Assessment and measurement of growth is vital and must be done with good precision and accuracy to be meaningful.
It provides a sensitive guide to a child’s: (Freeman et al, 1995; Gibson, 1990; Hall, 2000; Voss, 2000)
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health
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development
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nutritional status
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response to treatment
A healthy adequately nourished and emotionally secure child grows at an optimal rate (Paton et al, 1962; Stanhope et al, 1994).
A slow rate of growth could suggest a pathological disorder requiring diagnosis and possible treatment, eg malabsorption, an eating disorder, hypertension, psychosocial problems, craniopharyngioma (Sherwood, 1986; Skuse, 1989).
Regular measurement of children can allow early diagnosis of these problems (Stern, 1985). Minimal intervals between measurements should be no more than three months.
Many diseases do not cause obvious symptoms and poor growth may be the first or only indicator of a problem (Hall, 2000; Smith et al, 1986).
Whenever a child is admitted to Great Ormond Street Hospital (GOSH), including day cases, their height or length must be measured and documented on the charts relevant to their age within 24 hours.
This measurement must be:
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recorded in the child’s health care/parent held record
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recorded in the Patient Assessment Form (PAF)
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recorded on the Nutrition Screening Flowchart
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recorded on the Electronic prescribing system
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plotted on a centile chart
The date, time and the name of the measurer must also be recorded (Voss, 2000).
Unless specifically asked to do it more frequently, a child who attends the outpatient department should normally have their height or length measured at least every six months.
Every three months, all children over one year of age, must have their height measured and plotted on a centile chart (Rationales 2 and 3).
Every month children under the age of one need to have their length measured and plotted.
The Nutrition Screening Flowchart require infants who are in hospital to have their length measured monthly as this should be a period of rapid growth. A young infant on the 50th centile can grow 3cm over a four week period whereas a one year old on the 50th centile grows 3cm over a three month period.
A single measurement does not reflect the rate of growth (Rationale 4).
To be useful it is essential that a child’s height or length is: (Rationale 1)
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accurately measured using good equipment (Doull, 1995)
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recorded with the date in the child’s health care records
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plotted accurately on a centile chart
The technique used to obtain an accurate measurement of height or length is crucial (Voss, 2000; Voss et al, 1990).
Preparation
Child and family
Inform the family, and child if age appropriate, of the following: (Rationales 5, 6 and 7)
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that a measurement of height or length is required
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the reason for the measurement
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what it entails
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the likely length of the procedure
Prior to measuring a child it is essential to consider their: (Rationale 8)
The child should normally have the following removed: (Voss, 2000) (Rationales 9, 10, 11 and 12)
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their shoes
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hair clips
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braids, ie undo hair
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orthopaedic braces
The child’s health care records must indicate if any of these items are not removed. (Rationale 12)
The child should be advised that the headboard will make a noise (Rationale 13).
The child may require preparation from a play specialist or healthcare professional prior to measuring their height (Rationale 14).
Equipment
The technique used to measure the height or length of a child is the same regardless of the equipment to be used.
Most of the anthropometric instruments (measuring equipment) used in clinical practice have digital counter displays. (Rationale 15)
Prior to using the equipment it must be calibrated against a rod of standard length or by the baseline readout and checked for cleanliness. (Rationale 16)
The following equipment is recommended and can be ordered via E-Procurement:
The headboard of the stadiometre must be weighted with a 500gram wipeable beanbag. This may also be used to calibrate weighing scales (Rationale 20).
Equipment is available in the outpatient department for measuring a child’s sitting height.
The outpatients department must be contacted in advance to arrange access to the equipment (Rationale 21).
All the measuring equipment must be checked: (Rationale 16)
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prior to each use and after each session with the calibration rod (Voss, 2000)
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annually by the Biomedical Engineering department
If the equipment becomes faulty contact the Biomedical Engineering Department (Rationale 22).
Measuring technique
Selecting position
A child should be measured supine (lying face upward) until two years of age (Rationale 23).
Document method used in medical and nursing documentation.
A child who is unable to stand, or who finds standing difficult, due to illness or physical disabilities should also be measured supine (Rationale 23).
A child who has one leg shorter than the other should be measured standing on the longest leg. They should always be measured on the same leg and this leg documented in records for future use (Rationale 24).
In some forms of short stature, body proportions may also be clinically relevant, eg achondroplasia, or after spinal irradiation (Rationales 25 and 26).
The most useful body proportion is the relationship between trunk length and leg length.
This is obtained by measuring a sitting height & subtracting this from the total height.
Children who need to be measured lying down should have their crown rump length measured, ie head to bottom. This measurement is then subtracted from the child’s total length.
Standing height
The positioning of the child is crucial (Rationale 27).
Extreme care must be taken when measuring a child who has: (Rationale 28)
The person measuring the child must first: (Rationale 29)
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assess the need for standard precautions
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wear appropriate protective clothing to meet any identified risk
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perform a social hand wash and thoroughly dry their hands (Your 5 Moments for Hand Hygiene) (PDF, 185 KB)
The child may require play and distraction techniques to be utilised whilst obtaining the measurement (Rationale 30).
It is often easier if two people are involved in the measurement of a child, one of who may be a parent or carer (Rationale 31).
The measurer must ensure they are eyeball to eyeball with the child to be measured (Rationale 32).
The child’s body must be positioned with their:
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feet together
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feet flat on the ground
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heels touching the back plate of the measuring instrument
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legs must be straight
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buttocks against the backboard
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scapula, wherever possible, against the backboard
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arms loosely at their side
The child’s head must be positioned with the lower margins of the orbit in the same horizontal plane as the external auditory meati, ie the corner of the eyes horizontal to the middle of the ear (Schling et al, 1997) (Rationale 33) (See Appendix 1).
The headboard of the apparatus should be weighted with a 500gram wipeable beanbag and placed carefully on the child’s head (Rationales 34 and 35).
Ensure the child is in the correct position and hold their mastoid processes (Schling et al, 1997; Voss, 2000).
Ask the child to breath in normally and as they inhale maintain the pressure on the mastoids (Schling et al, 1997; Voss, 2000).
Ask the child to breath out normally and exert upward pressure on their mastoid processes (Schling et al, 1997; Voss, 2000) (Rationales 36 and 37).
Ensure feet and heels do not raise up from the ground.
DO NOT lift or over extend the child (Schling et al, 1997) (Rationale 38).
Once the child has fully exhaled record the measurement to the last complete millimetre, read instrument at eye level (Schling et al, 1997; Voss, 2000) (Rationale 39 and 40).
DO NOT round up the measurement (Schling et al, 1997).
The child must not be left on their own at any point with the headboard in contact with their head (Rationale 41).
Supine length
The positioning of the child is crucial (Rationale 27).
The persons measuring the child must first: (Rationale 29)
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assess the need for standard precautions
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wear appropriate protective clothing to meet any identified risk
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perform a social hand wash and thoroughly dry their hands
Two people are required to measure a child in the supine position (Rationale 42).
The child may require play and distraction techniques to be utilised whilst obtaining the measurement.
Place the measuring board on a firm, flat surface (Rationale 43).
Lay the child on the board (Rationale 44).
One person should ensure the head is held in contact with the headboard.
They should then place the child’s head with the lower margins of the orbit in the same horizontal plane as the external auditory meati, ie the corner of the eyes horizontal to the middle of the ear. (Rationale 32) (See Appendix 1)
The other person should position the child with their: (Schling et al, 1997) (Rationales 32 and 45)
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feet together
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heels touching the back plate of the measuring instrument
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legs straight and in alignment with the body
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buttocks against the backboard
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scapula, wherever possible, against the backboard
They should hold the ankles to ensure this position is maintained. Firm pressure may also need to be applied to keep their legs in position.
The child must be completely aligned and flat against the board (Schling et al, 1997) (Rationale 46).
Record the measurement to the last complete millimetre (Schling et al, 1997).
DO NOT round up the measurement (Rationale 47).
The child must not be left on their own at any point (Rationale 41).
Some conditions cause asymmetry and disproportion to the skeleton eg achondroplasia.
It may therefore be necessary diagnostically to undertake sitting height or crown rump (CR) length measurements (Rationale 48).
The positioning of the child is crucial (Rationale 27).
The person measuring the child must first: (Rationale 29)
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assess the need for standard precautions
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wear appropriate protective clothing to meet any identified risk
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perform a social hand wash and thoroughly dry their hands
The child may require play and distraction techniques to be utilised whilst obtaining the measurement (Rationale 30).
It is often easier if two people are involved in the measurement of a child, one of who may be a parent or carer (Rationale 31).
The measurer must ensure they are eyeball to eyeball with the child to be measured (Rationale 32).
The child’s body must be positioned on the sitting height table with their:
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backs of the knees resting on the edge of the table
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feet supported on adjustable step
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thighs horizontal
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back must be straight
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buttocks against the backboard
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scapula, wherever possible, against the backboard
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hands on knees
The child’s head must be positioned with the lower margins of the orbit in the same horizontal plane as the external auditory meati, ie the corner of the eyes horizontal to the middle of the ear (Schling et al, 1997) (Rationale 33) (See Appendix 1).
The headboard of the apparatus should be weighted with a 500gram wipeable beanbag and placed carefully on the child’s head (Rationale 34 and 35).
Ensure the child is in the correct position and hold their mastoid processes (Schling et al, 1997; Voss, 2000).
Ask the child to breath in normally and as they inhale maintain the pressure on the mastoids (Schling et al, 1997; Voss, 2000).
Ask the child to breath out normally and exert upward pressure on their mastoid processes (Schling et al, 1997; Voss, 2000) (Rationales 36 and 37).
DO NOT lift or over extend the child (Schling et al, 1997) (Rationale 38).
Once the child has fully exhaled record the measurement to the last complete millimetre, read instrument at eye level (Voss, 2000; Schlig, 1997) (Rationales 49 and 40).
DO NOT round up the measurement (Schling et al, 1997).
The child must not be left on their own at any point with the headboard in contact with their head (Rationale 41).
Crown rump (CR) length
The persons measuring the child must first: (Rationale 29)
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assess the need for standard precautions
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wear appropriate protective clothing to meet any identified risk
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perform a social hand wash and thoroughly dry their hands
Two people are required to measure a child in the supine position (Rationale 42).
The child may require play & distraction techniques to be utilised whilst obtaining the measurement (Rationale 30).
Place the measuring board on a firm, flat surface (Rationale 43).
Lay the child on the board (Rationale 44).
One person should ensure the head is held in contact with the headboard (Rationale 32).
They should then place the child’s head with the lower margins of the orbit in the same horizontal plane as the external auditory meati, i.e. the corner of the eyes horizontal to the middle of the ear (See Appendix 1) (Rationale 33).
The other person should position the child and: (Schling et al, 1997) (Rationale 32 and 45)
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grasp infant by ankles aiming to straighten legs
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buttocks touching baseplate of the measuring instrument
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thighs vertical
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scapula, wherever possible, against the backboard
They should hold the ankles to ensure this position is maintained. Firm pressure may also need to be applied to keep their legs in position.
The child must be completely aligned & flat against the board (Schling et al, 1997) (Rationale 50).
Record the measurement to the last complete millimetre (Schling et al, 1997).
DO NOT round up the measurement (Rationale 47).
The child must not be left on their own at any point (Rationale 41).
Completing procedure
The child should be redressed and left comfortable (Rationale 51).
After use the measuring equipment should be cleaned with detergent and hot water followed by an alcohol impregnated wipe (Rationale 29).
If the equipment is contaminated with blood, it should be cleaned with detergent and hot water followed by the hypochlorite solution. Protective clothing must be worn (Rationales 52 and 53).
If a Rollametre becomes damaged it must be discarded (Rationale 54).
Those involved in measuring the child must perform a social hand wash following the procedure (Rationale 29).
Documentation
Any member of professional staff who has had the appropriate training and experience can complete a growth chart.
The child’s height or length must be: (Rationale 21)
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recorded in the child’s health care/parent held record
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recorded in the Patient Assessment Form (PAF)
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written on Nutrition Screening Flowchart
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written on the Electronic prescribing system
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plotted on a centile chart
The date and time the measurement was made and the name of the person who made the measurement must also be included.
Please note: All 3-year course pre-registration student nurses must have all measurements verified by a qualified member of the nursing staff.
The UK-WHO Growth Chart 0-4 years and Neonatal and Infant Close Monitoring Charts are recommended for children under four years of age. The Trust has been using these UK-90 for children >4 years olds only since May 2010. These charts record the child’s age in years and calendar months, ie 12 months in a year.
'Four in One Duodecimal Growth Chart' is the centile chart that is recommended for general use in children over four years of age (Cole, 1994; Fry, 1994) (Rationale 55).
For endocrine growth disorder children the ‘Four in One Decimal’ growth chart is used. These charts record the child’s age in decimal years, ie 10 months in a year and must be plotted as described below:
The height should be plotted on the relevant grid of the growth chart with a well-defined dot and not a cross. The dot must not be circled. It should also be recorded in the recording box (Schling et al, 1997).
The growth curve should be traced with a clear track of dots (Rationale 57).
A normal growth curve is one that runs roughly on or parallel to one of the printed centile lines.
For endocrine/growth disorder children
The measurement needs to be plotted in for decimal age. The decimal age is obtained by: (Child Growth Foundation 1996) (Rationale 58)
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Identifying the year of birth eg 1998.
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Looking on the table to cross-reference the month of birth against the date of birth, eg 15 Sep=704.
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This gives the decimal date of birth, eg 15 September 1998 is 98.704.
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Repeating the formula for the measurement date, eg 12 December 1999 is 99.945.
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Subtract one from the other & round off the last figure to give the decimal age, eg 1.24.
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Measurements of growth need to be adjusted for prematurity if a child is born before 37 weeks gestation. The adjustment should continue to be made until the child is one year old (Rationale 12)
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For example, for a child who was born 20 weeks ago at 28 weeks gestation, draw a vertical line on the growth chart at 28 weeks and count 20 weeks across the grids. The height for the actual age is plotted with a dot and then use a horizontal dotted line and arrow back to the corrected age.
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A child born at or after 40 weeks gestation does not need any adjustments to be made and measurements should be plotted from the expected date of delivery.
Interpretation
The potential height of a child is calculated by obtaining the mid-parental height (MPH) (Schling et al, 1997).
This calculation is only valid if both natural parents are of normal stature.
To calculate the MPH for a boy: (Schling et al, 1997)
The height would still be normal for him if it deviates by 10cm either way.
To calculate the MPH for a girl: (Schling et al, 1997)
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add together the father’s height and the mother’s height
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divide this by two
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subtract 7cm from the total
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this gives the mid parental centile
The height would still be normal for her if it deviates by 8.5cm either way.
Care should be taken in:
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choosing the interval between height measurements (Rationale 59)
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interpreting growth rates measured over less than a year
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choosing the time of day, ie wherever possible measurements should be made at the same time of day (Rationale 60)
A child’s height is expressed as a standard deviation score (SDS). It is another way of expressing the child’s height relative to their peer group (Child Growth Foundation 1996) (Rationale 61).
This SDS can be calculated by following the formula:
SDS=(x - x-)/SD
x = the child’s height in cm
x- = the mean of stature in cms for the child’s age
Examples of this in practice are: (Rationale 62)
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a child of average height will have an SDS of 0
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a child near the 98th centile would have a SDS of about +2
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a child near the 2nd centile would have a SDS of -2
Children should be referred to their doctor if their height: (Rationales 63 and 64)
Also refer: (Rationale 64)
A height measurement should be repeated in six months if: (Rationale 64)
A child should also be referred if they or their parent is worried about the measurement irrespective of the centile (Rationale 64).
When a child’s growth pattern is abnormal a brief history should be taken & recorded in the child’s health care records. Relevant information may include: (Schling et al, 1997) (Rationales 65, 66 and 67)
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the child’s energy and school performance
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school attendance records
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behavioural and emotional concerns
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chronic or recurrent illness
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eating patterns
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decreased or increased patterns of buying clothes and shoes
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previous data recorded in parent held record
Appendix 1: Frankfurt plane (PDF)
Rationale 1: To monitor growth.
Rationale 2: Hospitalised children are at nutritional risk.
Rationale 3: Chronic illness compromises growth.
Rationale 4: Serial measurements allow for a more accurate assessment of a child’s growth rate.
Rationale 5: To obtain “consent”.
Rationale 6: To reduce anxiety.
Rationale 7: To aid compliance.
Rationale 8: This will affect: who will measure them; who will be present whilst they are measured.
Rationale 9: To avoid inconsistencies of measurements.
Rationale 10: To enable visualisation of the child’s feet flat on floor and the heels against wall.
Rationale 11: To enable an accurate measurement to be taken (buttocks, heels and scapulae against wall).
Rationale 12: To maintain an accurate record.
Rationale 13: To minimise fright from the equipment.
Rationale 14: To help to psychologically prepare the child.
Rationale 15: The digital counters greatly reduce observer error but they make it impossible to take a direct reading of the measurement.
Rationale 16: To ensure accuracy of medical device.
Rationale 17: To obtain an accurate length.
Rationale 18: To obtain an accurate standing height.
Rationale 19: To obtain an accurate length on a child who cannot stand.
Rationale 20: To ensure contact between the head and the headboard.
Rationale 21: To enable effective planning.
Rationale 22: To facilitate repair.
Rationale 23: To obtain an accurate measurement.
Rationale 24: To ensure accuracy of the measurement (same leg used each time).
Rationale 25: To determine body proportions.
Rationale 26: To identify skeletal dysplasia.
Rationale 27: Poor positioning results in inaccurate measurements.
Rationale 28: To reduce the risk of dislocating the child's cervical vertebrae. If this dislocation does occur, the child's head must be supported and urgent medical help sought.
Rationale 29: To minimise the risk of infection.
Rationale 30: To minimise discomfort and distress.
Rationale 31: To help maintain a correct position, eg ensuring contact of feet to the floor.
Rationale 32: To ensure accuracy of measurement (
Brook 1982).
Rationale 33: This position is referred to as the Frankfort plane.
Rationale 34: To compress their hair.
Rationale 35: To ensure good contact with between the head and the headboard.
Rationale 36: To relax the muscles down the spine.
Rationale 37: To allow the spine to be straightened.
Rationale 38: To counteract the effects of gravity.
Rationale 39: To obtain height of child.
Rationale 40: To enable an accurate reading (
Voss 2000).
Rationale 41: To maintain the child’s safety.
Rationale 42: One to ensure contact of the feet and other contact of the head with the measuring board.
Rationale 43: To ensure stability of the measuring device.
Rationale 44: To obtain measurement.
Rationale 45: To ensure the head and body are in complete alignment.
Rationale 46: To obtain their true length.
Rationale 47: It will lead to future measurement errors.
Rationale 48: To calculate sub-ischial length (height minus sitting height = leg length).
Rationale 49: To obtain sitting height of child.
Rationale 50: To obtain sitting height of child.
Rationale 51: To maintain safety and comfort of child.
Rationale 52: To ensure effective disinfection.
Rationale 53: To meet universal precautions.
Rationale 54: It is an infection risk.
Rationale 55: It is based on the latest growth data.
Rationale 56: Culture can affect height.
Rationale 57: To ensure original plotting is still visible.
Rationale 58: The chart is divided into 10 not 12.
Rationale 59: During times of acute illness the growth of a child may fluctuate seasonally and/or monthly (
Marshall 1997).
Rationale 60: To minimise diurnal variations i.e. there is less variation in height in the afternoon when the rate of height loss slows down (
Voss 2000).
Rationale 61: It enables simple statistical comparison between groups.
Rationale 62: To determine if medical referral is required.
Rationale 63: To facilitate appropriate management.
Rationale 64: To meet the guidelines of the British Society of Paediatric Endocrinology & Diabetes (BSPED) (
Schlig 1997).
Rationale 65: To identify organic and non-organic causes of abnormal growth.
Rationale 66: To identify measurement error.
Rationale 67: To enable effective follow-up.
Reference 1:
Brook CGB (1995) Clinical Paediatric Endocrinology (2nd edition). London, Blackwell Scientific
Reference 2:
Brook CGB (1982) Growth assessment in childhood and adolescence. Blackwell Scientific, Oxford
Reference 3:
Child Growth Foundation (1996) Four-in-one growth charts. London, Child Growth Foundation
Reference 4:
Cole TJ (1994) Do growth chart centiles need a face lift? BMJ 308 (6929): 641-2.
Reference 5:
Cox LA (1993) A guide to the measurement and assessment of growth in children. Ware, Castlemeas Publications
Reference 6:
Davies K (2004) Assessment of Growth Failure in Children. UK, Mims for Nurses Pocket Guide
Reference 7:
Doull IJ, McCaughey ES, Bailey BJ, Betts PR (1995) Reliability of infant length measurement. Archives of disease in childhood 72 (6): 520-1.
Reference 8:
Freeman JV, Cole TJ, Chinn S, Jones PR, White EM, Preece MA (1995) Cross sectional stature and weight reference curves for the UK, 1990. Archives of disease in childhood 73 (1): 17-24.
Reference 9:
Fry T (1994) Introducing the new Child Growth Standards. Professional care of mother and child 4 (8): 231-3.
Reference 10:
Gibson RS (1990) Principles of nutritional assessment. Oxford, Oxford University Press
Reference 11:
Hall DM (2000) Growth monitoring. Archives of disease in childhood 82 (1): 10-5.
Reference 12:
Hall DMB (1992) Health for all children (2nd edition). Oxford, Oxford University Press
Reference 13:
Marshall WA (1975) The relationship of variations in children's growth rates to seasonal climatic variations. Annals of Human Biology 2 (3): 243-50.
Reference 14:
Paton RG, Gardner LI (1962) Influence of family environment on growth. Paediatrics 30: 957-962.
Reference 15:
Schling S, Hulse T (1997) Growth monitoring and assessment in the commmunity. A guide to good practice. London, Child Growth Foundation
Reference 16:
Sherwood MC, Stanhope R, Preece MA, Grant DB (1986) Diabetes insipidus and occult intracranial tumours. Archives of disease in childhood 61 (12): 1222-4.
Reference 17:
Skuse DH (1989) ABC of child abuse. Emotional abuse and delay in growth. BMJ 299 (6691): 113-5.
Reference 18:
Smith DE, Booth IW (1986) Nutritional assessment in children: Guidelines on collecting and interpreting anthropometric data. Jounal of Human Nutrition and Dietetics 72: 520-521.
Reference 19:
Stanhope R, Wilks Z, Hamill G (1994) Failure to grow: lack of food or lack of love? Prof Care Mother Child 4 (8): 234-7.
Reference 20:
Stern M (1985) Assessing the child with short stature. Archives of Diseases in Childhood 11: 106.
Reference 21:
Tanner JM (1989) Foetus into man (2nd edition). Ware, Castlemead Publications
Reference 22:
Voss LD (2000) Growth Monitoring. Archives of Disease in Childhood 82: 14-15.
Reference 23:
Voss LD, Bailey BJ, Cumming K, Wilkin TJ, Betts PR (1990) The reliability of height measurement (the Wessex Growth Study). Archives of disease in childhood 65 (12): 1340-4.
Reference 24:
Wells J (2002) Growth and failure to thrive. Paediatric Nursing 14(3): 37-42.
Document control information
Lead author(s)
Zoe Wilks, Head of Nursing, Outpatients
Additional authors
Sinéad Bryan, Research Nurse, Endocrinology
Victor Mead, Auxologist, Endocrinology
Elin Haf Davies, Research NUrse, Metabolic Medicine
Vanessa Shaw, Head of Dietetics, Dietetics
Catherine Peters, Consultant, Endocrinology
Document owner
Zoe Wilks, Head of Nursing, Outpatients
Approved by
Clinical Practice Committee
First introduced: 1 September 2000
Date approved: 26 October 2011
Review schedule: Two years
Next review: 28 October 2013
Document version: 4.0
Replaces version: 3.0
