to current recommendations because many respondents were linked to academic centres. Finally, while we did not assess training of health professionals, the results of our study may be useful for informing future training.

Growth monitoring consists of serial measurement of weight, height/length and calculation of body mass index, with plotting of these measures on a growth chart. Our study suggests that growth monitoring can be improved by increasing the use of length boards for children <2 years of age and measuring and charting growth at both scheduled and unscheduled visits.



  • Contributors SC conceptualised the study design, analysed the data and drafted the manuscript. CSB, PCP and KT provided input on the study design and results. EP contributed to the data analysis plan and provided input on the study design and results. All authors critically reviewed the draft manuscript and approved the final manuscript as submitted.

  • Competing interests None declared.

  • Ethics approval Sick Kids Research Ethics Board.

  • Provenance and peer review Not commissioned; internally peer reviewed.