Monitoring growth: the benefits and challenges of integrating the Born in Bradford research project with routine growth monitoring practice.
Subject: Child development (Health aspects)
Growth (Health aspects)
Health promotion (Methods)
Health promotion (Management)
Medicine, Preventive (Study and teaching)
Medicine, Preventive (Practice)
Medicine, Preventive (Methods)
Preventive health services (Study and teaching)
Preventive health services (Practice)
Preventive health services (Methods)
Primary nursing (Methods)
Primary nursing (Practice)
Authors: Johnson, William
Cameron, Noel
Raynor, Pauline
Woffendin, Cathy
Wright, John
Pub Date: 10/01/2009
Publication: Name: Community Practitioner Publisher: Ten Alps Publishing Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 Ten Alps Publishing ISSN: 1462-2815
Issue: Date: Oct, 2009 Source Volume: 82 Source Issue: 10
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8000140 Health Problems Prevention; 9105230 Health Problems Prevention Programs NAICS Code: 621999 All Other Miscellaneous Ambulatory Health Care Services; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 209163267
Full Text: Why monitor child growth?

The growth rate of a child is perhaps a better indicator of general health than any other single measure. (1) Ill children often grow slowly, so monitoring growth is an important surveillance tool in all children, and more specifically in any child presenting with a suspected health problem. (2) It involves repeated cross-sectional measurement to identify size and rate of change. Growth data are compared against a reference population, and if a child's growth is unfavourable they are referred to an appropriate specialist. (3)

In the UK, growth monitoring typically involves the measurement of both weight and height. (4) It is therefore possible to identify any form of growth disorder involving short or tall stature, and any nutritional problem involving under- or overweight. In 2001, Bundred et al reported an increasing prevalence of childhood overweight and obesity in the UK. (5) Growth monitoring may become a useful tool to detect children who are overweight or obese and refer them, along with their parents, to specialist clinics for advice about exercise and diet. Growth monitoring also produces an important source of data for monitoring child health. (2) Between 2004 and 2006, there was an increase in the use of routine growth data to produce public health reports. (6) Researchers with interests in different aspects of child growth and health have utilised routine growth data--for example, Buchan et al reported substantial findings in obesity epidemiology using routine weight and height data. (7)

As the benefits are diverse, the NHS invests extensive resources to ensure that child growth is monitored routinely. In Bradford, a collaboration between the Born in Bradford (BiB) research project (8) and Bradford and Airedale Teaching Primary Care Trust (PCT) has worked to improve growth monitoring standards, so that routine growth data are developed to research calibre.

Integrating research with practice

BiB is a multi-ethnic longitudinal birth cohort study, which aims to recruit all pregnant women booked to deliver at Bradford Royal Infirmary over a period of two years. The project will follow the development of these babies, utilising routine data to investigate different aspects of child health. Growth monitoring provides a rich source of data for BiB, and changes to growth monitoring practice have been introduced to develop the quality of these data.

New practice

Prior to any intervention by BiB, the health visitor standards manual for the PCT stated that weight, length and head circumference (see Box 1) should be measured in all children at prescribed age periods of nought to 28 days, six to eight weeks and seven to nine months. The first change that BiB implemented on growth monitoring practice was the introduction of a new measurement. Health visitors were asked to measure abdominal circumference on all infants, not only those enrolled in BiB, at all three prescribed age periods and tape measures were provided. Abdominal circumference is a good indicator of total body fat and fat distribution, (9) and particularly relevant considering increasing prevalence of childhood obesity.

Health visitors were also asked to measure all infants between 10 and 14 days of age instead of at nought to 28 days. In the first few days of life, an average infant loses between 3.5% and 6.6% of their weight at birth, and this is not regained until roughly seven days of age. (10) The 10-to 14-day age period was chosen to ensure that infants are only measured when they have regained this weight.

Training and feedback

All community practice teachers and one health visitor from each health centre in Bradford were invited to attend a measurement training workshop, organised by BiB in collaboration with the Child Growth Foundation. Health visitors who attended these sessions then organised training days at their own health centres. A measurement protocol that provides precise step-by-step instruction on how to measure and record each dimension was produced and disseminated. A growth monitoring standard was written to incorporate the new measurement protocol, and to provide detailed information about growth monitoring. Among other things, the standard included a rationale for each measurement, information on how to record and plot data on growth reference charts, and guidance on when an infant should be referred to a specialist.

Growth monitoring data are entered onto an electronic system by the PCT child health department. BiB has worked with this department to set up protocols for data sharing and extraction, so that growth data are more accessible to researchers. The growth data processed at the child health department could be used to provide audit of performance. For example, BiB has produced statistics reporting the percentage of children who are measured during each prescribed age period. This type of information provides the PCT with a way to assess and improve growth monitoring standards.

Discussions are taking place to determine what information provides quality assurance for the PCT and good feedback for health visitors.

Benefits for practice

The changes to growth monitoring practice in Bradford were introduced to improve the ability of growth monitoring to detect health problems, and to develop the quality of growth data that are collected. Health visitors have been given the necessary tools to measure and interpret child growth. We believe that the introduction of the new measurement has been successful, and 80% of children are now measured for abdominal circumference between nought and 28 days of age. BiB has provided training on the importance and interpretation of abdominal circumference, aiming to improve awareness about obesity among health visitors. Growth monitoring has been modified to improve the early detection of childhood overweight and obesity.

The training of health visitors and production of a new measurement protocol have helped standardise measurement techniques in Bradford. This reduces measurement error and increases the likelihood that data are reliable. (9) In Bradford, the reliability of routine growth data has been assessed, and measurement error is comparable to anthropometric literature that reports acceptable levels of reliability. (11) This information has provided the PCT with assurance that health visitors measure child growth reliably, and BiB that routine growth data are reliable enough to use for research. This work has led to proposals for the PCT to commission a routine reliability assessment in Bradford, which will provide regular quality assurance for the PCT and act as a form of anthropo-metric training. Routine reliability assessments will reinforce the importance of measurement standards, and also act as a quality assurance mechanism with feedback to practitioners.

Research is now part of everyday growth monitoring practice in Bradford. The health visitors are responsible for data collection, while the child health department of the PCT is responsible for data entry, audit and feedback of performance to practitioners.

Challenges of integration

Health visitors monitor child growth in over 90% of PCTs, (6) and any changes to growth monitoring practice ought to consider the competing demands on health visitors and the additional work created by such changes. Aligning research with routine practice without increasing the workload of health visitors--and so losing their support for the study--presented a potential problem for BiB.

The sustainability of high growth monitoring standards relies upon the continued involvement and dedication of health visitors. Without any information about BiB, health visitors may not fully understand the importance of their contribution to the project. Similarly, a lack of feedback about routine data collection does not emphasise the importance of routine growth monitoring. If PCTs regularly produce individual performance-related information that can be fed back to health visitors, such information can provide quality assurance and public health intelligence for commissioners.

With the support of Bradford and Airedale Teaching PCT and practitioners across Bradford, a major research programme on child health has been integrated into routine practice, and we believe that growth monitoring in Bradford should be recognised as a national exemplar.

The next challenge for BiB is to develop interventions targeting childhood overweight, obesity and other health problems that can be implemented as part of routine practice.


(1) Cameron N. Growth patterns in adverse environments. American Journal of Human Biology, 2007; 19(5): 615-21.

(2) Hall DMB. Growth monitoring. Archives of Disease in Childhood, 2000; 82(1): 10-5.

(3) Garner P, Panpanich R, Logan S. Is routine growth monitoring effective? A systematic review of trials. Archives of Disease in Childhood, 2000; 82(3): 197-201.

(4) Hall DMB, Elliman D. Health for all children (fourth edition). London: Oxford University, 2003.

(5) Bundred P, Kitchiner D, Buchan I. Prevalence of overweight and obese children between 1989 and 1998: population based series of cross sectional studies. BMJ, 2001; 322(7282): 326-8.

(6) Patterson L, Jarvis P, Verma A, Harrison R, Buchan I. Measuring children and monitoring obesity: surveys of english primary care trusts 2004 to 2006. Journal of Public Health, 2006; 28(4): 330-6.

(7) Buchan IE, Bundred PE, Kitchiner DJ, Cole TJ. Body mass index has risen more steeply in tall than in short three-year-olds: serial cross-sectional surveys 1988 to 2003. International Journal of Obesity, 2007; 31(1): 23-9.

(8) Born in Bradford Collaborative Group. Born in Bradford: for a healthy future. Available at: (accessed 21 July 2009).

(9) Cameron N. The measurement of human growth. Guilford and King's Lynn: Croom Helm, 1984.

(10) Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Archives of Disease in Childhood Fetal and Neonatal Edition, 2003; 88(6): F472-6.

(11) Johnson W, Cameron N, Dickson P, Emsley S, Raynor P, Seymour C, Wright J. The reliability of routine anthropometric data collected by health workers: a cross-sectional study. International Journal of Nursing Studies, 2009; 46(3): 310-6.

William Johnson

PhD candidate, Loughborough University

Noel Cameron

Professor of human biology, Loughborough University

Pauline Raynor

Born in Bradford project manager, Bradford Institute for Health Research

Cathy Woffendin

Head of children and family services, Bradford and Airedale Community Health Services

John Wright

Director of research and deputy medical director, Bradford Institute for Health Research
Box 1: Measuring head circumference

Head circumference is a measurement that was taken routinely by
health visitors in Bradford prior to BiB--along with weight and
length--at nought to 28 days, six to eight weeks and seven to nine


The measurement of head circumference is used to detect
congenital microcephaly or excess growth due to hydrocephaly.
According to the BiB measurement protocol: 'Using the index fingers
on each hand, position the tape so that it crosses the most
anterior part of the head (midway between the eyebrows and the hair
line) and the most posterior part of head (occipital prominence).'

BiB changed the first period of measurement to 10 and 14 days, and
introduced the measurement of abdominal circumference.
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