Comparison of Broselow tape measurements versus physician estimations of pediatric weights
Original Contribution
Comparison of Broselow tape measurements versus physician estimations of pediatric weights?,??
Marcy Rosenberg MD?, Sarah Greenberger MD, Amit Rawal MD, Janese Latimer-Pierson MD, Josef Thundiyil MD, MPH
Emergency Department, Orlando Health, Orlando FL, USA
Received 25 August 2009; revised 2 December 2009; accepted 3 December 2009
Abstract
Objective: We sought to determine the agreement of physician estimates compared with Broselow tape measurements in accurately determining children’s weights. Our secondary objective was to evaluate whether physician adjustment of the Broselow tape weight measurement is a better estimate of pediatric weight compared with either method alone.
Methods: This cross-sectional study was conducted in the emergency department (ED) of a tertiary children’s hospital. Children between the ages of 0 and 14 years consecutively registered in the pediatric ED were eligible for enrollment. Height, weight, body mass index, and Broselow tape measurement were obtained for all subjects. Blinded ED physicians provided estimates for weight and Body habitus for enrolled subjects. Physicians next were given the Broselow weight measurement and then submitted a second, amended estimate (hybrid). Percentage differences were used to analyze the discrepancy between estimates and actual weight. Specifically examined were the proportion of estimates that fell within 10% of the patients’ actual body weights.
Results: A total of 372 subjects met the inclusion criteria. Mean age was 45.7 months, mean body mass index was 17.4, mean weight was 16.8 kg, and 39 participants (18.1%) met the definition for obese. Broselow estimates were within 10% of actual weight 63% of the time, physician estimates were within 10% of the actual weight 43% of the time and hybrid estimates 55% of the time. Based on average mean percent error, compared with actual weight, Broselow differed by 10.8% (95% confidence interval [CI], 9.7-12), hybrid estimate by 11.3% (95% CI, 10.3-12.2), and physician estimate by 16.2% (95% CI, 14.7-17.7). The Broselow tape was significantly worse than physician estimate for obese patients: 26.4% (95% CI, 19.7-33.1) versus 16.0% (95% CI, 12.3-19.8).
Conclusion: The Broselow tape generally has greater agreement with actual weight than physician visual estimation, except for obese children. Physician adjustment of the Broselow measurement also proved to be comparable to the Broselow tape.
(C) 2011
? Prior presentations: Abstract presented in poster format at Society for Academic Emergency Medicine Annual Meeting, Washington, DC, May 2008. Abstract presented in poster format at Society for Academic Emergency Medicine Southeast Meeting, Atlanta, Ga, March 2009. Abstract presented in poster format at Society for Academic Emergency Medicine Annual Meeting, New Orleans, LA, May 2009.
?? Nominated as semi-finalist in resident award category.
* Corresponding author. Tel.: +1 407 237 6329; fax: +1 321 843 6060.
E-mail address: [email protected] (M. Rosenberg).
0735-6757/$ - see front matter (C) 2011 doi:10.1016/j.ajem.2009.12.002
Introduction
Background
Providing sound pediatric resuscitative care depends on accurate dosing of medications; these selections are determined by pediatric patients’ weights. However, it is not always possible to measure weight on traditional scales, secondary to the urgency of certain patients’ conditions and need for Rapid treatment. Thus, it is necessary to rely on a set of measurement tools to quickly and precisely estimate pediatric patients’ weights. There are many systems available and multiple equations that have been developed for this purpose [1-5].
Currently, one of the most widely used systems for estimating a critically ill pediatric patient’s weight is the Broselow-Luten color-coded length-based estimation system (“Broselow tape”). Usage of this device is recommended by the Advanced Trauma Life Support and the pediatric advanced life support courses [6-8]. The Broselow tape was developed using the best data in population-based statistics to correlate patients’ height measurements with corresponding weights [1]. This color-coded system has improved the accuracy of selecting equipment size and Drug dosages in pediatric resuscitations. However, there is still room for improvement [2,9-11]: in a study where simulated pediatric trauma resuscitations were performed in both community hospitals and trauma centers, the Broselow tape was used correctly to estimate pediatric patients’ weights only 43% of the time [12].
Over the past 3 decades, population-based weight estimates in the pediatric population have changed dramat- ically [2]. The prevalence of overweight American children has increased greatly, with 22.6% to 31% of children now classified as either overweight or obese (based on body mass index [BMI]) [3]. With Childhood obesity still on the rise, current methods used to estimate pediatric weights could become more inaccurate, especially the Broselow tape, which only relies on the patient’s length to approximate the child’s weight.
Medical errors have been increasingly publicized in recent literature and are especially common in the pediatric population [13-15]. One study found a 39% medication error rate among children treated in the emergency department (ED), 16% with the potential to cause harm [14]. Moreover, incorrect patient weight is one of the most frequently reported errors in pediatric EDs [16].
For now, the Broselow tape remains one of the most commonly used method to estimate pediatric patients’ weights. Given the above circumstances, a more accurate- yet equally rapid-method to estimate pediatric weights seems warranted. It would stand to reason that direct physician visualization and estimation of weight could enhance the current system by including consideration of body habitus. Despite multiple studies evaluating the
accuracy of the Broselow tape, no study primarily compares the Broselow tape with direct physician visual estimation of pediatric weight. We sought to compare physician estimates to pediatric patients’ actual weights versus Broselow tape measurements to actual weights. Our secondary objective was to evaluate whether physician adjustment of the Broselow tape weight measurement is a better estimate of pediatric weight compared with either method alone.
Methods
Study design
This was a cross-sectional study that took place from September through December 2007. Our institutional review board approved this study. The study was exempted from obtaining written informed consent; however, verbal consent was obtained from the parents of all participants.
Study setting and population
This study was conducted in the ED of a tertiary children’s hospital with an Annual patient volume greater than 30 000. The ED is staffed by a consistent mix of board- certified ED physicians, board-certified pediatric ED physi- cians, pediatric residents, and ED residents.
Children were excluded if they were older than 14 years, known to be pregnant, in extremis, or if their height placed them outside the Broselow tape parameters.
Study protocol and data collection
All children between the ages of 0 and 14 years consecutively registered in the pediatric ED were considered for enrollment. Although the Broselow was optimally designed for patients up to 12 years old, we included subjects up to 14 years old, so as to capture the maximum number of subjects whose height placed them within the parameters of the Broselow Tape. Twelve years old was not selected as an absolute cutoff because age is not always known during resuscitation of critically ill patients. Eligible patients were enrolled only when 1 of the 2 trained data collectors were present and available. Data collectors were available Mondays to Fridays from 9 AM until 11 PM on randomly selected days. During these hours, the number of physicians on duty ranged from 4 to 6. The initial physician seeing the patient was selected for participation in the study. All physician providers in the ED, regardless of level of training or specialty, were eligible for participation. Participants were not given any specific training for this study or definitions for obesity. We collected the following data for each patient: age, sex, self-identified race, weight, and height. Subjects’ actual weights and Broselow estimated
weights were collected in triage. Upon meeting the patient and without the knowledge of the Broselow estimate, blinded treating physicians were asked to estimate the patient’s weight and body habitus (underweight, normal, overweight, or obese). After the physician estimated the subject’s weight, they were given the Broselow tape estimate for weight. The physician was then given the opportunity to amend their estimate (hybrid estimate).
Outcome measurements
Each patient’s demographic information, actual height and weight, Broselow estimated weight, physician estimated weight, hybrid estimate, and physician estimated body habitus were recorded. All measurements were performed, with shoes removed and with the children wearing light- weight apparel. All participants’ weights were collected using either the digital stand-on scale (Scale-Tronix 5202, Carol Stream, Ill), if the child was old enough to stand, or using the digital Pediatric/Neonatal Scale (Tanita BD-815U, Arlington Heights, Ill) in the case of infants. Trained data collectors then laid the child next to the Broselow-Luten 2007, edition B, measuring tape (Broselow Pediatric Emergency Tape; Armstrong Medical Industries, Lincolnshire, Ill), and esti- mated the weight based on where the child’s heels fell. Physician’s level and type of training were recorded.
Patients’ BMIs were calculated using the standard formula of: weight in kilograms divided by height in meters squared. Participants’ ages in months, sex, heights to nearest 0.1 centimeter, and weights to nearest 0.1 kg were inserted into the Centers for Disease Control and Prevention BMI calculator, and the patients’ BMI-for-age percentiles were calculated. From this percentile, each patient’s actual body habitus was classified using the standard of less than 5th percentile as underweight, 5th to 84th percentile as normal weight, 85th to 95th percentile as overweight, and greater than 95th percentile as obese. Based on Centers for Disease Control and Prevention guidelines, children younger than 2 years were excluded from BMI analysis [17]. The primary outcome was to determine whether physician estimates had greater agreement with actual weight than did the Broselow tape. As a secondary outcome, we compared the hybrid estimate with the other methods.
Data analysis
Using Microsoft Excel 2008, percentage differences were used to analyze the discrepancy between estimates and actual weight. Specifically, the proportion of estimates that were within 10% of the actual weight was measured [1,2]. Absolute values of percentage difference from actual weight were used to calculate mean, SD, and 95% confidence intervals (CIs) for physician, hybrid, and Broselow estimates. Absolute values were used to determine mean magnitude of variation because actual values would cause a false clustering around zero. We chose to look at estimates that fell within 10% of the patients’
actual body weights based on both the original, multicenter study used to validate the Broselow tape weight estimations and on recent Broselow studies [1,2]. We used a scatter plot to examine the direction and magnitude of differences for our primary outcome measure; this was done to determine whether underestimation or overestimation was more common. Furthermore, we used the Bland-Altman method to examine the agreement between each estimate type and the actual weight [18]. Ninety-five percent CIs were determined for each method. Results for each estimate type were stratified by age, race, height, obesity, and provider level/type of training to examine for patterns in variation of performance. Age comparisons were made for each tertile of age. Height was categorized into 4 groups based on pairing consecutive zones of the Broselow tape. The sample size was selected based on the comparison of 2 binomial proportions using the z test statistic to detect a difference of 20% between the groups. Group sample size of 120 in each group (total 240) would be required to achieve a 90% power at a significance of .05.
Results
There were initially 402 subjects consented for the study. Thirty subjects were excluded because their height placed them outside the parameters of the Broselow tape. The characteristics of the remaining 372 eligible subjects, as well as those of the physician participants, are described in Table 1. One hundred fifty-seven of the subjects were 24 months or younger and were excluded from BMI calculations. Table 2 describes the frequency that each estimate was within 10% of the actual weight. The Broselow tape and hybrid estimate performed significantly better than physician
Table 1 Characteristics of study subjects (n = 372)
Variable |
Mean age in months (SD) 45.7 (42.2) Mean weight in kg (SD) 16.8 (10.3) Sex (%male) 59.0 Race, n = 372 (%) White 26.8 Black 40.6 Hispanic 22.3 Mean BMI, n = 215 (%) 17.4 (63) Obese (BMI N95%) 18.0 Overweight (BMI 85%-95%) 17.7 Normal 56.3 Underweight (BMI b5%) 7.9 Physicians (n = 45) Pediatric trained 15 Nonpediatric trained 30 Resident (PGY 1-3) 26 Attending physician 19 Median number of estimates per physician 6 Range of estimates per physician 1-40 |
PGY indicates postgraduate year. |
22
50-60
54
24
13
58-68
63
by N10%
of actual of actual weight (%) weight (%)
38-48 27 29
of actual weight (%)
44
Physician estimate
Broselow tape
Hybrid
estimate
within 10% CI (%) by N10%
Overestimate Underestimate
Proportion 95%
Estimate type
Table 2 Comparison of proportion of estimates that are within 10% of the actual weight
estimate. Table 3 demonstrates that the Broselow tape differed from actual weight, on average, by 10.8% (95% CI, 9.7-12), hybrid estimate by 11.3% (95% CI, 10.3-12.2), and physician estimate by 16.2% (95% CI, 14.7-17.7). Based on mean percent error, physician estimate was worse than the Broselow estimate in every category except for obese patients, for whom physician mean percent error was 13.7% (95% CI, 10.2-17.2) versus 26.4% (95% CI, 19.7-33.1) for the Broselow tape. However, physicians were able to correctly identify patients as
Table 3 Breakdown of analysis, by specific category
being obese only 44% of the time. The Broselow tape estimates were notably worse than hybrid estimates for children older than 6 years: 15.5% (CI, 12.0-19.0) versus 9.3% (CI, 7.7-10.9) and children older than 120.75 cm tall (approximately 4 ft): 17.2% (CI, 12.8-21.5) versus 8.9% (CI, 6.9-10.8). Physician estimate did not vary significantly by level or type of training, or by subject race (Table 3).
Fig. 1 depicts a scatter plot comparing the difference between actual weight and 2 different estimation methods. The scatter of data is greater for larger patients. Figs. 2 to 4 are Bland-Altman plots demonstrating the agreement between the 3 methods of estimation and actual weight. The mean (SD) percent difference of each estimate from the actual weight (not absolute values) was -3.0% (15.3%; range, -85.6% to 29.3%) for Broselow, -2.8% (21.8%;
range: -95.6 to 53.7) for physician estimate, and -1.2%
(14.6%; range -53.5 to 42.3) for the hybrid estimate.
Discussion
The safety and success of Pediatric resuscitations depend on correct drug dosage administration, which, in turn,
Group (n) |
Mean percent error for physician estimate |
95% CI |
Mean percent error for Broselow |
95% CI |
Mean percent error for hybrid estimate |
95% CI |
Overall (372) |
16.2 |
14.7-17.7 |
10.8 |
9.7-12.0 |
11.3 |
10.3-12.2 |
Race |
||||||
Black (151) |
15.4 |
13.3-17.4 |
10.4 |
8.7-12.2 |
10.4 |
9.1-10.6 |
Hispanic (83) |
16.8 |
13.2-20.4 |
12.8 |
9.6-16.0 |
12.6 |
10.2-15.1 |
White (100) |
15.7 |
13.2-18.3 |
10.6 |
8.7-12.4 |
10.8 |
9.1-12.5 |
Obesity |
||||||
Underweight (17) |
18.3 |
13.0-23.6 |
13.4 |
10.7-16.1 |
15.4 |
11.2-19.5 |
(b5th percentile BMI) |
||||||
Normal (121) |
15.8 |
13.1-18.5 |
7.0 |
5.9-8.1 |
9.7 |
8.1-11.2 |
(5th-95th percentile BMI) |
||||||
Obese (39) |
16.0 |
12.3-19.8 |
26.4 |
19.8-33.1 |
13.7 |
10.2-17.2 |
(N95th percentile BMI) |
||||||
Age (y) |
||||||
0-2 (157) |
16.7 |
14.3-19.1 |
9.3 |
8.1-10.5 |
11.9 |
10.5-13.4 |
2-6 (124) |
16.9 |
14.1-19.6 |
9.4 |
7.8-11.0 |
11.9 |
10.1-13.7 |
N6 (91) |
14.6 |
11.9-17.3 |
15.5 |
12.0-19.0 |
9.3 |
7.7-10.9 |
Height (cm) |
||||||
b74 (88) |
17.3 |
14.1-20.5 |
9.6 |
7.8-11.4 |
12.5 |
10.5-14.5 |
74-97.5 (117) |
15.5 |
12.6-18.3 |
9.3 |
7.1-11.4 |
11.3 |
9.5-13.1 |
97.5-120.75 (102) |
17.9 |
15.0-20.8 |
9.6 |
7.7-11.5 |
11.7 |
10.0-13.5 |
N 120.75 (65) |
13.4 |
10.7-16.2 |
17.2 |
12.8-21.5 |
8.9 |
6.9-10.8 |
Pediatric trained physician |
||||||
Yes (155) |
15.8 |
13.7-18.0 |
11.2 |
9.2-13.3 |
11.3 |
9.8-12.7 |
No (217) |
16.5 |
14.4-18.6 |
10.5 |
9.2-11.8 |
11.3 |
10.0-12.5 |
Level of training |
||||||
PGY 1 (54) |
16.6 |
12.9-20.4 |
9.7 |
7.3-12.1 |
11.1 |
8.7-13.4 |
PGY 1-3 (179) |
16.3 |
13.9-18.7 |
10.5 |
9.1-12.0 |
11.4 |
9.9-12.8 |
Attending (193) |
16.2 |
14.3-18.1 |
11.1 |
9.4-12.9 |
11.3 |
10.0-12.5 |
PGY indicates postgraduate year. |
Fig. 1 Scatter plot comparing difference between actual weight and 2 estimation methods. Horizontal axis represents actual weight (kg). Vertical axis represents difference between estimate and actual weight. Dotted line represents estimates within +-10% of actual weight.
requires accurate determination of pediatric patients’ weights. However, published studies have questioned the accuracy of the Broselow tape, the standard method of estimating pediatric weights. Nieman et al [2] studied the accuracy of the Broselow tape in estimating weight and medication doses in 7500 children and found the Broselow tape to be accurate in predicting actual weights (to within
+-10%) in only 55.3% of the study population, leading to correct resuscitation medication doses in just more than 60% of the cases. Our study showed a similar accuracy with this study when comparing Broselow tape with patients’ actual weights. Our data further suggested that the Broselow tape’s performance was particularly poor in predicting obese patients’ weights. In this subset of our study population, physicians outperformed the Broselow tape. This may be of particularly importance when dosing lipophilic drugs, such as midazolam or amiodarone. Underestimating weight in this situation could necessitate multiple redosing of medication, prolonging the resuscitation process and possibly leading to adverse outcomes [2].
Despite concerns about the inaccuracy of Broselow- derived weight estimates, several studies that examined alternative weight estimation methods-often complicated reference tables or formulas requiring physician calculation
-failed to identify a clearly superior method. A 2002 study by Black et al [4] comparing 6 methods of estimating pediatric weight showed that the Broselow tape and the devised weight estimation method (DWEM) were more accurate than all other formulas and tables studied. However, in directly comparing the Broselow tape and DWEM in
400 children of varying weights, Dubois et al [3] found both methods plagued by underestimations, in all weight classes for the Broselow tape, and in those weighing more than 20 kg for DWEM. Of note, the DWEM requires providers to accurately assign body habitus to children. Our results suggest that physicians’ accuracy in estimating body habitus is poor, with physicians correctly identifying obese children as such only 44% of the time. It is possible that physicians have become accustomed to the increasing prevalence of obesity and have altered their expectations of a healthy body habitus or that gradations of obesity or muscularity may account for this discrepancy.
Seeking a simpler and better way to estimate pediatric weights, Krieser et al [19] recently compared various existing methods of pediatric weight estimation with not only the Broselow tape but also with parental estimation of children’s weights. Parental estimation was more accurate than the Broselow tape estimations (78% accuracy versus 61%). Other studies have demonstrated similar accuracy of parental estimations; unfortunately, parents are not always available to provide such estimations when needed [20,21]. Another recent study by Thompson et al [5] suggests using age-based weight estimation. However, accurate ages, too, may be unknown in resuscitation situations.
Generally, it is accepted that Medication errors have the potential to cause significant morbidity and mortality [22]. Although weight-based dosage of medications remains a tenet of pediatric resuscitation, the extent to which overdosage or underdosage of medications can cause harm is unclear. Certainly, errors in dosing have the potential to have significant effects in an infant, due to a combination of physiologic factors, such as size of Circulating blood volume and percent body fat, which leave children with limited internal reserves with which to buffer error.
Fig. 2 Bland-Altman plot for Broselow estimate. Horizontal axis represents mean of actual weight and Broselow estimated weight. Vertical axis represents percentage difference between Broselow and actual weight. Dotted lines represent 95% CI.
Administering incorrect amounts of resuscitative medi- cations to children potentially decreases the patients’ likelihood of survival. Therefore, an accurate and easy method of estimating pediatric resuscitation medication doses is imperative.
Limitations
Because our study used a single clinical site, generaliz- ability of our results to other EDs or clinical environments may be limited. Our study was conducted in a children’s hospital, in which almost half of the estimates were done by pediatrics-trained attendings. This could create a bias toward more accurate estimates, as compared with general EDs with much lower pediatric censuses. However, our results demonstrate no difference based on training. In addition, our data collection periods were dependent on availability of a trained data collector, potentially introducing further bias. A practice effect might have occurred in that physicians with multiple estimates may have improved with repetition. Also, some aspects of the study design may have affected physicians’ ability to estimate weight. For example, it is a policy at our hospital that all infants are weighed without clothes or diapers on; however, participants old enough to use the stand-on scale were weighed and had visual estimations of weight performed while clothed. Further- more, we excluded all patients older than 14 years, patients longer than the Broselow tape, and all pregnant patients. Physicians are more accurate in estimating adult weights than pediatric weights, so it is possible that the performance characteristics of our estimation methods might be different
Fig. 3 Bland-Altman plot for physician estimate. Horizontal axis represents the mean of actual weight and physician estimated weight. Vertical axis represents percentage difference between physician estimate and actual weight. Dotted lines represent 95% CI.
Fig. 4 Bland-Altman plot for hybrid estimates. Horizontal axis represents the mean of actual weight and hybrid estimated weight. Vertical axis represents percentage difference between hybrid estimate and actual weight. Dotted lines represent 95% CI.
for the older, larger population, which also might have a higher prevalence of obesity [23].
Enhancing its external validity, however, our study involved physicians of varying levels and types of educational training, as well as a diverse patient population. Moreover, the prevalence of obese children in our study was 18.1%, comparable with the national prevalence of 13.9% to 19% [17]. In addition, our Broselow estimates were accurate approximately 63% of the time, consistent with accuracy found in other studies reviewing the Broselow tape [2,19].
Although our study was not specifically designed to examine obese patients, physicians in our study out- performed the Broselow in estimating the weight of obese children; the significance of this finding is unclear. Future studies should explore whether the inaccuracies of Broselow estimates compared with physicians estimates for obese, older, and taller children hold true in a larger study.
Finally, care should be exercised in extrapolating that incorrect medication dosing necessarily result from inaccu- rate estimation of weights, particularly in the overweight/ obese population. Estimation of ideal body weight-rather than actual body weight-may be more important in correctly determining resuscitation needs [24-26].
Conclusions
Incorrect dosing of medication can lead to much morbidity and mortality [11,13-15,22,27-29]. More accurate weight estimates in critically ill children will help reduce medication errors. This study demonstrated that the Brose- low tape is more accurate than physician visual estimation in estimating pediatric patients’ weights. However, physician
adjustment of the Broselow tape estimate proved to be a useful adjunct, especially for children who are obese, older than 6 years, or greater than 4 feet tall. As such, continued use of the Broselow tape to determine pediatric weights in resuscitation situations is justified, albeit with the recognition that this method may underestimate weight. When weight estimations are needed for clearly obese, taller, or older children, physician adjustment of the Broselow estimate should be considered.
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