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PENS Position Statement on Linear Growth Measurement of Children

Published:January 22, 2015DOI:https://doi.org/10.1016/j.pedn.2014.12.008
      The Pediatric Endocrinology Nursing Society (PENS) is committed to advancing the art and science of pediatric endocrinology nursing. PENS members specialize in the nursing care of children with disorders of growth and hormone regulation. PENS believes that nurses are in a unique position to ensure accurate and reliable growth measurement, thereby promoting the timely recognition of abnormal patterns of growth.
      Since healthy infants and children have predictable patterns of linear growth (length/height), normal growth is used as a standard for assessing child health and well-being. Children with growth pattern deviations (e.g., unexplained short or tall stature, growth failure, growth acceleration) should be evaluated to differentiate between normal growth variants and pathologic conditions. Growth is such a sensitive indicator of health that abnormal growth may be the earliest sign of pathology (
      • Craig D.
      • Fayter D.
      • Stirk L.
      • Crott R.
      Growth monitoring for short stature: Update of a systematic review and economic model.
      ,
      • Haymond M.
      • Kappelgaard A.
      • Czernichow P.
      • Biller B.M.K.
      • Takano K.
      • Kiess W.
      Early recognition of growth abnormalities permitting early intervention.
      ). Pathological growth may result from nutritional disease, a genetic disorder, an endocrine cause, psychosocial problems, intrauterine growth retardation, or systemic disease and/or disease progression or exacerbation (
      • Haymond M.
      • Kappelgaard A.
      • Czernichow P.
      • Biller B.M.K.
      • Takano K.
      • Kiess W.
      Early recognition of growth abnormalities permitting early intervention.
      ,
      • Richmond E.J.
      • Rogol A.D.
      The child with tall stature and/or abnormally rapid growth.
      ,
      • Rogol A.D.
      • Hayden G.F.
      Etiologies and early diagnosis of short stature and growth failure in children and adolescents.
      ).
      Measurement error can occur when inaccurate instruments are used to obtain length or height (
      • Berkson S.S.
      • Espinola J.
      • Corso K.A.
      • Cabral H.
      • McGowan R.
      • Chomitz V.R.
      Reliability of height and weight measurements collected by physical education teachers for a school-based body mass index surveillance and screening system.
      ,
      • Gerner B.
      • McCallum Z.
      • Sheehan J.
      • Harris C.
      • Wake M.
      Are general practitioners equipped to detect child overweight/obesity? Survey and audit.
      ,
      • Lipman T.H.
      • Hench K.D.
      • Benyi T.
      • Delaune J.
      • Gilluly K.A.
      • Johnson L.
      • et al.
      A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement.
      ) or if accurate instruments are not properly calibrated (
      • Biehl A.
      • Hovengen R.
      • Meyer H.E.
      • Hjelmesaeth J.
      • Meisfjord J.
      • Groholt E.K.
      • et al.
      Impact of instrument error on the estimated prevalence of overweight and obesity in population-based surveys.
      ). Incorrect technique by the measurer is another source of measurement error (
      • Lima M.A.A.
      • Oliveira M.A.A.
      • Ferreira H.S.
      Reliability of anthropometric data obtained in children seen at the primary public healthcare service network in Alagoas, Brazil.
      ,
      • Lipman T.H.
      • Hench K.D.
      • Benyi T.
      • Delaune J.
      • Gilluly K.A.
      • Johnson L.
      • et al.
      A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement.
      ). Therefore, it is critical that measurers are educated and trained in correct technique, with their competency validated. Studies have shown that regular training, supervision and standardization increases the precision of anthropometric measures (
      • Becquey E.
      • Ouedraogo C.T.
      • Hess S.Y.
      • Rouamba N.
      • Ouedraogo J.B.
      • Brown K.H.
      Impact evaluation using child anthropometry: Technical error of measurement matters.
      ,
      • Lipman T.H.
      • Hench K.D.
      • Benyi T.
      • Delaune J.
      • Gilluly K.A.
      • Johnson L.
      • et al.
      A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement.
      ) as well as limiting the number of examiners obtaining measurements (
      • Geeta A.
      • Jamaiyah H.
      • Safiza M.N.
      • Khor G.L.
      • Kee C.C.
      • Ahmad A.Z.
      • et al.
      Reliability, technical error of measurements and validity of instruments for nutritional status assessment of adults in Malaysia.
      ). Measurements obtained by registered nurses were more accurate than those obtained by other personnel (
      • Hench K.D.
      • Shults J.
      • Benyi T.
      • Clow C.
      • Delaune J.
      • Gilluly K.
      • et al.
      Effect of educational preparation on the accuracy of linear growth measurement in pediatric primary care practices: results of a multicenter nursing study.
      ). Growth measurement error can lead to misinterpretation of growth patterns, resulting in delayed diagnosis and treatment in some children and inappropriate referral of normally growing children.
      An interdisciplinary team critically evaluated the evidence to develop a clinical practice guideline on linear growth measurement of children (
      • Foote J.M.
      • Brady L.H.
      • Burke A.L.
      • Cook J.S.
      • Dutcher M.E.
      • Gradoville K.M.
      • et al.
      Evidence-based clinical practice guideline on linear growth measurement of children.
      ), that was reviewed by PENS experts and endorsed by the PENS organization. The purpose of the guideline is to assist health care personnel in using standardized instruments and techniques to accurately and reliably measure growth. Pilot testing of the guideline revealed its ease of use and high intraexaminer and interexaminer reliability (
      • Foote J.M.
      • Brady L.H.
      • Burke A.L.
      • Cook J.S.
      • Dutcher M.E.
      • Gradoville K.M.
      • et al.
      Development of an evidence-based clinical practice guideline on linear growth measurement of children.
      ).
      PENS encourages nurses to examine and improve growth measurement practices in their primary care, acute care, specialty care, school, and other community health settings. Strategies to improve growth measurement practices have been published (
      • Foote J.M.
      Optimizing linear growth measurement in children.
      ,
      • Lipman T.H.
      • Hench K.D.
      • Benyi T.
      • Delaune J.
      • Gilluly K.A.
      • Johnson L.
      • et al.
      A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement.
      ). In addition, routine growth monitoring of children is a convenient and cost-effective method of assessing general health status (
      • Fayter D.
      • Nixon J.
      • Hartley S.
      • Rithalia A.
      • Butlet G.
      • Rudolf M.
      • et al.
      Effectiveness and cost-effectiveness of height-screening programmes during the primary school years: A systematic review.
      ).

      Position

      As nursing experts on children's growth and advocates for all children, PENS:
      • 1.
        Supports the American Academy of Pediatrics recommendations for growth measurement during periodic health maintenance visits;
      • 2.
        Encourages health care providers to measure linear growth during visits because of illness when health maintenance visits are missed, during chronic disease visits, and during hospitalizations to avoid missed opportunities to detect growth problems;
      • 3.
        Supports programs to train measurers and ensure competency (
        • Lipman T.H.
        • Hench K.D.
        • Benyi T.
        • Delaune J.
        • Gilluly K.A.
        • Johnson L.
        • et al.
        A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement.
        );
      • 4.
        Endorses the evidence-based clinical practice guideline on linear growth measurement (
        • Foote J.M.
        • Brady L.H.
        • Burke A.L.
        • Cook J.S.
        • Dutcher M.E.
        • Gradoville K.M.
        • et al.
        Evidence-based clinical practice guideline on linear growth measurement of children.
        );
      • 5.
        Supports the use of standardized and calibrated length boards and stadiometers;
      • 6.
        Opposes the use of tape measures (to measure the length of infants and other children who cannot stand alone) and height measurement instruments attached to weighing scales (with floppy-arm devices);
      • 7.
        Supports measuring children at least twice at each encounter and recording the mean of the measurements;
      • 8.
        Encourages institutions to adopt policies and procedures on growth measurement of children;
      • 9.
        Supports the use of growth charts to identify patterns of growth and compare them with population-based normative data. PENS supports the
        • Centers for Disease Control and Prevention
        Growth charts.
        recommendation for use of WHO growth charts for children from birth to 2 years and CDC growth charts for children age 2 and older for U.S. children; and
      • 10.
        Advocates for the review of growth patterns after each measurement to determine if: 1) the child is growing adequately; 2) the child's growth requires closer monitoring, further evaluation or referral; and 3) the child needs to be re-measured due to possible measurement error.
      Approved by the Pediatric Endocrinology Nursing Society on November 3, 2014
      Endorsed by the Pediatric Endocrine Society on November 7, 2014

      Resources

      The clinical practice guideline and resources can be accessed through the PENS Web site at http://pens.org/Pages/Linear-Growth-Measurement.aspx.
      The American Academy of Nursing features a Raise the Voice EDGE RUNNER training program on linear growth assessment at http://www.aannet.org/edge-runners--improving-the-accuracy-of-linear-growth-assessment-in-children.

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        Growth monitoring for short stature: Update of a systematic review and economic model.
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