A Validation Study of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) Tape–A New Weight Estimation Tool

doi:10.1016/j.jpeds.2015.04.006

The Journal of Pediatrics

Volume 167, Issue 1, July 2015, Pages 173-177.e1

https://doi.org/10.1016/j.jpeds.2015.04.006 Get rights and content

Objective

To evaluate the performance of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) tape, a new weight-estimation tool with a modifier for body habitus, in our increasingly obese population.

Study design

A convenience sample of children presenting to the pediatric emergency department of an urban public hospital was enrolled. A nurse or doctor assigned the patient a body habitus score and used the PAWPER tape to estimate the weight. The true weight was then recorded for comparison.The estimated weight was considered accurate if it was within 10% of the true weight.

Results

We enrolled 1698 patients; 579 (34%) were overweight or obese. Overall, the estimated weight was accurate for 64% of patients (95% CI 61%-65%). For children with an above-average body habitus, the tape was accurate 50% of the time (95% CI 46%-55%). There was no significant difference in the accuracy of the PAWPER tape for children assessed during medical and trauma resuscitations.

Conclusion

Although the PAWPER tape may ultimately be useful, its initial performance was not replicated in our population. A simple, accurate method of weight estimation remains elusive.

Section snippets

Methods

The study was approved by the institutional review board of the Albert Einstein College of Medicine (institutional review board no. 2013-2017). Before enrollment began, all nurses and participating doctors attended a 10-minute session in which the proper use of the PAWPER tape was demonstrated. Habitus score (HS) diagrams were posted in our PED triage areas and in both of our resuscitation bays. We encased the PAWPER tapes in rigid plastic to allow for ease of use and cleaning, particularly

Results

A total of 1698 patients were enrolled. Sample population characteristics are described in Table I. Figure 2 (available at www.jpeds.com) demonstrates the distribution of enrolled patients by their BMI-for-age percentile. The test characteristics of the PAWPER tape in our sample are listed in Table II. Using the PAWPER tape, we found only 63.5% of all patients had estimated weights within 10% of their true weight. Moreover, this measure of accuracy decreased as both the patient's weight and HS

Discussion

Obesity has more than doubled in children and quadrupled in adolescents in the US during the past 30 years.24, 25 This represents an important change in the habitus and weights of our nation's children since the 1980s when the Broselow Tape was first introduced. In the Bronx, NY, where our institution is located, prior studies have demonstrated that one third of children are overweight (BMI-for-age percentile 85 - 95%) or obese (BMI-for-age percentile ≥ 95%).¹⁸ Our sample is consistent with

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Cited by (19)

Weight estimation in two groups of Ghanaian children with chronic diseases using Broselow, Mercy, PAWPER XL and PAWPER XL-MAC tapes
2023, African Journal of Emergency Medicine
The performance of various weight estimation methods in children with sickle cell disease (SCD) and heart disease (HD) has not been studied. We aimed to determine and compare the accuracies of the Broselow, Mercy, PAWPER XL and PAWPER XL-MAC tapes in Ghanaian children with no known chronic diseases (controls), SCD and HD.
We prospectively recruited 631 children (199 with HD, 209 SCD and 223 controls) from the Komfo Anokye Teaching Hospital (KATH). Their weights were estimated using the Broselow, Mercy, PAWPER XL and PAWPER XL-MAC tapes. These estimated weights were compared to measured weight using mean percentage error (MPE), the proportion of weight estimates within ±10% (P10) and ±20% (P20) of measured weight. Bland-Altman limits of agreement (LOA) were determined to assess the precision of weight estimation and agreement with measured weight.
The PAWPER XL, Mercy and PAWPER XL-MAC were the most accurate in all groups of children studied. All methods except the Broselow tape (BT), which performed best in the control group, had their best performance among children with SCD with negligible critical error rates (proportion of children with weight estimates > 20% of their actual weight). The P20 in the various groups of children using the BT were 88.36%, 80.21% and 51.10% respectively in the control, SCD and HD groups. The Mercy, PAWPER XL and PAWPER XL MAC tapes were generally above 90% in all groups.
The Mercy, PAWPER XL and PAWPER XL-MAC tapes performed significantly better than the BT in all groups of children studied. These methods of weight estimation performed best in children with SCD with very little critical error.
The PAWPER tape as a tool for rapid weight assessment in a Paediatric Emergency Department: Validation study and comparison with parents’ estimation and Broselow tape
2022, Resuscitation Plus
Citation Excerpt :
In 2012, Wells et al. developed and validated the PAWPER tape in a South African population.6 The accuracy of the PAWPER has been confirmed in a small sample of 199 Australian children,10 while it has not been confirmed in a larger sample in the United States.1 To our knowledge, the PAWPER tape has not yet been validated in any European centre.
To validate the PAWPER tape and assess its inter-observer reliability in children accessing a Paediatric Emergency Department (PED). As secondary outcome we compared the accuracy of the PAWPER tape with that of parents’ estimation, the Broselow tape and the European Paediatric Life Support (EPLS) formula.
This was a cross-sectional study of children (0–12 years) enrolled in a tertiary Paediatric Emergency Department in Italy. Children’s weight was estimated by parents and by trained healthcare providers using the PAWPER tape, the Broselow tape and the EPLS formula. The root mean squared percentage error (RMSPE) for the estimation of precision was calculated. Overall accuracy was evaluated using the percentage of weight estimation falling within 10% (PW10) and 20% (PW20) of real weight.
The study included 2060 children. Parental estimation was the most accurate and precise method. The PAWPER tape was accurate throughout all habitus sizes except for extreme underweight and overweight categories. Furthermore, it was more accurate and more precise than the Broselow tape and the EPLS formula (p adjusted <0.001).
The PAWPER tape served as an accurate method for weight estimation in children accessing a Paediatric Emergency Department, with excellent inter-rater reliability. It performed significantly better than other length or age-based tools, showing good accuracy and precision except for very extreme weights. Whilst parents’ estimation yielded to be the most accurate and precise method, the age-based EPLS formula was not reliable for estimating weight in all subcategories of habitus.
Roll up the tape? Laser and optical technologies improve paediatric weight estimation
2020, Resuscitation
A robust estimation method is needed to prevent medication dosing and equipment sizing errors and improve time to administration during paediatric resuscitation. An electronic measurement with computer interface may improve accuracy and alleviate cognitive burden. This study evaluates the accuracy of two electronic height measurement methods, a laser and an optical device, and compares them to the Broselow™ Pediatric Emergency Tape (BT) for weight estimation.
We enrolled children ages 0–14 years from the emergency department of a free-standing, academic children’s hospital. We obtained sex, body habitus, true weight, true height, BT colour, and experimental heights. We converted experimental height measurements into weight estimates using standardised growth charts. We calculated Pearson correlations between experimental and actual measurements and the percentages of weight estimates within 10% and 20% of true weights. We repeated analyses on a restricted cohort of children 0–11 years, the intended BT age range.
We enrolled 198 children. The laser, optical device and BT weight estimates had strong positive correlations with the actual weight measurements with Pearson’s correlation coefficients of 0.946, p < 0.0001, 0.965, p < 0.0001, and 0.825, p < 0.0001 respectively. 47.8% of optical weight estimates fell within 10% of actual weight and 80.6% within 20%, compared to 40.5% and 75.4% of laser estimates and 39.8% and 65.1% of BT estimates.
Electronic-based weight estimates were more accurate than the BT. The accuracy of medication dosing and equipment sizing during paediatric resuscitation may be improved by integrating optical height-based weight estimates with electronic clinical decision support.
The accuracy of paediatric weight estimation during simulated emergencies: The effects of patient position, patient cooperation, and human errors
2018, African Journal of Emergency Medicine
Citation Excerpt :
The observed associations were unlikely to significantly impact on overall accuracy. Previous studies on the original PAWPER tape showed a high accuracy in populations with a low prevalence of obesity with a PW10 >80%, but a lower accuracy in populations with a high incidence of obesity with a PW10 60–70% [2,24,34,35]. The lack of association with habitus in this study provided preliminary evidence that the PAWPER XL tape may have addressed this problem.
The effect of patient position and patient cooperation on the accuracy of emergency weight estimation systems has not been evaluated previously. The objective of this study was to evaluate weight estimation accuracy of the Broselow tape, the PAWPER XL tape, the Mercy method, and a custom-designed mobile phone App in a variety of realistic simulated paediatric emergencies.
This was a prospective study in which 32 emergency medicine volunteers participated in eight simulations of common paediatric emergency conditions, using children models. The participants used each of the four methods to estimate the children’s weight. The accuracy of and time taken for the weight estimations were evaluated for each method. A regression analysis determined the effects of patient position and cooperation on weight estimation accuracy. Evaluation of subgroups of best-performers and worst-performers among the participants provided information on the effects of human user-error on weight estimation accuracy.
The Broselow tape, Mercy method, App and the PAWPER XL tape achieved percentages of weight estimation within 10% of actual weight in 47.7, 57.3, 68.1, and 73.0% of estimations, respectively. Patient position and cooperation strongly impacted the accuracy of the Broselow tape, had a minimal effect on the Mercy method and the App, and had no effect on the PAWPER XL tape. The best performing participants achieved very high accuracy with all methods except the Broselow tape.
The Mercy method, the App, and the PAWPER XL tape achieved exceptionally high accuracy even in uncooperative and sub-optimally positioned children when used by the best-performing participants. Human error, from inexperience and inadequate training, had the most significant impact on accuracy. The Mercy method was the most subject to human error, and the PAWPER XL tape, the least. Adequate training in using weight estimation systems is essential for paediatric patient safety.
The Use of Body Habitus Reference Images Improves the Ability of Novices to Accurately Estimate Children's Weight Using the PAWPER XL Tape System
2018, Journal of Emergency Medicine
The original methodology of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) tape relies on a gestalt visual assessment of a child's body habitus to adjust a length-based weight estimation. This assessment is dependent on the user's subjective opinion, which may result in aberrations in accuracy between users and populations. With the development of the second-generation PAWPER XL tape, a more objective method of habitus evaluation was desired.
The aim of this study was to evaluate a new, more objective figural reference image system and a new checklist system for quantifying body habitus.
Volunteers were asked to assess the body habitus score of 90 children from a sequence of photographic images using the standard gestalt visual assessment system, a new checklist system, and a system using figural reference images. PAWPER XL tape weight estimations were generated from these scores, which were compared between the three test groups. Participants were also surveyed on their preferences for the different methodologies.
There were 11,505 habitus score assessments from 138 doctor, nurse, and paramedic participants. The figural reference image system significantly outperformed the checklist system and the gestalt visual assessment system in terms of weight estimation accuracy, achieving 70.9%, 61.1%, and 60.9% of estimations within 10% of measured weight, respectively. The participants expressed a strong subjective preference for the image system because of speed of use, ease of use, perceived accuracy, objectivity, and low cognitive load.
The figural reference image system was objectively much more accurate than, and subjectively preferable to, the original gestalt visual estimation methodology.
Paediatric weight estimation by age in the digital era: optimising a necessary evil
2018, Resuscitation
Citation Excerpt :
There is considerable subjectivity in visual assessment of habitus. Correlation between evaluator assessment of patient habitus and actual BMI-for-age centile has been found by Garcia et al, to be suboptimal in one study, although for a considerably simpler tool [11]. Because it may be difficult to distinguish between adjacent body habitus scores when examining patients, misclassification will almost certainly occur for both the experimental model and the Wells formula, with a consequent decrease in performance.
Age-based weight estimation methods are regularly used in paediatric emergency medicine despite their well-established inaccuracy.
Determine the potential improvement in accuracy achievable by the use of a new mobile application, based on CDC/WHO weight-for-age centile data, which incorporates a gender assignment, a body habitus assessment, and which is capable of an age-in-months based calculation.
A theoretical, simulated validation study, comparing the performance of the widely used APLS/EPALS formulae against two contemporary habitus-adjusted methods, and the Helix Weight Estimation Tool. 1,070,743 children from the 2015/2016 UK National Child Measurement Program dataset, aged between 4 and 5 and 11 and 12 years, had age-based weight estimates made by all five methods.
Primary outcomes were the percentage of weight estimations within 10%, 20%, and those greater than 20% discrepant from actual weight for each method. Our theoretical, gender-dependent, habitus-adjusted method performed better than all other methods across all error thresholds. The overall number of estimations within 10% was 70.4%, and within 20% was 95.45%. The mean percentage error was −1% compared to actual weight.
The use of a digital tool incorporating a subjective assessment of body habitus, gender assignment, and the ability to estimate weight based on age-in-months might be able optimise the process of paediatric weight estimation by age, making this practice as safe and accurate as possible for the occasions when weight estimation by age is chosen over length-based methods.

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: The authors declare no conflicts of interest.

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Original ArticleA Validation Study of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) Tape–A New Weight Estimation Tool

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Resuscitation

Resuscitation

Am J Emerg Med

A comparison of two commonly used methods of weight estimation

Arch Dis Child

Make your Best Guess: an updated method for paediatric weight estimation in emergencies

Emerg Med Australas

Weight estimation in paediatrics: a comparison of the APLS formula and the formula 'Weight=3(age)+7'

Emerg Med J

Emergency weight estimation in Pacific Island and Maori children who are large-for-age

Emerg Med Australas

Original Article
A Validation Study of the PAWPER (Pediatric Advanced Weight Prediction in the Emergency Room) Tape–A New Weight Estimation Tool