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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 286-291

Evaluation of the use of electronic growth charts customized for race and national values

1 Evidence-Based Health Care and Knowledge Translation Research Chair, Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
4 Prince Sattam Chair for Epidemiology and Public Health Research, Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission29-Jul-2021
Date of Decision04-Jan-2022
Date of Acceptance18-Apr-2022
Date of Web Publication08-Jul-2022

Correspondence Address:
Amr A Jamal
Evidence-Based Health Care and Knowledge Translation Research Chair; Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_89_21

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Background: As compared with traditional paper-based charts, population-specific Saudi Growth Charts (SGC) integrated into electronic health records offer several functionalities. However, few studies have explored clinicians' perceptions and practices related to the recording of growth parameters as they adapt to the electronic methods. Objective: The objective of this study is to estimate clinicians' use of the recently adapted electronic SGC versus other known electronic international growth charts. Methods: This cross-sectional survey was performed on 116 pediatricians serving at the university medical center. An online questionnaire that included the types of growth charts used, clinicians' confidence level with the electronic interface, and documentation practices for children's growth parameters was uploaded using the SurveyMonkey® platform, and participants were invited to participate through an e-mailed link. Data were analyzed using the IBM software Statistical Package for the Social Sciences version 22.0. (SPSS Inc., Chicago, IL, USA) for Windows®. Results: Most of the pediatricians (76.7%) reported using electronic-based growth charts in preference to paper-based charts, whereas 17.3% preferred using both. Seventy-five percent agreed that the SGC can accurately diagnose underweight Saudi infants and children, as compared with 56% for the World Health Organization and 44% for the Centers for Disease Control and Prevention growth charts. Height, weight (body mass index), and nutritional status were the most documented parameters. Multivariate linear regression analysis showed physicians with longer experience in pediatric clinical practice years demonstrated lesser documentation of growth parameters. In addition, physicians caring for more number of children per week were more likely to frequently document growth parameters (P = 0.003). Conclusion: The integration and implementation of the electronic version of SGC have been encouraging, and the SGC shows promising results in recording child growth parameters for Saudi children with minimum discrepancies in interpretation as compared to the other international growth charts.

Keywords: Electronic health record, Saudi Arabia, usefulness

How to cite this article:
Jamal AA, AlHokair AA, Temsah MHA, Alsohime F, Al-Eyadhy AA, El-Mouzan M, Tharkar S. Evaluation of the use of electronic growth charts customized for race and national values. J Nat Sci Med 2022;5:286-91

How to cite this URL:
Jamal AA, AlHokair AA, Temsah MHA, Alsohime F, Al-Eyadhy AA, El-Mouzan M, Tharkar S. Evaluation of the use of electronic growth charts customized for race and national values. J Nat Sci Med [serial online] 2022 [cited 2022 Aug 17];5:286-91. Available from: https://www.jnsmonline.org/text.asp?2022/5/3/286/350306

  Introduction Top

Comprehensive reference growth charts for Saudi children and adolescents were developed in 2007.[1] The LMS parameters are the median (M), generalized coefficient of variation (S), and power in the Box‒Cox transformation (L); these parameters and percentiles were later incorporated in 2016.[2] Evidence suggests the risk of gross errors in the exaggerated prevalence of undernutrition in Saudi children with reference to the Centers for Disease Control and Prevention (CDC) 2000 standard growth charts.[3],[4] Pioneering research by El Mouzan et al. found differences between the CDC growth charts and the then newly developed Saudi growth charts (SGC), with the former showing moderate sensitivity that resulted in discrepancies and considerable implications.[4] El Mouzan et al. reported an increased shift of the lower percentiles, resulting in the increased prevalence of the stunted growth of Saudi children while using the CDC growth charts. It was subsequently recommended that the CDC and the World Health Organization (WHO) reference growth charts be replaced with the SGC for Saudi children in pediatric clinical settings.

The SGC were made available electronically and integrated into the electronic system for integrated health information (eSiHi). Incorporating the growth charts into electronic health records (EHRs) offers several functionalities as compared with traditional paper-based charts. Electronic growth charts facilitate the ease of use and enable calculations to be customized to pediatrician preferences and patient-specific characteristics, which supports the diagnosis and investigation through treatment and long-term care.[5],[6],[7]

However, there is currently no consensus on the use of specific pediatric growth charts in Saudi Arabia. Pediatricians differ in their assessment of these charts based on their previous clinical practice and medical training.[3],[8] A previous study from Saudi Arabia evaluated pediatrician preferences in using growth charts and found that nearly 70% of clinicians favored the CDC or WHO growth charts over SGC.[9] However, the availability of an electronic version of the SGC might have changed the physicians' perspectives, in addition to the reportedly false high rates of undernutrition that resulted from the use of other standardized international charts. Research assessing the acceptability and accuracy of the electronic SGC is sparse. This study was therefore conducted to evaluate the use of recently adapted electronic SGC by pediatric clinicians in a university hospital setting.

  Methods Top

Study design, participants, and setting

We used a cross-sectional study design to meet the research objectives. The study sample was composed of physicians involved in pediatric care at the university hospital. An invite to participate in the study was e-mailed to the pediatric department's internal mailing list. Data collection was performed using the SurveyMonkey platform from January 2017 to April 2017.

Study measurements and data collection

After an extensive literature search, a questionnaire to measure the acceptance and use of the SGC feature was developed with the help of technical experts from the field of pediatrics, bioinformatics, and information technology. The questionnaire was composed of five sections. The first part included questions in a true/false format on the type of growth chart used (WHO, CDC, or SGC), preference of EHR to paper-based medical records, mechanisms of incorporating growth chart records into the EHR, and the reliability of electronic growth charts as compared with paper copies.

The second part assessed clinicians' confidence level with the electronic interface features using a Likert-type scale with scores ranging between 1 and 5 to assess their opinion about the features of the eSiHi that hampered the various electronic growth charts in use in the Kingdom of Saudi Arabia, including the SGC, WHO, and CDC growth charts.

The third section asked physicians to rate how frequently they document child growth parameters, namely height, weight, head circumference, nutrition status, and growth percentiles, while at work, using a frequency rating scale between 1 and 5, with 1 denoting never and 5 denoting always.

The fourth section assessed the physicians to rate their level of trust in the accuracy of the three main known growth charts built in the eSiHi system in diagnosing Saudi children's developmental and growth problems, using a Likert-type rating scale between 1 and 5, with 5 denoting strongly agree.

The last section assessed the physicians' demographics and questions on certification, degree, position, years in practice, number of patients cared for per week, and the age range for which growth was recorded in their clinic.

The developed questionnaire was validated by pilot testing in the pediatric department. It was then suitably revised based on extensive feedback provided by the physicians. This version of the questionnaire was then approved by the panel of technical experts and again tested on a small sample of physicians. The final version was uploaded to SurveyMonkey® and was circulated among the target population. To increase participation, three reminder e-mails were sent at 5-day intervals.

Statistical methods

Frequencies and percentages were used to describe the categorical and binary variables, whereas means and standard deviations were used to describe the continuous variables. To identify significant relationships between variables, bivariate measures of association (Chi-square tests) were used. One sample independent t-test was used to assess the statistical differences between physicians' trust with the accuracy of the SGC, WHO, and CDC growth charts.

Furthermore, multivariate linear regression analyses were used to identify key physician characteristics and attributes that explained the greater or lower rate of documenting in the EHR. The multivariate analysis included mean rate of documenting growth parameters as dependent variable and other physician characteristics such as gender, years of experience, number of child patients attended per week, confidence with e-charts, and the knowledge score of the physicians were considered independent variables. Alpha (significance level) was set to 0.05 throughout the statistical analysis.

Ethical considerations

Approval for the study was obtained from the institution's Review Board Committee (reference 17/0123/Institutional Review Board [IRB]). In addition, before initiating the online survey, informed consent was obtained from all participants. Anonymity was maintained to enhance confidentiality. Electronic submission allowed for only one response per participant's IP address, prohibiting multiple survey submissions by the same individual.

  Results Top

Of the 250 e-mail surveys sent to the internal mailing list of the faculty and residents in the pediatric department, we received 160 response sheets, resulting in a response rate of 64%. After excluding responses due to missing data and incomplete response sheets, 116 analyzable records were included in the final sample.

[Table 1] shows the demographic details of the study participants.
Table 1: Demographic data of the participants

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[Table 2] displays the participants' knowledge of the SGC. Physicians were well aware of the representativeness of SGC among normal Saudi children and the 0–12-year age range of the growth charts (P < 0.001), whereas they were doubtful about the applicability of Saudi-specific growth charts for non-Saudi children (P = 0.063) and syndromic children (P = 0.353).
Table 2: Participants' knowledge of Saudi growth charts

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In addition, the frequency of self-reported recording infant-specific growth parameters was as follows: weight, 83.6%; nutrition status, 75%; child's growth relative percentile, 67.1%; head circumference, 56.1%; and body mass index (BMI), 20.2%.

[Table 3] displays the details of infants' growth parameter documentation as reported by the respondents. Weight (83.6%), nutritional status (75%), and child's growth relative percentile (67.1%) were the most recorded items, followed by head circumference (56.1%) and BMI (20.2%).
Table 3: Frequency of infant-specific growth parameter documentation according to respondents (n=116)

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[Table 4] presents the physicians' perceptions of the accuracy of the growth charts. The majority of the respondents (75%) preferred the SGC over the CDC and WHO charts for diagnosing underweight Saudi infants. Furthermore, the mean score of perceived accuracy of the SGC was also calculated (data not shown) and the SGC mean score was significantly greater than the WHO standard (t = 5.7, P < 0.001) and the CDC 2000 standard (t = 6.82, P < 0.001).
Table 4: Physician's perceptions on the accuracy of the Saudi growth charts, Centers for Disease Control and Prevention, and World Health Organization growth charts

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[Table 5] lists the factors associated with the frequency of documenting the growth parameters using the multivariate linear model. Physicians with greater experience in years demonstrated a lower documentation rate, whereas those who cared for a greater number of children reported a significantly higher documentation rate of growth parameters.
Table 5: Multivariate linear model demonstrating the associated factors with the mean rate of documenting pediatric growth parameters

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These findings are further supported by our analysis that revealed a trend in the association between the frequency of documenting growth parameters and clinical experience and the number of children cared for per week, as shown in [Figure 1] and [Figure 2].
Figure 1: Association between the rate of documentation of growth parameters and number of years in pediatric practice

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Figure 2: Association between the rate of documentation of growth parameters and the number of children cared for per week

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  Discussion Top

The Saudi Pediatric Association and the Saudi Council for Health Services adopted a nationally representative reference growth chart developed by El-Mouzan et al. for Saudi children and adolescents.[1],[2] These growth charts were recently integrated into the EHR system to support the clinical decisions of physicians and pediatricians. This study evaluated physicians' use of the electronic growth charts. Pediatric care providers preferred and readily accepted the electronic version of the growth charts to the paper-based model. Most of the respondents were aware of the representativeness of SGC to the Saudi population, and pediatricians preferred SGC for the diagnosis of underweight Saudi infants over the WHO and CDC standards.

For many years before the SGC were available, pediatric care providers used the multinational WHO growth charts or the CDC 2000 standards to assess the growth and development of infants and children in Saudi Arabia.[9],[10] Many factors such as ethnicity, nutrition standards, breastfeeding duration, environmental effects, and the economic status of the individual as well as the nation have an effect on the growth status of infants and children that can lead to a wide variation in growth, discrepancies in measurements, and erroneous interpretations.[11],[12] A systematic review comparing child growth data involving 55 countries and multiethnic groups with the WHO reference charts did not justify the use of standards for all countries, which was attributed to a suboptimal fit of height, weight, and head circumference curves.[13] Comparative studies of Saudi infants and children using the SGC and other standardized growth charts demonstrated moderate sensitivity with false-positive undernutrition and stunting, leading to a redundancy in investigations and referrals.[4]

The EHR system eSiHi at the university medical city is readily accessible and has an easy-to-use interface that allows for calculations of growth percentiles and targets while referencing other standards. This functionality potentially increases the usability of the electronic interface by the pediatric care providers. In addition, clinical data and patient details can be changed in the viewing process to show better comparison with the growth curves to facilitate decision support. This accounts for a greater predilection toward the electronic model, since more than three-fourths of the participants favored the electronic version. A previous report on the perceived usefulness of the EHR system from the same study center established higher levels of satisfaction regarding system use and patient care and service delivery, consistent with our findings.[14]

This study found that weight, height, nutrition status, and BMI have the highest rates of documentation. These indicators are assets in clinical applications for monitoring growth status and milestones. With the automatic availability of BMI percentile z-scores in the electronic growth charts, the rate of physician documentation may substantially rise as compared with the paper-based models, which depict lower documentation rates.[15] However, the study found that being a senior physician had an inverse relation to documentation practices, whereas increased documentation was prevalent among consultants who cared for more children per week. The possible explanation for this finding could be the conformity developed by physicians toward paper-based models and the difficulty in accommodating new electronic variants in everyday practice. A similar behavior was observed among US-based pediatricians during the introductory stage of electronic growth chart implementation.[16]

The other major finding of this study demonstrates the accuracy of the SGC in diagnosing underweight Saudi infants and children. The pediatric care physicians preferred the Saudi version of the growth charts over the WHO and CDC standards for underweight Saudi children. These findings were supported by a previous research by El Mouzan et al., who reported discrepancies in documenting measurements of underweight Saudi children using non-Saudi standards, as discussed earlier.

  Conclusion Top

The development and integration of population-specific growth charts into an electronic version is a major milestone in pediatric health service delivery. These findings are the first to demonstrate the use of population-specific electronic growth charts from the Eastern Mediterranean region that enable the documentation, manipulation, storage, retrieval, and data transfer to an EHR system. Overall, the integration and implementation of the population-specific growth charts have been encouraging and demonstrate promising results over minimal error documentation. Although our study was performed in a single center, the findings provide valuable insight into the perceived usability and feasibility of the electronic version. This may have a substantial impact on improving health service delivery in terms of more frequent documentation of growth parameters, increased communication with parents, and identifying early nutrition and growth discrepancies. More important is that the exaggeration of undernutrition can be minimized, curtailing unwanted referrals and anxiety. However, national studies are highly recommended to explore the acceptability, accuracy, and functionality of the electronic SGC in pediatric practice.

Ethics approval and consent to participate

The ethical approval was given by the IRB, Committee of the College of Medicine, King Saud University.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.


The authors are grateful to the Deanship of Scientific Research, King Saud University, for funding through Vice Deanship of Scientific Research Chairs.

Financial support and sponsorship

The research is supported by the Deanship of Scientific Research, King Saud University, for funding through Vice Deanship of Scientific Research Chairs.

Conflicts of interest

There are no conflicts of interest.

  References Top

El-Mouzan MI, Al-Herbish AS, Al-Salloum AA, Qurachi MM, Al-Omar AA. Growth charts for Saudi children and adolescents. Saudi Med J 2007;28:1555-68.  Back to cited text no. 1
El Mouzan M, Salloum AA, Omer AA, Alqurashi M, Herbish AA. Growth reference for Saudi school-age children and adolescents: LMS parameters and percentiles. Ann Saudi Med 2016;36:265-8.  Back to cited text no. 2
El Mouzan MI, Foster PJ, Al-Herbish AS, Al-Salloum AA, Al-Omar AA, Qurachi MM, et al. The implication of using the World Health Organization child growth standards in Saudi Arabia. Nutr Today 2009;44:62-70.  Back to cited text no. 3
El Mouzan MI, Al Herbish AS, Al Salloum AA, Foster PJ, Al Omar AA, Qurachi MM, et al. Comparison of the 2005 growth charts for Saudi children and adolescents to the 2000 CDC growth charts. Ann Saudi Med 2008;28:334-40.  Back to cited text no. 4
Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 2001;8:299-308.  Back to cited text no. 5
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Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, et al. 2000 CDC Growth Charts for the United States: Methods and Development. Vital and Health Statistics. Vol. 246. Series 11, Data from the National Health Survey; 2002. p. 1-190.  Back to cited text no. 9
de Onis M, Onyango A, Borghi E, Siyam A, Pinol A. The WHO Child Growth Standard: Methods and Development. Department of Nutrition for Health and Development. Geneva, Switzerland: WHO; 2006.  Back to cited text no. 10
Daymont C, Hwang WT, Feudtner C, Rubin D. Head-circumference distribution in a large primary care network differs from CDC and WHO curves. Pediatrics 2010;126:e836-42.  Back to cited text no. 11
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Natale V, Rajagopalan A. Worldwide variation in human growth and the World Health Organization growth standards: A systematic review. BMJ Open 2014;4:e003735.  Back to cited text no. 13
Alsohime F, Temsah MH, Al-Eyadhy A, Bashiri FA, Househ M, Jamal A, et al. Satisfaction and perceived usefulness with newly-implemented Electronic Health Records System among pediatricians at a university hospital. Comput Methods Programs Biomed 2019;169:51-7.  Back to cited text no. 14
Cummings EA, John H, Davis HS, McTimoney CM. Documentation of growth parameters and body mass index in a paediatric hospital. Paediatr Child Health 2005;10:391-4.  Back to cited text no. 15
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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