Via Research Recognition Day 2024 VCOM-Carolinas

Biomedical Studies

Are Physicians Capturing Enough Data to Make Infant Growth Charts Useful Diagnostic Tools? Joshua Ranta, OMS-III; Andrew Walker, OMS-II; Steven Enkemann PhD, JuliSu DiMucci-Ward, PhD Edward Via College of Osteopathic Medicine- Carolinas Campus, Spartanburg, SC.

Student Poster Winner H-07

Abstract

Results

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Figure 1 . Well-Check visits of participants where height and weight measurements were recorded.

Figure 3 . Various growth plots of height and weight with few measurements.

Introduction: • Growth Charts have been utilized for hundreds of years to identify aspects of normal human growth and development. They have been used as a clinical evaluation tool since 1977 1 • The American Academy of Pediatrics (AAP) recommends 10 well-child visits in the first two years of life; occurring at birth, 2 weeks, and 2 months of life and thereafter 4, 6, 9, 12, 15, 18, and 24 months of life 2 . Some studies indicate that growth trends in the 2 to 6 month age range can set metabolic expectations that follow a child throughout life. This period would therefore be critical for observing growth and possibly intervening when unfavorable conditions are observed 3 . • Growth charts can be the first thing to falter when health complications occur such as enzyme deficiencies, feeding difficulties, and genetic defects 4,5 . This would suggest that they should become more important in post-natal care. • With metabolic syndromes on the rise, it is more important than ever to properly plot growth curves for each patient. With enough measurements, it is easier than ever to make individual growth charts using modern technology. Getting those measures recorded accurately, however, seems to be the problem 5 . • Many studies looking at pediatric growth curves and relating them to metabolic complications have ignored the first two years of life due to the variability and volatility of these growth curves 8 . Accuracy in the recorded measurement seems to be only part of the problem. • Capturing enough measurements in the critical growth phases of life seems to also plague the desire to use growth charts for health monitoring. For this reason, we decided to document how far families in South Carolina fell behind the AAP recommendations for capturing infant measurements. Health Sciences South Carolina (HSSC) provided a dataset consisting of 186,849 patient visits from 9,513 patients that recorded growth measurements collected for infants from pediatric offices, outpatient clinics, hospitals, and emergency departments in the state. Inclusion criteria for the current analysis consisted of children at least 6 months old at the time the data was retrieved, for which 3 or more measures existed when considering only visits that occurred during the first 2 years of life. Exclusion criteria consisted of visits where both a height and weight measurement were not recorded and individuals with lengthy or frequent hospital stays (defined as over 30 visits). We conduct two independent analyses based on (1) all visits after considering inclusion and exclusion criteria, leaving 9449 patients with a combined 82,255 visits, and (2) well check visits, leaving 7806 patients with a combined 41,359 visits. Cohorts of children that had aged to at least 2,4,6,12, and 24 months by the end of the collection period were analyzed. At these timepoints, the expected number of well-check visits would be 3,4,5,7, and 10 respectively (including an initial visit within 1 week of birth). The cohorts were evaluated for the number of measurement events that had been recorded in the electronic health record during their life up to these time points and when these measurements occurred. Methods: Background: Growth monitoring is considered a fundamental component of routine pediatric care. Tracking the anthropometric measures of height, weight, and head circumference can be used to detect malnutrition, genetic and endocrine disorders, and even viral diseases. In the era of electronic health monitoring, what once was done with pencil and paper is now digital. The fundamental question is whether it is better. Objective: T his project was initiated to determine whether enough data was collected from infants to allow physicians to plot growth curves. Current pediatric recommendations indicate that a newborn infant should be measured at or shortly after birth, at 0.5, 2, 4, 6, and 9 months of life in the first year and 4 more times in the second year of life. We investigated the electronic health data of more than 9000 individuals to determine if this objective was being met for infants in South Carolina. Results: Infants in South Carolina were measured an average of 7 times in two years. Approximately half of all infants missed a measurement within the first two months of life and never record a later measurement. This trend continues with additional missed visits in the first two years. If only well visits were considered, more than half of all infants had missed 2 measurements within the first 6 months of life and averaged only 5 well check visits in two years. Conclusions: Anthropometric measurements are insufficient for detecting problems using growth curves. Introduction and Methods

With very few measurements it is not possible to develop a reliable pattern of growth. There are just too few data points with which to define a trend relative to growth standards. On the left are height and weight for an individual with just 5 measures in one year. These are plotted onto traditional growth charts. With just two measures in roughly 300 days, it is hard to trust that the final measures are establishing a trend towards overweight. On the right are height and weight measures plotted as the percentile in which the actual measurement fell relative to standard growth curves. This makes it easier to see how growth changes relative to expected normal growth. It is difficult to see anything in the first year of life for this individual.

The timing of well- check visits indicates that parents are trying to meet with their infant’s physician on the recommended schedule. However, the birth date measurements and the 2-week visits seem to overlap making it difficult to determine whether individuals have missed one of these scheduled measurements. After the first month of age the visit totals decrease as the child gets older. One can already see from this that parents are less diligent about obtaining measures at later ages.

Table 2 . Visit stats for all visits. ‘Š‘”–  —š ’‡„ ‡– ‡” † ‘ ˆ ˜‹•‹–• ‘ˆ‡ ˜†‹•‹ƒ‹–• —„‡” ƒ‘‰•– ‘Š‘”– ’ ‡—”‡„‡–”ƒ ƒ‰‡ †‘ ˆ ‹  ˆ ƒ  – • „ ‡— Ž‘ ™„ ‡ ‡”š ‘’ˆ‡ ˜ ‹–•‡‹ †– •

Table 1 . Visit stats for well-check visits only.

‘Š‘”–  —š ’‡„ ‡– ‡” † ‘ ˆ ˜‹•‹–• ʹȋ  α‘ ͹ͺ– ŠͲ•͸ Ȍ ͵ Ͷȋ  α‘ ͹ͺ– ŠͲ•͸ Ȍ Ͷ ͸ȋ  α‘ ͹ͺ– ŠͲ•͸ Ȍ ͷ ͳȋ ʹ Ꮰ͹‘Ͷ͵– Š͹•Ȍ ͹ ʹȋ Ͷ ᏠͶ‘ͷ͹– Š͵•Ȍ ͳͲ

’ ‡—”‡„‡–”ƒ ƒ‰‡ †‘ ˆ ‹  ˆ ƒ  – • –™Š‹ƒ– Š– ™‹ ‡ ʹ” ‡™ ‡ ‡‡ƒ•• —‘”ˆ ‡ –†Š ‹ • ”‡ ‘‡†‡† ˜‹•‹–

‘ˆ‡ ˜†‹•‹ƒ‹–• —„‡” ƒ‘‰•– ‘Š‘”–

’ ‡—”‡„‡–”ƒ ƒ‰‡ †‘ ˆ ‹  ˆ ƒ  – • „ ‡— Ž‘ ™„ ‡ ‡”š ‘’ˆ‡ ˜ ‹–•‡‹ †– •

’ ‡—”‡„‡–”ƒ ƒ‰‡ †‘ ˆ ‹  ˆ ƒ  – • –™Š‹ƒ– Š– ™‹ ‡ ʹ” ‡™ ‡ ‡‡ƒ•• —‘”ˆ ‡ –†Š ‹ • ”‡ ‘‡†‡† ˜‹•‹– 5519 (58.4%)

Discussion and Conclusions

ʹ ʹ ͵ Ͷ ͷ

ͷͶͶͷ ȋ͸ͻǤͺΨȌ ͶͲͶͷ ȋͷͳǤͺΨȌ ͷͺ͹Ͳ ȋ͹ͷǤͳΨȌ ͵ͷͷͺ ȋͶͷǤ͸ΨȌ ͸ʹͳͲ ȋ͹ͻǤ͸ΨȌ ʹͻ͹ͺ ȋ͵ͺǤʹΨȌ ͸͵͸ͳ ȋͺͷǤͷΨȌ ʹͷͲ͵ ȋ͵͵Ǥ͹ΨȌ Ͷ͵ͺͷ ȋͻͷǤͻΨȌ ͻͳͻ ȋʹͲǤͳΨȌ

3

2

4760 (50.3%)

2 months ( N = 9449) 4 months ( N = 9449) 6 months ( N = 9449) 12 months ( N = 9072) 24 months ( N = 5959)

3

4873 (51.6%)

5049 (53.4%)

4

A major health concern for infants in America is the early trend towards obesity. Research has suggested that unhealthy growth trends can be set in the first 1000 days of life, setting a child on a path of lifetime obesity. For this reason, many have suggested that infants, as early as two months of age, should be assessed for unhealthy growth trajectories to allow time to put a child on a healthier path. The data presented here shows that even though electronic record keeping should be conveniently capturing and storing anthropometric data, most infants are missing key data. Approximately three quarters of infants had fewer than the recommended number of recorded growth measurements and a majority of infants were missing at least one measurement during the key ages of 2 to 6 months. It is not possible to visually observe growth trajectories with the low number of measurements actually occurring in clinics at this time. Current guidelines suggest 10 well-check visits in the first 2 years of life and a recent publication proposed reasons for missing visits, including various socio-economic health concerns such as a lack of time, barriers to transportation, inability to afford care, and vaccination discrepancies 11 . Our data suggests that sick visits are often an excuse to miss the next well-visit and still the number of total visits does not meet recommendations. The critical growth phase from birth until 6 months of life is perhaps a period when even more growth measurements should be taken than currently recommended. Solutions to missing growth data could include at-home monitoring or programs reaching out to day care or rural homes. Fundamental growth monitoring is not currently occurring, so little opportunity exists for catching and reversing trends towards obesity.

4

5082 (53.8%)

4304 (45.5%)

5

6

5144 (56.7%)

3144 (34.7%)

7

7

4279 (71.8%)

1171 (19.7%)

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Figure 2 . Distribution of measurement visits accrued for infants at 2, 4, 6, 12 and 24 months after birth. A) Well-check visits only B) All visits with measurements. The missing measurements begin early. These tables show that most infants have missed 1 measurement opportunity by the 2-month well-check visit and that 40% of infants do not have a recorded measurement within two weeks of the recommended 2-month well-check visit. Infants fall further behind on well-check visits as they age although measurements are taken out of the recommended window, possible during illness visits. The expected number of measurement visits in the first two years is 10 when also counting the measures taken at birth.

References

1. Kuczmarski R, Ogden C. 2000 CDC Growth Charts for the United States: Methods and Development. Center for Disease Control and Prevention. 2002. Accessed June 6, 2023. https://www.cdc.gov/growthcharts/2000GrowthChart-US.pdf. 2. Cole TJ, Singhal A, Fewtrell MS, Wells JC. Weight centile crossing in infancy: correlations between successive months show evidence of growth feedback and an infant-child growth transition. The American Journal of Clinical Nutrition . 2016;104(4):1101-1109. doi:https://doi.org/10.3945/ajcn.116.139774 3. Roy SM, Spivack, JG, et al. Infant BMI or Weight-for-Length and Obesity Risk in Early Childhood. Pediatrics . 2016;137(5):e20153492. https://pubmed.ncbi.nlm.nih.gov/27244803/ 4. Scherdel P, Dunkel L, van Dommelen P, et al. Growth monitoring as an early detection tool: a systematic review. The Lancet Diabetes & Endocrinology . 2016;4(5):447-456. doi:https://doi.org/10.1016/s2213-8587(15)00392-7 5. Marchand V. The toddler who is falling off the growth chart. Paediatrics & Child Health . 2012;17(8):447-450. doi:https://doi.org/10.1093/pch/17.8.447 6. Gittner LS, Ludington-Hoe SM, Haller HS. Utilising infant growth to predict obesity status at 5 years. Journal of Paediatrics and Child Health . 2013;49(7):564-574. doi:https://doi.org/10.1111/jpc.12283 7. Berkey CS, Reed RA, I Valadian. Longitudinal growth standards for preschool children. 1983;10(1):57-67. doi:https://doi.org/10.1080/03014468300006181 8. Lioret S, Harrar F, Boccia D, et al. The effectiveness of interventions during the first 1,000 days to improve energy balance ‐ related behaviors or prevent overweight/obesity in children from socio ‐ economically disadvantaged families of high ‐ income countries: a systematic review. Obesity Reviews . 2022;24(1). doi:https://doi.org/10.1111/obr.13524 9. Amirabdollahian F, Haghighatdoost F. Anthropometric Indicators of Adiposity Related to Body Weight and Body Shape as Cardiometabolic Risk Predictors in British Young Adults: Superiority of Waist-to-Height Ratio. Journal of Obesity . 2018;2018:1-15. doi:https://doi.org/10.1155/2018/8370304 10. Schwarzenberg SJ, Georgieff MK. Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood Development and Adult Health. Pediatrics . 2018;141(2):e20173716. doi:https://doi.org/10.1542/peds.2017-3716 11. Wolf ER, O’Neil J. Caregiver and Clinician Perspectives on Missed Well -Child Visits. Annals of Family Medicine. 2020;18(1). doi:10.1370/afm.2466

The authors of this poster would like to acknowledge and thank the Edward Via College of Osteopathic Medicine Carolinas Library staff, several students who worked on early aspects of this project, and the Health Sciences South Carolina organization for their roles in this project.

The actual number of visits to a doctor where measurements are taken is far below the expected number for the majority of infants. By age two nearly half of the infants have 5 or fewer measurements recorded.

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2024 Research Recognition Day