Body Mass Index assessment 2 - 5 years (excluding SEHA) - WA Health
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Child and Adolescent Community Health
Community Health Manual
GUIDELINE
Body Mass Index assessment 2 – 5 years (excluding SEHA)
Scope (Staff): Community health staff
Scope (Area): CACH, WACHS
This document should be read in conjunction with this DISCLAIMER
Aim
To identify children with growth (height, weight, BMI) outside of the expected range for age
and gender, and to provide family support for making positive lifestyle changes and/or
referral when required.
Risk
Failure to identify children who are outside of a healthy body mass index (BMI) range for
their age increases the risk of unhealthy weight status intensifying with age. Overweight
and obesity increases the risk for short and long term health consequences, and increases
the burden of disease and associated health care costs1, 2.
Background
The prevalence of obesity in early childhood is high, with 23% of Australian children aged
2-4 overweight, including 5% who are obese. Research indicates that rates increase with
age3. The likelihood of childhood overweight and obesity persisting into adulthood is
correlated to the degree of adiposity, age of child4 and parental obesity. A systematic
review in 2008 revealed that 85% of overweight children aged 2-5 would become obese
adults5.
Growth assessment is most meaningful when serial measurements are collected to
enable monitoring over a period of time8. At the Universal contact 2 Years, Body Mass
Index (BMI) is introduced as an important component of the holistic growth assessment.
Infants and young children have a relatively higher proportion of fat as a normal
component of growth. During middle childhood BMI falls as children become relatively
leaner, and then increases as puberty approaches and body composition approaches that
of adulthood. BMI for age percentile charts reflect these normal, predicted changes of BMI
throughout childhood7.
BMI assessment is useful for screening for wasting and thinness, and overweight and
obesity in children from the age of 2 years7. Along with growth measurements, the child
should always be assessed according to their overall health and wellbeing, and
developmental progress.
Consideration of the combined factors of overall rate of growth, or growth trajectory, the
actual position on the growth chart, and clinical judgement, including a knowledge of the
child’s history, are required to determine whether further investigation is required8.
Additional monitoring should be undertaken and referral should be considered when the
direction of growth falls downwards or tracks upwards across percentiles7.Body Mass Index assessment 2 - 5 years (excluding SEHA)
The National Health and Medical Research Council (NHMRC) recommends the use of
BMI scores plotted on the BMI-for-Age Percentile charts (for boys or girls) as an initial
(first level) assessment to assist in identifying children who may be overweight or
obese7.
For further information on growth monitoring refer to the following:
Growth birth – 18 years
Growth faltering
Overweight and obesity
Body Mass Index assessment – primary school
Key points
When assessing BMI as part of the School Entry Health Assessment, refer to the
Body Mass Index assessment – primary school procedure.
Reviewing serial growth (length/height and weight) measurements from previous
child health contacts will assist in interpreting overall growth status at the 2 year old
contact.
At the Universal contact 2 years, growth will be assessed using a compilation of the
following assessments:
o Weight plotted on WHO Weight 2-5 years (CHS800A-7 – girls and CHS800-9
– boys)
o Height plotted on WHO Height 2-5 years (CHS800A-8 – girls and CHS800-
10 – boys)
o BMI-for-age calculation using height and weight measurements and plotted
on CDC BMI percentile chart 2-20 years (CHS 430A/B – girls/boys)
The assessment of BMI provides an overall measure of body size but does not
distinguish between fat, muscle and fluid composition (NHMRC).
Growth charts linked to the 2 year old Universal contact are only applicable to
children aged 2 years or older.
o Parents should be encouraged to make appointments on or soon after, their
child’s 2nd birthday.
o Children seen prior to the child’s 2nd birthday should be seen again soon
after the 2nd birthday to complete the growth assessment component of the
Contact.
Training on BMI assessment, chart plotting, sensitive communication with parents
and lifestyle counselling is essential. Refer to the online training package Talking
with parents about children's weight. Staff are required to complete this training
prior to undertaking a BMI assessment.
Unless advised by a paediatric specialist, weight loss is not recommended for
overweight children. The emphasis is on weight maintenance over time to improve
weight in relation to height and age. Parents should be encouraged to develop long
term family lifestyle behaviours that promote healthy weight status.
Page 2 of 13 Community Health ManualBody Mass Index assessment 2 - 5 years (excluding SEHA)
Equipment
Stadiometer or height rule
Digital weight scale
Calculator OR CDIS (CACH) or Communicare (WACHS) for automatic calculation
of BMI
Refer to Height and Weight Assessment procedures for further information on
equipment specifications.
Procedure
Steps Additional Information
1. Conduct height assessment For more information refer to the
Height assessment 2 - 5 years
Plot child’s height onto the gender procedure
specific WHO Height Chart 2 - 5years
(CHS800A). Accuracy of height measurement is
critical given the value is squared in
the BMI calculation. Ensure good
technique and repeat measure if
required.
2. Conduct weight assessment For more information refer to the
Weight assessment 2 - 5 years
Plot child’s weight onto the gender procedure
specific WHO Weight Chart 2 - 5years
(CHS800A).
3. Determine BMI for age percentile CDIS (CACH) and Communicare
Calculate BMI score. (WACHS) will generate a BMI score
and percentile automatically when the
Plot the BMI score onto the CDC BMI weight and height are entered.
for age (2-20years) growth chart,
relative to the child’s age and gender The online CDC BMI and percentile
(CHS430). calculator for children and
adolescents is also a useful tool to
This chart can be used as a visual generate raw BMI value, BMI
tool during discussions with parents percentile and corresponding weight
as required. classification. It also automatically
provides some corresponding
commentary on the individual’s
weight classification and brief
guidance on what action would be
recommended.
Manual calculation can be made on a
standard calculator:
BMI = Weight (kg) ÷ [Height (m)]2
Page 3 of 13 Community Health ManualBody Mass Index assessment 2 - 5 years (excluding SEHA)
Steps Additional Information
Example follows:
Weight 18.2 kg Height 1.083 m
BMI= 18.2 ÷ [1.083]2
BMI= 18.2 ÷ (1.083 x 1.083)
BMI= 18.2 ÷ 1.172
BMI= 15.52 kg/m2
4. Interpret results
Review height and weight percentiles Measuring and recording all growth
and any previous growth variables onto growth charts helps to
measurements available to identify confirm the impact of positive parenting
any deviations or to confirm practices. It also assists in identification of
appropriate growth tracking. deviations from the norm such as growth
faltering or excessive weight gain.
Use CDC BMI cut-points to identify
indicated weight status as follows: BMI is a screening tool and is not
diagnostic of weight status however
contributes to an overall clinical
impression.
Indicated Percentile range7
Weight status* While the cut-off points for weight
Underweight th categories on the BMI percentile charts
< 5 percentile
are clearly defined, their application
Healthy weight 5th to < 85th percentile should be used with professional
judgement and consideration of several
Overweight 85th < 95th percentile factors when assessing individuals. For
Obese ≥ 95th percentile example:
- Some children may have a higher
than average muscle mass;
- Some racial/ethnic backgrounds can
affect the proportion of body fat and
therefore have an impact on
appropriate BMI category cut-off
points. A BMI reference chart relevant
to the ethno-cultural mix of the current
Australian demographic has not yet
been developed (NHMRC);
- Children who have ongoing obesity
may grow in height faster than they
are genetically predisposed. This may
mask their obesity in BMI
assessment9. Plotting on height,
weight and BMI charts will help to
identify deviations.
Page 4 of 13 Community Health ManualBody Mass Index assessment 2 - 5 years (excluding SEHA)
Outcomes
Where a deviation in serial measurements is identified and/or BMI is outside of the Healthy
Weight Range (5th - < 85th percentile), a review of the child’s lifestyle factors should be
undertaken. This will include reviewing eating patterns, food and drink selection, and
physical and sedentary activity patterns. Appendix A outlines risk and protective factors for
the development and maintenance of childhood obesity.
Where growth faltering is indicated, staff should refer to the Growth faltering guideline
Where overweight or obesity is indicated community health staff may offer healthy lifestyle
brief intervention counselling with parents, using the Tips to support healthy choices 2 – 5
years resource.
Clinical pathways for BMI categories are indicated as follows:
BMI suggests Underweight: (Less than 5th percentile)
Refer the child to appropriate health care professionals for further assessment
and/or intervention, as per clinical judgement or parent request.
Provide additional information and support to parent if required. For more
information refer to the Tips to support healthy choices 2 -5 years resource.
BMI suggests Healthy Weight: (5th percentile to less than the 85th percentile)
Reinforce current positive lifestyle behaviours. No further action required
BMI suggests Overweight: 85th to less than 95th percentile
Inform the parent that the BMI is not diagnostic but based on their child’s results,
their child is in the overweight range. This feedback should be given with
sensitivity; it may be the first time that a potential concern has been raised.
Explore parent’s perception of their child’s weight status.
Explore parent concerns, lifestyle factors and other factors that may contribute
(e.g. ethnicity). Refer to the Tips to support healthy choices 2 – 5 years resource
and Appendices A.
Reinforce healthy nutrition, physical activity and screen time practices with
verbal and written information, including the Tips to support healthy choices 2 –
5 years resource and Appendices A.
Identify small achievable goals or lifestyle changes that can be made within the
family environment to help make positive changes to their child’s future health
and wellbeing. Reinforce that the aim is for the child to grow into their
weight and not for weight loss.
Using clinical judgement combined with growth assessment results and
lifestyle assessment, decide if referral to GP is indicated and/or other
referral options listed below.
Provide additional support as required.
Depending on referral outcomes and/or strategies agreed by parent, schedule
follow-up appointment. If care has not been transferred to an alternative health
Page 5 of 13 Community Health ManualBody Mass Index assessment 2 - 5 years (excluding SEHA)
care professional, community health nurse follow up is recommended within 12
months.
BMI suggests Obese: (Equal to or greater than the 95th percentile)
Feedback to the parent that the child’s growth assessment suggests they are in
the obese range should be given with sensitivity; it may be the first time that a
potential concern has been raised.
Explore parent concerns, lifestyle factors and other factors that may contribute
(e.g. ethnicity).Refer to Appendices A for more information.
Explore eating and activity behaviours; discuss causes and consequences of
overweight; and decide on interventions. Refer to Appendices A for key
messages and obesity risk factors.
Refer to medical practitioner and/or dietitian for further assessment and
treatment as a priority. Consider other suitable referral options (see below).
o If obesity is severe, consider referral to the PMH/PCH Healthy Weight
Program (formerly known as CLASP) via medical practitioner (see
‘Referral options‘ and ‘Useful resources’ sections below).
Where possible, refer to locally available healthy lifestyle programs or activities.
Reinforce positive nutrition, physical activity and screen time practices with
verbal and written information including
The NHMRC suggests that regular (3 monthly) BMI plotting on a percentile chart
is the recommended process to track weight management progress for obese
children. Ideally, this should be done under medical care.
If the child is not under medical care (due to access to services or no
parent engagement), community health nurse follow-up is recommended
between 3 and 12 months. Consider severity, referral outcomes and/or level of
engagement and strategies agreed by parent. Document clearly when follow- up
is planned to occur.
Provide additional support and information as required.
For concerns regarding family engagement or neglect, consider making a report
to Department for Child Protection and Family Support. Refer to Department of
Health WA - Information Sheet 8 Child obesity and Child Protection for guidance.
Referral options
Referral decisions will depend on the growth status of the child and the capacity and
preferences of the family. Referral will also depend on availability of local services which
are varied across the state.
The following are some suggested referral points:
Medical practitioner.
Dietitian - some local health services (hospitals or community health centres)
have dietetic services available for children. The Dietitians Association of
Australia can help to locate private dietetic services.
Page 6 of 13 Community Health ManualBody Mass Index assessment 2 - 5 years (excluding SEHA)
Allied health professionals including; physiotherapist, occupational therapist,
clinical psychologist or paediatrician.
PMH/PCH Healthy Weight Program (formerly known as CLASP). For children
and adolescents with complicated and/or significant obesity and their families
(Medical practitioner referral to the Healthy Weight Program is required. Consider
mentioning PMH Healthy Weight Program on Clinical handover (CHS663) when
referring a child to a medical practitioner).
Triple P (Group or Seminar Series) or other locally available quality parenting
programs.
Healthy lifestyle programs or activities according to local availability.
Community leisure and recreation services.
Adult weight management programs (helpful if the parent is concerned about
their own weight).
Parents can be referred to some of the online resources listed at the end of the
guideline for additional information and support.
Documentation
Community health staff will document relevant findings according to local processes.
Related internal policies, procedures and guidelines
The following documents can be accessed in the CACH Community Health Policy Manual
via the HealthPoint link or the Internet link
Body Mass Index assessment – primary school
Growth birth – 18 years
Growth faltering
Height assessment 2 - 5 years
Overweight and obesity
Physical assessment 0 – 4 years
Universal contact 2 years
Weight assessment 2 - 5 years
Related internal resources and forms
The following resources and forms can be accessed from the HealthPoint CACH Intranet
link
Body Mass Index Boys (CHS430B)
Page 7 of 13 Community Health ManualBody Mass Index assessment 2 - 5 years (excluding SEHA) Body Mass Index Girls (CHS430A) Child and Antenatal Nutrition (CAN) Manual Food For Kids How children develop Practice guide for Community Health Nurses Tips to support healthy choices (2 – 5 years) Toddler tucker World Health Organization Growth Charts (CHS800A series) Useful external resources BMI resources CDC BMI and Percentile calculator for Children and Adolescents (ensure ‘metric’ selected) Centers for Disease Control and Prevention. About BMI for Children and Teens Parenting Positive parenting programs - Triple P Raising Children Network Navigate for obesity, healthy eating, physical activity and screen-time related articles Ngala Food and nutrition Australian Dietary Guidelines Eat for Health Australian Dietary Guidelines Go for 2&5 Fruit and veg recipes Healthy Food For All - Food Sensations program practical nutrition education for schools, adults (families) and communities Good Food for New Arrivals provides resources for both service providers and families to improve nutrition knowledge and access to healthy foods for newly arrived humanitarian and refugee families. State Government of Victoria- Better Health Channel Why no sweet drinks for children - resource for parents produced by Royal Children’s Hospital Melbourne Page 8 of 13 Community Health Manual
Body Mass Index assessment 2 - 5 years (excluding SEHA) Physical activity Australia’s Physical Activity and Sedentary Behaviour Guidelines Pamphlets available- 0- 5years; 5-12 years; and Families. To order phone 1800 020 103 Get up and Grow Healthy Eating and Physical Activity for Early Childhood resources Nature Play WA Resources for parents and families to encourage kids to get active outdoors. Healthy Weight Weight Management tips for parents and carers produced by Children’s Hospital at Westmead, Sydney Children’s Hospital, Randwick and Kaleidoscope Children, Young People and Families NHMRC Clinical Practice Guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Live Lighter - Western Australian developed program promoting healthy lifestyles. Whilst the program targets adults, many of the tips, tools, resources and recipes can be used for families with children. Healthy Weight Service – PMH/PCH program for children with weight and growth issues (formerly known as CLASP). Other Guidelines for Protecting Children 2015 (Revised 2017) Page 9 of 13 Community Health Manual
Body Mass Index assessment 2 - 5 years (excluding SEHA)
Appendix A: Risk and Protective Factors for the Development and Maintenance of Childhood Obesity
GENETIC MAKEUP CHILD DIETARY INTAKE FAMILY ENVIRONMENT PARENTING
Risk Factors Risk Factors Risk Factors Risk Factors
Parental Obesity High intake of energy dense, Family has few economic Restrictive child-feeding
nutrient poor foods and resources practices (i.e. parent rarely
Ethnicity fluids (e.g. fast foods, soft Parent lacks nutritional gives child choices about what
Conservative metabolism drinks) knowledge to eat and how much)
(tendency to store energy)
Parent does not recognise Permissive child-feeding
Certain rare endocrine disorders Protective Factors
childhood obesity or is not practices (e.g. parent
(eg. Prader-Willi Syndrome). High intake of low GI foods (e.g.
concerned about it accommodates child’s
whole grains, legumes)
Protective Factors Parent has unhealthy eating neophobic responses)
High intake of dairy foods (e.g.
‘Active’ metabolism (tendency to habits (e.g. regular dieting) Coercive parenting style (e.g.
low fat milk, yoghurt)
expend energy) Parent has a sedentary lifestyle parent shows anger when child
Eating a healthy breakfast misbehaves)
(e.g. relies on TV for recreation)
Parent works long hours Inconsistent parenting style (e.g.
EARLY GROWTH & CHILD ACTIVITY PATTERNS Energy dense foods are available parents fails to follow through
DEVELOPMENT and easily accessible in the with discipline)
Risk Factors Risk Factors home. Low self-efficacy (i.e. parent
lacks confidence in managing
High birth weight High levels of sedentary activity Protective Factors child’s weight related behaviour)
Early adiposity rebound (e.g. >1hr screen time per day)
Parent has an active lifestyle
Formula feeding Poor sleep patterns (e.g. poor
Meals are eaten as a family
Protective Factors
routines or sleep apnoea) Parent monitors child food intake
Protective Factors Fruit and vegetables are available
and activity patterns
Breastfeeding Protective Factors and easily accessible in the home
Parent reinforces healthy
Physically active for at least 3 Child has access to safe outdoor
behaviours (e.g. through praise
hours throughout each day playing areas
and modelling)
Parent and child engage joint
Parent sets firm limits about food
physical activities
and activity
Parent supports access to activity
based sessions for child
Adapted from Lifestyle Triple P Facilitator Training Participant Notes. 2009. The University of QLD and Triple P International.Body Mass Index assessment 2 - 5 years (excluding SEHA)
APPENDIX B: Growth assessment process 2-5 years old
Process Documentation
Conduct height assessment CHS 800A
Conduct weight assessment (WHO 2-5 years)
Consider possible
aberrations in growth. Refer
to Growth faltering and
Growth birth – 18 years for
more information.
Calculate BMI and determine BMI percentile CHS 430 A/B
1. Use CDIS or Communicare and/or CDC BMI and (CDC BMI 2-
percentile calculator
20yrs)
2. Plot BMI CDC BMI growth chart
Determine indicated weight status category
UNDERWEIGHT HEALTHY OVERWEIGHT OBESE
WEIGHT
< 5th percentile 85th to < 95th > 95th percentile
Page 11 of 13 th
5 to < 85 th
percentile
percentile
Conduct holistic
Conduct holistic
assessment and provide
Conduct holistic assessment and provide
relevant BI.
assessment and provide relevant BI.
Conduct holistic
relevant BI. assessment and provide Consider if GP/Dietitian
Refer to GP/Dietitian.
relevant BI (if required). referral is required.
Consider if GP/Dietitian Follow up within 3-12
referral is required. Depending on referral
months if not under
decision/outcome, follow
medical care.
up within 12 months.
Provide appropriate parent communication, documentation and referral where required
Page 11 of 13 Community Health ManualBMI assessment 2 - 5 years (excluding SEHA)
References
1. Procter KL. The aetiology of childhood obesity: a review. Nutrition Research
Reviews 2007; 20:29-45.
2. Brown V, Moodie M, Baur L, Wen L & Hayes A. 2017. The high cost of obesity in
Australian pre-schoolers. Australian and New Zealand Journal of Public Health.
doi: 10.1111/1753-6405.12628.
3. Australian Bureau of Statistics. 4364.0.55.003 – Australian Health Survey:
Updated Results, 2011-2012 [Internet]. Canberra (AUST): ABS; 2013. Available
from:
http://www.abs.gov.au/AUSSTATS/abs@.nsf/%20DetailsPage/4364.0.55.003201
1-2012
4. Evenson, E., Wilsgaard, T., Furberg, AS., Skeie, G. Tracking of overweight and
obesity from early childhood to adolescence in a population-based cohort– the
Tromso Study, Fit Futures. BMC Pediatr. 2016; 16: 64. doi: 10.1186/s12887-016-
0599-5
5. Singh AS, Mulder C, Twisk JWR, van Mechelen W, Chinapaw MJM. Tracking of
childhood overweight into adulthood: a systematic review of the literature.
Obesity reviews. 2008; 9(5):474-88.
6. Australian Institute of Health and Welfare 2017. Impact of overweight and obesity
as a risk factor for chronic conditions: Australian Burden of Disease Study.
Australian Burden of Disease Study series no.11. Cat. no. BOD 12. BOD.
Canberra: AIHW.
7. National Health and Medical Research Council (2013) Clinical practice guidelines
for the management of overweight and obesity in adults, adolescents and children
in Australia. Melbourne: National Health and Medical Research Council.
8. Canadian Paediatric Society and Dietitians of Canada. Promoting optimal
monitoring of child growth in Canada: Using the new World Health Organization
growth charts - Executive Summary. Paediatric Child Health. 2010;15(2):77-83.
9. De Simone M, Farello G, Palumbo M, Gentile T, Ciuffreda M, Olioso P, Cinque
M, De Matteis F. Growth charts, growth velocity and bone development in
childhood obesity. International Journal of Obesity and Related Metabolic
Disorders : Journal of the International Association for the Study of Obesity [01
Dec 1995, 19(12):851-857] (PMID:8963351)
Page 12 of 13 Community Health ManualBMI assessment 2 - 5 years (excluding SEHA)
This document can be made available in
alternative formats on request for a person
with a disability.
File Path:
Document Owner: Senior Portfolio Policy Officer
Reviewer / Team: Statewide Policy
Date First Issued: 25 May 2017
Last Reviewed: Amendment11 April 2018 Review Date: 25 May 2020
Approved by: CACH/WACHS Community Health Clinical Nursing Policy Governance Group
Endorsed by: Executive Director CACH Date: 25 May 2017
Standards Applicable: NSQHS Standards: 1.7, 1.18
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