Journal Information
Vol. 93. Issue 1.
Pages 94-99 (January - February 2017)
Share
Share
Download PDF
More article options
Visits
...
Vol. 93. Issue 1.
Pages 94-99 (January - February 2017)
Original article
DOI: 10.1016/j.jped.2016.04.005
Open Access
Body mass index reference charts for individuals with Down syndrome aged 2–18 years
Gráfico de referência do Índice de Massa Corporal para os indivíduos com síndrome de Down entre 2 e 18 anos de idade
Visits
...
Fabio Bertapellia,
Corresponding author
fbertapelli@gmail.com

Corresponding author.
, Maira R. Machadoa, Raísa do Val Rosoa, Gil Guerra-Júniorb
a Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Campinas, SP, Brazil
b Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Tables (2)
Table 1. Body mass index (BMI) values of male children and adolescents with Down syndrome aged 2–18 years.
Table 2. Body mass index (BMI) values of female children and adolescents with Down syndrome aged 2–18 years.
Show moreShow less
Abstract
Objective

To develop Brazilian growth charts for body mass index (BMI-for-age) for individuals with Down syndrome (DS). The secondary objective was to compare the BMI-for-age with the Centers for Disease Control and Prevention standards (CDC).

Methods

A retrospective and cross-sectional growth study of 706 youth with DS (56.7% males) was performed in 51 centers in São Paulo state, Brazil. Weight and height were used to calculate the BMI (kg/m2). The LMS method was applied to construct the growth charts. Z-scores were based on the CDC 2000 growth standards.

Results

The BMI-for-age reference charts showed excellent goodness of fit statistics for boys and girls with DS aged 2–18 years. At 2 years of age, the mean BMI Z-scores of boys and girls with DS were lower compared to those of the CDC (Z-score=−0.2). In contrast, children with DS aged 3–18 years had higher mean Z-scores for BMI-for-age when compared to those of the CDC (Z-scores=+0.2 to +1.3).

Conclusions

The BMI of Brazilian youth with DS differs from those references established by CDC. These are the first Brazilian BMI-for-age charts for individuals with DS and will hopefully guide clinicians and parents in the evaluation and management of the nutritional status in children and adolescents with DS in Brazil.

Keywords:
Trisomy 21
Body mass index
Weight
Height
Growth charts
Nutritional status
Resumo
Objetivo

Desenvolver curvas específicas de Índice de Massa Corporal (IMC-para-idade) para população brasileira com síndrome de Down (SD). O objetivo secundário foi comparar os valores de IMC-para-idade com os valores normativos do Centro para o Controle de Doenças dos Estados Unidos (CDC).

Métodos

Trata-se de estudo do tipo retrospectivo e transversal. A amostra foi constituída de 706 jovens com SD (56,7%, meninos) recrutados em 51 instituições no estado de São Paulo, Brasil. Peso e estatura foram obtidos e empregados para o cálculo de IMC (Kg/m2). O método LMS foi usado para a construção das curvas. Escores Z foram calculados com base na referência do CDC 2000.

Resultados

As curvas de referência de IMC-para-idade para meninos e meninas com SD na faixa etária entre 2-18 anos apresentaram excelente ajuste estatístico. Aos dois anos de idade, o escore Z médio IMC de crianças com SD apresentou-se menor quando comparado ao CDC (escore Z=-0,2). Em contraste, os escores Z médios de IMC de jovens com SD foram superiores nas idades entre 3-18 anos (escores Z=+0,2 a +1,3).

Conclusões

A população brasileira com SD apresentou diferentes padrões de IMC quando comparada às referências do CDC. As curvas desenvolvidas nesse estudo representam a primeira referência nacional de IMC-para-idade para jovens com SD. Espera-se, portanto, que essas curvas possam guiar pais e profissionais na avaliação do estado nutricional de crianças e adolescentes com SD no território brasileiro.

Palavras-chave:
Trissomia 21
Índice de massa corporal
Peso
Estatura
Curvas de crescimento
Estado nutricional
Full Text
Introduction

Down syndrome (DS) is a chromosomal disorder with an approximate incidence between 3.05 and 14 cases per 10,000 live births in the United States and China.1,2 Recent studies have shown a population prevalence between 6.1 and 13.1 per 10,000 persons.3,4 The life expectancy of individuals with DS has increased considerably over the past years. A study suggests that 94.4% of children with DS born in 2000 will survive up to 2020, 90.8% up to 2030, and 76.3% up to 2050.3 Life expectancy is linked to the development of research and services provided to this population.5 Despite these advances, children with DS have health conditions that affect their quality of life, including congenital heart disease, hypothyroidism, gastrointestinal disorders, and obstructive sleep apnea.6 According to the guidelines of the American Academy of Pediatrics and of the Brazilian Ministry of Health, individuals with DS also have growth restriction and overweight.7,8

The adequate monitoring of the nutritional status of youth with DS helps to prevent and identify overall health problems. The body mass index (BMI) is a health indicator that is commonly used to classify the nutritional status of children, adults, and the elderly. The Centers for Disease Control and Prevention (CDC) has recommended the use of BMI to assess the health status of children older than 2 years. However, youth with DS have different weight, height, and BMI standards when compared to children in the general population without DS.9

Youth with DS aged 2–20 years had lower height and higher BMI when compared to the CDC charts, suggesting the need for specific growth charts for youth with DS.10 In Brazil, the Ministry of Health recommends the use of the weight-for-age charts by Cronk et al.11 for monitoring the nutritional status of Brazilian youth with DS aged 2–18 years. These charts combine cross-sectional and longitudinal data including 730 U.S. individuals with DS aged 1 month to 18 years.11 The clinical and practical use of these curves, however, had been questioned by the American Academy of Pediatrics.8

Due to the limitations of the existing charts and the absence of normative values of BMI-for-age for Brazilian youth with DS, this study aimed to develop Brazilian BMI-for-age charts for individuals with DS aged 2–18 years. The secondary objective was to compare the BMI-for-age of the study participants with the normative values established by the CDC/2000.

Methods

Children and adolescents with DS aged 2–18 years were recruited from a retrospective and cross-sectional study carried out between 2012 and 2015. The study was conducted at Universidade Estadual de Campinas, 48 specialized centers that provide care to individuals with intellectual disabilities, and two specialized centers for individuals with DS, all located in the state of São Paulo. The study was approved by the Ethics Committee of the Faculdade de Ciências Médicas of the Universidade Estadual de Campinas (No. 140.186/2012). An informed consent was signed by parents and guardians.

Clinical data records were obtained through interviews with families and from medical records. A questionnaire was applied to parents and guardians, including information on age, sex, gestational age, comorbidities, medications, weight, height, and head circumference. During the interview (2012–2014), information was also obtained from the Child Health record Card and questionnaires provided to parents (by healthcare facilities, medical clinics, and hospitals in the city of Campinas). Weight and height were measured by a trained team. Participants were measured barefoot and wearing light clothes. In Campinas, height was measured using a portable stadiometer, model E210 (Wiso®, SC, Brazil). Weight was measured using a digital scale, model W801 (Wiso®, SC, Brazil).

Data screening was carried out in different stages: 1) We excluded duplicated data based on identification code, birthdate, and measurement date; 2) We removed outliers (five standard deviations above or below the mean); 3) We excluded data points demonstrating loss of height over time. The questionnaires and clinical records were reviewed and data inconsistencies were resolved. Weight and height data were used to calculate BMI using the following formula: BMI=weight divided by height squared (kg/m2). Generalized additive models for location, scale and shape (GAMLSS)12 were used for the construction of the BMI-for-age curves, using the R software (R Foundation for Statistical Computing, version 3.2.2, Vienna, Austria). The LMS method and worm plots were used for modeling the curves.13,14

The percentiles generated for BMI-for-age were: 5th, 10th, 25th, 50th, 75th, 85th, 90th, and 95th. Mean Z-scores were calculated to compare the BMI-for-age with the normative references established by the CDC,15 according to the following equation: Z=[(X/M)L1]/L*S, where X is the observed measurement (BMI) of each participant, M is the median, L is the skewness, −1 is the constant, and S is the coefficient of variation. The values of L, M, and S were obtained from CDC/2000 normative charts.

ResultsParticipants

The sample consisted of 706 individuals with DS aged 2–18 years born between 1978 and 2012 (56.7% males). A total of 1,986 BMI data points were used to construct the charts. Preterm infants were 10.1% (<37 weeks gestation). A total of 17.9% had congenital heart disease, 13.1% had undergone cardiac surgery, and 22% had hypothyroidism (all controlled through laboratory tests). Missing data for gestational age, heart disease, and hypothyroidism were 57.9%, 31.3%, and 27.2%, respectively.

BMI charts

The reference charts of BMI-for-age for boys and girls with DS aged 2–18 years showed excellent goodness of fit statistics. Most subjects showed more than a single data point (82%). The number of data points, means, standard deviations, LMS, and percentiles for age and sex are shown in Tables 1 and 2. BMI-for-age charts of boys and girls with DS can be seen in Figs. 1 and 2. At 2 years of age, the mean BMI Z-score of children with DS was lower compared to the normative values of the CDC (Z-score=−0.2). In contrast, mean BMI Z-scores of children and adolescents with DS were higher at ages 3–18 years (Z-scores=+0.2 to +1.3).

Table 1.

Body mass index (BMI) values of male children and adolescents with Down syndrome aged 2–18 years.

Age  n  Mean  SD  L  M  S  Percentiles (BMI, kg/m2) – males
              5%  10%  25%  50%  75%  85%  90%  95% 
97  16.39  1.76  −1.2594  16.1884  0.1059  13.83  14.28  15.12  16.19  17.45  18.22  18.79  19.71 
86  16.60  1.69  −1.2747  16.3847  0.1107  13.91  14.38  15.26  16.38  17.72  18.55  19.16  20.16 
79  16.63  1.90  −1.2922  16.6125  0.1163  14.00  14.49  15.42  16.61  18.05  18.94  19.60  20.70 
72  17.47  2.27  −1.3133  16.9091  0.1235  14.12  14.64  15.62  16.91  18.47  19.45  20.19  21.42 
64  17.53  2.83  −1.3330  17.2500  0.1317  14.26  14.81  15.86  17.25  18.96  20.06  20.89  22.28 
72  18.11  3.24  −1.3468  17.6922  0.1418  14.44  15.04  16.17  17.69  19.60  20.84  21.79  23.41 
75  19.28  3.93  −1.3417  18.2846  0.1537  14.71  15.35  16.59  18.28  20.44  21.87  22.99  24.90 
70  20.35  4.04  −1.3018  18.9805  0.1660  15.03  15.73  17.10  18.98  21.42  23.06  24.35  26.60 
10  77  20.57  4.41  −1.2190  19.7185  0.1772  15.37  16.14  17.64  19.72  22.44  24.28  25.72  28.27 
11  76  21.13  4.60  −1.0920  20.6106  0.1867  15.81  16.66  18.32  20.61  23.60  25.62  27.20  29.96 
12  69  23.15  4.74  −0.9386  21.7209  0.1938  16.44  17.38  19.20  21.72  24.97  27.14  28.82  31.72 
13  65  23.27  4.18  −0.7887  22.8300  0.1982  17.08  18.11  20.10  22.83  26.30  28.57  30.31  33.28 
14  68  24.63  5.09  −0.6574  23.8454  0.2011  17.68  18.79  20.94  23.85  27.49  29.84  31.63  34.62 
15  49  25.75  5.10  −0.5447  24.7468  0.2030  18.21  19.40  21.68  24.75  28.53  30.94  32.76  35.78 
16  40  26.14  5.63  −0.4393  25.5368  0.2046  18.66  19.92  22.33  25.54  29.44  31.90  33.74  36.76 
17  39  26.53  5.58  −0.3356  26.2865  0.2060  19.07  20.41  22.95  26.29  30.31  32.81  34.66  37.67 
18  30  28.00  5.85  −0.2346  27.0475  0.2074  19.48  20.90  23.57  27.05  31.18  33.72  35.59  38.60 
Table 2.

Body mass index (BMI) values of female children and adolescents with Down syndrome aged 2–18 years.

Age  n  Mean  SD  L  M  S  Percentiles (BMI, kg/m2) – females
              5%  10%  25%  50%  75%  85%  90%  95% 
81  16.06  2.00  −0.0422  15.8660  0.1166  13.11  13.67  14.67  15.87  17.17  17.91  18.43  19.23 
76  16.19  1.80  −0.0230  16.1631  0.1262  13.14  13.75  14.85  16.16  17.60  18.42  19.01  19.90 
73  16.67  2.22  0.0019  16.5153  0.1360  13.20  13.87  15.07  16.52  18.10  19.01  19.66  20.65 
62  17.12  2.57  0.0362  16.9481  0.1459  13.32  14.05  15.36  16.95  18.70  19.71  20.42  21.52 
53  17.59  2.93  0.0761  17.4851  0.1557  13.50  14.30  15.74  17.49  19.41  20.53  21.31  22.53 
54  18.44  3.12  0.1135  18.1450  0.1649  13.78  14.65  16.22  18.14  20.27  21.49  22.36  23.70 
60  19.32  3.88  0.1491  18.9270  0.1734  14.14  15.10  16.82  18.93  21.25  22.60  23.55  25.03 
61  19.57  3.18  0.1836  19.8402  0.1810  14.61  15.65  17.54  19.84  22.39  23.86  24.90  26.51 
10  45  20.75  4.12  0.2129  20.8954  0.1878  15.18  16.32  18.38  20.90  23.68  25.29  26.42  28.18 
11  46  22.44  4.31  0.2358  22.0355  0.1937  15.82  17.06  19.30  22.04  25.06  26.81  28.05  29.96 
12  46  24.04  5.23  0.2525  23.1548  0.1987  16.46  17.80  20.20  23.15  26.42  28.30  29.64  31.70 
13  47  25.51  4.96  0.2652  24.1529  0.2029  17.03  18.45  21.01  24.15  27.63  29.64  31.06  33.26 
14  44  25.75  4.73  0.2762  24.9738  0.2064  17.48  18.97  21.67  24.97  28.63  30.74  32.24  34.55 
15  35  26.56  5.78  0.2878  25.6252  0.2093  17.83  19.38  22.19  25.63  29.43  31.63  33.18  35.58 
16  37  26.40  5.92  0.3008  26.1495  0.2118  18.10  19.70  22.60  26.15  30.07  32.34  33.94  36.42 
17  23  25.70  5.73  0.3136  26.6092  0.2137  18.33  19.98  22.96  26.61  30.64  32.96  34.61  37.14 
18  20  25.94  5.11  0.3252  27.0592  0.2154  18.57  20.26  23.32  27.06  31.19  33.57  35.25  37.84 
Figure 1.

Body mass index (BMI) curves for male children and adolescents with Down syndrome aged 2–18 years.

(0.34MB).
Figure 2.

Body mass index (BMI) curves for female children and adolescents with Down syndrome aged 2–18 years.

(0.31MB).
Discussion

This study depicts the first Brazilian BMI-for-age charts for children and adolescents with DS aged 2–18 years. The study also found differences in BMI among the children and adolescents with DS enrolled in the present study and the normative values established by the CDC. The results have clinical and practical implications regarding the monitoring of the nutritional status of children and adolescents with DS in Brazil.

At 2 years of age, the mean BMI values of boys and girls with DS were below the standards established by the CDC. Studies show that children with DS are characterized by reduced body weight during the first two years of life.10,16 Low birthweight may be related to growth restriction and food intake disorders.17,18 Growth restriction is related to genetic factors.19 Suction/swallowing disorders are associated with muscle hypotonia and dysfunctions in the oral motor system.18 After 2 years of age, the mean BMI-for-age Z-scores of children and adolescents with DS resulted in approximately one standard deviation above the normative values of the CDC. Zemel et al.10 also reported higher values of BMI-for-age in U.S. children with DS after 2 years of age when compared to CDC standards. After that age, children with DS are likely to have higher prevalence of overweight and obesity when compared to children in the general population without DS.20,21 Risk factors for obesity in DS include leptin hormone disorders, decreased resting energy expenditure, unbalanced diet, and low levels of physical activity.22–25

The percentiles of BMI-for-age of children with DS increased gradually in the age range from 2 to 18 years; a similar pattern was observed in the BMI-for-age percentiles of U.S. children with DS aged 2–20 years.10 The uninterrupted increases in BMI observed in individuals with DS are not consistent with the BMI standards from the general population without DS. Growth international references show a rapid acceleration in median percentiles of BMI-for-age in the first year of life, followed by a decline until the age of 5 years, and a reacceleration at later ages.15,26,27

These BMI-for-age curves are descriptive standards of growth in children and adolescents with DS. However, these curves do not indicate an optimal standard of weight, to which all children with DS should grow. The use these curves, however, allows for comparison and monitoring of body weight status of individuals with DS in Brazil.

The Brazilian Ministry of Health recommends using the weight-for-age charts by Cronk et al.11 for monitoring the nutritional status of Brazilian children with DS. However, the clinical applicability has been questioned by the American Academy of Pediatrics.8 The distribution of BMI-for-age percentiles among the population of this study and the CDC has shown differences from the practical standpoint. For example, a male child with DS aged 14 years (BMI: 23.85kg/m2, 50th percentile, see Table 1) would be classified in the overweight category by the CDC/BMI parameters (CDC/BMI: 22.66kg/m2, 85th percentile). The results suggest that further studies are needed to examine the association between BMI cutoffs and the overall health of children and adolescents with DS.

This study has some limitations. First, the data were obtained from clinical records and may include measurement errors. However, the data screening was rigorously performed to minimize biases. Second, the sample was restricted to the state of São Paulo and does not represent the total population of children with DS in Brazil. Conversely, the state of São Paulo, with an estimated population of 44,035,304 individuals (21.7% of Brazil) can represent the economic and ethnical diversity of the country. Finally, the curves do not represent the optimal growth status of children with DS, considering that some growth-influencing factors were not controlled, such as breastfeeding, lactation support, comorbidities, maternal health, and socioeconomic status. Further studies should investigate the association between these factors and the growth of children and adolescents with DS.

In conclusion, the Brazilian individuals with DS showed different BMI-for-age when compared to CDC references. The curves developed in this study represent the first national reference of BMI-for-age for youth with DS. Therefore, it is expected that these curves can guide parents and professionals in assessing the nutritional status of children and adolescents with DS in Brazil.

Funding

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgments

The authors received financial support from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES – BEX 3546/15-2) and from Conselho Nacional de Desenvolvimento Científico e Tecnológico (PIBIC – CNPq). The authors would like to thank Roberto A. Soares, João F. Cosmo, Alessandra C.P.D. Costa, Eliane T. Nogueira, Fabio Crozara, Célia de Oliveira, and Maria A. C. Pacheco for their excellent technical assistance. The authors would also like to thank the Associações de Pais e Amigos dos Excepcionais do Estado de São Paulo (APAEs/SP), Outpatient Clinic of Pediatric Specialty Integration of Faculdade de Ciências Médicas, Universidade Estadual de Campinas (AIEP/FCM/UNICAMP), Department of Medical Genetics (DGM/FCM/UNICAMP), Centro de Investigação em Pediatria (CIPED/FCM/Unicamp), Federação das APAEs do Estado de São Paulo (FEAPAES/SP), Centro de Educação Especial Síndrome de Down (CEESD), and Fundação Síndrome de Down (FSD) for their fundamental collaboration in this study.

References
[1]
C. Deng, L. Yi, Y. Mu, J. Zhu, Y. Qin, X. Fan, et al.
Recent trends in the birth prevalence of Down syndrome in China: impact of prenatal diagnosis and subsequent terminations.
Prenat Diagn, 35 (2015), pp. 311-318
[2]
S.E. Parker, C.T. Mai, M.A. Canfield, R. Rickard, Y. Wang, R.E. Meyer, et al.
Updated national birth prevalence estimates for selected birth defects in the United States, 2004–2006.
Birth Defects Res A: Clin Mol Teratol, 88 (2010), pp. 1008-1016
[3]
G. de Graaf, J.C. Vis, M. Haveman, G. van Hove, E.A.B. de Graaf, J.G.P. Tijssen, et al.
Assessment of prevalence of persons with Down syndrome: a theory based demographic model.
J Appl Res Intellect Disabil, 24 (2011), pp. 247-262
[4]
A.P. Presson, G. Partyka, K.M. Jensen, O.J. Devine, S.A. Rasmussen, L.L. McCabe, et al.
Current estimate of Down Syndrome population prevalence in the United States.
J Pediatr, 163 (2013), pp. 1163-1168
[5]
S.M. Day, D.J. Strauss, R.M. Shavelle, R.J. Reynolds.
Mortality and causes of death in persons with Down syndrome in California.
Dev Med Child Neurol, 47 (2005), pp. 171-176
[6]
N.J. Roizen, C.I. Magyar, E.S. Kuschner, S.B. Sulkes, C. Druschel, E. van Wijngaarden, et al.
A community cross-sectional survey of medical problems in 440 children with Down syndrome in New York State.
J Pediatr, 164 (2014), pp. 871-875
[7]
Brasil, Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas e Estratégicas.
Diretrizes de atenção à pessoa com Síndrome de Down (Série F. Comunicação e Educação em Saúde).
Ministério da Saúde, (2012),
v.1
[8]
M.J. Bull.
Health supervision for children with Down syndrome.
Pediatrics, 128 (2011), pp. 393-406
[9]
F. Bertapelli, J.E. Martin, E.M. Goncalves, V.J. de Oliveira Barbeta, G. Guerra-Junior.
Growth curves in Down syndrome: implications for clinical practice.
Am J Med Genet Part A, 164A (2014), pp. 844-847
[10]
B.S. Zemel, M. Pipan, V.A. Stallings, W. Hall, K. Schadt, D.S. Freedman, et al.
Growth charts for children with Down syndrome in the United States.
Pediatrics, 136 (2015), pp. e1204-e1211
[11]
C. Cronk, A.C. Crocker, S.M. Pueschel, A.M. Shea, E. Zackai, G. Pickens, et al.
Growth charts for children with Down syndrome: 1 month to 18 years of age.
Pediatrics, 81 (1988), pp. 102-110
[12]
D.M. Stasinopoulos, R.A. Rigby.
Generalized additive models for location scale and shape (GAMLSS) in R.
J Stat Softw, 23 (2007), pp. 1-46
[13]
S. van Buuren, M. Fredriks.
Worm plot: a simple diagnostic device for modelling growth reference curves.
Stat Med, 20 (2001), pp. 1259-1277
[14]
T.J. Cole, P.J. Green.
Smoothing reference centile curves: the LMS method and penalized likelihood.
Stat Med, 11 (1992), pp. 1305-1319
[15]
R.J. Kuczmarski, C.L. Ogden, S.S. Guo, L.M. Grummer-Strawn, K.M. Flegal, Z. Mei, et al.
2000 CDC Growth Charts for the United States: methods and development.
Vital Health Stat, 11 (2002), pp. 1-190
[16]
J.K. Morris, T.J. Cole, A.L. Springett, J. Dennis.
Down syndrome birth weight in England and Wales: implications for clinical practice.
Am J Med Genet Part A, 167 (2015), pp. 3070-3075
[17]
B. Weisz, A.L. David, L. Chitty, D. Peebles, P. Pandya, P. Patel, et al.
Association of isolated short femur in the mid-trimester fetus with perinatal outcome.
Ultrasound Obstet Gynecol, 31 (2008), pp. 512-516
[18]
Q. Spender, A. Stein, J. Dennis, S. Reilly, E. Percy, D. Cave.
An exploration of feeding difficulties in children with Down syndrome.
Dev Med Child Neurol, 38 (1996), pp. 681-694
[19]
J.D. Blazek, A.M. Malik, M. Tischbein, M.L. Arbones, C.S. Moore, R.J. Roper.
Abnormal mineralization of the Ts65Dn Down syndrome mouse appendicular skeleton begins during embryonic development in a Dyrk1a-independent manner.
Mech Dev, 136 (2015), pp. 133-142
[20]
H.B. Van Gameren-Oosterom, P. Van Dommelen, Y. Schonbeck, A.M. Oudesluys-Murphy, J.P. Van Wouwe, S.E. Buitendijk.
Prevalence of overweight in Dutch children with Down syndrome.
Pediatrics, 130 (2012), pp. e1520-e1526
[21]
M. Alexander, H. Petri, Y. Ding, C. Wandel, O. Khwaja, N. Foskett.
Morbidity and medication in a large population of individuals with Down syndrome compared to the general population.
Dev Med Child Neurol, 58 (2016), pp. 246-254
[22]
S.N. Magge, K.L. O’Neill, J. Shults, V.A. Stallings, N. Stettler.
Leptin levels among prepubertal children with Down syndrome compared with their siblings.
J Pediatr, 152 (2008), pp. 321-326
[23]
D.L. Hill, E.P. Parks, B.S. Zemel, J. Shults, V.A. Stallings, N. Stettler.
Resting energy expenditure and adiposity accretion among children with Down syndrome: a 3-year prospective study.
Eur J Clin Nutr, 67 (2013), pp. 1087-1091
[24]
K.L. O’Neill, J. Shults, V.A. Stallings, N. Stettler.
Child-feeding practices in children with down syndrome and their siblings.
J Pediatr, 146 (2005), pp. 234-238
[25]
K. Pitetti, T. Baynard, S. Agiovlasitis.
Children and adolescents with Down syndrome, physical fitness and physical activity.
J Sport Health Sci, 2 (2013), pp. 47-57
[26]
M. de Onis, A.W. Onyango, E. Borghi, A. Siyam, C. Nishida, J. Siekmann.
Development of a WHO growth reference for school-aged children and adolescents.
Bull World Health Organ, 85 (2007), pp. 660-667
[27]
WHO Multicentre Growth Reference Study Group.
WHO Child Growth Standards based on length/height, weight and age.
Acta Paediatr Suppl, 450 (2006), pp. 76-85

Please cite this article as: Bertapelli F, Machado MR, Roso RV, Guerra-Júnior G. Body mass index reference charts for individuals with Down syndrome aged 2–18 years. J Pediatr (Rio J). 2017;93:94–9.

Study carried out at Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil.

Copyright © 2016. Sociedade Brasileira de Pediatria
Idiomas
Jornal de Pediatria (English Edition)

Subscribe to our newsletter

Article options
Tools
en pt
Taxa de publicaçao Publication fee
Os artigos submetidos a partir de 1º de setembro de 2018, que forem aceitos para publicação no Jornal de Pediatria, estarão sujeitos a uma taxa para que tenham sua publicação garantida. O artigo aceito somente será publicado após a comprovação do pagamento da taxa de publicação. Ao submeterem o manuscrito a este jornal, os autores concordam com esses termos. A submissão dos manuscritos continua gratuita. Para mais informações, contate assessoria@jped.com.br. Articles submitted as of September 1, 2018, which are accepted for publication in the Jornal de Pediatria, will be subject to a fee to have their publication guaranteed. The accepted article will only be published after proof of the publication fee payment. By submitting the manuscript to this journal, the authors agree to these terms. Manuscript submission remains free of charge. For more information, contact assessoria@jped.com.br.
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.