DATA EVALUATION AND METHODS RESEARCH

Methodologic Problems

in Children’s Spirometry

TechnicaI problems encountered in the analysis of spirometry data

coHected on chiIdren aged 6-11 years in the United States, 1963-65,

and the solutions are detailed in a narrative account. Data from

other methodologic studies are presented and discussed. Behavioral

and technical problems in the survey measurement of pulmonary

function in children are discussed.

DHEW Publication (PHS) 78-1346

Series 2

Number 72

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

National Center for Health Statistics

Hyattsville, Md. November 1977
Libraty of Congress Cataloging in Publication Data

Palmer, Alan.

Methodologic problems in children’s spirometry.

(Vital and health statistics: Series 2, Data evaluation and methods research; no. 72)

(DHEW publication; no. (PHS) 78-1346)

Includes bibliographical references.

1. Spirometry. 2. Pediatric respiratory diseases–Diagnosis. 1. Hamill, Peter V. V., joint

author. II. Drizd, Terence, joint author. HI. Title. IV. Series: United States. National

Center for Health Statistics. Vital and health statistics: Series 2, Data evaluation and

methods research; no. 72. V. Series: United States. Dept. of Health, Education, and Welfare. DHEW publication; no. (PHS) 78-1346.

RA409.U45 no. 72 [RJ433.5.S6] 312’.07’23s 77-22566

ISBN 0-8406-0098-04 [618.9’22’40754]

For sale by tbe Snperintandent of Doenments, U.S. Government MIItlm o~~

Washington, D.C. !2tM@2

Wok No. 0174224602-2
NAT ONAL CENTER FOR HEALTH STATIST CS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph.D., Associate Director for Analysis

GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System

ELIJAH L. WHITE, Associate Director for Dtzta Systems

JAMES T. BAIRD, Ph.D., Associate Director for International Statistics

ROBERT C. HUBER, Associate Director for Management

MONROE G. SIRK.EN, Ph.D., Associate Director for Matherwtical Statistics

PETER L. HURLEY, Associate Director for Operations

JAMES M. ROBEY, Ph.D., Associate Director for Program Devebpment

PAUL E. LEAVERTON, Ph.D., Associate Director for Research

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH EXAMINATION STATISTICS

MICHAEL A. W. Hattwick, M.D., Director

PETER V. V. HAMILL, M. D., M. P.H., Medical Adviser

JEAN ROBERTS, Chiej Medical Statistics Branch

ROBERT S. MURPHY, Chiej Survey l?kming and Development Branch

COOPERATION OF THE US. BUREAU OF THE CENSUS

Under the legislation establishing the National Health Survey, the Pubfic Health Service is

authorized to use, insofar as possible, the services or facilities of other Federrd, State, ar private

agencies.

In accordance with specifications established by tbc Nationrd Center for Health Statistics, the

Bureau of the Census, under a contractual agreement, participated in planning the survey and

collecting the data.

Vital and Health Statistics-Series 2-No. 72

DHEW Publication (PHS) 78-1346

Library of Congress Catalog Card Number 77-22566
CONTENTS

Introduction ............................................................................................................................................

Background .............................................................................................................................................

Physiology of Airflow .............................................................................................................................

Sources of Signal Variances .....................................................................................................................

Methodology ...........................................................................................................................................

Initial Limitations of Dat&......................................................................................................................

Criteria Development ..............................................................................................................................

Remeasurement Procedure ......................................................................................................................

Classification of Spirogram......................................................................................................................

Class I ................................................................................................................................................

Class II .............................................................................................................................................. .

Discarded Data ...................................................................................................................................... ..

Class 111.................................................................................................................................... ..........

class Iv ..............................................................................................................................................

Verification and Validation of the Data Classification System ................................................................

Criteria for Merging the Data Clmscs .......................................................................................................

Strengths of the Data ..............................................................................................................................

Comparison With Other Data ..................................................................................................................

Analytic Problems ...................................................................................................................................

Interaction of Volume and Flow .............................................................................................................

Substudics .......................................................................................................................................... .....

Miscellaneous Substudies ...................................................................................................................

Salt Lake City Substudy ....................................................................................................................

Annapolis Substudy ......... .................................................................................................................

References ...............................................................................................................................................

1.

2*

3.

LIST OF FIGURES

Schematic drawing of a wet system spirometer ..................................................................................

Normal time-volume spirogram showing the three component ph~es ................................................

Forced expiatory spirogram illustrating measurements of FVC, FEV 1.Cl,and FEF25.75% md

. . .

identification of zero tme ...............................................................................................................

I

1

3

3

4

5

6

6

7

7

7

8

8

8

8

8

9

10

11

13

14

14

17

21

23

2

2

2

...

Ill
4. Maximum expiatory flow-volume mme ............................................................................................ ~

5. Effect of TLC and RV attenuations of FES on FEF25-75~0 me=ure of flow rate ............................. 13

6. FES curves: acceptable decay curves and curves prematurely terminated .......................................... 15

LIST OF TEXT TABLES

A. Frequency distribution of standing height, by age, sex, and sex and age: Salt Lake City, 1974 ......... 17

B. Frequency distribution of FVCT (best of five trials), by age and sex: Salt Lake City, 1974 .............. 19

C. Frequency dktribution of FVCT (better of first two tri~s): Sdt Lake City, 1974 ............................ 20

SYMBOLS

Data not available-----—---—-----—-------- ---

Category not applicable— ----------------------- . . .

Quantity zero-------— ------------------------ -

Quantity more than Obut less than 0.05---- 0.0

Figure does not meet standards of

reliability or precision-—-—---—---—-- *
METHODOLOGIC PROBLEMS IN CHILDREN’S SPIROMETRY

Alan Palmer, Ph.D., Center for Occupational Environmental Safety and Health,

Stanford Research Institute, Peter V. V. HamiIl, M.D., M.P.H., and

Terence A. Drizd, M.S.P.H., Divzkion of Health Examination Statistics

INTRODUCTION

This report is a companion piece to Series

11, No. 1641 and most profitably the reader

should, at least, read the introduction and skim

that report before reading this one. This report

could be considered as playing the subordinate

role of a series of very long technical footnotes

to that report. The justification of two separate

publications (in two different NCHS report

series) is an attempt to maintain narrative flow

of the primary report, to better handle unwieldy

length, and to appeal to different sets of

specialized readers.

However, these are not the only considerations. This report presents spirometry results

on 6- and 7-year-olds from two small studies

which have not been presented before; and this

rep ort, although presenting data and detailed

arguments that support the Series 11 report,

can be considered to have a narrative flow of

its own.

While the primary function of the first

report was to present and discuss data collected

in HES Cycle II (and, subsidiarily, to take into

consideration the methodologic complexities

and limitations), this report, although presenting

some new data, details the methodologic

problems encountered in the collection and

analysis of the HES Cycle II spirometry data,

provides a narrative account of how some of

them were solved, and touches on most of the

problems and limitations involved in spirometry

testing in children, especially in a survey setting.

This report does not simply expand the

technical details of the companion Series 11

report. It has a different emphasis and provides

the basis for the many refinements in spirometry

data collection, data processing, and data

analysis made in subsequent HES cycles of

examinations that will appear in forthcoming

spirometry reports on children and on adults.

BACKGROUND

The father of modern spirometry was John

Hutchinson, an English physiologist, who was

the first to name the subdivisions of lung volume and describe methods for measuring them.z

In 1846 Hutchinson devised the first spirometer, an instrument to measure static Iung volume. This closed circuit volume measuring device consisted of a cylindrical bell immersed in

a reservoir of water into which air forcefully

expired from the lungs could be blown by means

of a connecting breathing hose. Using this

instrument he was able to diagnose or exclude

various forms of pulmonary disease. Only in

recent years has this testing technique been

deveIoped to include measurements of the rate

or airflow, which now form the basis of the

most widely used test of lung function, the

forced expiatory spirogram (FES). This advance

was made by Tiffeneau and Pinelli, who

connected a rotating kymograph to the spirometer (figure 1), permitting assessment of the

dynamic, as well as the static, characteristics of

the h_mg.3 The kymograph, rotating at , a

constant speed, permits the display of a

time-volume coordinate recorded by a pen

attached to the spirometer beIL

1
Mo.llwece

Record, ng pen

Kymograph

Figure 1. Schematic drawing of a wet system spirometer

The test instruction calls for a maximal

inhalation, placing the cardboard mouthpiece

(fastened to the air tube of the spirometer) into

the mouth, carefully sealing the lips to prevent

air leakage and then forcefully expiring as

rapidly and as completely as possible. During the

maneuver the attending technician verbally

exhorts the standing subject to blow as hard as

possible until no more air can be expired. A

correctly executed maneuver provides a monotonically increasing volume curve which ultimately presents a plateau, and is free from inhalation

artefacts (figure 2). From this wave form,

calculations are made of numerous time and

Phax I

Effort dependent

6/

Phase I I Phase I I I

Critical flow Terminal leakage flow

TIME IN SECONDS

Figure 2. Normal time-volume spirogram showing the three

volume increments from which volume and

flow-rate measurements are derived.

The three most common measurements

obtained from the FES and used in the

assessment of pulmonary function are: (1) the

forced vital capacity (FVC), defined as the

maximal volume of air that can be forcefully

expelled from the lungs from a maximal

inhalation; (2) the forced expiatory volume

during the first second (FEV1 ..); and (3) the

forced expiatory flow rate (FEF) between 25

percent and 75 percent of the forced vital capacity (FEFZ5.T5%). (See fi~re 3.)

Measurement of the FVC can reveal

mechanical defects of the chest cage that

prevent the full expansion of the lungs, i.e.,

chest wall deformity, loss of lung tissue, or Ioss

of lung elasticity as in restrictive lung diseases.

The flow-rate measurements, FEV1.O and

FEF25 -7594,provide an objective method of

quantitating obstructive lung diseases, since in

their presence these flow rates are impaired.

Volumes are calctdated by multiplying the

number of millimeters of bell movement as

recorded on the kymograph by a bell calibration

factor. This gives a volume correct to ambient

temperature and pressure saturated with water

vapor (ATPS). Because expired air is collected in

a spirometer at room temperature (usually

25° C), gas expired from the lungs (at body temperature, 37° C) cools and subsequently contracts. This underestimate of gas volume is cor-

/

—FEF25.7E%

FV c

T

~25% FVC

Zero.time adiusted

/1.secoml p.im

Baseline

o 1 2 3 4

TIME IN SECONDS I

Figure 3. Forced expi ratory spirogram illustrating measurements

of FVC, FEV1 .. . and FEF25.75% and identification of

component phases zero time
rectable to body temperature andpressuresaturated with water vapor (BTPS) by multiplying

the ATPS measurement value by the BTPS correction factor obtained from a reference chart or

calculated using the following equation:

Volume (BTPS) =

273 + 37° C (body temp.)

273 + 25° C (spirogram temp.)

~ 750 mm Hg (BP) -24 mm Hg (pH 20 at 25”C)

750 mm Hg -47 mm Hg (pH 20 at 37°C)

PHYSIOLOGY OF AIRFLOW

Dayman has shown @at during the performance of the FES, airflow can be divided into

three components:4 Phase I is effort-dependent

flow culminating in the peak fIow, the maximal

flow velocity, for that breath. This is foIlowed

by a phase of constant deceleration of volume

exhaled (phase II). A third phase is terminal

leakage flow (figure 2). A conrectly executed

spirogram, therefore, demands that phase I begin

at the total lung capacity (TLC), and end at the

residual volume (RV) in phase III. Phase I is a

measure of how fast the subject initiated the

expiatory effort and is called “effort dependent” because it directly reflects the subject’s

understanding of the test instruction and his

willingness and ability to cooperate. The dynamics of airflow are best demonstrated when

the flow rate and the volume signals are displayed as a single graph (figure 4). Examination

of a flow-volume spirographic loop illustrates

how the volume signal abruptly leaves the volume baseline and rapidly culminates in peak

jl!ow and then shifts into phase II, the beginning

of critical flow. This phase is believed to be most

independent of effort variation, implying that

both the constant of deceleration and the flows

are regulated by airway size and not by the subject’s effort. It is this phase of the spirogram

that imparts diagnostic character and reproducibility. The point at which critical flow emerges

is approximately 25 percent after the initiation

of the FES while phase III occurs at approximately 75 percent of the FES and represents

asynchronous emptying of various portions of

the lung due to air trapping. Here flow rate is

reduced and the volume of air expired is miniPhase I Phass 1I Phase III

!

8-

2~

%= 6-

*

m

K-

:

i4-

~

~

m

~2-

Cj

u.

0 1 2 3 4 5 6

VOLUME IN LITERS

Figure 4. Maximum expiatory flow-volume curve

maI and it is at this point in the test that the

subject strains to exhale the last of his air and

his face becomes red due to effort. A correctly

executed spirogram must include phase III, since

it is the portion of the curve that insures reproducibility of the FVC and all of those flow-rate

measurements which are expressed as a proportion of the FVC. (Phase III is also of current

interest for the early detection of obstructive

lung disease.)

SOURCES OF SIGNAL VARIANCES

Three important factors contribute to the

variability of the test maneuver: equipment

accuracy, subject cooperation, and technician

expertise. The spirometer should be accurate,

linear, and have a frequency response of at least

8-10 Hz to permit capture of the highest frequency components present in the FES. Careful

attention to the calibration of the kymograph

speed and volume response of the instrument

will permit accurate and reproducible data to be

recorded. Subject cooperation depends on individual motivation and complete understanding

of the test instructions. Contrarily, maximaI

effort may also be withheld in circumstances

where this maneuver precipitates pain or coughing spasms or if the subject is a candidate for

disability status and stands to gain financially by

producing a positive test.

An astute technician can usually identify

these problem areas and act appropriately either

3
to correct a subsequent FES trial or to discard

the data. Such a technician takes on the multiple

roles of monitor, bully, cheerleader, and psychologist as he strives to elicit a maximal. response from the subject. The end result of these

skills is a strong interaction between technician

and examinee which results in the collection of

data that represents the best possible estimate of

the physiologic capability of the lungs. Experienced technicians frequently vary in their performance. Day-to-day testing can be extremely

boring and test subjects can be frustratingly uncooperative; therefore, the stamina to maintain

the same level of expertise during a lengthy testing operation is variable.5 *6

A correctly performed spirogram trial should

embody the three phases described, even in the

presence of disease. Those with an obstructive

defect will have a reduced velocity in phases II

and III, but can often achieve a normal vital

capacity by greatly lengthening the duration of

expiration. Conversely, in the presence of restrictive lung disease, flow rates can be normal

and the vital capacity reduced. Testing without

adequate quality control can result in spurious

measurements. For example, should a subject

with an obstructive lung defect prematurely terminate his expiatory effort before the emergence of phase III of the spirogram, the

FEF2 ~.7s % measurement will be artificially elevated since it will now fall between phases I and

II of the spirogram, a steeper portion of the signal, as opposed to between phases II and III

(figure 2). Likewise, the ratio FEV1 .o/FVC will

be artificially increased. Another serious procedural error occurs when a subject trumpets into

the mouthpiece (pursing the lips in front of the

mouthpiece as opposed to fully inserting the

tube into the mouth). The incomplete lip seal

can result in a Venturi defect in which air from

the outside is drawn into the spirometer along

with the expired air, resulting in spuriously large

vital capacities. Such errors can be reduced by

instituting a series of quality control checks

upon the data; those used by this survey will be

diskussed in the section “Methodology” that follows.

A fundamental error is committed in spirometric evaluation when a composite spirogram is

used in diagnosis, especially when inadequate

quality control standards are operative. This

occurs when, from a series of trials, the largest

FVC is taken from one trial and the largest

FE F2s.7 G% is taken from another of the trials.

As already discussed, a subject with an obstructive lung disease could achieve a normal vital

capacity but with low flow rates because of the

obstructive defect. Then on a subsequent trial he

could perform a maximal effort that encompasses phases I and II of the spirogram but prematurely ends prior to the emergence of phase

III, therefore, artificially elevating the flow rate.

Conceivably, by use of a composite trial, the

FVC and FEF25.7 ~% could both be in a normal

range when in fact moderate to severe obstructive lung disease is present, and so could result in

a false negative test.

METHODOLOGY

The child entering the spirometry room was

met by a trained technician who described and

demonstrated the breathing maneuver.

The test instruction required that the subject

inhale to maximal inspiratory capacity through

the spirometer hose, then blast the air out as

forcefully and rapidly as possible into the

mouthpiece, sustaining the effort until no more

air could be expelled. During the expiatory

effort, the attending technician verbally exhorted the subject. During the test procedure

the child was standing, and a nose clip was used

to prevent air from escaping through the subject’s nose.

Although the test procedure called for several practice attempts prior to executing the

test, usually (because of the lack of time) only

one practice trial was given; then at least two

trials were recorded. Because of the physics of

airflow when a maximal expiatory effort is

achieved, it can be expected that the personal

morphology of each subject’s volume signal will

be reproducible within the limits of biologic variation. Although no systematized procedures

were devised in Cycle II to quantitate the degree

of variability between trials during the test procedure, the attending technician visually monitored the spirographlc wave forms to determine

if the tracings were reasonably reproducible. Re-
gardless of whether or not reliable data were

demonstrated owing to a limitation of time the

test was discontinued after two or three trials.

The forced expiatory spirogram was measured on a Collins 6-liter Vitalometer, a watersealed, counterbalanced system. Volume displacements were recorded on a moving chart

(kymograph) by a writing device connected to

the bell by a pulley system (figure 1). The

kymograph was driven by a motor at a constant

speed (32 mm/s).

Prior to each day’s testing, the barometric

pressure and temperature were noted and recorded. During the day the temperature was rechecked periodically and recorded whenever

change occurred. The water level in the spirometer was carefully maintained within 11%inches

of the top of the bell canister to prevent excessive spirometer dead space, which could cause an

underreading of the recorded signal.

INITIAL LIMITATIONS OF DATA

Of the 7,119 subjects examined, no spirographic data were obtained for 187 exarninees.

Reasons for this data loss ranged from lack of

the subject’s physical coordination and/or his inability to follow any verbal directions, to the

presence of pathoIogy that precIuded valid data

collection. The spirographic tracings obtained on

the other 6,932 subjects were initially measured

by technically inexperienced clerks, whereby

measurements of the FVC, FEV1.0, and the

FEF25 -75% parameters were made on the trial

judged to represent the best spirometer effort.

Ideally, both the best and second-best trial

should have been measured to permit better

assessment of data reliabilityy; however, this

could not be done because of the large amount

of additional time and money involved. In addition, the maximum number of recorded trials

per subject was, in most cases, two–occasionally

three.

As a preliminary to analyzing the data, a reassessment of their overaII quality and potential

value was made by Palmer and Harnill. All of the

spirometric tracings were reexamined and compared with the measurements origirdy performed by the unskilled clerks to determine the

overall technical quality of the data (i.e., spirograms, morphology, and the recorded measurements). The quality of the spirograms ranged

from good to technically unsatisfactory and the

measurements, as recorded, were frequently unacceptable. The two most frequent measurement

errors were the wrong choice of “the best trial”

(on which all measurements are based) and the

incorrect determination of zero time point. In

addition, many of the actual measurements were

underestimated and several hundred sets of

spirograms, although measured, were obviously

unacceptable because of technical errors in the

original performance of the FES. Because of

these problems, the decision was made to abandon the analysis.

However, one year later the decision to

abandon Cycle H data was reversed because a

Iarge part of the HES Cycle III (youths 12-17

years old) spirometry recordings were lost. The

Cycle III data were of much better technical quality: the testing situation was improved, more

sophisticated electronic equipment was used,

and the technicians were well instructed, supervised, and monitored. Most of the limitations

just mentioned in Cycle II data on the younger

children had been successfully corrected. In

addition, the FES was recorded on magnetic

tape which would have enabled greater scope

and ease of data processing, minimized measurement and recording error, and allowed much

greater range and flexibility of analysis.

However, when seven cartons containing

most of these tapes were being moved from one

location to another for “safekeeping,” they were

carelessly left on the building’s loading platform

and were carted off to the city’s sanitary landfill. Despite enormous efforts made to recover,

clean, and reprocess those tapes and parts of

tapes which were recovered, more than half of

the total data set proved irretrievable.

Subsequent to this disaster, a decision was

made to go ahead and attempt to cIean up the

Cycle II data by culling the bad, remeasuring,

reclassifying, and reassessing alI the data. The

two most serious limitations of the data about

which nothing could be done had been built into

the original design and test protocoI: first, the

faihre to obtain four or five triak, and second,

the complex of factors in the testing milieu
that did not insure that enough children would

come to maximal inspiration (TLC) immediately

before the full expiatory effort. These limitations, although recognized at an early date, have

become increasingly apparent as the analysis has

proceeded.

The analysis and discussion of all the factors

in the testing milieu that affect the data occupy

much of this document. The consequences of

the limited number of trials (i.e., practice trials,

recorded trials, and measured trials) are also discussed under two general topics: (1) criteria development and tests of reliability of trials and

(2) learning curves as they influence the performance of maximal voluntary, cooperative

effort on the subject’s part, especially in

younger children.

Several investigators have demonstrated that

learning occurs with practice.7-l 0 Maximal

values have been shown to occur most frequently on trials four and five, but because of

the development of fatigue beyond trial five,

values then tend to be attenuated. Since not

more than three trials were ever attempted, it is

evident that the observed “best” recordings were

frequently underestimates of the child’s true

functional state.

One of the more limiting assessment errors

made by the initial Cycle II readers, in addition

to measuring only one trial, was the lack of

documentation of the criteria used to judge the

trial considered best and ascertain its reliability.

Given this information, a more efficient assessment of the data might have been made. For

example, if the original reader had used incorrect logic to identify the best trial, then those

best trials considered by the reviewing reader to

have been chosen correctly would have come

under much closer scrutiny since then the correct choice would have been due to chance. The

most valid method of judging reliability would

have been to measure the best and second-best

trials and compare the variance between them.

CRITERIA DEVELOPMENT

In view of the limitations of the data, a set

of criteria was developed to evaluate the quality,

reliability, and measurement precision of the

spirograms.

Criteria for judging the quality of the spirogram required that an acceptable test demonstrate at least two trials with complete volume

curves (i.e., phases I, II, and III) and be free

from inhalation artefacts.

Reliability of the data was satisfied when the

replicate trials of forced vital capacities, a measure of a sustained expiatory effort, agreed

(within a range of *1OO ml) with the original

trial. This “window” of variance has been established by pulmonary physiologists as the limit of

biological variation in a healthy person when

performing the test maximally.1 1 The variance

of the flow-rate measurement (FEF2s.7 b% ) has

been given wider limits (+10 percent) and is considered a measure of expiatory thrust since the

characteristics of critical flow will insure reliability.1 2‘14 Such limits of physiological variability were accepted as valid for this population

of children with full knowledge that research

data supporting such limits were developed on

adults. In the absence of any such data for children, this decision appeared to be the only logical choice.

To lend precision to the measurement of

FEV1 o the technique employed to identify true

zero t;me was that described in a report by the

American College of Chest Physicians.1 Z A line

was drawn tangent to the steepest portion of the

volume curve and was extrapolated back until it

intersected with the volume baseline (figure 3).

The intersect is considered the point of true volume departure had there been no intervening

variables such as equipment inertia or hesitation

on the part of the subject at the initiation of the

test. It is from thk point that the 1-second volume measurement was made.

REMEASUREMENT PROCEDURE

After careful visual inspection of the 6,932

sets of measured spirograms, it was decided to

separate them into three groups. One group of

3,506 were classed as valid, meaning that they

were of acceptable quality by any conceivable

set of criteria applied to them and also had been

correctly measured. Group two consisted of almost 3,000 spirograms which obviously had

been incorrectly measured and required careful

perusal and remeasuring before final disposition

6
was made. The third group consisted of spirograms considered of such poor quality that they

were summarily discarded.

There were two primary reasons for remeasuring spirograms of apparently good quality. First

were those tests which, although technically satisfactory, had measurements performed on the

second-best trial. This measurement (or selection)

error caused an underestimate of both the volume

and rate measurements. Remeasurements were

made on the best trial using the same technique

employed by the origimd readers.

The second reason to remeasure the spirograms was to correct the improper selection of

zero time. (This error would have consistently

underestimated the FEV1.0.)

The three measurements made on the forced

expiatory spirograph (FES) were:

1.

2.

3.

Forced vital capacity (FVC), i.e., the largest volume measured on complete forced

expiration after the deepest inspiration.

Forced expiatory volume at 1 second

(FEVI.0 ), i.e., the volume of gas expired

over the first l-second time interval during the performance of the FES.

The forced ex~iratorv flow rate between

the 25-perce;t and 75-percent FVC

(FEFz5.75%), i.e., the average rate of

flow during the middle half of the FES.

Measurements were made by determining

the number of millimeters traveled by the

kymograph pen from the baseline to the intersect of the volume line at defined points by use

of a dividing caliper, and converting these distances to volume by multiplying by the spirometer bell factor. For example, the FEV1.0 is the

distance in millimeters from the l-second point

on the time baseline to the intersect of the volume curve. The FVC is measured from the baseline to the highest point reached by the volume

curve. Measurement of the FEF2 5.75% is determined by the volume and time increment between the FVC 25 percent and 75 percent, and

is expressed as milliliters per second. (Figure 3

expresses it in liters per second.)

In order to avoid introducing any computational error, all of the measured millimeter

values were directly recorded and later were

automatically converted to volume and ilow

rates at BTPS (i.e., the volume of gas as corrected for body temperature, barometric pressure, saturated with water vapor) by a programed digital computer.

CLASSIFICATION OF SPIROGRAMS

After the initial sorting into three groups

and competing the necessary new measurements, all group one and two spirograms were

reclassified according to the foIIowing criteria:

Class 1

The prime group consisted of 5,155 records

that demonstrated at least two trials in which

the FVC’S reproduced within a tolerance of

approximately 100 ml, and the slopes of the

spirograms were within approximately 10 percent of each other. Since maximum effort

results in regdated airflow, a reliable spirometric

test would demonstrate flow rates and volume

measurements reproducible within acceptable

physiological limits on consecutive tests.

It is a relatively easy task to choose the best

trial from a series of trials when the largest FVC

and FEF2 5.7s% flow rates occur on the same

spirogram. A dilemma exists, however, when the

largest FVC and FEF25 .75% values are split between different trkds. At that time, for purposes

of consistency, all component measurements in

class I data were always made on the trial with

the largest FVC. However, reconsidering this

today, there is good reason to believe that rule

need not have been so inflexibly applied.= Because current refinability criteria suggest that the

differences within these ranges are due to normal physiologic variation and are not clinically

significant, the best FVC and FEF25 -75% values

could have been used regardless of the trial on

which they occurred, as long as they were

chosen from the best and second-best trials that

did not exceed the stated refinability criteria.

Class II

Reliability was not as satisfactorily demonstrated in this group (n = 648) since only the

‘The current iso-volume technique to better focus on

phase III abnormalities violates these strictures, but only

within tight quality limits of reproducibility.

7
volume criteria were met (*1 00 ml). The slope of

the FEF25.7 ~% of the two best trials was found

to fall within a range of 10-20 percent. In most

cases the trial used for analysis contained both

the best volume and flow rate, while in a few

cases the best slope was measured from the trial

with the smaller FVC.

To this class were also added 17 spirograms

in which the comparison trial in the test had

been terminated prematurely due obviously to

a technician’s error. If upon careful visual inspection, the reviewer determined the completed

trial would have met “primary quality” criteria

had the incomplete spirogram been permitted to

run to completion, the test was classified as reliable. The judgment was made by comparing the

slope of both curves and extrapolating the unfinished slope to determine if the flow-rate

decay curve (phase III) of the spirogram appeared in the same position as the complete

trial.

By limiting the sample to those data meeting

the stringent criteria of class I, a response rate of

72.4 percent would have resulted which would

have impaired the sample reliability of the HES

data. However, relaxing the flow limits slightly,

yet maintaining the important I?VC criteria (see

“Physiology of Airflow” for discussion on the

FVC’S effect on flow rate) permitted the inclusion of 648 class 11 spirograms. This raised the

response rate to almost 82 percent.

Discarded Data

Class III

These data (n = 134) exhibited an intolerably large FVC variability, within the range of

100-200 ml, though the flow-rate slopes remained within *10 percent of the best trial. In

most cases the trial with the largest FVC contained the best flow rate, though several spirograms were included that definitely had the

better slope on the trial with the smaller FVC.

Class IV

A total of 1,182 tests were eventually judged

to have no clinical value. This included those

initially discarded together with those subsequently discarded after further review and remeasurement. The most common faults were:

tracings with inhalation artefacts, incomplete or

nonreproducible set of tracings, only one spirogram recorded, and those trials where no two

trials exhibited quality data equal to classes 1[

and III spirograms. In addition, there were 187

examinees with no record of ever having taken

a spirogram who were included in this group.

VERIFICATION AND VALIDATION

OF THE DATA CLASSI FICATION SYSTEM

The first step in testing this classification

system and the validity of the remeasured and

reassessed data was its ability to be replicated b y

an independent expert observer. A systematic

sub sample of more than 700 spirograms, made

up of samples from each class, was given to am

other highly experienced spirometrist to reclassify the spirograms using the same criteria as we

had defined them, but without knowing how

they had been previously classified. This project,

was performed by Gladys Dart, Senior Pulmonary Technician, under the direction of Dr. Glles

Filley, at the University of Colorado Medical

Center’s Webb-Waring Lung Institute. This trial

study was a success: it yielded a concordance

greater than 95 percent between the two

independently classified sets of spirograms. This

was a critical stage in the life of the project: if

this independent assessment had revealed a

marked disagreement between the two expert

readers, subsequent analyses would have been

futile.

CRITERIA FOR MERGING

THE DATA CLASSES

Having created the four classes of data, it

was necessary to evaluate them in terms of

acceptability: that is, which of the data classes

were good enough to be considered as valid estimates of the best efforts (and/or true physiologic capacity) of the children?

At this point, the authors were faced with a

problem of the cost/benefit nature which was a,

hallmark of the entire project. To have thrown

out too large a portion of the available data,

would have severely weakened our confidence

8
that the remaining sample represented the U.S.

population of 6-1 l-year-olds. To have kept too

large a portion of the available spirograms would

have made the technical quality of that sample

highly suspect; so the solution was to strike the

most satisfactory bahmce between quality and

quantity (i.e., spirometric quality and sampling

qudlty).

In order to achieve an optimal balance for

the best possible population estimates, a variety

of distributions was examined to determine the

kmd and extent of differences between the

classes. In particular, differences were sought between quality classes of FVC and FEV1.0, by

region, income, education, IQ (as measured by

the Wechsler Intelligence Scale for Children),

and stature. All of these distributions were further crossed by age, race, and sex to insure that

any differences detected could be attributed as

specifically as possible to their source. Partial

tabulations for some of the more important variables involved in this massive effort can be

found in tables 1-9.

The distributions by region, income, education, and IQ did not differ between classes in

any regular fashion, nor did mean statures differ

significantly. There were no consistent differences between means of the FVC’S and

FEV1.0’s for any of the classes where these data

existed.

The only important differences were found

between the classes I, II, and III and class IV data

(which contained cases with missing tests and

tests of no clinical value) where substantial age,

race, and sex effects .were demonstrated. The

percentage of each age group in class IV declined

with increasing age, from a maximum of 26.4

percent for 6-year-olds to a minimum of 12.1

percent for 1l-year-olds. Also, 22.3 percent of

the black children fell in this class, while only

15.7 percent of the white children were included

here. The difference in proportion by sex was

small (17.0 percent for females versus 16.2 percent for males), but in the expected direction.

This class was later subjected to an intense and

lengthy scrutiny in an attempt to discover causative factors which might account for a subject’s

inclusion in class IV. Although class IV chiklren

differed from those in classes I-III on severaI

variables (e.g., they were slightly shorter than

their cohorts), no factor or combination of factors was found that exclusively identified class

IV children. Consequently, it was not necessary

to modify the imputation procedure to adjust

for any unique characteristics of this group.

Classes I, II, and III were essentially alike

demographically and physiologically. Class IV

alone was different.

The final decision, then, was to combine

classes I and 11 as our basic working data set.

The data in class III were less than 2 percent of

the original sample but evidenced a serious

methodological faiIing. The spirometric values

for these 134 subjects were discarded and later

replaced by imputed values, as was the case for

all class IV subjects.

STRENGTHS OF THE DATA

Despite the known deficiencies of these data

the distributions of the component parameters

of the forced expiatory spirogram are the most

representative population estimates ever obtained on children. The 7,119 children examined

in HES Cycle II are representative of 23,784,000

noninstitutionalized children, ages 6.0 to 12.0

years residing in the coterminous United States

in 1963-65. In addition to the enormous sampIing strengths of these HES data, a large battery

o f psychologic, physiologic, anthropometric,

demographic, and sociologic data were also available for each person. This mass of additional

information contributed immeasurable strength

to the data amdysis since it permitted the development of FVC and FEV1.0 data using imputation techniques on those 1,316 subjects who did

not have acceptable spirometric data; and, of

course, these variables can be cross-tabulated

and correlated in detailed analyses.

Several methods of imputation were considered, but stepwise multiple regression was

chosen as most appropriate for FVC and

FEVI.0. The appendix in the Series 1 l-No. 164

paper on children’s FVCl includes a detailed

description of the rationale and details of this

imputation process. The 5,803 cases with acceptable spirometric values were the data base

upon which the imputed vzdues were generated.

It was determined that from the many physiologic and demographic variables avaiIable as

regressors, 37 of these (see section on imputa9
tion in appendix of reference 1) might manifest

significant correlations with the spirometnc

parameters. The values for these 37 independent

variables and the two dependent spirometric

variables were input to a packaged multiple

stepwise regression procedure, and the equations

in the appendix of reference 1 were the result.

After the FVC’S and FEV1.0’s were imputed

for the 1,316 subjects who did not have acceptable spirometric data, the validity of the imputation process was verified in the several ways just

described. Distributions of the imputed values

by age, race, and sex were compared with those

of the basic data set of 5,803 (i.e., ‘(acceptable”

population) and no significant differences were

shown by the sign test at the 5-percent level.

Nor were there any significant differences when

these distributions were further crossed by sitting height (the first variable to be included in

both equations). There were no apparent differences in the relationships by age, race, and

sex between the imputed and nonimputed data

sets within classes.

Combining the data sets resulted in age-racesex specific mean values very similar to those of

the original nonimputed data set. However, the

mean values for combined age or race or sex

groups were reduced somewhat. This would be

expected since younger children, females, and

Negroes (all of whom tended to have lower

values than their respective complements) were

overrepresented in the “unacceptable” class.

Consequently when the data sets were combined, more lower values were added to the final

data set than higher ones, thus lowering any

overall statistics that did not control for age or

race or sex effects.

COMPARISON WITH OTHER DATA

Of course, comparison with data from other

studies is one of the important steps in validating one’s own data but such a comparison

was almost impossible in 1970 and 1971. The

published data on spirometry in chkiren was

then and remains now sparse, with conflicting

estimated values and of quite uneven quality.

Besides the paucity of solid comparative data,

the important distinctions between data collected in a survey and those collected in a laboratory are sometimes ignored. (However, because

of vast improvements in electronic equipment

and development of spirometric technique in a

survey setting, these differences are not as great

now as they were before 1970.)

In general, spirometric data obtained in a

clinical laboratory setting have two distinct advantages: a better motivated and more willing

subject on the one hand, and time and opportunity to establish rapport, give more thorough

instruction, with better opportunity of obtaining a valid test, on the other hand. Most people

coming into a laboratory are usually there for a

specific purpose and have something to gain by

undergoing the tests. Time is available to individually explain and demonstrate the test procedure in as much detail as necessary and to run

through several practice procedures. The subject

may return another day for additional trials, if

necessary. In addition, the subjects are selected:

they self-select themselves to come to that particular laboratory and because the laboratories

are not trying to obtain representative population samples they can simply discard bad data.

They will exclude from their “normal” values

people with very low IQ’s, the hostile, the indifferent, the suspicious, the frightened, and any

others who are either incapable or unwilling to

give a satisfactory test response even after repeated attempts. Additionally, because most

subjects’ procedm-al errors give underestimates,

and the errors are additive, especially in the

parameters involving volume measurements,

there is a general rule of thumb: all else being

equal, the larger of two volume measurements on

the same subject is likely to be the more accurate. (This special set of circumstances tends

to increase the clinical laboratory spirometrilc

values over those obtained in a survey setting.)

An unusually comprehensive and very useful

handbook of laboratory techniques, “Pulmonary

Function Testing in Children: Techniques and

Standards,” by Polgar and Promadhat was published in 197 l.ls However, in a section entitled,

“Standard Values,” Polgar and Promadhat ambitiously attempted to bring together most of the

early literature on childhood spirometry and

synthesize the findings into one set of composite

standard values. They were prompted to such an

10
effort by the realization that so-called “normal”

values from the various indkidual studies could

not be considered representative of general

population values. By combining the various

studies they had hoped that the composite normal predicted values might take on more of the

characteristics of a representative sample that

could be generalized to all children. This hope

was not realized.

For vital capacity, data on 45,000 subjects

between the ages of 3 and 19 years were assembled. Children comprising the test populations came from schools, orphanages, and hospitals, and originated from nine different countries

of four continents. Although all measurements

were made on wet systems, there were enormous

and immeasurable variations in both the characteristics of the instruments, in testing methodologies, and measurement techniques among the

various laboratories. Although the majority of

measurements were made in a sitting position,

several were made either in the semirecumbent

or standing positions. All semirecumbent values

were corrected to sitting position vital capacity

values before being averaged with standing

values. Data were corrected to BTPS. The composite mean FVC’S are 100-150 ml higher than

those observed by this survey for children of the

same age and sex.

Polgar and Promadhat did not satisfactorily

distinguish between survey and laboratory data

nor did they consistently define important differences in technique when combining and adjusting data. This makes precise comparisons

with their data very difficult. But more restrictive as reference data was the statistical handling

and presentation of the data.

For example, when the mean FVC values

from HES were directly plotted onto the graphs

as taken from the book,l 5 the HES means were

at the line designated as 2 standard deviations

below the “Polgar composite means.” After several hours’ work, we were able to reconstruct

how the graphs were made: instead of using any

estimate of variance from an actual study, the

standard deviation was calculated using the summary means of the separate studies as data; consequently, rather than this being any measure of

population variation, it was a standard deviation

of means from various studies. Borrowing the

standard error of FVC’S from the HES data, it

was then found that HES’ mean FVC’S were

only 1 standard deviation less than Polgar’s,

rather than 2. Because of this evidence of a

major statistical flaw and the fact that there is

not enough documentation of other statistical

techniques used attempting to arrive at the composite values, this section of the book cannot

reliably serve for epidemiologic comparisons.

Polgar’s published “normal values” would be

more appropriately viewed as estimates representative of his own laboratory findings-for all

their strengths and weaknesses. On the other

hand, the remainder of the book has great value

when used as a compendium of techniques employed in assessing all aspects of pulmonary

function in children.

ANALYTIC PROBLEMS

The spirometric data obtained by this survey

presented a series of problems so challenging and

widespread in nature that a proper analysis required the use of a variety of analytic techniques

and substudies and a great deal of time, patience, and effort to produce a report that might

be both useful and informative. AU of the various major problems were not immediately

apparent; some only surfaced as the analysis

proceeded.

Already detailed in this report was the problem encountered with initial measurement and

review of the original 7,119 spirograms, and the

remeasurement of several thousand spirograms

that had been incorrectly measured. After careful development of volume and flow reliability

criteria, all available spiroqams were classified

by quality. Verification of the classification

system was accomplished by having a subsample

of spirograms read and classified “blind” by a

second expert spirometrist, as described earlier.

The high level of concordance demonstrated

(over 95 percent) encouraged the authors to

continue with the analysis.

In spite of the care taken in this verification

step, we knew that a residual group of procedural failings inherent in all the data would permanently defy adjustment. A practice trial,

when done at all, had been frequently inade11
quate. Too few trials had been taken to insure a

maximum effort. Since only the best trial was

measured, intratrial comparisons were impossible. And finally, a strong possibility existed

that some proportion of the subjects failed to

reach their total lung capacity. (As will be discussed, the new visual criteria are vulnerable to

this type of error; they are incapable of either

detecting or adjusting minor errors of this type.)

In the absence of further research in these areas,

a quantification of these effects is impossible.

The next major project was the evaluation of

the newly classified data set in order to optimize

merging and to determine the validity of merging the classes. As described previously, this

analysis revealed no marked differences between

the groups where spirometric data were available. The greatest sample size (n = 5,803) was

achieved with the least dimunition of quality by

combining classes I and II. This data set was

used to generate equations to impute spirometric values for the 1,316 subjects who didn’t

have acceptable spirograms. An earlier section

has described the procedure used to impute the

FVC, FEV1. o, and FE F25.7s% measurements

for the 1,316 subjects, and the verification of

that procedure.

During the analysis and development of the

spirometric population estimates, serious problems with the FEF25.75% became evident. Regression lines of this variable against age were

extremely unstable, particularly for blacks and

younger children. No immediate explanation for

this behavior could be found; but when digging

deeper for answers, several more immediate

problems with the two other parameters were

uncovered: (1) A large proportion (28 percent)

of the original sample (n = 5,803) had an FVC

equal to FEVI. o (i.e., the forced expiatory

spirogram was completed in less than 1 second

and hence, for these subjects, the FEV1.0 is a

meaningless parameter because the required time

duration is too long); this defect was sex-raceage related (i.e., girls, Negroes, and younger children were overrepresented). (2) The mean FVC’S

by age, race, and sex are probably underestimated. The effect of these problems on

FEF2s.7s% are explained in the following section, “Interaction of Volume and Flow,” but

their significance to the entire data set transcends their effects on FEF2 5-7570.

A study was immediately undertaken to

determine if thk FVC-FEV1 o phenomenon was

the result of the subjects’ failure to reach residual volume (RV) because of premature termination of expiatory effort, and, if so, to quantify

its contribution to underestimating FVC for the

data set. (A more detailed description of this

and subsequent substudies follows in a later section.) To this end, a proportional sample of the

available tracings was reevaluated by two expert

spirometrists paying special attention to the

terminal end of the curve.

Two more substudies were also performed to

provide an accurate idea of the distribution of

valid FVCT ‘s, particularly the proportion less

than 1 second. The first, conducted on a very

small sample, under optimal conditions, confirmed that a valid FV~ of less than 1 second

was possible in children of thh young age. A

second, larger sample provided a distribution of

FV~ ‘s, and also provided FVC and FEV1.9

data for comparison both with the HES estimates and Polgar’s published values. Finally, a

fourth sub study was performed to measure the

effect on TLC of having used the “closed” versus the “open” system during inspiration in

Cycle II.

Before describing the details of the substudies, it is necessary to understand some of the

complex interactions of the lung function measurements that are produced by variations in the

performance of the forced expiatory spirogram.

Literature dealing with the performance of

the FES frequently ascribes certain component

measurements as being either effort dependent

or independent. Such statements need to be

viewed with caution because specific dynamic

test conditions must first exist before claims of

effort independence can be made; viz, an FES

maneuver performed by a normal lung gives a

true measure of vital capacity only if the inspiratory phase is taken completely to the total

lung capacity (TLC) and the expiatory phase to

residual volume (RV). The failure to achieve

either parameter causes an underestimate of the

true vital capacity and distorts almost all of the

component dynamic measurements of flow rate.

12
INTERACTION OF VOLUME AND FLOW

The morphology of the FVC curve is a sensitive indicator as to whether or not the RV was

reached by the pattern described by airflow

because it proportionally diminishes until residual volume is achieved. The airflow from the

gradually smaller airways in the peripheral portions of the lung is characteristically displayed

by a smooth decay curve that finally plateaus at

RV. Absence of this terminal decay curve is

strong evidence that the expiration was terminated prior to reaching RV (figure 5), caused

either by abrupt closure of the glottis or by

cessation of expiatory effort.

Unfortunately, no accepted criteria have been

developed that permit a similar visual assessment to be made as to whether or not the TLC

was achieved during the inspiratory phase of the

test. Both errors (failure to reach TLC and failure to reach RV) not only reduce the FVC but

may also reduce the forced expiatory volume at

various time intervals (FEVT ). Either one of

these procedural errors, in addition, effectively

compresses the volume displacement between

the onset of the curve and its termination, and

spuriously elevates these FEVT /FVC ratio measurements. Such distortions destroy the sensitivity of these measures of airway resistance.

In the section on technical background, the

concept of critical flow and its importance to

the validity of flow-rate measurements has been

discussed. If the FES is correctly performed and

critical flow is achieved, then measures of flow

rate are accurate (i.e., FEF25.75% ). However, if

the FVC is attenuated due to failure to come to

TLC or expire to RV, flow rates will be either

erroneously high or low, even in the presence of

critical flow (see figure 5). When the FES is performed correctly, the FE F2s.7s% measurement

falls within that part of the curve considered to

be in critical flow (phase II). However, when RV

is not achieved, this flow measure is pushed

higher up the FES curve which includes a larger

percentage of phase I of the spirogram. This now

artificially elevated flow rate picks up another

undesirable characteristic, that of variabilityy,

since it is computed using in part the highly variable (effort-dependent) portion of phase I. An

opposite effect, however, takes place when fail-

/

w True FEF23 ,5%

?

~

0

>

FVC

———.—.——

LC

TIME

Normal FES

la)

A?uftc!a!!y elevated FE F25,5%

——.——— — 75%

F Vc

———__—— - 25%

TLC TIME

RV attenuated F ES

lb)

TLC.mtenuamd F ES

(c I

Figure 5. Effect of TLC and RV attenuations of FES on FEF ~5.75% maasure of flow rate. (Note increased slope of flow-rate line in (b)

and decreased slope of flow-rate line in (c) as compared with (a))

13
ure to reach TLC causes an attenuated FES. The

flow-rate measurement is pushed down the curve

so that it now includes not only phase II, but

some of phase III as well. This effectively

reduces the flow rate, and also adds stability to

the measurement since both phases H and III are

included in the less variable effort-independent

portion of the curve. Paradoxically the distortion to FEV2s.7s % is less if both errors are

committed on the same trial: in other words,

these two effects are counterbalanced and somewhat neutralized when an attenuated FVC has

equzd components of both procedural errors.

Current practice attempts to get around this

probIem by use of an iso-volume curve whereby

a resting vital capacity is obtained independently

on one trizd and then partial expiatory efforts

are subsequently obtained and measured in the

context of the resting vital capacity.

SUBSTUDIES

Miscellaneous Substudies

The first of the substudies was designed to

closely e x amine the phenomenon of the

FVC = FEVI.0, and to determine its effect on

the main body of the data.

A systematic subsample of 205 subjects

from the 1,624 HES subjects with FVC =

FEVI.0 data was chosen and was found to be

representative of its parent group for the variables of age, sex, and race. These data were intensively reviewed by Drs. Alan Palmer and

David Discher to determine the extent and cause

of the FVC = FEV1. o phenomenon. There was a

working hypothesis based on the belief that all

children should be able to maximally expire for

more than 1 second. On this assumption, any

spirogram with an FVC = FEV1. o would be

prima facie evidence that the test effort had

been incomplete due to failure to reach residual

volume which prematurely truncated the decay

curve and would therefore be technically unacceptable. The consequences of such a finding

would have been threefold:

1.

14

It would go a long way toward explaining the apparent FVC underestimates.

2.

3.

It would explain why FEV1.0’s were

more similar to FVC’S than was reasonable, particularly for the younger ages.

It would Partiallv explain the erratic be-.

havior of ~he flow-ra~e data (as explained,

in the previous section). Conversely,

such a finding would have had a very

serious implication, so serious as to challenge the validity of the entire resezuch

effort to that date. Specifically, it would

have discredited the entire spirometry

classification system that had been created by evidencing that a high percentage

of truncated spirograms had slipped by

the rigorous screening procedures used

to preclude invalid tests.

Prior to the reexamination and classification

of the 205 spirograms, a set of morphologic criteria was developed that permitted consistent

decisions on the technical quality of the terminal portion of the recorded FES. Pattern-1

spirograms included all of those which, upon

visual inspection, contained all three spirometric

phases, particularly a terminal section (phase III)

that showed a smooth deceleration of volume

over time, to an eventual plateau (zero change

in volume). Figure 6(a) demonstrates two commonly seen decay patterns, both acceptable as

pattern-1 spirograms.

Pattern-2 spirograms differed by having a

premature termination of airflow during phase II

or III of the curve indicating that the test subject had locked the glottis, thus forcing an

abrupt deceleration of airflow to zero. The sudden plateauing of the volume signal with no

intervening decay section was considered evidence that the residuil volume (RV) was

probably not attained; therefore, the test was

declared to be artificially attenuated. Figure

6(b) shows the morphology of unacceptable

pattern-2 spirograms. Pattern-2 morphology, of

course, can also exist in spirograms with an FVC

greater than 1 second, but because this subsarnple was limited to those spirograms with an

FVC less than 1 second, none was encountered in

thk investigation. To extend the reexamination

for all pattern-2 errors in the entire remaining

data set (n = 5,598) would have been prohibitively expensive in time and cost.
RV

~,().”,o”ta, W

2

3

0

>

Acceptable curve

TLC

TIME

(a}

Termmalion recomplete

No ro.ndout present

ii

>

:

>

I

TIME

{b)

Fiaure 6. FES curves: (a) Dattern l–acceptable decaycurves;b) PetterflZ–curvesPreMatUrWterminated.[Notethatdew curvesare

incomplete or absent)

This investigation had surprising results:

only 18 percent (n. = 36) of the 205 subsample

spirograms had a pattern-2 morphology! This

unexpectedly small percentage of RV-deficient

spirograms, although forcing a drastic reassessment of our assumptions and further investigations, did vindicate the visual classification

system which we had devised. (The prevalence

of the pattern-2, premature termination of expiatory flow error probably far exceeded 50

percent in the group of spirograms earlier discaded as technically unsatisfactory.) Because in

larger spirograms it is easier to detect pattern-2

errom, and because the larger FES tends to indicate a better performance containing fewer

technical errors, it would be unreasonable to

assume a prevalence of greater than 18 percent

in the larger part of the data set (i.e., in which

FVC is greater than FEV1.0 or l-second duration). Therefore 18 percent (15-20 percent)

appears to be a sound estimate of the prevalence

of pattern-2 errors in the data set.

15
The pattern-2 curves were then reviewed to

quantify the amount of underestimation of the

FVC due to truncation by use of a technique

known as the measurement of the “angle of incidence. ” This procedure required that at least

three-fourths of the decay curve be present on

the trial measured, and that another trial belonging to the same subject be present with a full

decay. (The latter requirement is helpful in

determining the shape of the estimated decay

curve. ) The difference in millimeters between

the estimated (extrapolated) FVC and the observed FVC was determined and expressed as a

percentage of the observed value (figures 6(a)

and 6(b)).

This technique projected underestimated

volumes ranging only from 3 percent to 7 percent, averaging about 5 percent.

A 5-percent underestimate occurring in

approximately one-fifth of the data set at the

most would result in the contamination of the

final data set by pattern-2 errors causing only 1

percent or less underestimate of the average

FVC.

The unexpectedly small frequency of pattern-2 curves and their small magnitude of

underestimate strongly suggested that most of

the problem was probably due to technical

errors committed at the beginning of the spirogram rather than at the terminal part. This conclusion appears even more plausible after careful

review of several separate items of data, i.e., the

distribution of FVC = FEVI.0, the distribution

of pattern-2 obtained from thk substudy, and

the patterns of the regression lines of the flow

rate. The most frequent occurrence of the

FVC = FEV1.0 phenomenon was seen to occur

in the youngest age groups (6- and 7-year olds) in

females and among Negroes. Since most of the

pattern-2 data were seen to occur in 8- and

9-year-olds, in this subsample it can be conjectured that much of the attenuation of FVC

values for 6- and 7-year olds seen in this main

data set was caused by failure to achieve TLC.

Coefficients of variation derived from data

in tables 10 and 11 show that flow rates for

Negroes are extremely variable between the ages

of 6 and 8, and this is also true, to a small extent, for white females, Because of the effect on

flow rates of the reduced FVC (as discussed),

the erratic pattern of the curves may be the

result of both types of FVC errors perturbating

the estimated flow rates.

The failure of this substudy to adequately

explain the cause of the high percentage of data

in which FVC equals FEV1. o and low FVC values

in the HES sample indicated the need to pursue

the following additional questions:

1.

2.

3.

Is the assumption that almost all young

children should be able to maximally expire for more than 1 second correct? In

other words, is it possible to obtain an

optimally performed FES, where all test

criteria have been met (TLC, critical

flow, and RV), with attainment of a

proper FVC, in less than 1 second?

If so, what is the expected frequency of

FVC = FEVI.0 in the youngest children?

What is the expected distribution of

FVC~ by age (i.~., the shape of the distribution curve and the actual time

values as obtained under ideal testing circumstances) ?

(To go back and remeasure each time duration accurately by hand on 5,803 Cycle II tracing would not only have been an enormous logistic task but it would have also begged the

question: “Do these FES tracings in Cycle H

represent ideal or even adequate testing circumstances-even after all of the work to screen out

the bad trials?”)

In order to answer the first question, we had

to fmd one or more children over 6.0 years of

age who, under optimal testing circumstances,

and in the opinion of highly skilled spirometrists, completed a proper FES in less than 1

second. (Corollary: No matter how hard and

effectively the children tried, their physiologic

ventilator capacity could not sustain an effective expiatory effort, even after maximal inspiration, for 1 second.) In testing 10 conveniently available children between 6 and 8

years old, one child was found to clearly and

unequivocally meet these conditions. This finding, of course, negates the working hypothesis

(stated above) that all spirograms with FVC~ less

than 1 second are, prima facie, technically inadequate spiropams in chddren over 6 years of

age.

16
Salt Lake City Substudy

WM this information, a second study was

devised to answer the second and third questions

using an at-hand sample of 79 six- and sevenyear-olds. The survey was performed by highly

competent technicians on equipment capable of

producing the same parameters that were earlier

measured. A number of factors combined to make

this testing situation almost unique: (1) The technicians who did the testing were very knowledgeable, very well trained, and highly skilled in administering the FES pulmonary test. (2) The

equipment on which the FES was taken was

of the most modem design, reflecting every advance in the state of the art. (3) Because the

children were from two cktsses in the same grade

at the same school, a lot of the anxiety which

typically vitiates performance on the FES was

absent; i.e., there was a good deal of peer support and friendly competition. (4) The data collected were analyzed by the most modem computer analysis program availabIe, reflecting every

advance in the science of spirometry up until the

present. (5) AU the data were collected in a very

short time, a single day. This circumstance contributed to the overall quality of the data by

providing a great deal of consistency insofar as

barometric pressure, temperature, technician

performance, and other factors were concerned.

(6) Where only three trials, at the most, were

taken in the HES, five trials were taken on the

79 children, and as might be expected, performance generally improved with the increased

number of trials, due to a practice (or learning)

effect.

Since the new spirometric data were to be

compared with the HES spirometric data, it was

important to eliminate (or at least quantify the

effects of) differences in factors that might have

influenced spirometric performance. For instance, the data indicated that the race and sex

compositions of the two samples were different

and it may or may not have been necessary to

compensate for the dissimilarities.

Relevant factors may be of two general

kinds, demographic or physiologic. While a large

amount of this type of data was available for

each of the HES subjects, relatively little was

colIected on the 79 subjects who were all white

and residents of a SaIt Lake City (SLC) suburb.

Among demographic data available for the latter

group were age, race, and sex, and some fairly

substantial data concerning the socioeconomic

status of the group as a whole. The only independent physiologic variable measured was

stature. Preliminary demographic distributions

for the SLC sample are given in table A.

It has been demonstrated that age, sex, race,

stature, and to a lesser extent, socioeconomic

Table A. Frequency distribution of standing height, by ege, sax, and sex end age: Salt Lake City, 1974

Age, sex, and sex and age

Total .....................................................................

Age —

6 ymrs ...................... .............................................................

7 years ...................................................................................

Sex —

Male ......................................................................................

Female ..................................................................................

Sex and age

Male, 6 yeers .........................................................................

Male, 7 years .........................................................................

Female, 6 yaars .....................................................................

Female, 7 years .....................................................................

Total

79

30

49

35

44

z

15

28

—

42

—

1

=

1

1

1

—

—

44

—

6

=

3

2

1

4

1

2

2

—

—

46

—

1

=

1

1

1

—

Standing height in inches

.

46

—

8

=

:

6

2

3

3

1

1

—

—

47

—

11

=

8

3

6

5

4

2

4

1

—

—

46

—

17

=

5

12

1:

3

4

2

8

—

—

49

—

11

=

5

6

4

7

2

2

3

,4

—

—

50

—

13

=

3

10

7

6

2

5

1

5

—

—

51

—

9

=

2

7

4

5

4

2

3

—

—

52

—

2

=

2

2

2

—

53

1

1

1

1

17
indicators are all related to spirometric performance.

Age.–It has been noted that for children

there are positive relationships between age and

FVC and age and FEVI.0. The mean age of SLC

and HES 6- and 7-year olds are:

Study 6 years 7 years

6 and

7 years

SAC ........................ 6.80 7.30 7.12

HAS ........................ 6.50 7.50 7.00

Treating the two age groups separately would

require estimating the adjustments necessary to

make the two samples comparable. But the differences between the combined age groups were

relatively slight, so the age groups were combined, and the comparisons were made between

two groups rather than among four groups.

Sex.–The relationship between sex and

spirometric performance (at least in adults) is

that maIes have greater vzdues than do femaIes,

given the same structure and age. The two

samples are compared as follows:

Study Males Females

SAC ...................................... 44.3% 55.7%

HES ....................................... 50.8% 49.2%

The mean statures and ages by sex for the SLC

sample were:

Age and stature Males Females

Mean age in months ............... 85.1 85.6

Mean stature in inches ............ 48.3 48.2

Although the proportions by sex for the two

groups are not precisely comparable they are

fairly close. Within the SLC sample the sexes are

essentially identical as far as age and stature are

concerned.

Race. –This variable was related to spirometric performance. Negroes did significantly less

well than whites on both FVC and FEV1.0. The

SLC group was all white, but since the percent

of blacks in the HES sample was relatively small

(10 percent), no attempt was made to adjust for

differing racial comparisons.

Stature .–This variable is highly and positively related to both FVC and FEVI.0 (r= 0.69,

0.67, respectively). Although HES data indicate

that sitting height may be a slightly better predictor of these parameters (and in fact may

eliminate much of the race effect), it was not

measured on the SLC children. The mean standing height of the SLC sample was 48.27 inches

with a standard error of 0.243 inch, while that

of the HES sample was about 47.68 inches with

a standard error of about 0.103 inch. The two,

means were not significantly different at the

5-percent level, but the difference of about 0.6

inch is worth noting. The difference may be a

function of the secular trend for mean heights of

children to increase with the passage of decadesl 6 and there was a 10-year lag between the

HES and SLC studies. Using a regression line published by HES earlier,l 7 it is possible to estimate

this effect to be about 0.5 inch. The differences

may also be partially explained by considering

that alI the SLC subjects were volunteers, while

some of the HES children were examined only

after strenuous persuasion. Finally, standing

height is significantly related to the last effect to

be considered.4

Socioeconomic status.–Using published HES

estimates,l T we know that there is a positive

relationship between height of child and parental income and between height of child and

parenta.I educations For instance, the mean

height of a 6-year-old whose family’s income is

$500-$999 is 45.2 inches, while that of a 6-

year-old whose family income is $15,000 or

more is 47.1 inches. It is quite conceivable that

much of the observed height difference between

the two samples can be accounted for in this

way, since the SLC suburban residents were

somewhat more affluent than the general U.S.

population, being composed primarily of professionals associated with the University of Utah

and “corporate executives .“ It is known that the

median income for the HES sample was in the

$5,000-$7,000 range and that the 6- and 7-yearold boys and girls in this category had mean

heights, respectively, of 48.03 and 47.34

inches. 1T On the other hand, the SLC sample

18
would correspond best to the $10,000-$15,000

range, for which the mean heights were about

48.13 and 47.93 inches. The weighted HES

mean for boys and girls combined was 47.71

inches, while that for the SLC distribution

applied to the HES means was about 48.02

inches. The conclusion reached was that socioeconomic differences might account for about

half the observed difference in standing height

between the two samples.

Figures 6 and 7 in reference 1 show the regression of FVC against standing height. Although

the values themselves may be suspect, the depicted slopes are probably near the truth, so that

the graph can be used to determine what effect

the various height differences have on the mean

overall FVC’S. Since the lines are nearly linear

and parallel, any two height benchmarks uniformly applied to each Iine will describe the

same difference in FVC. Using the overall mean

heights for HES and SLC, 47.63 and 48.27 inches,

respectively, a net difference of about 40 ml is

noted.

Best trz”alselection, SLC.–Prior to displaying

the distributions of the FV~’s and FVC’S, and

FEV1.0’s of the SLC sample, some mention

should be made of the manner in which the best

of the five trials of each SLC subject was chosen.

Although the procedure has been described elsewhere,G a brief review follows to help the reader

understand the subsequent discussion.

Predicted values for FVC and FEVI.0 were

calculated for each subject, based on equations

found in the Journal of Occupation Medicine,

September 1972, in an article entitled “Development of a New Motivational Spirometer.”G Although these equations axe intended for use with

adults only, the use of any constant works

equally well for the best trial selection procedure.

Standard deviations from the predicted

values were calculated for the FVC and the

FEV1.0 of each of the five trials.

The two z values were summed for each reliable trial, and the trial with the most positive

sum was declared the best.

Best trial selection, HES.–For the HES data,

the better trial from the two (or best trial of

three) available tracings was selected by a highIy experienced spirometrist after being subjected

to the consistency criteria described earlier in

thk report. Both the SLC and HES procedures

evaluated the spirographic curves in terms of the

same criteria; i.e., maximum FVC, maximum

flow rate, and some measure of consistency, so

that “best trials” were selected in a comparable

manner.

The distributions of FV~’s for the SLC

sample are shown in table B. Ordy 4 of the 79

cases (or 5.1 percent) had an FVC time less than

1 second. This compares very unfavorably with

the HES value of 709 out of 1,784 six- and

seven-year-olds (39.7 percent). The z value of

the significance test for the difference between

the two proportions is 12.662, more than

enough to reject the null hypothesis of no difference (p < .0001).

So, what has happened? The first conclusion

that comes to mind is that a mass screening

mechanism such as the Health Examination Survey fails to eIicit the same quality performance

from a group of examinees as did the optimal

testing situation (SLC). But examination of

other data suggests additional possibilities. Of

particular interest is the possibility that a practice effect exists; i.e., a subject becomes more

familiar with the test with repeat trials and conTable B. Frequency distribution of FVCT (best of five trials), by

age and sex: -Salt bke City, 1974

‘“” B

r

Total ............................ 15

0.8-0.8 second .......................... -

0.9-1.0 second ......................... 1

1.0-1.1 seconds ........................ 1

1.1-1.2 seconds ........................ 2

1.2-1.3 seconds ........................ 2

1.3-1.4 seconds ........................ 1

1.4-1.5 seconds ........................ -

1.5-1.6 SS!COndS . . . . . . . . . . . . . . . . .. . . . . . . 1

1.6-1.7 seconds ........................ -

1.7-1.8 seconds ........................ 1

1.8-1.9 seconds ........................ 1

1.9-2.0 seconds ........................ 2

2.0 seconds and over ............... 3

15

1

1

1

1

1

1

2

2

5

20128

1

1 2

1 1

1

1

2 4

2 1

1 1

1 3

5

12 9

19
sequently does better on later trials. The distribution of the number of the best trial was tabulated to investigate the question:

Best tn”al Percent of

occurrence

1..................................................... 6.3

2..................................................... 19.0

3..................................................... 12.7

4..................................................... 22.8

5..................................................... 39.2

Thus 74.7 percent of best trials were third,

fourth, or fifth. And since the HES used only

two or three trials, it is evident that as much as

three-fourths of the time even the best of the

recorded HES trials did not reflect the child’s

true capability, in spite of having achieved a visual level of reliabiM.y.

In the SLC data, the better of the first two

trials was chosen by the “sum of z’s” method

(after all subjects with unreliable pairs of trials

had been rejected), and FVCT’s were taly.dated.

(See table C.)

This resulted in 9 out of 59 (15.3 percent)

subjects having FVCT’s less than 1 second. The z

value for the difference of the SLC and HES

proportions (39. 7 percent and 15.3 percent) is

4.821, while the z value for the difference between the two SLC proportions (15.3 and 5.1

percent) is 1.924. The first is significant at the

l-percent level, while the second is significant at

the 10-percent level,

Table C. Frequency distribution of

trials): Salt Lake C

FVCT

0.7-0.8 second .......... .......................

0.6-0.9 second ................................

0.6-1.0 second ................................

1.0-1.1 seconds ...............................

1.1-1.2 seconds ...............................

1.2-1.3 seconds ...............................

1.3-1.4 seconds ...............................

1.4-1.5 seconds ...............................

1.5-1.6 seconds ...............................

1.6-1.7 seconds ...............................

1.7-1.8 seconds ...............................

1.8-1.9 seconds ...............................

1.9-2.0 seconds ...............................

2.0 seconds and over .......................

NOTE: n = sample size.

VC~ (better of first two

, 1474

.

n

—

2

3

4

1

3

4

2

3

2

3

6

3

5

18

—

Percent

3.3

5.1

6.8

1.7

5.1

6.8

3.3

5.1

3.3

5.1

10.2

5.1

8.5

30.5

;umulative

—

n

—

2

5

9

10.

13

17

19

22

24

27

33

36

41

59

—

Percent

3.3

8.4

15.2

16.9

22.0

28.8

32.1

37.2

40.5

45.6

55.8

60.6

69.4

99.9

The mean values of FVC and FEV1.0 also

demonstrated that the SLC children were very

unlike the HES sample in terms of spirometric

performance. Using the better trial from only

the first two of the five, the mean Salt Lake City

FVC was 1,546 ml with a standard error of

30.38 ml. The mean Salt Lake City FEV1.0 was

1,395 ml with a standard error of 49.05 ml. For

the HES sample (n = 7,119), the mean values

were 1,363 ml and 1,287 ml with respective

standard errors of 6.3 ml and 5.8 ml. Signific~ce

tests comparing the FVC’S and FEV1.0’s both

fell in the region of rejection, with z values of

5.89 and 2.18. It should be noted that the difference between the mean FVC’S was almost 0.2

liter, while that between the mean FEV1.0 ‘S Was

nearer 0.1 liter. The greater difference in FVC’s

than FEVI o‘s suggests that the HES tri~s were

nearer termination by the time 1 second had

elapsed.

Of primary concern in explaining the large

differences between the HES and SLC spirometry means is the question of difference in testing milieu. Although the HES technicians were

generally very competent and responsible, especially in body measurements and X-ray technique (by initial qualification they were all certified X-ray technicians), they were not highly

trained spirometrists. In HES Cycle II, spirometry had not yet been given the importance it

achieved in later HES work. Training and experience of technicians, sophistication and quality

of equipment, and guidance-motivation monitoring were all at a much lower level than in SLC.

Added to this, it seems likely that more than

7,000” examinations dulled the technicians’

enthusiasm to some degree. In addition, the

2%-hour testing period (after a trip of from 15

to 45 minutes to the trailers) and the confusing

and awesome array of examinations could bore,

tire, and overwhelm the young child. Also, it

became apparent, that, in spite of efforts to put

the children at ease, they were sometimes intimidated by the new environment and the unfamiliar examinations. These effects were especially pronounced in the younger chMren.

The SLC children, on the other hand, were

taken from their classes in school to the nearby

examination unit, so were in more familiar surroundings. The children went in a school group

so they had the enthusiasm and support of their

20
peers. In fact, a good deal of competition developed among them, since the children entered the

examination room in pairs, one to take the test

and one to observe. They were spurred on by

clearly excited, friendly, and extraordinarily

knowledgeable and skilled technicians and a

motivation mechanism called the “Motivational

Assisted Spirometry System (MASS),” which

was attached to the spirometer itself.6 The

spirometer used for the SLC study, although

achieving the same end as that used in the HES,

was by design more accurate and sensitive. Particularly, it minimized the initial mechanical inertia which tended to dktort the early part of

the curve, an important consideration since the

curve tends to be rather short and of less mechanical force for 6- and 7-year-olds. These advantages and those mentioned earlier created an

ideal testing situation.

In summary, it can be seen that the children’

in the Salt Lake City sample performed significantly better than those in the HES sample,

both in terms of rate and volume-timeexpiration. The comparison can be formulated

in two ways: (1) the HES data versus the Salt

Lake City “best of five trials” data (this is

assumed to be an ideal condition because it permits each child to reach the maximum of his

learning effect) and (2) the HES data versus the

Salt Lake City “best of two trials” data (a more

direct comparison because similar amounts of

learning occur between the samples).

The first comparison demonstrates that the

percentage of HES children having FV@’s less

than 1 second was almost eight times as great as

that of Salt Lake City chiIdren having FV~’s

less than 1 second (39.7 percent versus 5.1 percent). Also, the mean Salt Lake City FVC

(1,617 ml) was almost 19 percent greater than

the mean HES FVC (1,363 ml), and the mean

Salt Lake City FEV1 -0 (1,441 ml) was almost

12 percent greater than the mean HES FEV1.0

(1,278 ml). Although the mean standing heights

of the samples differed by about 0.6 inch, by

the HES regression of FVC on height it is estimated that this difference accounts for less than

40 ml of the net FVC difference.

Using only two of the five Salt Lake City

trials for the comparison reduced the differences

somewhat. The percentage of HES subjects having FV~’s iess than 1 second (39.7 percent)

was a little more than 21/2 times as great as the

percentage of Salt Lake City subjects having

FVC+.’s less than 1 second (15.1 percent). The

mean Salt Lake City FVC was more than 13

percent greater than the mean HES FVC (1,546

ml versus 1,363 ml), and the mean Salt Lake

City FEV1. o was more than 8 percent greater

than the mean HES FEV1. O (1,395 ml versus

1,278 ml).

There seems to be little doubt, having found

the samples quite similar in terms of relevant

independent variables, that the spirometric differences are due almost entirely to differences in

testing milieus. Perhaps the most important

single factor is the greater opportunity available

to the Salt Lake City subjects to achieve maximum learning, as demonstrated by the measurable and consistent differences between the

“best of two trials” data and the “best of five

trials” data just offered. This effect is more distinct in boys whose mean FVC increased from

1,543 ml to 1,649 mI with the three additional

trials, than it is in girls whose mean FVC increased only from 1,549 ml to 1,594 ml, suggesting that girls in this age range either learn

faster or fatigue earlier.

The Salt Lake City spirometry data collection was methodologically and mechanically

superior to the HES spirometric operation in

almost all respects: the equipment had less inertia and was more sensitive and accurate, the

quality of encouragement, motivation and instruction was distinctly better, and the subjects

had ample opportunity to achieve maximum

learning. These factors all contributed to bringing

the SaIt Lake City children to a closer approximation of their true maximal effort and hence

to a more accurate estimate of the physiologic

parameter of interest, forced expiatory volume.

Annapolis Substudy

The methodology of the Salt Lake City substudy differed from that of HIM Cycle II in one

respect not yet evaluated. The HES subjects all

inhaled through the spirometer hose after the

bell was lifted to draw room air into the spirometer (called a “closed” system), while the SLC

subjects all inhaled ambient room air (caJled an

“open” system), which is the more commonly

used technique. It was conjectured that the

21
closed system might be inhibitory (a respiratory

claustrophobia), because many children did not

inhale maximally (and reach TLC) when they

could not see the source of the inhaled gas. To

test this hypothesis, a final substudy was performed on 22 six- and seven-year-old boys and

girls enrolled in an Annapolis, Maryland, private

school.

The children were first introduced to the

subject of spirometry via a short classroom discussion of the objectives and a demonstration of

the proper technique of the test. Pairs of children were then brought into the testing room,

and the procedure was reviewed. Each child performed two complete sets of FES’S, one with

the open system and one with the closed. The

spirometer used in this study was the same one

used for almost half of the subiects in HES

Cycle II, 1963-65. (After it was cleaned and recalibrated, its present performance was found to

be identical to its Cycle II performance.) Half of

the children did the open system first, and the

other half did the closed system fh-st. In all cases

the children were allowed practice trials until

Dr. Palmer, acting as the technician, felt that

they understood the maneuver, and then up to

four trials were performed. Measurements (in

millimeters), from the tracings thus recorded

and information on age and stature were the raw

data of this study.

The mean age of the children was 6.71 years

(many of the children were completing their second year of school). Their average stature was

124.2 cm, while for HES Cycle II the average

stature for 6.7-y ear-olds was 119.4 cm. The

mean FVC of all best trials on the open system

was 1,528 ml, while the mean FVC of zdl best

trials on the closed system was 1,541 ml. Of

course, this minuscule difference is not significant at the Q = 0.05 level.

Males did slightly (but not significantly)

better on the open than on the closed system,

with mean FVC’S of 1,643 ml and 1,637 ml. For

females, the relationship was reversed, with the

mean FVC for the open system (1,391 ml) insignificantly less than that of the closed system

(1,428 ml).

The relationship of FVC and stature was very

strong, P < .01, when the best trial by either system for each child was used. A l-cm stature difference accounted for an FVC difference of

about 35 ml. This value compares closely with

that noted for HES of about 30-40 ml/cm.

A final observation concerns the difference

between the mean male and female FVC values.

Using the best observed trial for each sex (1,643

ml and 1,428 ml) a difference of 215 ml was

obtained. However, there was also a 3.7-cm difference in mean statures (126.0 cm for males

versus 122.3 cm for females), and applying the

aforementioned 35 ml/cm adjustment factor reduces the mean FVC difference from 215 ml to

about 85 ml. This value falls between the 55-lnl

difference estimated from the SLC study and

the 150-ml difference estimated from the HES

data.

This study provides the strongest possible

demonstration that the difference in results

from an open or closed system is totally negligible in children given an optimum testing environment and some preinstruction. Also, the similarity of mean FVC values between this substudy and the SLC substudy and the disparity

between them and the mean FVC values of the

HES provide further support for the hypothesis

that the testing milieu is one of the most significant factors affecting FES performance in children (probably even greater than sophisticated

electronic equipment).

000

22
REFERENCES

1National Center for Health Statistics: Forced vital

capacity of children 6-11 years, United States. Vital and

Health Statistics. Series 11, No. 164. To be published.

2Hutchinson, J.: On the capacity of the lungs and on

respiratory functions: With a view of establishing a

precise and easy method of detecting disease by the

spirometer. Trans. Med. Chir. Sot. London 29: 137-252.

1846.

3Tiffeneau, R., and Pinelli: Am circuhmt et air captif

clans l’exploration de la fonction ventilatrice pulmonaire.

Park Med. 133:624-628, 1947.

4Dayman, H.: The normal expiatory spirogram

technique, in Current Research in Chronic Obstructive

Lung Disease. 10th Aspen Emphysema Conference,

1967. pp. 443-447.

5Discher, D. P., Massey, F. J., and Hallet, W. Y.:

Quality evaluation and control methods in computer

assisted screening. Arch. Environ. Health 19: 323, 1969.

6Discher, D. P., and Palmer, A.: Development of a

new motivational spirometer-rationale for hardware and

software. J. Occup. Med. 14: 179, Sept. 1972.

7Sobol, C. J.: The mid-maximum flow rate, a

re-examination. Amer. Rev. Resp. Dis. 92:915, 1965.

‘Hyatt, R. E., Schildre, D. P., and Fry, D. L.:

Relationship between maximum expiatory flow rate

and degree of lung inflation. J. App. Physiol. 12: 331,

1958.

‘Palmer, A. et al.: Spirometry using motivational

techniques. ]. Chronic Dis. 24:643,1971.

10Brough, F. K., Schmidt, C. D., and Dickman, M.:

Effect of two instructional procedures on the

performance of the spirometry test in children five

through seven years of age. Amer. Rev. Resp. Dir. 106:

604-606, 1972.

11 Gaensler, E. A., and Wright, G. W.: Evaluation of

respiratory impairment. Arch. Environ. Health 12: 146,

1966.

12American College of Chest Physicians: Recommendations of the Section on Pulmonary Function Testing Committee on Pulmonary Physiology. Dis. Chest 43:

214-219, Feb. 1963.

13 Fairbaim, A. S.: A comparison of spirometric and

peak expiatory flow measurements in men with and

without bronchitis. Thorax 17: 118, 1962.

14Afschrift, J. et al.: hkximal expiatory and

inspiratory flows in patients with chronic obstructive

pulmonary disease. Amer. Rev. Resp. Dis. 100:147-152,

1969.

15Polgar, G., and Promadhat, V.: Pulmonary Function

Testing in Children: Techniques and Standards.

Philadelphia. W. B. Saunders Co., 1971.

16 National Center for Health Statistics: NCHS growth

curves for children, birth- 18 years. Vital and Health

Stat&tics. Series 1 l-No. 165. DHEW Pub. No. (HRA)

77-1650, Health Resources Administration, Washington.

U.S. Government Printing Office, Sept. 1977.

17 National Center for Health Statistics: Height and

weight of children: Socioeconomic status, United States.

Vital and Health Statistics. Series 11-No. 119. DHEW

Pub. No. (HShi) 73-1601. Health Services and Mental

Health Administration. Washington. U.S. Government

Printing Office, Oct. 1972.

23
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

LIST OF DETAILED

FVC of children 6-11 years of age, by quality group, age, rata, and sex:

TABLES

Sample siza, mean, and standard daviation, Health

Examination Survay Cycle 11, 1963-65, unedited data ...............................................................................................................

FEV1 of children 6-11 years of age, by quality group, age, race, and sex: Sample siza, mean, and standard deviation, Health

Examination Survey Cycle 11, 1963455, unedited data ..............................................................................................................

‘EF25.75% of childran 6-11 years of aga, by quality group, age, rata, and sex: Sampla siza, mean, and standard deviation,

Health Examination Suwey Cycle 11, 1963-65, unedited data ...................................................................................................

Number and percent of childran 6-11 years of age, by education Ieval of first-listed parent, quality group, and age of

children: Haalth Examination Survey Cycle 11, 1963-66, unedited data ....................................................................................

Numbar and parcent of children 6-11 years of age, by animal family income, quality group, and age of children: Health

Examination Survay Cycla 11, 1963-65, uneditad data ...............................................................................................................

IQ of children 6-11 years of age, by annual family income, quality group, and age of children: Haalth Examination Suway

Cycle II, 1963-65, unedited data ............................................................................................................................................ ...

Number and percant of children 6-11 years of aga, by geographic ragion, quality group, and age: Health Examination Survey

Cycle 11,1963-65 ............................................................................................................................... ............................. ...........

Height in centimeters of children 6-11 yeara of aga, by quality group, age, rata, and sex: Sample size, mean, and standard

deviation, Health Examination Suwey Cycla 11,1963-65 ...........................................................................................................

Sitting height in centimeter of children 6-11 years of age, by qualitY group. a9e, race, and sex: SamPle size, mean zstandard

deviation, Haalth Examination Survey Cycle II, 1963-65 ............................................................................ ...............................

FEV1 of children 6-11 years of age, by age, sex, and race: Sample size, weighted sample size, standard deviation, standard

error of the mean, mean, and selactad percantilas, Health Examination Survey Cycle 11,1963.65 ..............................................

FEF 25.75% of children 6-11 years of age, by age, sex, and race: Sample siza, weighted sample size, standard deviation,

standard error of the mean, mean, and salactad percentiles, Health Examination Survay Cycla 11,1963%5 ..............................

25

27

29

31

32

34

35

36

38

40

42

24
Table 1. FVC of children 6-11 years of age, by quality group, age, race, and sex: %mple size, mean, and standard deviation,

Health Examination Suwey Cycle 11,1963-S5, unedited data

Quality group

Age, race, and sex IB IGIE II

n n n n Xlsc)

Total Milliliters Milliliters Milliliters

1253

1,420

1,618

1,827

2,013

2~90

1#26B

1,446

1,653

1,847

2,050

2/332

1,146

1,262

1,428

1,706

1,780

1~B8

1,299

1,4S6

1,691

1~oo

2,089

2>85

1#203

1,354

1J542

1,740

1928

2,186

247

262

303

35a

377

445

247

259

1,309

1,518

1,669

1,846

2,044

2287

1,308

1,538

1,694

1,877

2,070

2,335

1,308

1,358

1,504

1,617

1,863

2.042

1,380

1,582

1,75s

1930

2,120

2,357

1J?34

1,433

1,564

1,764

1#866

2~oo

245 1,248

1,415

1,808

1,798

1,857

2,212

1,270

1,435

1,642

1,826

1,987

2,259

1,122

1,155

1,4s5

1,50s

1,65S

1/810

1,312

1,4s0

1,662

1~38

2,061

228

1,169

1,356

1,534

1,755

1J378

2,122

254

285

278

336

412

44s

1,282

1,439

1,633

1,755

2,026

2,197

1,286

1,428

1,566

1,788

2,041

2,195

1,215

1,5s4

1,374

1,154

1,686

2,210

1,363

1,428

1,656

1,ss4

1,882

2,261

1,155

1,448

1,448

1,662

2,083

2,155

271

237

281

357

3s6

6 yeara .....................................................

7 years .....................................................

8 years .....................................................

9 yaars .....................................................

10 years ...................................................

11 years ...................................................

510

646

606

184

219

303

279

308

345

171

195

263

246

269

2s8

23

24

40

33

39

57

10U

125

147

136

94

121

98

114

110

111

20

29

22

19

19

25

19

27

18

18

17

21

1

2

4

1

2

4

12

13

9

8

10

10

8

16

13

11

9

15

306

297

343

381

434

242

303

294

345

5s0

320

White

6 yeara .....................................................

7 yeara .....................................................

8 years .....................................................

9 years .....................................................

10 yeara ...................................................

11 years ......................... ..........................

44s

554

512

513

502

496

64

92

94

85

78

70

265

322

308

315

so

112

77

104

?00

290

272

328

392

431

212

240

28s

281

508

451

235

242

287

335

392

344

54

106

434

174

186

262

356

363

353

36s

437

218

225

272

365

374

422

273

288

26s

226

96

Nearo

6 yea= .....................................................

7 years ...................................... ...............

8 years .....................................................

9 years .....................................................

10 years ...................................................

11 years ...................................................

14

9

21

10

10

15

52

57

57

58

47

57

42

64

41

55

63

54

351 391

387

255

254

280

376

378

436

228

254

298

315

357

433

416

257

330

298

343

377

426

207

Male

6 years .....................................................

7 years .....................................................

8 yea~ .....................................................

9 years .....................................................

10 years ...................................................

11 years .......................................... .........

2s4

273

335

422

535

257

285

270

335

390

314

156

285

245

324

287

283

281

271

191

84

94

166

141

152

188

319

223

182

337

379

380

Female

6 yeara ........................................... ..........

7 yeara .....................................................

8 yeara .....................................................

9 years .....................................................

10 yeare ...................................................

11 years ...................................................

250

271

324

371

155 428

NOTE: n = sample size, ~ = mean, SD tandard deviation.

25
Table 1. FVC of children 6-11 years of age, by quality group, age, race, and sex: Sampla size, mean, and standard deviation,

Health Examination Survey Cycle 11, 1963-65, unedited data–Con.

Age, race, and sex

White male

6 years .....................................................

7 years .....................................................

8 years .....................................................

9 years .....................................................

10 years ...................................................

11 years ...................................................

White female

6 years .....................................................

7 years .....................................................

8 years ................ .....................................

9 years .....................................................

10 years ................................ ...................

11 years ...................................................

Negro male

6 years .....................................................

7 years .....................................................

8 years .....................................................

9 years .....................................................

10 years ...................................................

11 years ...................................................

Negro female

6 yeare .....................................................

7 years .....................................................

8 years .....................................................

9 years .....................................................

10 years ...................................................

11 years ...................................................

n

227

286

270

275

256

259

219

266

242

238

246

237

38

36

39

40

33

36

26

56

55

45

45

34

3k SD

Milliliters

1,319

1,505

1,717

1,840

2,137

2,438

1,216

1,364

1,581

1,741

1,858

2,217

1,180

1,334

1,513

1,676

1,805

2,008

1,096

1,216

1,370

1,733

1,761

1,867

258

252

285

363

365

424

225

252

293

310

350

423

202

216

269

368

349

328

235

220

260

345

365

444

Quality group

—

n

—

85

111

131

123

137

167

86

84

132

123

132

122

15

14

16

15

19

24

8

10

24

18

20

33

—

18

31.X

Milliliters

1,399

1,601

1,784

1,861

2,155

2,388

1,220

1,454

1,604

1,793

1,882

2,247

1,270

1,434

1,546

1,673

1,867

2,063

1,382

1,251

1,475

1,571

1,860

2,028

256

330

298

346

372

416

190

243

261

323

355

415

246

302

206

170

315

382

323

246

303

260

461

444

—

n

—

44

54

46

53

42

45

36

58

31

51

58

51

8

3

11

6

5

12

6

6

10

4

5

3

—

IC-IE

L.k

Milliliters

1,331

1,495

1,697

1,872

2,088

2,414

1,196

1,380

1,561

1,778

1,914

2,123

1,209

1,217

1,516

1,540

1,838

1,862

1,007

1,124

1,450

1,460

1,478

2,103

237

281

277

326

392

491

260

289

248

326

379

317

208

222

207

274

636

480

167

263

332

352

306

301

—

—

n

—

11

12

9

8

9

8

8

15

9

10

8

13

1

1

1

2

1

4

1

1

2

—

II

_I-k

Milliliters

1,398

1,411

1,656

1,864

2,037

2,272

1,155

1,442

1,481

1,712

2,045

2,147

1,215

1,622

1,590

2,217

1,545

1,374

1,164

2,203

2,202

200

267

358

363

407

16’1

319

229

204

30[1

401

419

269

106

136

NOTE: n = sample size, ~ = mean, SD = standard deviation.

26
Table 2. FEV, of children 6-11 vears of age, by auality grow, age, race, and sex: Sample size, mean, and standard d~iaticm, Health

;arninat;on Sum-ey Cycle 11, 1963-65, unedited data

Quality group

Age, race, and sex lC-lE

Zlz

Milliliters

II —

n n n n

Total Milliliter Milliliter Milliliters

1,188

1,344

1,513

1,664

1,838

2,062

1,199

1,365

1,537

1,698

1~66

2,080

1,113

1 ~20

1,380

1,597

1,685

1,662

1,227

1,400

1,576

1,733

1,901

2,124

1,146

1#268

1,447

1,628

1,776

1 ~84

1#228

1,423

1#544

1,713

1,844

2,073

1,234

1,439

1,566

1,736

1,663

2,110

1,195

1,287

1,401

1,544

1,719

1,6S7

1,279

1,475

1,621

1,782

1,880

2,103

1,176

1,353

1,472

1,645

1,808

2,037

226

275

1,160

1,351

1,494

1,636

1,805

1,961

1,173

1,368

1,508

1,657

1326

1,884

1,087

1,138

1,436

1,422

1,600

1,811

1,202

1,406

1,542

1,676

1,903

1,958

1,108

1,300

1,427

1,563

1,732

1~64

232

262

257

327

345

510

646

606

588

680

566

446

554

512

513

502

496

64

92

94

85

78

70

265

322

308

315

289

285

245

324

267

263

281

271

194

219

303

279

308

346

171

195

263

246

269

289

23

24

40

33

39

57

100

125

147

138

156

191

94

94

156

141

152

155

6 years ..................................................

7 years ..................................................

8 years .......... ........................................

9 years ..................................................

10 years ................................................

11 years .................................................

238

244

272

321

344

406

242

243

269

320

340

94

121

98

114

110

111

80

112

77

20

28

22

79

19

25

19

27

18

18

17

21

1

2

4

1

2

4

12

13

9

8

10

10

8

16

13

11

9

15

1,216

1,380

1,441

1,594

1,770

1,886

1,217

1,366

1,468

1,618

1,767

1,865

1,192

1,572

1,324

1,154

1,796

2,010

1,296

1,375

1,498

1,720

1,658

1,753

1,086

I ,364

1,402

1,502

1,684

1,978

253

211

236

281

399

444

260

211

253

268

414

458

38

50

355

389

128

242

316

291

425

541

348

180

164

246

350

307

353

389

White

223

273

259

310

350

6 years .................................................. 235

7 years ..................................................

8 years ..................................................

9 years ........... .............b.........................

10 years ................................................

11 years .................................................

258

254

321

324

377

208

225

266

321

485

446

227

245

242

315

342

451

231

104

100

96

14

9

21

10

10

15

52

57

57

59

47

57

42

64

41

55

63

54

402

Nemo

6 years ..................................................

7 years ..................................................

8 years ..................................................

9 years ..................................................

10 years ................................................

11 yaars ................................................ .

186

211

250

312

318

378

250

263

283

219

360

364

237

302

246

284

346

361

202

219

268

—Mala

6 years ..................................................

7 yeara ..................................................

8 yeara ..................................................

9 yaars ..................................................

10 years ................................................

11 years .................................................

250

237

336

344

380

215

238

268

264

332

413

Female

6 years ..................................................

7 years ................................................. .

8 years ..................................................

9 years ..................................................

10 years ................................................

11 yearn .................................................

269

265

336

332

315

305

355

396

NOTE: n = sample size, ~ = mean, SD = standsrd deviation.

--”

27
Table 2. FEV1 of children 6-11 years of age, by quality grow, age, race, and sex: Sample size, mean, and standard deviation, Health

Examination Survey Cycle 11, 1963-65, unedited data–Con.

Age, race, and sex

White male

6 years ..................................................

7 years ..................................................

8 years ..................................................

9 years ................ ..................................

10 years ................................................

11 years ................................................

White female

6 years ..................................................

7 years ..................................................

8 years ..................................................

9 years ..................................................

10 years .................. ..............................

11 years ................................................

Negro male

6 years ..................................................

7 years ..................................................

8 years ..................................................

9 years ..................................................

10 years ................................................

11 years ................................................

Nagro female

6 years ..................................................

7 years ..................................................

8 years ................................................ ..

9 years ..................................................

10 years ................................................

11 years ................................................

n

—

227

286

270

275

256

259

219

268

242

238

246

237

38

36

39

40

33

36

26

56

55

45

45

34

&k SD

Milliliters

1,241

1,416

1,594

1,760

1,930

2,159

1,155

1,310

1,474

1,628

1,799

2,014

1,147

1,270

1,449

1,552

1,681

1,871

1,064

1,189

1,331

1,636

1,654

1,853

259

237

256

333

338

382

216

238

269

280

329

411

172

196

254

302

311

357

198

216

238

318

326

403

Quality group

n

85

111

131

123

137

167

86

84

132

123

132

122

15

14

16

15

19

24

8

10

“24

18

20

33

Y~

SD

Milliliters

1,303

1,492

1,638

1,800

1,912

2,133

1,166

1,368

1,494

1,671

1,812

2,080

1,145

1#337

1,479

1,635

1,656

1,688

1,280

1,217

1,349

1,468

1,779

1)379

233

302

243

301

346

377

191

210

255

307

348

391

221

266

231

175

277

352

287

255

306

226

406

377

—

n

44

54

46

53

42

45

36

58

31

51

58

51

8

3

11

6

5

12

6

6

10

4

5

3

IC-IE

=

Milliliters

1,206

1,421

1,561

1,692

1,924

2,008

1,133

1,319

1,431

1,620

1,754

1,963

1,181

1,173

1,458

1,538

1,726

1.770

962

1,121

1,416

1,249

1,473

1,976

236

243

241

318

287

438

231

284

256

324

327

316

182

147

238

275

631

469

185

266

305

341

304

361

n

—

11

12

9

8

9

8

8

15

9

10

8

13

1

1

1

2

1

4

1

1

2

k: x SD

Milliliters

1,305

1,356

1,498

1,720

1,671

1,729

1,096

1,373

1,437

1,537

1,875

1,948

1,192

1,599

1#645

1,850

1,545

1,424

1,154

2,047

2,169

130

243

316

291

449

572

348

191

187

229

369

373

564

50

184

NOTE; n = sample size, ~ = mean, SD = standard deviation.

28
Table 3. FEF25.75% of children 6-11 years of age, byquality group, aga, race, and sex: Semplesize, mean, and standard deviation,

Health Examination Survey Cycle II, 1963-65, unedited data

Age, race, and sex

Total

6 yeara .................................................

7 years .................................................

8 years .................................................

9 years .................................................

10 years ...............................................

11 years ...............................................

White

6 yeara .................................................

7 years .................................................

8 yea= .................................................

9 years .................................................

10 years ...............................................

11 years ... ................................ ............

Negro

6 yeara .................................................

7 years .................................................

8 years .................................................

9 yaars .................................................

10 years ...............................................

11 years ....... ........................................

Male

6 years ................................. ................

7 years .................................................

8 years .................................................

9 years .................................................

10 years ...............................................

11 years ...............................................

Female

6 years .................................................

7 years .................................................

8 yea= .................................................

9 years .................................................

10 years ...............................................

11years ...............................................

n

510

646

606

588

580

566

446

554

512

513

502

496

64

92

94

85

78

70

265

322

309

315

289

285

245

324

287

283

281

271

Y~

SD

Milliliters

1,768

1/873

2,122

2,263

2,413

2,651

1,755

1,966

2,105

2J59

2,415

2,662

1,866

2,003

2,215

2#288

2,400

2,574

1,798

2,002

2,167

2245

2,428

2,659

1,738

1,945

2,075

2,283

2,397

2,642

497

523

557

628

665

762

501

517

542

627

657

752

461

559

628

637

717

830

495

537

525

623

635

750

488

508

587

635

694

775

NOTE: n = sample size, ~ = mean, SD = standard deviation

Quality group

—

n

—

194

219

303

279

308

346

171

195

263

246

269

289

23

24

40

33

39

57

100

125

147

138

156

791

94

94

156

141

152

155

*

~ SD

Milliliters

1,742

1,917

2,068

2,272

2,335

2,579

1,756

1,925

2,074

2265

2,325

2,608

1,639

1,852

2,031

2320

2,400

2,428

1,782

1,987

2,170

2,287

2,313

2,540

1,700

1,825

1,972

2,257

2,357

2,627

530

507

577

666

662

534

537

652

688

688

502

517

788

770

700

635

614

526

593

532

734

658

424

466

546

776

641

706

n

94

121

98

114

110

111

80

112

77

104

100

96

14

9

21

10

10

15

52

57

57

59

47

57

42

64

41

55

63

54

IC-IE

-

Milliliters

1,746

2,012

2,065

2,159

2,432

2,508

1,719

2,014

2,051

2,139

2,414

2,503

1,686

1,992

2,114

2,368

2,604

2543

1,836

2,110

2,123

2,116

2,515

2,457

1,634

1926

1#884

2#204

2,370

2,562

515

517

536

640

589

746

510

520

547

630

566

740

535

488

503

739

682

813

504

508

537

601

512

776

512

613

531

662

653

716

—

n

—

20

28

22

19

19

25

19

27

18

18

17

21

1

2

4

1

2

4

12

13

9

8

10

10

8

16

13

11

9

15

II

*

Milliliters

1,757

2,008

2,075

2,167

2,207

2,464

1,753

1,922

2,048

2,169

2223

2,400

13.42

3,182

2,196

2,137

2.070

2,797

1,8!59

2,018

1,887

2,423

2,036

2,284

1,604

2,002

2,205

1,881

2,397

2,577

554

557

470

650

711

817

568

467

498

668

741

755

252

333

536

1,167

367

543

481

778

856

1,010

758

586

432

495

466

672

29
Table 3. FEF25.75% of children 6-11

Healtl

Age, race, and sex

White male

6 years .................................................

7 years .................................................

8 years .................................................

9 years .................................................

10 years ...............................................

11 years ...............................................

White female

6 years .................................................

7 years .................................................

8 years .................................................

9 years .................................................

10 years ...............................................

11 years ...............................................

Negro male

6 years ..... ............................................

7 years .................................................

8 years .................................................

9 years .................................................

10 years ...............................................

11 years ........... ....................................

Negro female

6 years .................................................

7 years .................................................

8 years .................................................

9 years .................................................

10 years ...............................................

11 years ...............................................

aars of age, by quality group, age, rata, and sex: Sample size, mean, and standard deviation,

Examination Survev Cvcle II. 1963-65. unedited data–Con.

Quality group

n

227

286

270

275

256

259

219

268

242

238

246

237

38

36

39

40

33

36

26

56

55

45

45

34

YF SD

Milliliters

1,776

2,006

2,161

2Z66

2,437

2,671

1,733

1928

2,043

2,263

2,392

2,652

1,928

1,973

2,208

2,172

2,362

2,576

1,781

2,022

2,220

2,393

2,427

2/672

502

530

517

631

620

742

500

501

563

624

694

763

430

601

578

564

745

808

500

535

666

686

703

864

n

85

111

131

123

137

167

86

84

132

123

132

122

15

14

16

15

19

24

8

10

24

18

20

33

Y~

SD

Milliliters

1,823

1,996

2,156

2,274

2,326

2,556

1,690

1,832

1392

2,256

2,324

2,682

1,550

1,913

2,264

2,393

2,217

2,435

1,807

1,766

1,862

2J56

2,574

2,424

623

529

548

547

737

653

422

461

515

744

636

730

519

508

381

727

704

454

542

696

994

642

591

—

—

n

44

54

46

53

42

45

36

58

31

51

56

51

8

3

11

6

5

12

6

6

10

4

5

3

IC4E

=

Milliliters

1,787

2,105

2,132

2,092

2,504

2,455

1,636

1,928

1,932

2,187

2,349

2,545

2,103

2,195

2,085

2J36

2,601

2,466

1,618

1,891

2,147

2,416

2,607

2,852

498

518

546

624

435

774

521

512

536

638

640

713

466

322

521

270

1,033

820

502

565

509

1,230

627

866

—

n

—

11

12

9

8

:

8

15

9

10

8

13

1

1

1

2

1

4

1

1

2

—

*

SD

Milliliters

1,861

1,936

1,887

2,423

2,075

2,356

1,604

1,912

2,208

1,966

2,390

2,427

1,842

3,004

1,681

2,042

3,361

2,196

2,137

2,449

3,552

385

476

481

778

898

1,084

758

476

488

519

521

511

897

333

999

NOTE: n = sample size, X = mean, SD = standard deviation.

30
Table 4. Numtxr and percent Of children 6.11 yearn Of age, by ~ucati~n IeWI Of fimt.lified parent, quality group, and age of children: Health Examination 6urvey Cycle 11,

1963.65, unedited data

Education of first-listed parent

Less than

5 years

17years

or more

C2uallty group

and age 5-7 vears 8veam 9-11 years 12 years 13-15 years 16 years Unknown

Number

.

Percent

Number

22

36

33

48

43

42

12

-1

12

7

13

18

6

4

3

14

8

11

2

2

21

31

14

13

13

11

9

6

3

2

1

4

Per- Num.

Ix

Per. Number

Per- Per- Num.

bw

Per- Num.

ber

Per. PercentPer.

cent ber ber ber cent —

4.3

5.6

z

7.4

7.4

6.7

3.2

4.0

2.5

4.2

5.2

6.4

3.3

3.1

12.3

7.3

9.9

10.5

10.5

8.5

16.6

8.2

89

10.8

8.8

!0.0

I5.4

9.7

7.7

4.3

9.0

—

y

6 years .....................

7 wars .....................

8 years ..... .............

9years,..,,,,..,.,..,..,,.,

10 years . .. .... .. ...

11 years.,,.,,.,,,,,,,,..,..

~

6 vears .... ....... .. .....

7 years ............... ......

8 years .... ........ .. . ..

9 years .....................

70 yeart ...................

11 years.,.,...,..,..,..,..,

—IC-IE

6 years .. ...... .. ... . .....

7 years .. . . ......... .. .....

8 years ................ ...

9 vears .....................

10 years .. ...............

11 years.,.,.,...,..,..,...

~

6 years ...... .............

7 years ................. ...

8 years ............... .....

9 years .....................

10 years ............. .....

11 years....................

y

6 years .....................

7 veam . ...................

8 years ...... . .. .. ...... ...

9 years .. .. ... ............

10 years ... ......... .....

11 years.., ................

45

Ea

Sa

65

61

57

13

11

25

17

26

35

:

10

5

10

6

2

2

2

21

22

12

23

12

14

2

3

6

3

3

3

—

8.8

9.0

11.2

109

10.5

10.1

6.7

5.0

8.3

6.1

8.4

10.1

6,4

6.6

10.2

4.4

9.1

5.4

9.1

10.5

a.0

8.5

11.8

7.0

15.8

10.0

11.4

4.4

7.7

19.4

10.7

13.0

14.3

53

w

67

69

68

77

16

22

27

27

37

38

7

11

10

8

14

19

1

3

1

2

4

7

28

17

23

22

14

16

5

7

2

3

1

10.4

9.3

11.1

11.5

11.9

13.6

82

10.0

89

9.7

12.0

11.0

;::

10.2

7.0

12.7

17.1

6.0

10.3

4.5

10.5

21.1

26.0

11.3

9.1

13.5

15.1

11.7

13.0

11.1

179

6.5

13.0

4.6

112

140

134

110

101

110

33

41

:

64

71

23

21

23

27

18

19

3

14

3

4

3

7

53

49

28

27

22

25

13

11

6

11

4

7

22.0

21.7

22.1

18.4

77.4

19.4

17.0

18.7

22.1

22.2

20.8

20.5

24.5

17.4

23.5

23.7

16.4

17.1

15.0

46.3

13.6

21.1

15.6

28.0

21.4

26.2

16.4

18.5

16.3

20.3

26.9

28.2

19.4

38.3

17.4

33.3

167

206

15S

166

185

160

:;

105

100

105

96

32

51

51

34

32

28

10

8

10

;

6

66

35

47

40

38

32

10

11

10

7

5

4

32.7

31.9

27.9

31.1

28.4

31.8

36.6

37.0

34.7

35,8

34.1

28.3

34.0

42.1

31.6

29.8

29.1

25.2

50.0

27.6

45.5

36.8

15.8

24,0

27.4

18.7

27.5

27.4

31.7

26.0

22.2

28.2

32.3

25,0

21.7

19.0

39

61

51

38

51

30

17

24

26

21

23

26

8

10

5

6

12

9

2

2

2

1

2

1

19

15

15

7

11

5

4

1

3

1

7.6

9.4

8.4

6.4

8.6

5.3

8.8

11.0

8.6

7,5

7.5

8.1

8.5

8.3

5.1

5.3

109

8.1

10.0

6.9

9.1

5.3

10,5

4.0

H

8.8

4.8

9.2

4.1

8.9

3.2

0.7

43

39

57

36

46

46

37

m

21

25

24

19

33

9

7

7

9

7

11

2

1

1

1

1

18

9

16

7

5

14

1

1

4

1

7.6

8.6

5.9

8.0

7.9

6.5

10.3

9.6

8.3

8.6

6.2

9.5

9.6

5.8

7.1

7.9

6.4

9.9

10.0

3.4

4.5

5.3

4.0

7.3

4.8

9.4

4.8

4.2

11.4

3.2

3.6

17.4

4.8

26

21

38

24

35

32

10

11

13

20

21

22

2

8

:

7

6

2

2

2

3

1

13

4

10

4

5

4

2

1

2

1

2

1

5.1

3.3

6.3

4,0

6.0

5.7

5.2

5.0

4.3

72

6.8

6.4

2.1

7.4

8.2

7.8

6.4

5.4

0.0

9.1

0.5

5.6

4.0

5.2

2.1

5.8

2.7

4.2

3.3

4.4

::

3.6

8.7

4s

7

7

10

10

9

1

1

1

3

1

3

1

1

2

2

2

1

1

7

5

6

3

2

1.4

1.1

1.7

1.7

1.6

0,2

0.5

0.5

1.0

0,4

0.9

1.1

1.0

1.8

1.8

1.8

3.4

4.5

2.6

2.7

3.5

2.1

1.6

Deck 56 only

6 years .. ..................

7 Veam .....................

8 years ..... ..... .. ......

9 years ....................

10years ...................

11 years..., .............

31
Table 5. Number and percent of children 6-11 years of age, by annual family income, quality group, and age of children: Health

Examination Survey Cycle 11,1963-65, unadited data

Quality group and age

6 years .....................................................................

7 years .....................................................................

8 years .....................................................................

9 years .....................................................................

10 years ...................................................................

11 years ....................................................................

6 years .....................................................................

7 years .....................................................................

8 years .....................................................................

9 years .................................................................. ...

10 years ...................................................................

11 years ...................................................................

IC-IE

6 years .....................................................................

7 years .....................................................................

8 years .....................................................................

9 years .....................................................................

10 years . ..................................................................

11 years ....................................................................

6 years .....................................................................

7 years ................................ .....................................

6 yearn .....................................................................

9 years .....................................................................

10 years ...................................................................

11 years ...................................................... ..............

JIJ

6 yaars .....................................................................

7 years .....................................................................

8 years .....................................................................

9 years .....................................................................

10 Years ...................................................................

11 years ....................................................................

Deck 56 only

6 years .....................................................................

7 years .....................................................................

8 years .....................................................................

9 years .........r...........................................................

10 years ...................................................................

11 years... )...............................................................

Less than

$500

Number

7

6

3

7

8

4

1

4

1

1

1

1

2

1

4

3

1

2

3

1

2

Per-

:ent

1.4

0.9

0.5

1.2

1.4

0.7

0.5

1,3

0.3

0.3

1.1

0.8

2.0

0.9

1.6

1.6

0.6

1.4

2.5

2.2

5.1

$600-

$899

Annual family income

Vumber

11

17

13

15

10

12

3

3

3

8

12

17

3

3

6

1

2

1

1

9

6

8

9

2

5

2

1

1

1

1

Percent

2.2

2.6

2.1

2.5

1.7

2.1

1.5

1.4

1.0

2.8

3.9

4.9

3.2

3.1

5.3

0.9

1.8

5.0

5.3

3.6

3.2

4.7

6.2

1.7

11.1

5.1

3.2

3.6

4.3

4.8

$1,000-

$1,888

Number

27

38

31

42

42

27

8

11

17

12

20

20

6

3

9

3

8

8

1

3

1

3

24

18

12

11

11

9

5

4

2

2

1

3

Percent

5.3

5.9

6.1

7.0

7.2

4.8

4.1

5.0

5.6

4.3

6.5

5.8

6.4

2.5

9.2

2.6

7.3

7.2

5.0

10.3

5.3

15.8

9.7

9.6

7.0

7.5

9.2

7.3

11.1

10.3

6.5

7.1

4.3

14.3

$2,000-

$2%9

Number

31

45

64

48

44

41

12

16

16

14

19

22

7

6

1

6

10

5

1

1

2

3

1

1

31

19

16

1?

11

12

3

4

4

1

3

1

Parcant

6.1

7.0

10.6

8.0

7.6

7.2

6.2

7.3

5.3

5.0

6.2

6.4

7.4

5.0

1.0

5.3

9.1

4.5

5.0

3.4

9.1

15.8

5.3

4.0

12.5

10.2

9.4

7.5

9.2

9.8

6.7

10.3

12.9

3.6

13.0

4.8

$3,000-

$3989

Number

50

50

54

48

52

48

16

18

28

22

18

33

9

12

11

7

9

12

1

3

4

1

2

4

25

24

14

14

8

9

2

4

7

2

2

Parcent

9.8

7.7

8.9

8.0

9.0

8.7

8.2

8.2

9.6

7.8

5.8

9.5

::

11.2

6.1

8.2

10.6

5.0

10.3

18.2

6.3

10.5

16.0

10.1

12.8

8.2

9.6

6.7

7.3

4.4

10.3

22.6

7.1

8.7

32
Tabla 5. Num&r and percent of children 6-11 years of age, by annual familv income. aualitv wouP, and am of childran: Health

Examination Survey Cycle 11, 1963-65, un&lited deta-”@n. ” -

Annual family incoma

$15,000

or more

Unknown

or refused

$7,000-

$9,988

$10,000-

$14s

$4,0C0

$4,988

$5,000-

$6s88 Quality group and age

Percant

24.5

25.2

22.9

23.2

21.2

25.6

26.3

24.2

22.4

19.4

21.8

20.8

25.5

26.4

23.5

28.1

20.0

18.8

30.0

34.5

22.7

26.3

26.3

16.0

17.3

24.6

22.8

19.8

20.0

32.5

!4.4

?8.2

12.8

12.1

?1.7

14.3

—

Par- Percent

—

ParcentNum- Num- Num Num- Num

bar

Percent

Num- Perber cent ber ber bar

59

62

60

62

70

66

28

26

42

40

44

38

8

16

10

16

15

15

3

4

3

5

4

4

21

14

22

13

12

13

5

1

3

4

3

3

bar

18.4

21.2

20.3

20.1

22.6

17.5

20.6

22.4

23.4

26.8

22.1

19.7

22.3

27.3

21.4

18.4

19.1

25.2

25.0

13.8

13.6

5.3

5.3

28.0

17.7

17.1

18.7

21.2

20.0

14.6

11.1

I 2.8

22.6

14.3

21.7

14.3

g

6 years ...........................................

7 years ...........................................

8 years ...........................................

9 year5 ...........................................

10 years .........................................

11 yaars .........................................

~

6 years ...........................................

7 years ...........................................

8 years ...........................................

9 yaars ...........................................

10 years .........................................

11 years ..........................................

IC-I E

6 years ...........................................

7 years ...........................................

8 years ...........................................

9 yaars ...........................................

10 years .........................................

11 years ..........................................

Q

6 yfreK ...........................................

7 years ...........................................

8 years ...........................................

9 years ...........................................

10 yaars .........................................

11 years ..........................................

~

6 years ...........................................

7 years ...........................................

8 yearn ..... ......................................

9 yaars ...........................................

10 years .........................................

11 years ..........................................

Dack 56 only

6 years ...........................................

7 years ...........................................

8 yaars ...........................................

9 years ...........................................

10 years .........................................

11 years ...................................... ....

11.6

9.6

9.8

10.4

12.1

11.7

14.4

11.4

139

14.3

14.3

11.0

8.5

13.2

10.2

14.0

13.6

13.5

15.0

13.8

13.6

26.3

21.1

161)

8.5

7.5

129

8.9

10.0

10.6

11.1

2.6

9.7

14.3

13.0

14.3

27

23

35

24

27

31

7

13

12

18

19

25

2

2

4

5

5

4

2

1

1

2

11

6

5

4

5

3

1

1

1

1

2

5.3

3.6

5.8

4.0

4.7

5.6

3.6

5.9

4,0

6.5

6.2

7.2

2.1

1.7

4.1

4.4

4.5

3.6

I 0.0

4.5

5.3

8.0

4.4

3.2

2.9

2.7

4.2

2.4

2.2

2.6

3.6

4.3

9.5

23

37

36

37

27

31

10

12

14

5

12

23

3

5

3

10

9

7

1

3

2

14

8

9

9

3

7

3

1

2

;

4.5

5.7

5.9

6.2

4.7

5.6

5.2

5.5

4.6

1.8

3.9

6.6

3.2

4.1

3.1

8.8

8.2

6.3

3.4

13.6

10.5

5.6

4.3

5.3

6.2

2.5

5.7

6.7

3.2

7.1

4.3

19.0

56

68

48

56

46

61

19

18

27

31

28

27

10

11

11

7

10

9

3

1

2

3

22

11

13

13

17

12

4

5

2

2

1

1

11.0

10.6

7.8

9.4

7.9

10.6

9.8

8.2

8.9

11.1

9.1

7.8

10.6

9.1

11.2

6.1

9.1

8.1

10.3

4.5

10.5

12.0

8.8

59

7.6

89

14.2

9.6

89

12.8

6.5

7.1

4.3

4.8

125

163

139

139

123

14!5

51

53

68

54

67

72

24

32

23

32

22

21

6

10

5

5

5

4

43

46

39

28

24

40

11

11

4

9

5

3

94

137

123

120

131

99

40

49

71

75

68

68

21

33

21

21

21

28

5

4

3

1

1

7

44

32

32

31

24

18

5

5

7

4

5

3

_

33
Table 6. IQ of children 6-11 years of age, by c

Health Exal

Quality group and age

~

6 years ................................................................

7 years .....................................................c..........

8 years ................................................................

9 Vears ................................................................

10 years ..............................................................

11 vears ..............................................................

~

6 yaars ................................................................

7 yaars ................................................................

8 years ................................................................

9 years ................................................................

10 yearn ..............................................................

11 years ..............................................................

IC-IE

6 years ................................................................

7 years ................................................................

8 years ................................................................

9 years ................................................................

10 years ..............................................................

11 years . .............................................................

~

6 years ................................................................

7 yean ................................................................

8 Vean ................................................................

9 years ................................................................

10 Vears ..............................................................

11 years ..............................................................

—Ill

6Vea~ ................................................................

7 years ................................................................

8 yearn ................................................................

9 years ................................................................

10 years ..............................................................

11 years ...................................................... .........

Deck 56 only

6Veam ................................................................

7 years ................................................................

8 yea fi ................................................................

9 yearn ................................................................

10 ymrs ..............................................................

11 years ............................................................. .

IIity

latio

n

510

646

606

598

580

566

184

219

303

279

308

346

94

121

98

114

110

111

20

29

22

19

19

25

248

187

171

146

120

123

45

39

31

28

23

21

—

NJpand age: sample size, mean, standard deviation, and selected percentiles,

;urvey Cycle 11, 1963-65, unedited data

Percentile

x SD

5th 10th 25th I

50th 75th 90th 95th

97.0

96.8

97.6

96.7

97.8

96.0

99.4

99.7

99.2

100.8

98.8

97.5

96.1

99.8

100.3

98.3

98.8

98.1

100.3

99.1

101.3

95.3

96.9

102.7

92.8

91.3

95.1

939

93.7

94.7

92.7

87.2

96.4

93.1

95.8

89.7

13.1

13.5

13.7

14.7

15.8

15.2

14.4

13.1

13.5

13.7

14.1

17.2

13.1

13.6

15.1

15.1

16.2

16.1

10.7

8.8

12.5

13.1

15.7

15.2

13.2

14.4

15.8

15.1

15.6

16.8

16.6

19.0

17.5

17.1

24.5

17.7

73.7

74.2

74.0

71.6

70.8

70.0

75.6

78.2

77.8

78.5

73.4

67.6

72.3

75.7

76.5

72.1

71.2

66.1

0.0

85.7

80.2

0.0

0.0

73.6

70.7

67.3

58.1

68.8

66.4

67.8

65.4

54.9

64.2

63.6

50.7

60.2

79.0

80.2

79.5

77.0

74.9

73.7

81.5

84.0

81.9

82.4

80.5

73.9

75.5

80.1

82.0

79.2

75.8

75.2

84.9

88.1

82.9

79.4

69.7

86.2

74.5

72.3

75.0

75.3

71.2

72.6

69.1

59.7

75.2

68.9

56.5

70.2

IQ

88.2

88.1

89.1

86.3

86.9

85.4

90.3

91.4

90.3

91.0

89.0

86.0

87.4

91.8

89.7

80.4

90.2

88.8

95.8

94.0

95.6

84.5

84.5

92.8

82.7

80.9

83.6

82.8

83.4

82.9

80.4

69.7

82.7

81.6

83.7

75.6

97.8

96.7

97.7

96.5

98.9

97.4

99.2

99.5

99.5

100.6

99.8

98.7

96.6

100.1

98.6

97.7

98.8

98.6

99.9

99.5

103.3

93.1

98.7

99.4

93.0

92.3

95.6

94.0

94.9

95.9

93.4

89.3

93.7

93.9

101.5

92.4

105.9

104.8

106.3

107.5

108.8

106.4

108.8

108.6

108.3

111.0

108.6

108.4

104.7

108.4

110.7

107.7

108.1

108.8

107.4

105.7

108.7

107.0

107.0

116.2

102.5

101.2

104.7

104.8

104.6

106.2

105.7

103.0

109.4

106.6

108.7

99.7

112.7

113.4

115.6

116.0

117.3

113.7

15.4

16.7

15.7

20.0

16.4

19.7

12.8

16.6

19.2

19.5

21.6

15.7

13.3

10.2

14.4

12.7

15.5

21.8

08.0

08.1

14.4

12.6

12.1

16.9

12.4

10.2

17.2

15.5

26.7

09.7

118.0

121.9

120.!3

121.7

122.8

120.6

122:3

121.5

122.2

123.4

121.2

126.2

117.1

122.4

123.3

124.3

128.’7

121.1

114.!3

113.8

119.4

115.1

120.2

123.2

114.7

114.0

123.4

116.7

119.!3

122.8

114.7

115.2

122.2

118.!3

129.5

121.3

NOTE: n = sample size, ~ = mean, SD = standard deviation.

34
Table 7. Number and percent of children 6-11 years of age, by geo

Cycle 11,

Quality group and aga

1A

-

6 years ...............................................................................................

10yams .............................................................................................

11years.............................................................................................

6 yaars ...............................................................................................

7 yaars ...............................................................................................

8 years ...............................................................................................

9 years ............... ................................................................................

10 ymn .............................................................................................

11 years .............................................................................................

IC4E

6 years ...............................................................................................

7 yaam ....................................... ........................................................

9 +eam ...............................................................................................

10 vwrs .............................................................................................

11 years ..............................................................................................

6 years ...............................................................................................

7 years ...............................................................................................

8 yea= ...................................................... .........................................

9 years ...............................................................................................

10 ymn .............................................................................................

11 yearn .............................................................................................

6 yearn ...............................................................................................

7 yaars ........................................................................... ....................

8 yaars ........................................................................... ....................

10years .............................................................................................

11 years ............................................................................................. .

Deck 56 only

6 years ...............................................................................................

7 yearn ........................................................................... ....................

8 years ...............................................................................................

9 years ........................................................................................... ....

10 years .............................................................................................

11 years .................................................................. ............................

aphic region, quality group, and age: Health Examination Survey

963-65

Geographic ragion

Northeast

N umber

146

171

176

157

135

137

46

52

71

73

79

89

18

37

14

26

22

25

6

8

9

1

7

4

62

41

48

35

21

29

12

5

8

8

2

2

Per.

cerd

28.6

26.5

28.0

26.3

23.3

24.2

23.7

23.7

23.4

26.2

25.6

25.7

19.1

30.6

14.3

22.8

20.0

22.5

30.0

27.6

40.9

5.3

36.8

16.0

25.0

21.9

28.1

24.0

17.5

23.6

26.7

12.8

25.8

28.6

8.7

9.5

Midwest

Numbar

137

169

139

149

157

150

56

66

108

93

88

99

24

36

24

30

34

26

3

11

2

6

7

9

50

51

38

32

32

28

6

7

4

5

8

3

Percent

26.8

26.2

22.9

24.9

27.1

26.5

26.8

31.1

35.6

33.3

32.1

28.6

25.5

29.8

24.5

26.3

30.9

23.4

15.0

37.9

9.1

31.6

36.8

36.0

20.2

27.3

22.2

21.9

26.7

22.8

13.3

17.9

12.9

I 7.9

34.8

14.3

South

Number

108

168

158

159

150

161

44

36

38

44

57

68

23

21

27

28

30

27

6

3

6

7

3

76

54

46

47

28

37

10

13

6

6

4

6

Percent

21.2

26.2

26.1

26.6

25.9

28.4

22.7

16.4

12.5

15.8

18.5

19.7

24.5

17.4

27.6

25.4

27.3

24.3

30.0

10.3

27.3

36.8

12.0

30.6

28.9

26.9

32.2

23.3

30.1

22.2

33.3

19.4

21.4

17.4

28.6

west

Number

119

137

133

133

138

118

52

63

86

69

73

90

2S

27

33

29

24

33

5

7

5

5

5

9

m

47

39

32

39

28

17

14

13

9

9

10

Percant

23.3

21.2

21.9

22.2

23.8

20.8

26.8

28.8

28.4

24.7

23.7

26.0

30.9

22.3

33.7

25.4

21.8

29.7

25.0

24.1

22.7

26.3

26.3

36.0

24.2

21.9

22.8

21.8

32.5

23.6

37.8

35.8

41.9

32.1

39.1

47.6

35
Table 8. Height in centimeters of children 6-11 years of age, by quality group, age, race, and sex: Sample size, mean, and standard devia.

Age, race, and sex

Total

6 years ...........................................

7 years ...........................................

8 years ...........................................

9 years ...........................................

10 yaars .........................................

11 years .........................................

White

6 years ...........................................

7 yaars ...........................................

8 years ...........................................

9 years ...........................................

10 years .........................................

11 years .........................................

Negro

6 years ...........................................

7 years ...........................................

8 years ...........................................

9 years ...........................................

10 years .........................................

11 years .........................................

Male

6 years ...........................................

7 years ................................ ...........

8 years ...........................................

9 years ...........................................

10 years .........................................

11 years .........................................

Female

6 years ...........................................

7 yaars ...........................................

8 years ...........................................

9 years ................ ...........................

10 years .........................................

11 years .........................................

tion, Health Examination Survey Cycle 11, 1963-65

n

—

510

646

598

580

566

446

554

512

513

502

496

62

89

94

78

76

68

265

322

309

315

289

295

245

324

297

283

291

271

Y~

SD

Centimeters

118.4

123.9

129.7

135.2

140.5

146.3

118.4

123.9

129.5

134.8

140.3

146.3

118.8

124.0

130.5

137.0

142.2

146.6

118.8

124.4

129.8

134.9

140.3

145.8

118.1

123.5

129.6

135.4

140.8

147.0

5.29

5.63

5.57

7.06

7.12

7.76

5.31

5.60

5.48

6.89

6.88

7.61

5.15

5.67

5.99

7.67

8.44

8.92

5.29

5.30

5.27

7.05

6.97

6.94

5.28

5.92

5.87

7.04

7.28

8.53

Qualit

—

n

194

219

303

279

308

346

171

195

263

246

269

289

21

21

37

33

37

54

100

125

147

138

156

191

94

94

156

141

152

155

18

Centimeters

119.0

124.8

130.2

136.0

141.2

146.8

119.0

124.8

130.2

136.2

141.1

146.5

119.9

126.3

130.0

134.5

141.0

148.8

119.5

125.2

130.5

136.5

140.8

146.2

118.6

124.3

129.8

135.5

141.5

147.5

4.99

5.40

6.22

6.01

6.97

7.07

5.05

5.36

6.28

6.04

6.81

7.00

4.57

5.03

6.06

5.62

8.01

7.21

4.91

5.22

6.28

5.82

5.92

6.60

6.06

5.61

6.17

6.18

7.91

7.57

Iroup

—

n

94

121

98

114

110

111

80

112

77

104

100

96

13

9

20

10

10

15

52

57

57

59

47

57

42

64

41

55

63

54

IC-IE

=l=_

Centimeters

118.5

123.8

130.0

135.6

139.4

146.3

118.3

123.6

130.0

135.5

139.9

146.8

118.4

126.3

130.3

136.7

134.5

143.5

119.1

123.5

130.3

135.3

139.4

145.1

117.6

124.1

129.5

136.0

139.5

147.6

5.09

6.22

6.34

6.38

7.00

6.89

4,91

6.31

6.21

6.49

6.31

6.87

5.28

4.39

7.04

5.31

11.18

6.51

4.79

5.47

5.32

6.37

8.14

7.20

5.37

6.84

7.58

6.43

6.09

6.36

n

20

29

22

19

19

25

19

27

18

18

17

21

1

2

4

1

2

3

12

13

9

8

10

10

8

16

13

11

9

15

+-F--

122.0

123.1

128.5

134.0

141.4

150.9

121.6

122.7

129.1

133.8

141.6

150.5

130.6

128.4

125,9

137.5

140.1

151.5

123.1

122.3

131.6

133.3

140.3

148.6

120.4

123.7

126.5

134.5

142.7

152.5

6.33

4.51

4.92

6.13

6.95

6.23

6.17

4.41

4.79

6.24

6.80

6.54

0.0

1.48

5.29

0.0

11.24

4.20

5.62

3.30

3.27

4.52

8.01

3.53

7.39

5.32

4.86

7.25

5.78

7.22

NOTE: n = sample size, ~ = mean, SD = standard deviation.

36
Table 8. Height in centimeters of children 6-11 years of age, by quality group, a!ie, race, and sex: Sample size, mean, and standard devietion, Health Examination Survey cyc~ 11, 1963-65-Con.

Quality group

Age, race, and sex 1A IB II

n n n XISD n

White male

6 yaars ...........................................

7 years ...........................................

8 yaara ...........................................

9 years ...........................................

10 years .........................................

11 yeers .........................................

White female

6 years ...........................................

7 years ...........................................

8 years ...........................................

9 years ...........................................

10 years .........................................

11 ymrs ................... ......................

Negro male

6 yaars ...........................................

7 years ...........................................

8 yeara ................................ ...........

9 yaars ...........................................

10 yaars .........................................

11 years .........................................

Nagro famale

6 years ...........................................

7 yaars ...................................... .....

8 years ...........................................

9 yaars ...........................................

10 years .........................................

11 years .........................................

Centimeters Centimeters Centimeters

118.8

124.3

129.6

135.0

140.2

145.9

117.9

123.5

129.4

134.7

140.4

146.7

118.7

125.0

130.8

134.2

140.9

144.6

118.9

123.4

130.3

139.4

143.1

148.6

5.41

5.33

5.20

7.14

6.98

6.69

5.17

5.86

5.78

6.60

6.79

8.50

4.60

5.17

5.65

6.58

6.88

8.80

5.87

5.94

6.25

7.79

9.38

8.71

119.5

125.2

130.6

136.6

140.9

146.1

188.5

124.3

129.8

135.8

141.3

147.0

119.2

126.1

130.2

135.3

140.0

147.6

121.5

126.8

129.9

133.8

142.0

149.7

5.04

5.33

6.46

5.96

5.93

6.56

5.02

5.40

6.08

6.12

7.63

7.56

4.18

4.38

4.77

4.51

6.08

7.02

5.48

6.24

6.91

6.45

9.54

7.33

118.6

123.4

130.5

135.3

140.2

145.8

117.9

123.9

128.2

135.8

139.8

147.6

120.6

125.9

130.1

135.4

132.6

142.4

115.8

126.5

130.4

138.5

136.3

747.6

4.50

5.54

5.40

6.51

6.66

7.18

5.41

7.00

7.28

6.53

6,11

6.54

4.49

3.93

5.19

5.57

15.58

6.91

5.26

4.96

8.81

5.01

5.47

1.62

122.4

121.7

131.6

133.3

141.2

146.0

120.4

123.5

126.7

134.2

142.0

152.1

130.6

128.4

132.1

150.8

127.3

125.9

137.5

146.0

153.0

5.34

2.63

3.27

4.52

7.92

3.12

7.39

5.41

4.97

7.57

5.79

7.68

0.0

0.0

0.0

5.66

0.0

5.28

0.0

0.0

0.0

227

286

85

111

131

123

137

167

86

84

132

123

132

122

15

13

15

15

18

23

6

8

22

18

19

31

44

54

46

53

42

45

36

58

31

51

56

51

7

3

10

6

5

12

6

6

10

4

:

11

12

9

8

9

8

8

15

9

10

8

13

1

1

1

2

1

4

1

1

1

270

275

256

259

219

268

242

238

246

237

37

35

39

36

32

34

25

54

55

42

44

34

NOTE: rr = sample size, ~ = mean, SD = standard deviation.

37
Table 9. Sitting height in centimeters of children 6-11 years of age, by quality group, age, racer and sex: Sample size, mean, and standard

deviation, Health Examination Survey Cycle 11, 1963.65

Age, race, and sex

Total

6 years ................ .........................................

7 years .........................................................

8 years .........................................................

9 years .........................................................

10 years .......................................................

11 years ............. ..........................................

White

6 years .........................................................

7 years .........................................................

8 yaars .........................................................

9 years .........................................................

10 years .......................................................

11 years .......................................................

Negro

6 years ........................................... ..............

7 years .........................................................

8 yaars .........................................................

9 years .........................................................

10 years .......................................................

11 years .......................................................

Male

6 years .........................................................

7 years .........................................................

8 years ........................................................

9 years .........................................................

10 yaars .......................................................

11 yaars .......................................................

Female

6 years .........................................................

7 years .........................................................

8 years .........................................................

9 yaars .........................................................

10 years .......................................................

11 years ............... ........................................

n

510

646

606

598

580

566

446

654

612

513

502

496

62

89

94

78

76

68

265

322

308

315

288

295

245

324

297

283

291

271

1A

2-IS

Centimeters

64.4

66.5

68.7

71.0

73.1

75.8

64.6

66.7

69.0

71.2

73.3

76.0

62.7

649

67.1

69.4

72.0

73.9

64.8

66.8

69.1

71.1

73.1

75.5

63.9

66.1

68.4

70.8

73.2

76.1

2.89

2.92

2.97

3.37

3.33

3.76

2.82

2.86

2.85

3.23

3.19

3.70

2.87

2.79

3.12

3.71

4.00

3.75

2.76

2.65

2.80

3.43

3.28

3.26

297

3.12

3.10

3.30

3.39

4.23

Quality group

n

194

219

303

279

308

346

171

195

263

246

269

289

21

21

37

33

37

54

100

125

147

138

156

191

94

94

156

141

152

155

*

—

SD

Centimeters

64.7

67.0

69.2

71.4

73.4

75.8

64.9

67.2

69.6

71.7

73.7

75.8

63.5

65.8

67.1

69.2

71.4

74.8

65.1

67.6

69.7

71.7

73.3

75.5

64.3

66.3

68.8

71.2

73.5

76.1

2.82

2.85

3.14

2.94

3.22

3.48

2.85

2.82

2.88

2.83

3.07

3.43

2.32

2.95

3.53

2.80

3.38

3.73

2.62

2.83

3.07

2.87

2.86

3.08

2.86

2.84

3.16

2.99

3.56

3.8(3

—

n

94

121

98

114

110

111

80

112

77

104

100

96

13

9

20

10

10

15

52

57

57

59

47

57

42

64

41

55

63

54

IC4E

=

Centimeters

64.5

66.8

88.8

71.1

72.8

75.5

64.7

66.9

69.3

71.2

73.1

76.0

62.8

66.3

67.2

70.3

70.0

72.7

65.1

67.0

68.0

71.2

73.1

74.6

63.8

88.7

88.6

71.0

72.6

76.5

2.64

3.18

3.01

3.08

3.57

3.61

2.38

3.21

2.87

3.04

3.39

3.34

2.57

2.88

3.04

3.37

4.22

4.07

2.30

2.80

3.15

3.11

3.40

3.72

2.67

3.84

2.82

3.04

3.70

3.24

—

n

—

20

29

22

19

19

25

19

27

18

18

17

21

1

2

4

1

2

3

12

13

9

8

10

10

8

16

13

11

9

15

-5=-

Centimeters

66.7

66.2

68.3

70.2

73.8

77.8

66.7

66.4

69.0

70.3

74.2

78.0

65.7

64.0

65.5

68.3

71.2

75.2

66.6

65.7

70.0

70.5

73.2

76.2

66.8

66.6

67.2

69.9

74.6

78.8

2.79

2.37

3.06

3.25

3.49

3.91

2.86

2.37

2.81

3.32

3.44

3.86

0.0

0.07

2.71

0.0

3.61

3.65

2.02

1.66

1.88

2.96

4.15

2.39

3.83

2.81

3.25

3.57

2.80

4.zX2

NOTE: n=samplesize, ~ =mean, SD= standard deviation.

38
Table 9. Sitting height in centimeters of children 6-11 years of ege, by quality group, age, race, and sax: sample size, mean, and standard

deviation, Health Examination Survey Cyclell, i963-65-Con.

Age, race, and sex

White male

6 years .........................................................

7 years .........................................................

8 years .........................................................

9 years .........................................................

10 years .......................................................

11 years .......................................................

White famale

6 years .........................................................

7 years ..................... ....................................

8 years .........................................................

9 years .........................................................

10 years .......................................................

11 years .................................... ...................

Negro male

6 years .........................................................

7 years ........... ................................ ..............

8 years .........................................................

9 years .........................................................

10 years .......................................................

11 years .......................................................

Negro female

6 years .........................................................

7 years .........................................................

8 years ..................................................... ....

9 years .........................................................

10 years .......................................................

11 years .......................................................

n

227

286

270

275

256

259

219

268

242

238

246

237

37

35

39

36

32

34

25

54

55

42

44

34

*

SD

Centimeters

65.1

67.1

69.3

71.5

73.3

75.8

64.1

66.4

68.7

71.0

73.3

76.3

63.2

65.6

67.5

68.4

71.2

73.0

62.1

64.5

66B

70.3

72.6

74.8

2.71

2.64

2.70

3.27

3.16

3.22

2.86

3.04

2.98

3.17

3.24

4.15

2.58

2.45

3.02

3.56

3.66

2.53

3.19

293

3.18

3.66

4.18

4.53

Quality group

—

n

—

85

111

131

123

137

167

86

84

132

123

132

122

15

13

15

15

18

23

:

22

18

19

31

—

IB

Centimeters

65.4

67.8

69.8

72.0

73.7

75.6

64.4

66.4

69.1

71.5

73.7

76.4

63.6

66.3

67.8

69.4

70.7

74.6

63.2

55.1

56.5

59.1

72.0

75.2

2.61

2.86

3.09

2.75

2.63

3.05

3.00

2.84

2.84

2.90

3.48

3.86

2.20

2.27

2.37

2.87

3.34

3.30

2.78

3.88

4.11

2.83

3.39

4.06

—

n

44

54

46

53

42

45

36

58

31

51

58

51

7

3

10

6

5

12

6

6

10

4

5

3

—

IC-IE

E

Centimeters

65.1

67.0

68.6

71.3

73.4

75.4

64.1

66.7

68.8

71.1

72.9

76.4

63.8

66.5

66.8

70.2

70.6

71.6

61.8

66.2

67.6

70.5

58.3

77.1

2.17

2.65

3.20

3.15

3.18

3.31

2.53

3.6a

2.30

2.95

3.55

3.32

2.04

1.72

1 .m

2.81

4.55

3.75

2.87

3.47

4.04

4.57

4.26

1.20

—

n

—

11

12

9

8

9

8

8

15

9

10

8

13

1

1

1

2

1

4

1

1

1

—

2LESD

Centimeters

66.7

65.8

70.0

70.5

73.7

76.5

66.8

66.8

68.0

70.1

74.7

78.9

65.7

63.9

68.6

75.2

64.;

65.5

68.3

73.7

75.2

2.10

1.64

1.88

2.96

4.06

1.76

3.83

2.82

3.30

3.72

2.76

4.54

0.0

0.0

0.0

5.16

0.0

2.71

0.0

0.0

0.0

NOTE: n = sample size, ~ = mean, SD = standard deviation.

39
Table 10. F EV ~ of children &1 1 years of age, by age, sax, and race: Sample size, weighted sample size, standard deviation, standard error of the mean,

mean, an~ salected percentiles, Health Examination Survey Cycle 11,1963-65

Percentile

SD S E~ Y

I

—

5th 10th 25th 50th 75th 90th 95tfl

Age, sex and race N

23,784

-

4,098

4,084

3,986

3,957

3,867

3,792

12,081

n

Total

6-11 years..,.., .....

6 years .. .... .. ... ... .. .... .... ... .

7 years ..... .... .. ....... ... ...... .

6 years .... ........ ... ....... ......

9 years ... ... . ...... ... ... .. .... ...

10 veals ... ..... ... .... ...........

11 years ..... ... ... ...... ........ ..

—Male

6-11 years ...... .. ....

6 years ..... ...... ... .. ....... .... .

7 years ..... ...... .................

8 years ...... ... ... ... ...... ...... .

9 years ... ... ... ...... ............ .

10 years ......... .. .. .. .......... .

11 years .. ... ... ........... ........

Female

6.11 years ...........

6 yea . .. .. ..... ...... ........... .

7 years .... ....... .. ... ... ... ......

6years ..... ......................

9 years ........... ...... ...... .... .

10 years .... ..... ............... ..

11 years . ................. ... .... .

White

6-11 years ..... ... .. . .

6 years ..... . ..... ...... . ..........

7 years ... ... ... ... ... .............

8 years . ..... ... ... .......... ..... .

9 years ....... .... .. .. ............ .

10 years ..... .... .. .. .......... .. .

11 years .. ... .. . .............. ... .

Negro

6-11 years .. ... ......

6 years .... ... ...... ... ...... ... .. .

7 vears .. .. ...... ... ...............

8 years ................. ...... ... ..

9 yaws. .. .... ..... ... ... ... ... ... .

10 years ... ... ... ... .. .... ........

11 years ................ ... ...... ..

7,119

1,111

1,241

1,231

1,184

1,150

1,192

3,632

575

632

618

W3

576

628

3,487

428.6 9.06

-

13.19

11.44

11.01

12.24

13.58

14.26

11.43

16.54

16.24

15.82

19.71

15.35

22.84

6.14

1,594.7 947.3

—

730.3

923.3

1,043.5

1,140.2

1,253.1

1,433.2

884.2

819.0

966.3

1,160.1

1,202.3

1,276.0

1,458.3

911.6

677.6

883.5

974.9

1,111.2

1,230.5

1,383.6

965.2

1,071.7

—

858.1

1,008.2

1,147.5

1,268.6

1,404.3

1,570.8

1,130.1

905.2

1,077.9

1,244.3

1,335.7

1,447.5

1,619.0

1,023.1

7929

966.3

1,073.5

13)8.6

1372.5

1,550.1

1,083.4

1,283.4

—

1,007.3

1,166.6

1,326.1

1,463.7

1,615.0

1,805.1

1,344.2

1,054.9

1,235.1

1,398.1

1,523.7

1,663.1

1,855.3

1,227.8

966.4

1,150.6

1,259.3

1,368.8

1,567.6

1,765.7

1,305.1

1,584.0 1,872.4 2,172.0 2,345.0

256.0

263,7

284.1

328.1

345.5

369.0

425.1

254.9

267.6

268.5

331.7

344.6

384.6

427.2

246.0

247.6

282.5

311.1

339.7

388.5

428.4

1,172.2

1,353.1

1,520.7

1,682.1

1,831.4

2,059.0

1,848.8

1,223.9

1,407.0

1,589.3

1,745.7

1,878.5

2,098.0

1,538.2

1,172.3

1,351.2

1,528.1

1,882.6

1,821.3

2,054.1

1,622.5

1,227.4

1,411.1

1,589.3

1,751.7

1,658,3

2,096.3

1,508.3

1,128.4

1,295.1

1,470.0

1,624.5

1,772.8

1,997.1

1,585.9

1,339.7

1,521.5

1,711.6

1,905.4

2,058.6

2,308.3

1,929.5

1,386.3

1,581.2

1,775,7

1,967.8

2,114.9

2,330.3

1,808.0

1,284.4

1,458.9

1,628.3

1,814.8

1,986.4

2,274.8

1,886.0

1,361.2

1,535.0

1,724.5

1,919.1

2,068.1

2,329B

1,728.2

1,240.7

1,413.0

1,593.1

1,760.3

1,841.8

2,098.4

1 ,EJ34.7

1,679.0

1 @84.3

2,086.6

2,270.7

2,541.0

2,213.6

1558.6

1,728.5

1.929,1

2,165.7

2,309.0

2,578.3

2,1 ?4.0

1,417.1

1,598.8

1,790.1

2,018.3

2,224.6

2,486.6

2,192.7

1,520.2

1,867.2

1,867.0

2,117.5

2,286,4

2,564.1

1,880.5

1,598.9

1,786.8

1 /880.3

2,215..0

2,385.1

2,701.8

2J73.1

1,639.2

1,817.8

2,010.2

2,261.2

2,409.7

2,728,4

2,295.3

——

1,535,2

1,~8.O

1317.1

2,138.6

2,380.4

2,646.8

2,363.4

——

1,809.5

1,792.8

1,882.2

2/226.1

2,381.6

2,725.8

2,139,8

2,062

2,074

2,026

2,012

1,983

1,924

11,703

536

608

613

581

564

584

6,100

2,016

2,010

1,960

1,945

1,808

1,888

20,403

13.01

11.22

14.34

14.06

16.97

16.04

9,19

1,118.8

1,297.5

1,449.8

1,616.4

1,783.0

2,016.9

1,616.3

950

1,063

1,035

1,019

1,014

1,019

967

155

172

192

156

142

167

3,508

3,497

3,413

3,393

3,324

3,267

3,272

570

570

580

534

530

507

251.4

280.0

280.1

324.6

339.4

384.7

404.2

265.0

259.2

262.1

315.8

330.3

371.9

13.82

11.53

12.38

13.21

12.39

13.34

13.36

17.97

27.19

21.84

20.78

30.33

35.73

1,166.8

1,371.7

1,5399

1,702.9

1,868.2

2,065.2

1,469.7

1,076.4

1,241.8

1,403.9

1,555.2

1,665.1

1,882.5

765.7

946.2

1,070.1

1,161.0

1,283.6

1,452.5

854.2

880.1

852.7

951.2

1,057.2

1,123.6

1,267.6

878.0

1,041.1

1,176.6

1.288.7

1,425.2

1,807.9

967.8

722.2

924.4

1,030.8

1,171.6

1,262.6

1,466.9

1,023.0

1,208.3

1,355.7

1,488.6

1,647.5

1,834.1

1,170.5

914.9

1,076.4

1,207.3

1,330.6

1,483.8

1,634.2

1,183.8

1,358.8

1,542.0

1,703.2

1,848.3

2,080.3

1,435.5

1,085.1

1,211.1

1,388,4

1,541.2

1,681.2

1,893.5

1,400.5

1,612.8

1,788.3

1,887.5

2,050.3

2,324.3

1,491%

1,898.4

1,887.4

2,063.5

2,230.3

2,480.5

NOTE: II =sanlplesize, .Y = estimated numher, )f I ldren in thou~~nds, Sl) =standard dwiation, SK~ =standardt urofthemean, X =mean.

40
Table 10. FEV, of children 6-11 years of ag by age, sex, and race: Sample size, wight~sample size, standard dwiation, standard error of the mean,

lectedpercentiles,H ealthExaminationS urveyCyclell, 1883.65-Con.

Percentile

SD SEX F

5th

I

10th 25th

I

50th 75th

I

80th 95th

an, and

-

Age, sex and race n N

White male

6-11 years............ 1,155.5

912.1

1,112.8

1,25-$.4

1,370.7

1,476.0

1,674.7

1,047.6

1,365.2

1,067.2

1,257.4

1,423.5

1,557.8

1,710.7

1,892.8

1,250.9

1,847.5

1,250.3

1,428.0

1,610.0

1,788.6

1,821.3

2,134.3

1,525.4

1,956.6

1,398.0

1,E&12.2

1,789.8

1,884.3

2,134.0

2,348.3

1,823.9

3,153 10,391 427.0 11.74 1.672.7 2,240.0

1,560.2

1,738.8

1.938.4

2,163.6

2,327.6

2,587.0

2,133.2

2@l .5

1,848.3

1,824.5

2,017.8

2,284.8

2,427.5

2,744.8

2,314.1

1,012.9

829.6

989.0

1,166.2

1,262.2

1,326.3

1,471.1

932.2

6 years ....... .. .... .. . .......... ..

7 yeas ............................

8 yeare ............................

9 years ............................

10 yaws. .........................

11 years...........................

488

551

537

525

508

542

?,947

1,787

1,781

1,739

1,730

1,692

1,662

10,012

257.6

2s3 .5

268.9

327.9

336.1

376.2

424.2

18.69

16.55

16.93

21.55

1394

22.11

7.82

1,238.3

1,425.6

1,6CM.O

1,773.2

1,811.9

2,128.4

1,558.2

White female

6-11 year. ...........

6 years ............................

7 years............................

8 years, ...........................

9 years............................

10 years..........................

11 years..........................

Negro male

6-11 years............

1,420.0

1,615.3

1,797.6

2,015.0

2,234.7

2,498.6

1,978.5

461

512

498

484

505

477

484

1,722

1,716

1,674

1,863

1,632

1,805

1,842

233.1

244.0

276.0

304.3

333.7

388.0

379.7

13.02

10.88

16.59

14.42

17.39

16.85

17.70

i ,133.4

1,315,9

1,473.3

1,628.7

1,802.7

2,039.6

1,497.0

695.7

910.1

1,002.1

1,123.5

1,254.2

1,433.2

922.8

846.0

985.5

1,104.7

1,231.2

1,396.5

1,570.0

1,030.1

987.5

1,167.4

1,293.1

1,417.0

1,606.1

1,790.8

1,217.2

1,137.4

1,316.3

1,484.6

1,835.7

1,789.6

2,021.8

1,480.7

1,281.8

1,471.9

1,845.3

1,824.1

2,009.0

2,293.2

1,745.8

1,5m.8

1,715.8

1,824.6

2,138.4

2,362.2

2.677.6

2,115.4

84

78

79

74

86

83

523

283

286

279

268

284

255

1,629

22.06

36.37

35.75

25.08

45.42

55.21

14.26

6 Veal ............................

7 years ............................

8 years............................

9 years ............................

10 yews. .........................

11 years..........................

Negro female

6-11 years........

217.2

286.5

249.6

285.7

325.7

371.4

424.2

1,131.2

1,291.0

1,486.4

1,586.9

1,675.1

1,884.4

1,422.2

736.5

806.2

1,084.6

1,046.1

1,118.1

1,284.8

776.2

866.8

951.7

1211.5

1,171.2

1,238.7

1,491.2

921.3

881.9

1,115.4

1,323.3

1,364.2

1,509.1

1,842.0

1,128.2

1,138.7

1,288.1

1,491.1

1,581.8

1,m5.7

1,801.9

1,373.5

1,27; .7

1,4489

1,681.4

1,783.9

1,80S.6

2,079.1

1,7089

1,407.1

1,646.1

1,852.5

1,975.8

2,040.0

2.304.6

1,861.9

1,344.1

1,501.5

1,718.9

2/027.1

2,053.8

2,378.0

1,472.S

1,7769

1,921.3

2,088.5

2,226.0

2,475.1

2,165.0

1,573.1

1,613.6

1,862.1

2,153.5

2Z35.4

2,463.7

6 years............................

7 years............................

8 y=l’e. ...........................

9 yeafs ............................

10 years ..........................

11 years..........................

72

93

113

84

77

84

—

281

284

281

265

234

253

296.1

241,6

282.5

334.3

334.6

372.3

36.80

26.98

19.88

38.36

36.62

39.00

1,019.9

1,192.1

1,312.0

1,541.3

1,655.1

1,860.5

550.4

827.1

920.2

1,062.6

1J?OO.5

1,245.2

673.1

903.6

975.6

1,172.1

1,271.1

1,372.8

804.9

1,038.9

1,085.7

1295.8

1,446.6

1,6279

1,008.3

1,180.0

1,268.3

1,515,6

1,624,3

1,886a

1,206.7

1,335.8

1,501.1

1,730.0

1,874.8

2,117.1

NOTE: n = aempIe size, N = estimated number of children in thousands, SD = standard deviation, SEg = standard error of the mean, 2 = mean.

41
Table 11. FEF25.75Y0 of children 6-11 years of aae. bv aae. sex. and rata: Samde size. weiahted samDla size. standard deviation. standard error of the

an~ kkka~ percentiles, Health Examination ;urvey Cycle 11, 1963-65

=

mean. mea

Percentile

SD SEX x

5th 10th

I

25th 50th 75th 90th I

95th

Age, sex and race N

23,764

n

7,119

Total

6-11 years.,., ....

Milliliters

671.4 16.45

_

22.51

24.11

21.53

26.84

22.94

30.47

21.65

2,173.6 1,1522 1,348,3 1,704.5 2,138.1

—

1,752.1

1,959.2

2,109.0

2,233.4

2,372.6

2,623.3

2,158.1

1,798.0

1,986.1

2,154.9

2,244.5

2,360.5

2,592.1

2,115.2

2,589.9 3,036.5 3,317:0

1,111

1,241

1,231

1,164

1,160

1,192

3,632

575

632

618

603

576

628

3.487

4,098

4,0s4

3,886

3,857

3,867

3,792

12,081

529.8

539.4

573.6

635.9

652.8

719.8

657.2

1,762.0

1,968.6

2,080.3

2,259.3

2,387.1

2,621.7

2.190.6

926.3

1,085.2

1,168.1

1,245a

1,356.4

1,420.1

1,179.5

931.8

1,067.7

1,244.3

1,332.9

1,388.0

1,382.6

1,127.9

1,119.9

1,298.S

1,346.0

1,463.8

1,574.5

1,697,1

1,364,1

1,144.4

1,304.6

1,418.8

1,519.6

1,588.8

1,648.0

1,310.1

1,407.9

1,582.0

1,677.0

1,830.7

1,837.1

2,140.2

1,743.1

1,444.5

1,623.5

1,774.7

1,853,4

1$32.4

2,105.7

1,662.9

2,100.5

2,310.3

2,459.5

2,652.3

2,821.9

3,067.4

2,605.6

2,143.3

2,368.3

2,503.2

2,644.4

2,812.7

3,045.6

2,576.0

2,419.7

2,672.6

2,801.7

3,084.4

3,202.3

3,519.4

3,025.8

2,429.1

2,752.5

2,837.1

3,060.4

3,174,5

3,479.5

3,046.7

2,589.0

2,6S6.2

2,970.2

3,314.6

3,46s.0

3,768.4

3,300.7

2,633.4

2,942.5

3,012.3

3,306.8

3,457.2

3,731.0

3,335.5

—Male

6-11 years, ..... ..

6years ............................

7 years ..... ...... ... ... ... ...... ..

8 year.%...... ...... ...... .........

9 years ...... . ................. ....

10 years .. ...... ...... ... ... .... ..

11 years ... .......... .. .... ...... ..

2,082

2,074

2,026

2,012

1,983

1,824

11,703

542.4

559.4

568.5

591.7

657,5

708.1

685.3

26.23

29.98

28.29

37.86

29.35

50.34

19,85

1,793.9

2,006.1

2,152.7

2,265.6

2,385.6

2,584.1

2,156.2

Female

6-11 years ... .....

1,100,8

1,292.6

1,269.8

1,402.3

1,563,0

1,753.3

1,344.2

1,364.2

1,547.3

1,593.4

1,793,1

1,942.7

2,188.9

1,701.6

1,706.6

1,932.9

2,046.6

2,222.8

2,368.1

2,661.3

2,134.9

2,059.5

2,267.0

2,416.9

2,665.4

2,834.4

3,081.5

2,586.6

2,415.4

2,567.8

2,756.0

3,122.9

3,239.1

3,569.1

3,032.1

2,582.4

2,782.4

2,940.9

3,328.8

3,475.7

3,794.2

3,325.7

6 years ........... .................

7 years ..... .... .. .... ... ... ...... .

8years . ...... .. ....... ............

9 years ................. ...... .....

10 years ... ...... ...... ...........

11 years ............. ... .. .... .... .

White

6-11 years .......

636

608

613

581

5s4

564

6,100

2,016

2,010

1,960

1,945

1904

1,86S

20,403

514.5

515.2

571.5

678.7

648.1

728.7

670.5

27.46

26.58

33.37

31.47

29.44

42.82

16.89

1,728.2

1,929.9

2,026.0

2,252.8

2,3S8.7

2,6Kt.4

2,170.8

922.4

1,108.4

1,097.7

1,202.0

1,344.7

1,468.0

1,149.8

1,403.1

1,576.7

1,684.9

1,810.9

1,842.2

2,149.6

1,741.6

1,436.9

1,645.9

1,617.4

1,934.4

1911.5

2,061,4

1,7439

1,951.1

2,103.3

2,227.4

2,367.0

2,633.1

2,159.2

2,080.5

2,309.7

2,461.9

2,651.6

2,812.7

3,073.6

2,615.0

2,420.2

2,653.7

2.793.9

3,112.8

3,193.7

3,532.5

3,061.8

2,586.6

2,8%.3

2,967.8

3,322.8

3,474.3

3,780.7

3,274.8

6 years ...... ... ...... ...... ... ... .

7 years ....... ... ...... ............

8 years .... ............ ......... ...

9 yaars .. .... .. ...... ... ...... ... ..

10 years ... ...... ..... ............

11 years ............ ...... ...... ...

950

1,063

1,035

1,019

1,014

1,019

987

156

172

192

158

142

167

3,508

3,497

3,413

3,393

3,324

3,267

3,272

570

570

560

534

530

507

530.2

535.3

559.1

637.3

647.0

719.3

676.6

528.5

564.7

653.1

622.2

6s0.6

724.5

26.23

22.71

23.25

26.33

19.75

29.58

50.75

46.88

60.66

56.74

58,35

81.17

7323

1,753.0

1,962.0

2,085.3

2,262.3

2,384.8

2,632.3

2,194.7

1,S16.2

2,017.8

2,121.8

2,315.6

2,40S.1

2,552.4

908,3

1,079,5

1,168.2

1.227.8

1,373.1

1,431.8

1,166.5

1,027.4

1,112.3

1,187.1

1,428,4

1,214.0

1.356,9

1,112.3

1,293.3

1,346.5

1,453.8

1,577.4

1,714.2

1,370.6

1,183.4

1,322.2

1,349.3

1,576,9

1,586,0

1.579.6

Negro

6-11 years., ......

6 years . ... ........ ......... . ......

7 years .... ... ... ...... ... ... .... ..

8 years .. .... .. ... ..... . ...... .....

9 years ..... ...... .... .. ......... ..

10 yaars ..... ...... ..... ... ... ... .

11 years ... ... .....................

1,798.2

2,00S.8

2,144.7

2,274.9

2,428.6

2,555.8

2,163.2

2,332.8

2,451.1

2,652.3

2.686.3

3,038.2

2,454.4

2,771.0

2/638.0

3,054,5

3,2229

3,447.2

2,772.2

3,071.6

2,991,5

3,248.8

3,375.7

3,664.2

NOTE: n ❑ wmplc $i?e. IV = estimated number of children in thousands, S1) - standurd deviation, SEX = standard error of the mean, ~ = mean.

42
Table 11. FE F25.75% of children 6-11 years Of age, by age, sex, and race: Sample size, weighted sample size, standard deviation, standard error of the

mean, mean, and s-elected percentiles, Health Examination Survey Cycla II, 1963-65-Can.

Percentile

SD SEX F

5th 10th 25th 50th 75th 90th 95th

Age, sex and race n N

White male

6-11 years ... .. ..

6 years .. ... ...... ...... ...... .....

7 years .. ........ ...... ... ... .... ..

8 years ............... ....... ......

9 years .... .. .......... .. ... ... .. ..

10 years .. .... ...... ...... ...... ..

11 years .... ... ..... ...... ...... ..

White female

6-11 years .. ... .. .

6years, . .... ........... .... ..... ..

7 yams...........’ ..... ......... ..

6years . ...... ......... ...... ... ...

9 yaws. ......... .. .... ...... ......

10 year....,..........., ... ......

11 years......, .............. ... ...

Negro male

6-11 years .... ....

6 years ..... .. .......... ...........

7 years ..... ............ ... ... ... ..

8 years . ... ... ... ...... ......... .. .

9 yearn ..... ... ....... ....... .....

10 years . .... .. ... ..... .... ...... .

11 years ....... ....................

Negro female

6-11 years .. .....

6 years ... .. .. .... ..... ..... ..... ..

7 years ..... ...... ... .. ..... ..... ..

6yeara .. ... .. ....... ... .... .. .... .

9 yaara ...... .......... ... ... ......

10 years .... ...... ..... .... ... ... .

11 years . ... ... ................. ...

Milliliters

3,153 10,391 658.3 20.27 2,169.8 1,180.7 1,388.4 1,740.9 2,154.2 2,802.8 3,023.9 3,315.6

489

551

537

525

509

542

2.947

461

512

498

484

505

477

484

1,787

1,781

1,739

1,730

1,692

1,662

10,012

1,722

1,716

1,674

1,683

1,632

1,805

1,842

538.6

551.5

558.2

807.7

652.8

704.9

882.5

519.8

514.3

553.7

686.7

640.7

731.7

651.2

29.60

26.29

30.28

39.87

25.03

48.71

1,760,1

2,004.7

2,143.4

2,261.2

2,398.3

2,592.4

2.151.5

920.6

1,063.7

1,228.2

1,315.3

1,411.9

1,408.0

1,125.0

1,140.3

1,288.5

1,420.8

1,504.2

1,603.6

1,886.9

1,295.9

1,438.2

1,628.0

1,766.7

1,832.5

1,948.7

2,110.8

1,656.7

1,784.7

1,965.5

2,152.8

2,225.6

2,369.0

2,594.8

2,112.0

2,113.7

2,366.2

2,506.8

2,653.9

2,816.5

3,047.2

2,571.5

2,411.2

2,745.5

2,824.9

3,081.9

3,180.9

3,487.0

3,039.7

2,594.6

2,925.6

2,888.7

3,331.9

3,480.2

3,74s.5

18.83 3,337.2

31.06

27.05

33.69

27.88

28.50

46.89

1,724.9

1,917,7

2,025.0

2,243.2

2,370.9

2,673.7

2,197.5

900.1

1,102.5

1,116.0

1,183.8

1,335.9

1,461.9

1,177.7

1,084.8

1,288.0

1,273.0

1,388.1

1,554.3

1 ,77i .2

1,363.4

1,346.0

1,535.2

1,607.5

1,775.5

1,935.3

2.181.7

7,761.3

1,703.6

1,919.5

2.038.2

2,226.9

2,364.1

2,8ss.0

2,182.4

2,087.6

2,263.5

2,417.0

2,648.3

2,807.2

3,102.5

2,6192

2,424.5

2,555.0

2,756.9

3,123,7

3,215.7

3,5S8.6

3,037.2

2,576.2

2,716.7

2,942.2

3,307.2

3,470,4

3,953.4

58.29 3,250.4

84

n

79

74

65

83

523

288

288

279

268

284

255

1,629

561.2

808.3

630.0

465.0

8609

725.7

701.3

70.31

B2.81

93.11

66.88

95.S6

28.45

1,872.8

2,017.7

2,200.8

2,315.6

2,312.4

2>20.8

2,191.8

988.6

1,L?85.6

1,306.8

1,532.3

1,152.5

I ,202.0

1,147.8

1,184.1

1,323.3

1,393.2

1,835.7

1,403.6

1,436.7

1,379.1

1,208.2

1,319.3

1,2EJJ.3

1.467.3

1,889.7

1,640.6

1,488.6

1,592.9

1,s47.3

2,024.8

1,643.6

2,058.2

1,721.5

1,415.1

1,738.0

1,543.0

1,888.7

2,040.1

2,062.6

1,861.3

1,988.6

2,152.2

2,363.5

2,248.4

2,552.0

2,138.1

1,747.6

2,038.1

2,137.4

2,171.3

2,542.0

2,5609

2/258.1

2,404.2

2,4S1 .6

2,830.0

2,7629

3,032.5

2,808.1

2,007,0

2,282.3

2,421.6

2,718.5

2*.O

3,046.7

2,572.8

2,792.4

2$77.4

2$27.1

3,146.5

3,387.4

3,069.1

2,358.5

2,721.8

2,?56.6

3,144.4

3,264.7

1,483.6

2,928.7

3,18&4

3,126.5

3,082.5

3,295.6

3,839.5

3,325.6

2,887.4

3,004.4

2.935.4

3,633.7

3,467.3

3.885.9

49.35

72

93

113

84

77

84

281

284

281

285

288

253

487.6

515.9

888.0

748.7

888.1

721.8

$6.63

70.53

35.08

74.86

}0.84

36.74

1.757.6

2,017.8

2,043.4

2,315.5

2,497.2

2,5S4.2

1,042.3

1,126.8

1,005.2

1,362.5

I ,477.7

I ,482.0

NOTE: n = sample size, IV = estimated number of children in thousands, SD = standard deviation, SE~ = standard error of the mean, ~ = mean,

*U.S. GOVERNMENT PRINTING OFFICE 1977-260.937:39

43
I

“1

—

series 1.

series 2.

Series 3.

series 4.

VITAL AND HEALTH STATISTICS PUBLICATIONS SERIES

Formerly l%blu Health Senn”ce tiblication No. 1000

programs and Collection Rocedures. –Reports which des~be the general programs of the National

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and

other material necessary for understanding the data.

Data Evaluation and Methods Research. –Studies of new statistical methodology including experimental

tests of new survey methods, studies of vital statistics collection methods, new analytical techniques,

objective evaluations of reliability of collected data, contributions to statistical theory.

Analytical Studies. –Reports presenting analytical or interpretive studies based on vital and health

statistics, carrying the analysis further than the expository types of reports in the other series.

Documents and Committee Reoorts. –Final reports of major committees concerned with vital and

health statistics, and documen~ such as recommended model vital registration laws and revised birth

and death certifkatez.

Series 10. Data from ~the Health Interview Survey. -Statistics on illness; accidental injuries; disability; use of

hospital, medical, dental, and other services; and other health-related topics, based on &ta collected in

a continuing national household ihterview survey.

Series 11. Data J%om the Health Examzkation Survey .-Data from direct examination, testing, and measurement

of national samples of the civilian, noninstitutionzlized popdation provide the basis for two types of

reports: (1) estimates of the medically defined prevalence of ipecific diseases in the United States and

the distributions of the popul~on with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements wi{hout reference to an

explicit finite univeme of persons.

Sera”es12. Data j%om the Institutionalized Population Surveys. –Discontinued effective 1975. Future reports from

these surveys will be in Series 13.

Sert”es13. Data im Health Resources Utilization . –Statistics on the utilization of health manpower and facilities

provid~ long-term care, ambulatoq care, hospital care, and family planning services.

Ser12s 14. Data on Health Resources: Manpower and Facilities. –Statiztim on the numbers, geographic distribution, and characteristics of health resources including physkians, dentisti, nurses, other health occupations, hospitals, nursing homes, and outpatient facilities.

Sen”es20. Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthly

reports. Special analyses by cause of death, age, and other demographic variables; geographic and time

series analyses; and statistics on characteristics of deaths not available from the vital records, based on

sample surveys of those records.

Series 21. Data on Ak?aIity, Mare-age, and Divorce. –Various statistia on natality, marriage, and divorce other

than as included in regular annual or monthly reports. Special analyses by demographic variables;

geographic and time series analyses; studies of fertility; and statistics on characteristics of births not

available from the vital records, baaed on sample surveys of those records.

Series 22. Data j%om the National Mortality and Natdity Surveys. –Discontinued effective 1975. Future reports

from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Series 23. Dab from the National Survey of Family Growth. –Statistia on fertility, family formation and diszoIution, family planning, and related maternal and infant health topics derived from a biennial survey of

a nationwide probability sample of ever-married women 1544 years of age.

, For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch

. National Center for Health Statistics

Public Health WIce

Hyattsville, Md. 20782