European Journal of Cardiovascular Medicine

Accurate estimation of a child’s weight is the critical first step in the management of pediatric emergencies, because most pediatric drug dosing and equipment sizes are determined using body weight.^[1] Given the impracticality of weighing children during emergencies, weights are often estimated.^[2]

The Broselow Tape was developed using height/weight correlations from Western data. ^[3] This validated tape estimates weight of the supine child based on length. The tape has a series of colour coded zones (boxes) with details of all necessary doses and sizes for emergency interventions.^[4]

The Indian Academy of Pediatrics supported Paediatric Advanced Life Support Programme recommends that Broselow tape can be used in such circumstances. ^[5]

Although the Broselow tape has been validated in both ambulatory and simulated emergency situations in the United States and is believed to reduce complications arising from inaccurate drug dosing and equipment sizing, but given the prevalence of malnutrition and consequent aberration in growth in Indian children, it may overestimate the weight of these children. ^[6]

The Broselow Paediatric emergency tape is used for measuring the children weight by measuring the length, which is widely used in emergency settings worldwide. ^[7] Even though it is used widely, there will be error in estimating the weight of children who are malnourished an obese. ^[8]

During emergency settings, using the broselow tape is questionable due to its weight difference compared to normal weight. Across worldwide, most of the studies proved that, broselow tape can be used as emergency protocol provided that the actual weight measured by weighing scale and broselow tape weights seems to be equal. ^[9] This study is to prove the validity of broselow tape in indian pediatric population aged 1 month to 12 years

AIM: To assess the competency of the Broselow pediatric emergency tape in estimating the weight of Indian Children Aged 1month to 12years.

This is a Descriptive study was conducted in the Department of Paediatrics, Mallareddy institute of Medical sciences,  Hyderabad from September 2023 to August 2024.

Inclusion criteria

Children aged 1 month to 12 years attending pediatric OPD and admitted in pediatric ward for minor illness.

Exclusion criteria

• Children having length <46cm or height 146

Methodology:

• After obtaining informed consent from parent/guardian, various patient demographic characteristics, history, clinical details, was entered in a pre- structured proforma.
• Subjects name, age, date of birth and reason for the visit to the hospital was recorded before the actual measurements of height and weight were taken.
• The weight was measured by using a digitalized weighing scale to the nearest 0.1kg. Prior to measurement, weighing machine was calibrated as per the manual and after making sure the read displayed ‘0’ the footwear and heavy clothing was removed and weight was recorded.
• Consequently, the child was made to lie in supine position on a bench parallel to the Broselow Pediatric Emergency tape, 2007, Edition B, Armstrong, Medical industries, IL, USA.
• Two pieces of cardboard were used to hold against the crown and heel of the
• The red arrow on the tape was held by the crown perpendicular to the cardboard, and the predicted weight was read from the corresponding colour zone on the heal end and particular weight on the Broselow tape was noted.
• In a similar manner, a stadiometer was used to measure the height of the subject and match the height to corresponding colour In case of children <2yr or those who were still too young to stand, the measurement of weight was obtained by placing the child on infant scale. The height was measured by placing the child on Infantometer

Statistical analysis

Data was entered in excel sheet. Statistical analysis of data was performed by statistical software SPSS, OpenEpi. Descriptive statistics was completed. To find the significant difference between the bivariate samples in Paired groups the Paired sample t-test was used. To assess the relationship between the variables Pearson's Correlation with Scatter plot was used. In all the above statistical tools the probability value < 0.05 was considered as significant level.

Table 1: Distribution of the study population based on Age

In table 1, the first group, 1-6 months, consists of 90 individuals, making up 17.6% of the total population. The second group, 7-12 months, includes 73 individuals, accounting for 14.3%. The third group, children aged 1-5 years, comprises 119 individuals, representing 23.3% of the study population. The largest group, children aged 6-12 years, includes 228 individuals, which is 44.7% of the total. This distribution indicates a higher concentration of participants in the older age groups, particularly those between 6 to 12 years old.

Table 2: Distribution of the study population based on Gender

In table 2, males constitute 251 of the participants, accounting for 49.2% of the total population. Females make up the remaining 259 participants i.e, 50.8%.

Table 3: Distribution of the study population based on Colour coding on Broselow tape.

In table 3, the distribution is as follows: Grey: 40 individuals (7.8%), Pink: 68 individuals (13.3%), Red: 50 individuals (9.8%), Purple: 3 individuals (0.6%), Yellow: 47 individuals (9.2%), White: 74 individuals (14.5%), Blue: 18 individuals (3.5%), Orange: 151 individuals (29.6%), Green: 59 individuals (11.6%). The largest group is coded Orange, representing 29.6% of the population, indicating that a significant portion of the children fall into this category. The smallest group is Purple, with only 3 participants (0.6%).

Table 4: Distribution of the study population based on weight predicted by Broselow tape

In table 4, it shows the following distributions: Grey (3-4.9 kg): 32 individuals, Pink (5-6.9 kg): 70 individuals, Red (7-9.9 kg): 56 individuals, Purple (10-11.9 kg): 8 individuals, Yellow (12-14.9 kg): 80 individuals, White (15-18.9 kg): 39 individuals, Blue (19-23.9 kg): 87 individuals, Orange (24-28.9 kg): 98 individuals and Green (29-33 kg): 40 individuals.

The table indicates that the Orange zone (24-28.9 kg) has the highest number of children (98 individuals), while the Purple zone (10-11.9 kg) has the fewest (8 individuals). This detailed distribution helps in understanding the weight categories of the children in relation to the Broselow tape’s color coding.

Graph 1: Pearson correlation between Broselow tapes’s predicted weight and measured weight.

This graph presents the sample size is 510, with a correlation coefficient (r) of 0.9965, indicating a very strong positive correlation. The significance level is P<0.0001, meaning the result is highly statistically significant. The 95% confidence interval for the correlation coefficient ranges from 0.9959 to 0.9971, further supporting the reliability of the correlation.

Table 5: Accuracy by weight and Colour zone

The table also shows the percentage of underestimation or overestimation of weight in each color zone: Grey: Mean actual weight 4.46 kg, Broselow weight 4.78 kg, mean difference -0.32 kg, 80.00% underestimation. Pink: Mean actual weight 6.05 kg, Broselow weight 6.47 kg, mean difference -0.42 kg, 102.94% overestimation. Red: Mean actual weight 8.37 kg, Broselow weight 8.64 kg, mean difference -0.27 kg, 112.00% overestimation. Purple: Mean actual weight 11.10 kg, Broselow weight 11.00 kg, mean difference 0.10 kg, 266.67% overestimation. Yellow: Mean actual weight 12.58 kg, Broselow weight 13.57 kg, mean difference -0.99 kg, 170.21% overestimation. White: Mean actual weight 15.00 kg, Broselow weight 16.16 kg, mean difference -1.16 kg, 52.70% underestimation. Blue: Mean actual weight 20.69 kg, Broselow weight 22.11 kg, mean difference -1.42 kg, 483.33% overestimation. Orange: Mean actual weight 25.62 kg, Broselow weight 28.41 kg, mean difference -2.80 kg, 64.90% underestimation. Green: Mean actual weight 4.46 kg, Broselow weight 4.78 kg, mean difference -0.32 kg, 67.80% underestimation.

Table 7: Accuracy in three weight groups <10kg, 10-18kgs, >18kg.

 Graph 2: Comparison of mean actual weight with mean Broselow weight.

This table examines the accuracy of Broselow tape’s weight predictions in three weight groups, group1 (<10kgs), group 2 (10-18kgs), group 3(10-18kgs). It compares the mean actual weight and the mean Broselow predicted weight, providing the mean difference at a 95% confidence interval.

In Group 1(i.e <10kgs.) the mean actual weight is 6.38 and the mean Broselow weight is 6.73 with a difference of 5.48% and a p-value of 0.025814 (statistically significant). In Group 2(10-18kgs) the mean actual weight is 13.99 and the mean Broselow weight is 15.706 with a difference of 7.64% and a p-value < .00001 (statistically significant). In Group 3(>18kgs) the mean actual weight is 25.23 and the mean Broselow weight is 27.92 with a difference of 10.66% and a p-value < .00001 (statistically significant).

In the present study, the participants are divided into four age groups. The first group, 1-6 months, consists of 90 individuals, making up 17.6% of the total population. The second group, 7-12 months, includes 73 individuals, accounting for 14.3%. The third group, children aged 1-5 years, comprises 119 individuals, representing 23.3% of the study population. The largest group, children aged 6-12 years, includes 228 individuals, which is 44.7% of the total. This distribution indicates a higher concentration of participants in the older age groups, particularly those between 6 to 12 years old.

Zhu S et al[10] (2022) conducted a study to validate the Broselow tape for estimating the weight of children in a pediatric emergency setting. The study included 442 children from the Children’s Hospital of Zhejiang University, with a similar demographic distribution: mean age of 48 months, and a near-equal male-to- female ratio (1.13:1). This study highlighted the variability in weight and height among children and the critical need for accurate weight estimation to ensure appropriate medical interventions in emergencies.

Gender distribution within the study population, revealing a nearly equal split between males (49.2%) and females (50.8%). This balanced distribution ensures that the findings are applicable across genders, minimizing gender bias. In group <10 kgs, there were 68 males (43%) and 90 females (57%). In group 10 to 18 kgs, there were 62 males (50%) and 62 females (50%). In group >18 kgs, there were 121 males (53%) and 107 females (47%). There is equal distribution of individuals in group 10 to 18 kgs. There was no significant difference between the groups in terms of gender based on weight (p=0.1496).

Silvagni et al[11] (2022) included a larger cohort of 2060 children but did not explicitly break down the gender distribution in the available summary. However, given the comprehensive nature of the study, it likely included a representative gender distribution, further supporting the reliability of their findings on weight estimation accuracy across genders.

The study population according to the color zones of the Broselow tape, which is used to estimate children’s weights based on their height. The distribution shows variability across the different color zones, indicating a diverse range of body sizes in the pediatric population.

Piyawan et al[12] (2014) reported a higher accuracy for children within the Grey, Pink, and Red zones, with accuracy decreasing in higher weight zones.

This table details the actual weights of the study population and their corresponding Broselow tape color zones. Though the results are statistically significant, it shows significant variability, highlighting the challenges of using a one- dimensional tool like the Broselow tape for weight estimation.

Mishra et al[13] (2016) and Knight et al[14] (2011) found similar trends, with significant overestimations occurring in heavier weight categories. The consistent overestimation noted in our study corroborates these findings, indicating that while the Broselow tape is a useful tool, it may not be as reliable for children in higher weight brackets.

In the present study, the statistical analysis of the correlation between Broselow tape-predicted weights and actual measured weights. A high correlation coefficient (r= 0.9965) indicates a strong positive relationship, though some limitations are evident.

However, Knight et al[14] (2011) highlighted that despite high correlation coefficients, significant underestimations in heavier children pose a risk of under resuscitation. This indicates that while the Broselow tape shows strong overall correlation, individual discrepancies, especially in higher weight categories, need to be addressed to prevent dosing errors.

The accuracy of Broselow tape weight predictions across different weight and color zones. It compares actual weights with predicted weights and indicates areas of underestimation and overestimation.

Zhu S et al[10] 2022) found similar patterns of accuracy and error in their study of the Broselow tape. The tape’s performance varied across different weight zones, with notable inaccuracies in certain groups. This study called for the development of more precise weight estimation tools to improve pediatric emergency care.

Though all the groups were statistically significant, there is a difference in the mean actual weight and mean broselow predicted weight in all the three groups. In group 1(i.e, <10kgs,) mean difference was 5.48%, in group 2(i.e, 10-18kgs) it was 7.64% and in group 3(i.e, >18kgs) it was 10.66%. Mean difference was more in group 3, suggesting more accuracy in lower weight group.

Shah V, Bavdekar SB. Et al [15] 2017 showed a weight difference of around 10% between the weight measured by measuring scale and weight predicted by broselow scale. It showed similar results in three weight groups and the mean difference was more in children belonging to weight groups of 10-18kgs and >18kgs.

Though the overall precision of broselow pediatric tape was statistically significant, more accuracy was seen in lower weight corresponding colour zones. It showed a mean difference of around 10% in children above 18kgs. The consistent findings across most Indian studies and our data underscore the need for ongoing validation and potential recalibration of the Broselow tape to ensure accurate weight predictions across all pediatric populations in India, considering its use in emergency settings for more accurate dosing. Further studies are needed to validate broselow tape in Indian setting.

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