doi:10.1111/j.1440-1754.2007.01056.

ORIGINAL ARTICLE

Overweight in medical paediatric inpatients: Detection and

parent expectations
Karen McLean,1 Melissa Wake1,2,3 and Zoe McCallum1,2,3
1

Centre for Community Child Health, Royal Childrens Hospital, 2Murdoch Childrens Research Institute and 3Department of Paediatrics, University of Melbourne,
Parkville, Victoria, Australia

Aims: (i) To determine prevalence and rates of detection of overweight/obesity among general paediatric inpatients. (ii) To explore parental
expectations regarding detection and management of overweight/obesity during admission.
Methods: This is a cross-sectional survey conducted in the Royal Childrens Hospital, Melbourne, Australia. A total of 102 children aged 2
12 years admitted to a general paediatric unit at the Royal Childrens Hospital and their parents participated in the survey. The main outcome
measures are body mass index (BMI); documentation of weight, height and BMI in patient notes; parent description of childs weight, parent
concern about childs weight, and parent opinion about detection and management of overweight.
Results: Twelve of 102 children (11.7%, 95% condence intervals 6.2%, 19.7%) were overweight or obese. All children had a documented
weight, two children (2.0%) had a documented height and none had BMI documented. Seven of 12 parents of overweight children described
their childs weight as healthy; ve of 12 parents of overweight children were not concerned about their childs weight. Eight of 12 parents of
overweight children believed all admitted children should have their BMI calculated. All parents thought the hospital should take action if a
child was found to be overweight.
Conclusions: Although prevalence of overweight was lower than expected, documentation of overweight did not occur for any patient in
the study. Parents of overweight children with acute illnesses believed that the hospital should screen for overweight and discuss it with parents.
Further studies are required to determine expectations among other patient populations.
Key words:

child; inpatient; obesity; parent attitude; surveillance.

Few would dispute that the increasing prevalence of childhood

overweight and obesity in Australia is of great concern. In 1997,
approximately 16% of Australian boys and 18% of Australian
girls were overweight, with more than 5% of both sexes obese.1
The physical and psychosocial morbidity of childhood obesity
has been well documented. Overweight children typically
become overweight adults, with long-term metabolic and cardiovascular risk.25 There is a significant negative effect of childhood overweight and obesity on quality of life, particularly in
the physical and social domains.6
Body mass index (BMI) is widely accepted as a surrogate
measure of childhood adiposity, as are international childhood
Key Points
1 11.8% of general paediatric inpatients were overweight or
obese.
2 All patients had a documented weight and none had a documented body mass index.
3 All parents of overweight or obese children thought that the
hospital should act if they nd an admitted child is overweight.
Correspondence: Dr Karen McLean, Centre for Community Child Health,
Royal Childrens Hospital, Flemington Road, Parkville, Vic. 3052, Australia.
Fax: +61 39345 5900; email: karen.mclean@rch.org.au
Accepted for publication 6 September 2006.

256

cut-off points with which to ascertain overweight and obesity.7,8

The National Health and Medical Research Council (NHMRC)
2003 Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents support detection of overweight and obesity in childhood, and recommend
that all children should be weighed, measured and have BMI
calculated every 6 months.9 Direct measurement is necessary,
as research has shown that at least a third and probably more
than half of parents may not recognise overweight in their child,
even when their child may be obese.10,11 Most parents unaware
of their child being overweight also have little concern regarding their childs weight.10 Acknowledging a lack of evidence for
effective intervention, the NHMRC guidelines advise use of
conventional components of weight management (e.g. dietary
modification, increased physical activity).9 However, there is in
fact little evidence about the benefits versus harms of systemic
detection of overweight/obesity in the general population.12
Understanding the views of parents of overweight children is
an important component of establishing such benefits or harms.
Melbournes Royal Childrens Hospital (RCH) is a major secondary and tertiary referral centre that admits around 25 000
children and treats over 10 times that number annually. As
such, the hospital directly impacts the health of many children
and has a leadership role in the community with respect
to changes in child health practice. Although public health
initiatives are predominantly the domain of community-based

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K McLean et al.

health care, junior medical staff are encouraged to utilise opportunities provided by a childs admission. For example, providing
catch-up immunisations and discussing the impact of parental
smoking are considered a standard part of patient management.
Anecdotally, in the inpatient setting, discussion of a childs
weight rarely occurs.
One previous study of paediatric inpatients showed a population prevalence of 22% of overweight/obesity,13 comparable
to the rates in the community. It also noted marked underrecording of height and weight and thus under-reporting of
obesity.14 These findings have not been replicated in other institutions, nor have any studies ascertained the views of parents
of overweight/obese children regarding the appropriateness of
surveillance for overweight during admission.
The aims of this cross-sectional survey were to: (i) establish
prevalence and detection of childhood overweight/obesity
among general paediatric inpatients at the RCH, Melbourne;
and (ii) explore attitudes of parents with overweight/obese
children towards detection and management of childhood
overweight.

Methods
Patients
Patients were recruited from all four general paediatric units at
the RCH on every Thursday and alternate Wednesdays from late
July to mid-November 2005. Together these units admit on
average 5228 patients annually, with an average length of stay
of 2.5 days. The four units rotate through a 4-week cycle of
receiving days which gave each unit an equal chance of being
sampled. The five most frequent Diagnosis Related Groups for
general paediatrics are bronchitis and asthma, gastroenteritis,
whooping cough and bronchiolitis, respiratory infection and
inflammatory musculoskeletal disorder. Patient lists were
obtained each recruitment day from the hospitals computer
clerical system. Specialty units were not included, as they typically admit fewer patients who often have chronic medical
conditions that may directly alter both weight status and its
interventions. Patients were eligible if aged 212 years. No cutpoints exist to define overweight/obesity in younger children.
As patients aged 1318 comprised only around 10% of general
paediatric admissions in 20012004, it was therefore felt
unlikely that the study would provide useful data for this age
group. Exclusion criteria were inability to stand for obtaining a
weight and height (either due to acute severe illness or due to
chronic disability), current admission to the intensive care unit,
admission under a general paediatrician for subspecialty care, a
syndromic diagnosis affecting height and weight (e.g. Down
syndrome) or inability to obtain written parent consent in
English. Approval was obtained from the RCH Ethics in Human
Research Committee prior to commencement of recruitment
(EHRC #25031A).

Procedures and measures

Prior to weighing and measuring the child, the parent completed a very brief verbal questionnaire ascertaining his/her
view of the childs weight status (very underweight, under-

Overweight in paediatric inpatients

weight, healthy weight, overweight or very overweight (obese))

and his/her level of concern about the childs weight (not concerned, a little concerned, very concerned). Each child was
weighed to the nearest 0.1 kg and measured to the nearest
0.01 m using a single set of standardised and calibrated scales
(Tanita THD Model 646) and an Invicta portable rigid stadiometer, according to established protocols.15 If the child was classified as overweight or obese, a second verbal questionnaire was
immediately administered. This addressed parental attitudes
towards detecting and addressing child weight.
The patient history and bedside charts were reviewed for
documentation of weight, height and BMI. If the child was
overweight, the history and charts were reviewed for a record
of discussion about the overweight. Postcode of residence was
recorded for non-responders as well as responders.

Statistical analysis
Body mass index (kg/m2) was calculated and the child classified
as not overweight, overweight or obese according to International Obesity TaskForce criteria.8 For purposes of comparing
parent assessment of underweight versus actual BMI, we arbitrarily defined underweight as a BMI third percentile for age
and sex on the 2000 Centers for Disease Control and Prevention
(CDC) charts.16 A Disadvantage Index score was derived from
the childs postcode of residence using the Australian Bureau of
Statistics Socioeconomic Indexes for Areas (SEIFA).17 SEIFA
values are standardised scores by geographic area compiled
from 2001 census data to numerically summarise the social and
economic conditions of Australia (national mean 1000, SD 100;
higher values represent greater advantage).
Simple descriptive statistics were generated to describe the
sample. For two-group comparisons of responders versus nonresponders, we used Students t-test and MannWhitney test for
normally and non-normally distributed continuous data,
respectively, and the 2-test for categorical data. Statistical analyses were conducted using Stata release 8 (Statacorp, Texas,
USA).

Results
Of 136 patients eligible for participation, 22 parents refused
consent and contact with parents of seven children was not
achieved. The remaining 107 were successfully recruited into
the study, but five children were uncooperative with measurement so that complete data were obtained for 102 patients
(75%) (Fig. 1). Patient characteristics are shown in Table 1. The
34 non-responders were comparable for sex (male 50.0% vs.
59.8%, P = 0.32) and age (median 4.05 years (range 2.239.62)
vs. 4.58 years (range 2.0312.14), P = 0.44) but showed a trend
to greater socio-economic disadvantage (mean 991.8 (SD 78.1)
vs. 1019.4 (SD 73.1), P = 0.06). SEIFA scores suggested that the
study population was slightly less disadvantaged than Australia
as a whole. The age distribution of included patients was positively skewed, the greater number of younger children reflecting expected admission patterns to the general medical units.
Ten patients were overweight (seven boys, three girls) and
two were obese (both boys), ranging in age from 2.1 to
11.4 years (median 4.8 years). This prevalence of 11.8% (95%

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257

Overweight in paediatric inpatients

K McLean et al.

POTENTIALLY ELIGIBLE

INELIGIBLE

All children aged between 2 and

12 years inclusive, admitted as
general paediatric patient

Too sick: n = 28
ICU: n = 8
Unable to consent: n = 18
Subspecialty patient: n = 16
Syndrome: n = 3

n = 209

n = 73

CONTACT NOT
ESTABLISHED
n=7

ELIGIBLE
n = 136

CONSENT REFUSED
n = 22

CONSENTED

INCOMPLETE DATA
(Child refused to cooperate with weight/height
measurement)
n=5

n = 107
(79% of eligible)

FULL ASSESSMENT
n = 102
(75% of eligible)
Fig. 1 Participant owchart. ICU, intensive care unit.

confidence interval 6.2%, 19.7%) is less than population prevalence of around 2025% for 2- to 12-year-old children. Fifty
patients (49%) had a diagnosis that was likely to cause dehydration (and acute weight loss) through increased losses (e.g.
vomiting, diarrhoea, fever), decreased intake (e.g. sepsis,
encephalitis, abdominal pain) or both; many parents commented that their child had recently been unable to tolerate
their usual intake and some stated that their child had lost
weight because of the current illness. Adding a hypothetical
500 g to the weight of each child would have added nine more
children to the overweight category (21 overweight or obese
children in total, which at 20.6% approximates the population
prevalence). The median weight (range) for these 21 children
was 18.5 kg (13.454.1); the 500 g estimated loss of body
weight equates to 3.7% dehydration in the smallest child.
All patients had a weight recorded on admission paperwork.
Six children were recorded as having an estimated weight only
the true number is likely to be greater as some parents men258

tioned they had supplied their childs weight on admission.

Only two of 112 included patients (1.8%) had a height
recorded. One of the five consented patients who was uncooperative with measurement also had a height recorded, although
inches were erroneously recorded as centimetres to give a
highly improbable recorded height of 44 cm. No patient had
BMI documented, and discussion about the childs weight was
not recorded for any of the 12 overweight/obese patients.
Parent description of their childs weight and parental concern about weight are shown in Table 2. Seven of 12 parents
(58.3%) of overweight/obese children were concerned about
their childs weight, despite four of these describing their childs
weight as healthy. Concerns mentioned included impact on
health in childhood and poor diet behaviours such as not being
a good eater. One parent was concerned about rising weight
with a lack of activity. Five parents of overweight/obese children
(including two who described their child as overweight) were
not concerned about their childs weight.

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K McLean et al.

Overweight in paediatric inpatients

Table 1 Characteristics of the sample (n = 102)

Variable

Value

Table 3 Attitudes towards detecting and addressing child weight

among the 12 parents of overweight/obese children
Question

Age
Median (range) in years
Age group, n (%)
25 years
69 years
1012 years
Sex, n (%)
Male
Female
SEIFA disadvantage index
Mean (SD)
Range
BMI status, n (%)
Non-overweight
Overweight/obese
BMI z-score (USA)
Mean (SD)
Range

4.58 (2.0312.14)
70 (68.6)
21 (20.6)
11 (10.8)
61 (59.8)
41 (40.2)
1019.4 (72.8)
798.71136.3
90 (88.2)
12 (11.8)
0.09 (1.09)
3.452.42

BMI, body mass index; SEIFA, Socioeconomic Indexes for Areas.

Table 2 Parent description of childs weight and concern about weight

Child weight status, n (%)
Non-overweight
(n = 90)
Parental description of childs weight
Obese or very overweight
0
Overweight
2 (2.2)
Healthy weight
61 (67.8)
Underweight
26 (28.9)
Very underweight
1 (1.1)
Parental concern about childs weight
Very concerned
6 (6.7)
A little concerned
16 (17.8)
Not concerned
68 (75.6)

Overweight or obese
(n = 12)

0
5 (41.7)
7 (58.3)
0
0
3 (25.0)
4 (33.3)
5 (41.7)

Six parents of non-overweight children were concerned

while describing their childs weight as healthy. Three were
concerned that their child might become overweight, whereas
the other three were concerned about loss of weight. Fifteen
parents described their child as underweight or very underweight and were concerned. Their concerns included their child
being too small/skinny, not eating properly, impact of underweight on health and that being unwell would exacerbate
underweight. Of the six children whose BMI was actually
below the third percentile, only three parents were concerned
about their weight. There seemed to be no relationship
between weight description and concern for either overweight
or underweight.

Surprised child overweight/obese

Can recall when child last weighed/measured
Can recall child having BMI calculated
Previous suggestion that childs weight might be a problem
Ever taken action to address childs weight
Sees a need for childs weight to change
Planning to make signicant changes so childs weight can change
Would seek help from a health professional if wanted to change
childs weight
First choice of help source if were seeking help
Dietitian at RCH
GP
MCH nurse
Paediatrician (etc.)
Dietitian in community
Doctor at RCH
School nurse or other school staff
Internet
Family/friend
All children admitted to the RCH should
Be weighed
Be measured
Have BMI calculated
Action RCH staff should take for children found to be overweight
Discussion during admission
Referral to dietitian service
Written information
Referral to GP
Outpatient appointment
Nothing
Parents should be told if their child is found to be overweight
Yes, always
Yes, if parent asks
No
People who should raise overweight with parents
GP
Maternal and child health nurse
Doctor at RCH
Nurse at RCH
Dietitian at RCH
School nurse
Family/friend
Other school staff

n
5
8
0
2
2
7
6
6

4
2
2
2
1
1
0
0
0
11
9
8
10
8
7
5
4
0
9
1
1
11
11
10
10
8
6
4
3

BMI, body mass index; GP, general practitioner; MCH, maternal and child
health; RCH, Royal Childrens Hospital.

Table 3 shows the results of the second parent questionnaire

from the 12 parents of overweight/obese children. All five parents who expressed surprise about their childs weight classification had described the weight as healthy. Four parents could
not recall when their child was last weighed or measured (ages
2.39.7 years). No parent could recall their childs BMI ever
being calculated. The two parents who described taking action

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K McLean et al.

to try to change their childs weight had described their child as

overweight and were concerned. One had tried to improve diet,
whereas the other had tried to increase activity. Neither parent
had sought help. All parents were asked to nominate their
preferred help resource should they wish to try to change their
childs weight and all named a health professional in preference
to school supports, family or the Internet.
When asked about RCH identifying and managing overweight in inpatients, most parents thought all in-patients should
have their BMI calculated. All parents believed the hospital
should act if a child was found to be overweight. Nearly all
considered a general practitioner (GP), maternal and child
health nurse, or an RCH doctor or nurse well placed to discuss
childhood overweight and felt they should raise the issue with
parents.
Only three parents identified any concern about addressing
overweight in their child. One did not want the child to have
body image problems, and another did not want to label the
child as having a weight problem. The third was more concerned that childhood overweight is not solely an individuals
responsibility, but that a community response is necessary for
effective intervention.

Discussion
Although our survey of general paediatric inpatients at a major
paediatric hospital showed a lower-than-expected prevalence of
overweight/obesity, it also confirmed that, almost uniformly,
parents of overweight children with acute illnesses believed that
the hospital should be screening for overweight during admission and discussing overweight with parents. With no child in
our study having had a BMI recorded during admission, there
is a gap between current practice and parental expectation.
Our prevalence of overweight of 11.7% (95% confidence
intervals 6.2%, 19.7%) contrasts with a recent study in a similar setting that found a prevalence of 22%,13 equivalent to
population prevalence.1 However, the upper limit of the 95%
confidence interval puts the sample in line with the known
prevalence. Several other reasons may have contributed to a
lower prevalence. First, the age distribution of our population
was heavily skewed towards preschool children (particularly 2year-olds), with at least one recent study suggesting that obesity rates probably increase rapidly after the age of 3 years.18
The finding may be spurious because, when the admission
diagnoses of our sample were considered, it became apparent
that weight loss in the context of the acute illness may have
had a significant impact on the detection of overweight or
obesity; however, these children would have remained close to
the cut-point for overweight even if re-categorised. Some parents of overweight children may have refused participation
because of concerns about negative self-esteem impact, even
though more than half the parents were unaware of their
childs overweight. Finally, children with chronic conditions,
orthopaedic problems, and children attending outpatient
services were not included, and may be more likely to be
overweight/obese.19
Although poor identification of childhood overweight by parents has been well documented across different settings and
cultures,10,11,2023 there are fewer data for detection by health
260

professionals. Although there may be some reassurance for our

patient management in 100% of our patients having a documented weight, at least six had an estimated weight only, and
the true number is probably higher than this. Although OConnor et al. were able to report 27% of inpatients having had their
height recorded,14 we only found two patients (2%) with a
documented height. It is then not surprising that no patient had
their BMI recorded during admission, and no discussion about
overweight was documented for any of our 12 overweight
patients.
Despite the 2003 NHMRC guidelines that recommended that
GPs calculate BMI at 6 monthly intervals,9 no parent of an
overweight child could ever recall their child having had their
BMI calculated. Only two of the 12 parents had ever been told
that their childs weight might be a problem. A study examining
the practices of Melbourne GPs found that calculation of childrens BMI in general practice was a rare event.24 A study
auditing the identification of obesity in children attending
health visits in primary care in the USA found only 53% of
obese children had been identified as such during the visit.25
Thus, an acute hospital admission may represent a real opportunity to identify overweight in some children and to raise the
issue with their parents.
However, current practice would need to change to detect
overweight and obese children during admission. The lack of
detection is not due to a lack of equipment or access to BMI
calculators or BMI percentile charts (readily accessible through
the widely used intranet of this hospital). It may be due to a
lack of comfort in health professionals regarding management
of childhood overweight/obesity. Change of practice would
need to include training, particularly around sensitive discussions with parents, and a hospital expectation that BMI calculation is part of standard care. The timing of any screening
would ideally follow adequate rehydration and treatment to
optimise accuracy and co-operation, but still allow appropriate
discussion prior to discharge. Not all parents (nor practitioners)
are comfortable with or convinced by growth charts or BMI cutoff points,20 and the first step after identification would be
successful communication of the childs weight status to the
parent(s). Perhaps the lack of evidence about the next step of
management is a deterrent to surveillance, and with time this
may be addressed by ongoing research. Adequate resource allocation to allow referral of overweight children for ongoing management is also critical.
The greatest limitation of our study was the small sample size,
particularly for the second survey of parents of overweight
children. However, on a number of questions, there was great
consistency in answers even in this small group. Although
response bias may have led to exclusion of some overweight
children, the response rate was good and the non-responders
were similar to responders. Our study population was restricted
to a subset of hospital patients and did not extend to outpatients, adolescents, surgical or subspecialty patients. Because we
recruited on Wednesdays and Thursdays the sample did not
include many patients admitted on a weekend, but we have no
reason to suppose that weekend and weekday admissions
would vary systematically according to child BMI status. The
population was also skewed towards preschool children. The
views of parents of older children, and the children themselves,

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K McLean et al.

would need to be studied separately to establish attitudes

towards routine screening for overweight.
On the one hand, we lack evidence addressing the benefits
and harms of population screening for obesity. However, many
groups including the NHMRC have made recommendations in
favour of routine BMI screening based on the best available
evidence.9,2627 This study confirms that very few children are
being assessed for overweight/obesity in the inpatient setting,
and suggests that most parents of overweight children favour
routine measurement, detection and subsequent discussion of
the issue. Clearly, further research is vital into the actual acceptability and effectiveness of this approach when implemented.
Equally clearly, if paediatric hospitals are to address the issue of
childhood overweight with their own patients, major practice
changes and a strong commitment are required.

Acknowledgements
We would like to thank the patients and their families who
participated in the survey.

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