Pediatric Corner

Obese children at risk for wrong weight estimation

Tool accurately predicts endotracheal tube size

Many emergency nurses routinely use the color-coded Broselow Pediatric Emergency tape to obtain medication dosages for pediatric patients who can't be weighed. However, researchers in a new study compared the actual weight of 7,500 children with their predicted weight and found that the tape inaccurately predicted actual weight in one-third of children.1

ED nurses should not solely depend on the Broselow tape for accurate information when estimating weight during the resuscitation of a child, according to Carolyn T. Nieman, MSN, ACNP, the study's author and faculty at the School of Nursing at Case Western Reserve University in Cleveland.

"One should never rely on any system in place of clinical judgment," she says.

The tape seems to be more accurate if the children are the normal weight for their size, she says. Obese pediatric patients are at higher risk for discrepancies, Nieman says. "If the patient looks large for their size, you may need to make some adjustments," she says. "Weigh the child whenever possible."

However, weight will need to be estimated if it is not safe to weigh a critically ill or injured child, or if the child is frightened and uncooperative, says Susan M. Hohenhaus, MA, RN, FAEN, clinical human factors nurse researcher at Duke University Health System's Office of Patient Safety and Quality in Durham, NC. Hohenhaus has reported extensively on the use and misuse of the Broselow tape over the past several years.2,3

ED nurses should have formal education on how to use any resuscitation tool, including the Broselow tape, she emphasizes. "There is a need for this type of training to be incorporated into all standardized pediatric advanced life support education," Hohenhaus says. [To download a free educational packet on the tape, go to the Duke University Medical Center's "Duke Enhancing Patient Safety" web site at www.dukehealth.org/deps. Click on "Clinical Education" and then "Study Packet (Version 2) on the Correct Use of the Broselow Pediatric Emergency Tape."]

In 2005, a new edition of the tape was created, eliminating the infusion section, to comply with the Joint Commission's National Patient Safety Goal requiring that all hospitals move to standardized concentrations of drugs by 2008.

Hohenhaus notes that the hallmark study that reported on the validity of the Broselow tape was looking at its accuracy in predicting equipment size, not weight. "So its original purpose still is valid. As illustrated in this study, the Broselow tape length accurately predicted endotracheal tube size," she says.

Medications used for resuscitation should be based on lean body mass, says Hohenhaus. Therefore, going by the child's length instead of actual weight, which is unlikely to be available during a pediatric resuscitation anyway, actually may be best to ensure correct dosages of resuscitation drugs, she says.

Other studies have shown that the correlation between actual weight and weight estimated using the tape seems to be better in children who weigh less than 15 or 20 kg, says Hohenhaus.4,5 "This is a particularly vulnerable group of pediatric patients — the smallest ones," she says.

Hohenhaus cautions nurses against interpreting the study's findings as an indication that the Broselow tape is not safe. Studies have shown that parents and clinicians are inaccurate when guessing a child's weight, she notes. "There is no method that is currently available that has been proven to be more accurate for clinicians to use in a pediatric resuscitation to estimate a weight, other than the Broselow tape," says Hohenhaus.

References

  1. Nieman CT, Manacci CF, Super DM, et al. Use of the Broselow tape may result in the under resuscitation of children. Acad Emerg Med 2006: 13;1,011-1,019.
  2. Hohenhaus SM, Frush KS. Pediatric patient safety: Common problems in the use of resuscitative aids for simplifying pediatric emergency care. J Emerg Nurs 2004; 30:49-51.
  3. Hohenhaus S. Assessing competency: The Broselow-Luten resuscitation tape. J Emerg Nurs 2002; 28:70-72.
  4. Varghese A, Vasudevan VK, Lewin S, et al. Do the length-based (Broselow) Tape, APLS, Argall and Nelson's formulae accurately estimate weight of Indian children? Indian Ped 2006; 43:889-894.
  5. Hofer CK, Ganter M, Tucci M, et al. How reliable is length-based determination of body weight and tracheal tube size in the paediatric age group? The Broselow tape reconsidered. Br J Anaesth 2002; 88:283-285.

Sources

For more information about obtaining accurate medication dosages for pediatric patients, contact:

  • Susan M. Hohenhaus, MA, RN, FAEN, Clinical Human Factors Nurse Researcher, Duke University Health System, Office of Safety and Quality, Box 3701, Durham, NC 27710. Phone: (570) 724-1715. E-mail: shohenha@ptd.net.
  • Carolyn T. Nieman, MSN, ACNP, Faculty, School of Nursing, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106. Fax: (216) 368-3542. E-mail: carolyn.nieman@case.edu.