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• Patients are weighed but not plotted
  Udoka Onyeaso
  Published on: 22 March 2016
• Assessment of growth
  David M Hall
  Published on: 22 March 2016
• Children's growth: measured but rarely plotted
  Louisa Pollock
  Published on: 22 March 2016

• Published on: 22 March 2016

  Patients are weighed but not plotted

  • Udoka Onyeaso, ST5 in Paediatrics

  Most patients presenting to a paediatric department for acute care will be weighed as part of the nursing assessment especially because weights are important for drug and fluid prescriptions. Junior doctors however generally fail to take the next step in this opportunistic contact to plot these weights. Unless clinically indicated e.g. as part of body surface area for drug prescriptions, the height is often not measured,...

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  Most patients presenting to a paediatric department for acute care will be weighed as part of the nursing assessment especially because weights are important for drug and fluid prescriptions. Junior doctors however generally fail to take the next step in this opportunistic contact to plot these weights. Unless clinically indicated e.g. as part of body surface area for drug prescriptions, the height is often not measured, nor is head circumference routinely measured. Indeed, this is a reflection of less than best practice and needs to be highlighted as part of junior doctor induction.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Assessment of growth

  • David M Hall, emeritus professor

  The paper by Lek and Hughes highlights a serious deficiency in the assessment of children admitted to their hospital and there is no reason to think that their findings are atypical. However, there are two important issues arising from their work.

  First, the authors failed to define good practice. Is it realistic to expect specialist surgeons to measure a child’s height and weight in their outpatient consul...

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  The paper by Lek and Hughes highlights a serious deficiency in the assessment of children admitted to their hospital and there is no reason to think that their findings are atypical. However, there are two important issues arising from their work.

  First, the authors failed to define good practice. Is it realistic to expect specialist surgeons to measure a child’s height and weight in their outpatient consultations? And it appears that the clinical episodes included both new patients and follow-up visits – but should paediatricians do this at every consultation or would it be sufficient to measure a child at the first visit and thereafter only as indicated? The paper would have been more convincing if the authors had followed good audit principles and decided what constitutes good practice before collecting their data.

  The second concern about this paper is the terminology used by the authors. If a child presents with a health concern, whether identified by parents or by health professionals, clinical evaluation should normally include assessment of growth. That is no more “opportunistic” than taking a proper history and conducting a physical examination. An example of how the term “opportunistic” can be used legitimately would be catching up on missed immunisations for a child admitted to the ward.

  This paper tells us that current practice is poor and that we lack a consensus statement on good hospital practice in assessing growth. There is a legitimate continuing debate about monitoring the growth of all children to detect disorders of growth and emerging obesity but this paper throws no new light on that debate, except perhaps to warn us that if we cannot even get paediatricians to weigh and measure appropriately, there would be a long battle ahead to introduce a more ambitious programme of growth monitoring in primary care settings.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Children's growth: measured but rarely plotted

  • Louisa Pollock, Specialty Registrar Paediatrics
  • Other Contributors:
    • Paul Higgins, and Adrienne Sullivan

  Lek and Hughes(1) recently highlighted concerns that opportunities for growth measurement in children attending hospital are frequently missed. This has important implications for the current UK policy for growth monitoring, which encourages opportunistic measurement. It also has important implications for clinical practice –growth faltering may result from any chronic illness or may be the only marker of abuse or neglect...

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  Lek and Hughes(1) recently highlighted concerns that opportunities for growth measurement in children attending hospital are frequently missed. This has important implications for the current UK policy for growth monitoring, which encourages opportunistic measurement. It also has important implications for clinical practice –growth faltering may result from any chronic illness or may be the only marker of abuse or neglect. In this context growth measurement in children attending hospital should not be seen as opportunistic, but as an essential part of good clinical care.

  Lek and Hughes examined measurement of growth in a hospital with both paediatric and non-paediatric patients. We aimed to determine the frequency of growth measurement in a dedicated children’s hospital. In addition we examined whether growth was assessed by plotting data on a centile chart.

  We undertook a cross-sectional study of all patient episodes (outpatient visits, admissions and inpatients) over a 24 hour period in September 2009 at the Royal Hospital for Sick Children, Glasgow. We excluded children attending specifically for growth problems, and those attending the emergency department, fracture clinic and day care units. We examined case records to determine whether height, weight and head circumference (in children <2 years) had been recorded and plotted on a standardised growth chart. Recent measurements during the current admission were accepted for in-patients.

  Comparisons were made between measurements below and above 2 years of age and between in-patient and out-patient settings. Statistically significant differences were identified using Fisher’s exact test.

  Data were available for 323 children (140 in-patients, 183 out- patients). Mean age was 6.14(range 0.02-17.79) years. 89 children were under 2 years (53 in-patients, 36 out-patients). Table 1 summarises measurements recorded and plotted, and comparison between groups. Weight was recorded in 234 (72%) cases, of which 59 (25%) were plotted. Weight was significantly more likely to be recorded in in-patients (p=0.02), but less likely to be plotted (p=<0.01). Height was recorded in 152 (47%) cases, of which 49(32%) were plotted. Outpatient heights were more likely to be plotted (p=0.03). Head circumference was recorded in 5 (6%) of the 89 children under 2 years, only 3 were plotted.

  In Lek and Hughes study weight and height were recorded in 51.5% and 12.5% of children respectively. Our data suggests that growth measurements are more frequently recorded in this children’s hospital, however opportunities are still missed. Measurement of head circumference was particularly poor. We also found that growth measurements were rarely assessed by plotting on a growth chart. Plotting is a key method of identifying growth trends.

  Some specialities used computer calculated standard deviation scores for growth monitoring. This may be useful as a screening tool but only identifies children outwith the normal range and not those with abnormal trends. In-patient height recording is likely to have been improved by local use of the PYMS score(2)for nutritional screening; however this tool is not designed to monitor growth.

  We agree with Lek and Hughes that growth measurement in hospital needs to be improved. In busy hospitals measurement and plotting of growth parameters may be time-consuming, but simple changes such as mandatory placement of growth charts in notes, decimal age calculators and staff training could help. Computer software could potentially be used to plot growth parameters, flag up ‘danger’ signs and provide a central database for monitoring. Any such software would need to be easily accessed by all professionals.

  Growth measurements need to be made, recorded, assessed and acted upon to form an effective part of good paediatric care.

  References

  1. Opportunistic growth measurements are not frequently done in hospital. Lek N, Hughes IA. Archives of Disease in Childhood 2009;94:702- 704

  2. Implementing a novel paediatric nutritional screening tool (Paediatric Yorkhill Malnutrition Score)-challenges and impact in paediatric nursing practice. Macleod et al. Journal of paediatric gastroenterology and nutrition 2009; 49(4). ESPGHAN abstract AHP-08.

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  Conflict of Interest:
  None declared.

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