Taking care of a critically ill child can be nerve-racking to say the least, and downright petrifying for those who don’t do it frequently, even if they are well-trained and brilliant clinicians. Dr. James Broselow, a family medicine-turned-emergency medicine physician from Hickory, North Carolina, recognized that his team spent a lot of time trying to calculate doses of medications rather than spending their mental energy on the actual medical decisions for the resuscitation. He, along with Dr. Bob Luten, a PEM physician in Jacksonville, FL, designed the Broselow-Luten color-coded length-based system to help estimate a child’s weight, and thereby offload the cognitive burden of medication dosing and choice of equipment sizes in pediatric resuscitations. This system has now become the “industry standard.” We have previously talked about how to manage critically ill children with Pediatric Resuscitation Pitfalls, Medication Errors, Neonatal Intubations and RSI, and we have even touched on resuscitation equipment by discussing Cuffed Endotracheal Tubes in Children, and Endotracheal Tube Depth. Now, let’s discuss the benefits (and caveats) of using the Broselow-Luten system for estimating weight in children.
Broselow-Luten Color-Coded Length-Based Weight-Estimation System: History of
[Emergency Medical Services for Children]
- Designed by Dr. James Broselow.
- Dr. Broselow was family medicine but switched to emergency medicine. From Hickory, NC.
- Joined with Dr. Robert “Bob” Luten of Jacksonville, FL to study and market the system.
- Used National Center for Health Statistics data on child ages and weights to design system.
- Came out in 1986. [DeBoer 2020]
- Now seen as industry standard in pediatric emergency care.
- Reduces dosing errors during resus, up to 33.88%.
- Recommended by ATLS and PALS.
Broselow-Luten System: Supportive Data
- Physician estimates of weight can underdose children by 49% or overdose by up to 116%. [Rosenburg 2010]
- B-L system is designed for 12yo and younger, patients up to 80 lbs, height 46-143 cm [Meguerdichian 2012]
- Estimates the 50%ile weight for height (Length vs Ideal Body Weight).
- Most drugs distributed in lean body mass, so dosing is relatively accurate. [Luten 2007]
- Estimates weight within 15% error of actual weight in 79% of children. [Lubitz 1988]
- Very accurate for 3.5-25kg, but not as accurate >25kg. [Lubitz 1988]
- Good agreement with actual weight if average body habitus, better than physician estimate. [Rosenberg 2011, Yamamoto 2009]
- Not as accurate in obese children (physicians were better at estimating).
- Good correlation to bed scale weight in trauma patients (Pearson coefficient 0.86), but there was some error in the highest weight category. [Sinha 2012]
- It is useful in the prehospital setting, correlating well with actual weight and ED Broselow weight. [Heyming 2012]
How Do You Use The Broselow-Luten System/Tape?
[Emergency Medical Services for Children]
- “Red to Head.” One end of the tape is red with an arrow. Put this end level with the top of the child’s head.
- Stretch the child out with straight legs. Extend the tape along the side of the child.
- Measure to the child’s heel, not the toes.
- The color category will tell you the estimated weight of the child. The tape includes common resuscitation medication doses and equipment sizes.
- There are two sides to the tape! If you don’t see what you need, check the other side!
- At this time it does not include medication volumes/amounts, which still poses challenge to nurses who have to calculate volume based on dose. [Krug 2007]
What If the Child is Obese or Emaciated?
- Most emergency drugs except for amiodarone and succinylcholine are based on ideal body weight [Emergency Medical Services for Children, Luten 2007]
- Epinephrine, dopamine, fentanyl, ketamine based on what child should weigh.
- There are other systems that account for body habitus.
- PAWPER [Wells 2013, Silvagni 2022]
- Takes into account body habitus. Broselow does not.
- Initially tested in Johannesburg, South Africa: 1 month old to 12 years old
- Broselow predicted within 10% of weight in 63.6% of children; PAWPER predicted within 10% for 89.2%
- Biggest difference between PAWPER and Broselow was in children >20kg and those above or below average weight for length.
- PAWPER was better for all weight categories and body habitus.
- Validation study done in Italy. PAWPER was an accurate estimate of weight except in extreme weight categories (malnourished or obese).
- PAWPER was more accurate than EPLS (European life support formula) as well.
- PAWPER [Wells 2013, Silvagni 2022]
Broselow-Luten System: Evidence in Other Countries
- Doesn’t work as well in Indian children. Overestimated weight by >10% in most Indian children. [Shah 2017]
- In Turkey, it has a “reliable correlation.” Parental estimate was slightly better than Broselow, but Broselow better than other methods. [Gültekingil-Keser 2017]
- Broselow out-performed age-based formulas (Theron, APLS, and Shann) in New Zealand, estimating within 10% of actual weight 73% of the time. [Britnell 2015]
- Broselow tape performed better than APLS method in Chinese children. [Zhu 2022]
- In Nepalese children, the Broselow correlated well at lower weights, but accuracy decreased at higher weights >18 kg. [K 2020]
- In Mexican children, the Broselow differed from actual weight by <10% in 46-64% of patients. But the study stated the dosing would still be clinically appropriate if using the Broselow. [Khouli 2015]
- In South Sudan, the Broselow system overestimated weight by 26.6% in malnourished children and by 16.6% in non-malnourished children. The authors recommended alternate methods to estimate weights and doses of medications in low to middle income countries. [Clark 2016]
Other Weight-Estimation Systems
- EPLS (European life support formula) [Silvagni 2022]
- DWEM – Derived Weight Estimating system (accounts for body habitus) [Silvagni 2022]
- Yamamoto Obesity Icon system (accounts for body habitus) [Yamamoto 2009]
- Parental estimation
- Theron (age-based formula) [Zhu 2019]
- Ages 1-10: weight (kg) = exp[0.17557 x age(years) + 2.197099]
- APLS (Advanced Pediatric Life Support age-based formula) [Zhu 2019]
- Ages 1-5: weight (kg) = 2 x [age(years) + 4 ]
- Ages 6-9: weight (kg) = 3 x [age(years) + 7 ]
- Shann (age-based formula)
- Traub-Johnson Formula (age-based formula) [Zhu 2019]
- Ages 1-18: weight (kg) = 2.05 x exp[0.02 x length or height (cm)]
- There is a great review article that lists many other weight estimation formulae. [Bowen 2016]
Moral of the Morsel:
- Weight Matters! Selection of medical equipment and medications is very dependent upon what a patient’s weight is.
- MDs for MDs! The Broselow-Luten system was designed BY physicians, FOR physicians to make your life and pediatric resuscitations EASIER!
- Know your tools! Practice using the Broselow tape and looking at what information is and is not included on the tape so that it’s of most benefit when you need it.
- Nothing is perfect… You may need to use a different weight estimation systems if providing care in other countries.
- Consistency Matters! No matter what your chosen system is, know it inside and out and use it consistently!
- Emergency Medical Services for Children- Enhancing Pediatric Safety (no date) Study Packet for the Correct Use of the BroselowTM Pediatric Emergency Tape. Available at: https://info.ncdhhs.gov/dhsr/ems/pdf/kids/DEPS_Broselow_Study.pdf (Accessed: 26 October 2023).
- DeBoer, S., DeBoer, L. and Seaver, M. (2020) The Times & Tapes Are a-Changin’: The Latest Broselow-Luten Tape for EMS, EMS World. Available at: https://www.hmpgloballearningnetwork.com/site/emsworld/article/1224785/times-tapes-are-changin-latest-broselow-luten-tape-ems (Accessed: 27 October 2023).
- Rosenberg, M.S. et al. (2010) ‘140: Does physician estimates of pediatric patient weights lead to inaccurate medication dosages’, Annals of Emergency Medicine, 56(3), p. S47. doi:10.1016/j.annemergmed.2010.06.187.
- Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review of the literature. J Pediatr Nurs. 2012;27(4):416-420. doi:10.1016/j.pedn.2012.04.009
- Luten, R.C., Zaritsky, A., Wears, R. and Broselow, J. (2007), The Use of the Broselow Tape in Pediatric Resuscitation. Academic Emergency Medicine, 14: 500-501. https://doi.org/10.1111/j.1553-2712.2007.tb01817.x
- Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW. A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group. Ann Emerg Med. 1988;17(6):576-581. doi:10.1016/s0196-0644(88)80396-2
- Rosenberg M, Greenberger S, Rawal A, Latimer-Pierson J, Thundiyil J. Comparison of Broselow tape measurements versus physician estimations of pediatric weights. Am J Emerg Med. 2011;29(5):482-488. doi:10.1016/j.ajem.2009.12.002
- Yamamoto LG, Inaba AS, Young LL, Anderson KM. Improving length-based weight estimates by adding a body habitus (obestity) icon. Am J Emerg Med. 2009; 27(7):810-815. https://doi.org/10.1016/j.ajem.2008.06.023
- Sinha M, Lezine MW, Frechette A, Foster KN. Weighing the pediatric patient during trauma resuscitation and its concordance with estimated weight using Broselow Luten Emergency Tape. Pediatr Emerg Care. 2012;28(6):544-547. doi:10.1097/PEC.0b013e318258ac2e
- Heyming T, Bosson N, Kurobe A, Kaji AH, Gausche-Hill M. Accuracy of paramedic Broselow tape use in the prehospital setting. Prehosp Emerg Care. 2012;16(3):374-380. doi:10.3109/10903127.2012.664247
- Committee on Pediatric Emergency Medicine, American Academy of Pediatrics, Krug SE, Frush K. Patient safety in the pediatric emergency care setting. Pediatrics. 2007;120(6):1367-1375. doi:10.1542/peds.2007-2902
- Wells M, Coovadia A, Kramer E, Goldstein L. The PAWPER tape: A new concept tape-based device that increases the accuracy of weight estimation in children through the inclusion of a modifier based on body habitus. Resuscitation. 2013;84(2):227-232. doi:10.1016/j.resuscitation.2012.05.028
- Silvagni D, Baggio L, Mazzi C, et al. The PAWPER tape as a tool for rapid weight assessment in a Paediatric Emergency Department: Validation study and comparison with parents’ estimation and Broselow tape. Resusc Plus. 2022;12:100301. Published 2022 Sep 15. doi:10.1016/j.resplu.2022.100301
- Shah V, Bavdekar SB. Validity of Broselow tape for estimating weight of Indian children. Indian J Med Res. 2017;145(3):339-346. doi:10.4103/ijmr.IJMR_837_14
- Gültekingil-Keser A, Tekşam Ö. Comparison of weight estimation methods and evaluation of usability of Broselow Luten tape in Turkish children. Turk J Pediatr. 2017;59(2):150-154. doi:10.24953/turkjped.2017.02.006
- Britnell S, Koziol-McLain J. Weight estimation in paediatric resuscitation: A hefty issue in New Zealand. Emerg Med Australas. 2015;27(3):251-256. doi:10.1111/1742-6723.12389
- Zhu S, Zhu J, Zhou H, et al. Validity of Broselow tape for estimating the weight of children in pediatric emergency: A cross-sectional study. Front Pediatr. 2022;10:969016. Published 2022 Aug 16. doi:10.3389/fped.2022.969016
- K C P, Jha A, Ghimire K, Shrestha R, Shrestha AP. Accuracy of Broselow tape in estimating the weight of the child for management of pediatric emergencies in Nepalese population. Int J Emerg Med. 2020;13(1):9. Published 2020 Feb 12. doi:10.1186/s12245-020-0269-0
- Khouli M, Ortiz MI, Romo-Hernández G, Martínez-Licona D, Stelzner SM. Use of the Broselow tape in a Mexican emergency department. J Emerg Med. 2015;48(6):660-666. doi:10.1016/j.jemermed.2014.12.082
- Clark MC, Lewis RJ, Fleischman RJ, Ogunniyi AA, Patel DS, Donaldson RI. Accuracy of the Broselow Tape in South Sudan, “The Hungriest Place on Earth”. Acad Emerg Med. 2016;23(1):21-28. doi:10.1111/acem.12854
- Zhu Y, Hernandez LM, Dong Y, Himes JH, Caulfield LE, Kerver JM, Arab L, Voss P, Hirschfeld S, Forman MR. Weight estimation among multi-racial/ethnic infants and children aged 0-5·9 years in the USA: simple tools for a critical measure. Public Health Nutr. 2019 Jan;22(1):147-156. doi: 10.1017/S1368980018002549. Epub 2018 Oct 18. PMID: 30333072; PMCID: PMC6312489.
- Bowen, L., Zyambo, M., Snell, D., Kinnear, J. and Bould, M.D. (2017), Evaluation of the accuracy of common weight estimation formulae in a Zambian paediatric surgical population. Anaesthesia, 72: 470-478. https://doi.org/10.1111/anae.13780