Parent perceptions of routine growth monitoring: A scoping review

Abstract

Background

Despite being a well-accepted part of paediatric care, little is known about the benefits or potential harms of routine growth monitoring (RGM) from a parent’s perspective.

Objective

To explore parental experiences with RGM.

Methods

Literature searches were performed on Google Scholar, psycINFO, CINAHL, and PubMed. Included studies were published after 2000 and described parental comprehension, preferences, attitudes toward, and/or behaviour change related to RGM.

Results

Of 24 reviewed studies, four themes were identified: reliance on growth monitoring, understanding, influence on feeding and behaviour, and response to obesity-related classification. RGM was familiar but not strongly preferred to identify a child’s weight status. Parental understanding of RGM was poor, particularly among parents with low socioeconomic status. A common belief was that heavier babies were healthier, while smaller babies should prompt concern. Parents may be anxious and change behaviour in response to RGM, such as by halting breastfeeding, supplementing, or restricting their child’s diet. Parents frequently discounted RGM information when their child was identified as overweight, and expressed concerns about self-esteem and eating disorders.

Conclusion

This scoping review identifies that although RGM is familiar and sometimes reassuring to parents, increased consideration should be given to potential harms from parental perspectives when conducting growth monitoring.

Routine growth monitoring (RGM) is considered to be an integral part of paediatric primary care. It has traditionally been used for detection of malnutrition and growth faltering, but increasingly is also being recommended for diagnosing childhood obesity. The current Canadian Task Force on Preventive Healthcare guideline offers a strong recommendation for growth monitoring and obesity prevention based on ‘very-low-quality evidence’ and advises that research is needed to examine its effectiveness despite common use in practice (1–5). Systematic reviews on the effectiveness of RGM highlighted the paucity of high-quality evidence behind the practice to support its use as a screening tool, and a complete lack of research evaluating its harms (4,5).

Although RGM is perceived to be a low-cost and low-risk intervention, harms such as increased caregiver anxiety and guilt, disordered eating, decreased rapport between caregivers and physicians, increased health care costs from false positive results, and stigma in childhood have been reported (3,4,6,7). Many of these theoretical harms arise from parental perceptions of RGM; however, no formal evaluation of parental perceptions of RGM has been completed. We decided to conduct a scoping review to explore the risks and benefits of RGM from parents’ perspectives which could guide future studies or identify the need for a full systematic review.

The objective of this scoping review is to explore parents’ comprehension, attitudes toward, and/or behaviour change related to RGM. For the purposes of this review, RGM was defined as the entire process of performing a child’s height/length and/or weight measurements (once or serially) to monitor growth over time or to screen for over- or underweight, interpreting this data, and counselling parents (and children) about the results.

METHODS

This scoping review was performed in accordance with methods described by Ferrari and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews (8,9) (Supplementary Appendix B).

In March 2019, a preliminary literature search was performed on Google Scholar to gauge the breadth of the existing literature and formulate a formal search strategy. This was followed by formal literature searches on PsycINFO, Pubmed, and CINAHL (see Supplementary Table 1 for details of search strategy). The primary author completed title/abstract review, screened full texts for inclusion, and searched bibliographies of selected articles. The second author reviewed reasons for exclusion during full-text screening. Studies were considered for inclusion if they met the following criteria: any study design, published in English after 2000, and focusing on parental comprehension, preferences, attitudes, or behaviour change in relation to the exposure to growth chart. Figure 1 outlines the article selection process, and Supplementary Table 2 outlines inclusion criteria for studies and the rationale for each criterion.

Figure 1.

PRISMA flow diagram depicting the article selection process. (Adapted from: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097.)

Data related to experiences with RGM were extracted by the primary author. The second author reviewed these data after reading the full texts of included articles. Findings were recorded in a standardized data extraction sheet that was defined a priori, summarizing key information from each article into findings that were favourable or unfavourable toward RGM (Supplementary Appendix A). Risk of bias analysis was not performed due to the variety of study designs that limited the ability to objectively compare the quality of studies to each other. It was apparent that the key findings were clustered around several main topics. Formal thematic analysis was not conducted. For the purposes of clarity of reporting, key messages were summarized into several themes through discussion and consensus between the two reviewers.

RESULTS

Twenty-four studies were included for review and described in Supplementary Table 3. The findings fell into four major themes: reliance on growth monitoring, understanding, influence on feeding and behaviour, and obesity.

Reliance on growth monitoring

Although growth monitoring with growth charts was familiar to parents, and many wanted to see this in a clinical setting, only 9.2% of parents relied on it to decide if their children were at a healthy weight and 79% preferred a simplified weight ruler or colour-coded charts for communicating the information compared to traditional growth charts (10–12).

A number of studies reported that parents often preferred other sources of information alongside or instead of growth monitoring to assess children’s weight such as comparison to other children, clothing and diaper sizes, children’s activity level, teasing by other kids, visual appearance, and ‘appearing healthy’ (10–12).

Understanding growth monitoring

Many parents were found to have difficulty understanding numerous aspects of RGM. Of the 1,000 parents in a national Internet-based survey, only 64% could identify a child’s weight accurately when plotted on a graph (13). Almost half of the parents did not understand the significance of high or low percentiles. There was confusion about the term ‘Body Mass Index (BMI)’ and the concept of proportionality, and 41% said that growth charts had never been explained to them (13). Some parents also reported being confused when different growth charts or units (pounds versus kilograms) were used (14,15).

Jones et al. showed that after an educational intervention with parents using literature and specific recommendations about their child’s BMI status, there was improved parental categorization of their child’s weight status (Centre for Disease Control growth charts) in the ‘at risk of overweight’ group (between 85th and 94th percentile), but no change in the ‘normal’ or ‘overweight’ (greater than 95th percentile) groups (16).

Comprehension of growth charts was significantly affected by socioeconomic status, education, literacy level, and minority ethnicity (13,15,17–19). Studies evaluating parental understanding with novel tools such as colour-coded charts or ‘weight rulers’ demonstrated more significant improvement in parental understanding with lower education levels and household income (17,18).

A common misperception held by parents across a number of studies was that heavier babies are healthier while lower weights should prompt concern, particularly in parents without college education (20–23). They believed that children go through ‘growth spurts’ and ‘stretch out’, converting excess weight into height (22).

Parents also reported more uncertainty with growth monitoring during infancy. Sachs et al. reported that some parents were anxious and obsessive about children remaining on a certain percentile, being under the impression that the 50th percentile represented ideal growth (14). These parents were also unsure about how much of a deviation was enough to warrant concern (14). Parents of children from regions with a high prevalence of childhood obesity felt that slower infant growth curves suggested inadequate milk supply, leading them to believe that they needed to top-up with formula, or stop breastfeeding altogether (21). Large amounts of weight gain would generate a sense of fulfillment, particularly for parents of premature infants, where catch-up growth to age-appropriate norms was seen as the goal (21). Some of these parents believed infant weight levels out around 1 year of age (when children begin to be more active), and frequent monitoring by health care providers is unnecessary before then (21).

Influence on feeding and behaviour

Growth monitoring was reported to influence parents’ behaviour. Moore et al. found that if parents were informed that their child was obese as indicated by BMI percentile, they were more likely to place their child on a diet and have their child skip meals and snacks while 16% of parents would tell a child to eat more if they were following the 25th percentile (24). In Mathai et al., 42% of parents of children 2 to 5 months old reported that growth information influenced parent-reported feeding practices, making changes such as decreasing frequency of feeds, and providing more breastmilk and less water, solid foods, or juice to infants (25). In a pre- and postintervention survey of 115 parents of children 4 to 12 years old exposed to an intervention incorporating growth chart education and counselling about health choices, there were improvements in parent-reported quality of food intake and screen time, but no changes in their children’s obesity categorization after 3-month follow-up (26).

Growth monitoring and obesity

Parental perceptions of their child’s weight status is often relatively unaffected by BMI and growth chart evidence presented by health care providers, especially when growth chart findings were interpreted as overweight (12,20,27,28).

A commonly cited reason for discounting growth charts in classifying obesity was parents’ beliefs that growth charts cannot take into consideration the unique ethnic and genetic background of an individual child (12,27–30). Parents of minority race preferred ethnicity-specific growth charts instead of ‘generic’, and ‘mass produced charts and stats’. (28) Some mothers felt that growth charts should be used to reassure about adequate weight gain rather than to identify excess weight gain (27).

Parents reported feeling offended when told their child was overweight and others reported experiencing shame or stigma (21,29). Parents also thought it would be helpful to have a private conversation about the matter without the child present in the room, in order to protect the child from self-esteem issues and eating disorders (29).

Despite mostly negative perceptions of growth charts in the context of obesity, one study described growth charts as useful tools for ‘telling the truth’. (29) These parents preferred to be reassured that the child did not need to lose weight but ‘grow into normal weight’ (29).

DISCUSSION

This review provided an overview of parents’ understanding of, attitudes toward, and behaviour changes related to RGM. Many of the findings contrast with the commonly held assumptions that RGM is harmless.

For RGM to be effective in improving child health, parents must trust and understand growth information in order to play an active role in the process of translating the information into appropriate behaviour change. Many parents in the reviewed studies did not fully understand growth monitoring, nor believe that measuring growth is a meaningful reflection of their own child’s weight. Interpreting growth charts is an intellectually complex task and even health care providers have been shown to often fail to use or interpret growth charts correctly (3,7). Information to guide providers’ appropriate responses to abnormal measurements are often vague and inconsistent, which may lead to more confusion for parents (3,7).

Parents’ poor comprehension and misconceptions such as ‘bigger is better’, especially in lower socioeconomic status groups, is concerning given the higher burden of obesity in this population (31). The anxiety around growth generated by frequent RGM may actually undermine normal healthy feeding practices, with parents inappropriately pressuring, restricting, or supplementing their children’s diets. This could inadvertently lead to more, rather than less, disordered eating (32).

This review found that parents of children classified as overweight often respond negatively and may feel stigmatized, in accordance with previous findings (33). Discussions about weight and growth can be sensitive and negatively affect the physician–patient relationship. Parents may feel they are being judged as bad parents particularly when terms such as ‘obesity’ or ‘failure to thrive’ are used (34).

In addition to the potential harms of RGM related to parental experience, concerns have been raised elsewhere about the overall cost-benefit analysis of RGM as a screening tool. The reliability of growth monitoring is highly dependent on accuracy of measurements which have been shown to be frequently performed incorrectly (2). In addition to direct costs of screening such as providers’ and parents’ time, there are other costs related to potentially inappropriate investigations and referrals. There is a paucity of evidence evaluating the cost-effectiveness of using RGM for obesity or detection of short stature and related pathologies (5). For obesity, there is the additional cost of treatment programs which have, as yet, failed to demonstrate any significant long-term effectiveness (35,36).

LIMITATIONS

This was not a systematic review and may not represent an exhaustive summary of the existing literature. Only 18 of 24 included studies were identified using database searching, suggesting a potential limitation in the search strategies and/or databases utilized in selecting sources of evidence. There was limited discussion about parental perceptions of height or length measurements among the studies. Many smaller studies were conducted in populations at higher risk of both under- and overweight (low income, minority, or already overweight families) which could affect the results since these groups were also found to be at highest risk for poor acceptance and understanding of growth monitoring; however, the larger studies included more generalized populations. Grey literature was excluded, however should be considered as a rich source of data on parents’ perceptions in future reviews.

CONCLUSION AND FUTURE DIRECTIONS

Although parents reported being familiar with and sometimes reassured by RGM, harms related to the parental experience with RGM were raised. This included poor understanding that may lead to anxiety and potentially harmful feeding practices, and negative stigma and lack of acceptance when children are classified as overweight.

Future research should include a systematic review on parent perceptions of RGM, and directly assess its potential benefits, harms, and costs based on clinically significant and system-based outcomes. While awaiting more evidence, it is important for health care providers to mitigate potential harms associated with RGM reported by parents in this review.

Funding: There are no funders to report for this submission.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.