Anthropometry and body composition analysis in children with cerebral palsy

doi:10.1016/j.clnu.2009.10.009

Clinical Nutrition

Volume 29, Issue 4, August 2010, Pages 477-481

https://doi.org/10.1016/j.clnu.2009.10.009 Get rights and content

Summary

Background & aims

This study was undertaken to describe anthropometry, body composition parameters and assess serum levels of leptin and other biochemical markers of the nutritional status in a sample of Egyptian children with cerebral palsy(CP).

Methods

Anthropometric measurements (body weight, knee height, head, mid-upper arm, waist and hip circumferences, triceps and subscapular skin-fold thickness) were taken. Using the bioelectrical impedance technique, total body water(TBW), fat-free mass, fat mass, fat percentage and basal metabolic rate(BMR) were calculated. Serum levels of total proteins, albumin, ferritin and leptin were measured. Results were compared to that of healthy controls.

Results

Patients had significantly lower anthropometric measurements than controls, except for mid-upper arm and hip circumferences, and subscapular skin-fold thickness which were not different in both groups. Fat mass, fat free mass, fat percentage, TBW and BMR were lower in the patients. Serum protein and leptin levels were not different in patients and controls, though other biochemical markers were reduced in the patients. Patients with more severe motor handicap had lower skin-fold thickness, fat percentage and serum ferritin than those with milder affection.

Conclusion

Parameters of growth, body composition analysis and nutritional status are significantly altered in CP patients especially those with severe motor handicap and oromotor dysfunction.

Introduction

Children with cerebral palsy (CP) are generally undernourished and growth retarded than normal children. Conditions like impaired oral-motor function, temporomandibular joint contractures, vomiting, and aspiration pneumonia associated with gastroesophageal reflux, all cause lengthy mealtimes and fatigue, contributing to malnourishment.¹ The reasons for malnutrition are not only due to poor nutritional status, but also non-nutritional factors including negative neurotropic effects and indirect factors such as immobility, endocrinological abnormalities, or spasticity.²

Furthermore, even children with only mild feeding dysfunction do not consume enough food to meet their nutritional needs.³ Fat-free mass is deficient in those patients. The childhood and adolescent nutritional profiles are relevant to adult patients, since they result in an adult with low fat-free mass.⁴

Measurement of body composition is an indispensable component of nutritional assessment which is paramount to the success of any nutritional program. There are few studies incorporating body composition analysis in assessment of the nutritional status of children with CP, the included patients' sample in those studies are usually very limited. Bioelectrical Impedance Analysis (BIA) recording is a feasible nutritional assessment method. The analysis uses the body's conductance and impedance of a low level electrical current to assess total body water. Fat mass and fat free mass are then calculated using the published equations.⁵

Thus, we aimed to describe observed growth pattern and body composition parameters in a representative sample of Egyptian children with cerebral palsy, in comparison to healthy controls, and its relation to the different disease manifestations. A secondary objective was to compare the levels of serum leptin and other biochemical markers of the nutritional status in both groups and to relate our findings to the different disease manifestations.

Section snippets

Materials and methods

The study is a cross-sectional study that was conducted in Children's hospital, Ain Shams University in the period from April to October 2007. The population of this study comprised forty children, of both sex, with cerebral palsy included according to the following criteria:

Statistical analysis

Data were collected in a Microsoft® Excel® Worksheet and were analyzed using the Statistical Analysis Toolpack. Parametric data were analyzed using the mean, standard deviation and the student's t-test. Non-parametric data were analyzed using the median, interquartile range (IQ) and the z-test. Categorical data were analyzed using the Pearson chi-square test. Correlation between different parameters was tested using the Pearson correlation coefficient and scatter-plot diagrams. P values were

Results

The study included 40 children (21 males and 19 females) with cerebral palsy. Their age ranged between 2 and 8 years (mean 4.44 ± 2.0 years) (Table 1). The patients were studied in comparison to 40 clinically healthy children (21 males and 19 females), with the same age range (mean age of 5.01 ± 1.72 years).

Discussion

Growth retardation in children with cerebral palsy, as seen in the results of the current study, has been previously documented in the literature.13, 14, 15 The marked decrease in anthropometric measurements in CP patients as regards body weight, height, and head circumference may be attributed to nutritional as well as non-nutritional factors.16, 17

Many of CP patients suffer from oro-motor dysfunction, resulting in difficult swallowing, recurrent aspirations, and hence poor intake that can be

Conflict of interest statement

The authors declare that there are no financial and personal relationships with other people, or organizations, that could inappropriately influence (bias) the present work.

Acknowledgment

The authors would like to express their appreciation for effort done by Dr. Eman S. El-Hadidi, Department of Clinical Pathology, Ain Shams University, Cairo, Egypt, who undertook the laboratory part of this study.

Statement of authorship: HT participated in the design of the study, its coordination, data analysis and writing of the manuscript. NB participated in the study design, and provided significant advice and consultation all through the study. NH participated in the design of the study

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Cited by (61)

Body Fat Distribution in Children and Adolescents With Cerebral Palsy
2022, Journal of Clinical Densitometry
Citation Excerpt :
A description of the registry can be found at http://www.germanctr.de (DRKS00011331), which is a primary register of the International Clinical Trials Registry Platform of the WHO. The register was approved by the ethics committee of the University of Cologne (16)-(26),(9) The severity of CP can be classified by GMFCS.
To evaluate the body fat distribution in children with cerebral palsy (CP). The present study focusses on a monocentric retrospective analysis of body fat distribution from children diagnosed with CP. The children participated in a rehabilitation program. Reference centiles were calculated based on data from the National Health and Nutrition Examination Survey (NHANES, 1999–2004). Z-scores for trunk-to-leg fat ratio were calculated. Further, fat mass index (FMI) was evaluated based on percentiles that have already been published. 237 males and 194 females with CP were considered (mean age: 11 years and 11 months [SD 3 years]). These were compared to 1059 males and 796 females from the NHANES (mean age: 14 years and 7 months [SD 3 years and 4 months]). The z-scores for trunk-to-leg fat ratio showed the following values: mean –0.47 (SD 1.50) for males, –0.49 (SD 1.11), for females, –0.48 (SD 1.34) for all. The z-scores for FMI showed the following values: mean –0.29 (SD 0.70) for males, –0.88 (SD 2.0) for females, –0.55 (SD 1.46) for all. The results showed rather a gynoid fat distribution and a lower FMI in children with CP than in the reference population (NHANES 1999–2004).
Physical activity, sedentary time and nutritional status in Brazilian children with cerebral palsy
2022, Jornal de Pediatria
Citation Excerpt :
In contrast, the fat mass was lower in children with severe CP, dysphagia, and feeding difficulties, and no previous nutritional intervention when compared to children without dysphagia.25 In addition, children with CP had a lower basal metabolic rate,26 and lower energy expenditure compared to neurotypical children.27 Likewise, a previous study was carried out on the same service of the present study, showed that children in the same social context and receiving similar nutritional support when started the treatment later had a tendency to preserve more body fat than weight, height and lean mass.28
This study had the purpose investigate the physical activity (PA) and sedentary time profile of children with cerebral palsy and its association with body composition.
A cross-sectional study evaluated 53 children, between 2 and 10 years old, enrolled in three health services Recife-city, northeast of Brazil. Sedentary and PA were measured for a week using the ActiGraph GTX3 accelerometer. Body composition was assessed by anthropometry and an electrical bioimpedance device.
Time on PA was one hour longer among the mild/moderate CP compared to severe ones, but, sedentary time is similar. Dyskinetic children spent more time in PA, but also in sedentary activities (15.5 hours a day) than spastic ones (12.8). Stunting occurred in 15 (30%) of the sample, all children with stunting had severe impairment. Underweight occurred in 25% of the severe group and 11.8% in the mild/moderate group. Overweight affected 3% of the sample; no overweight children were in the severe group. Body fat% was inversely related to time spent in moderate to vigorous PA.
Children with CP spend more than a half of their daily time in sedentary activity. In contrast, children with mild to moderate CP spent twice as much time in moderate to vigorous PA and had a tendency (p = 0.07) to spend 50% more time in light PA. Moreover, time spent on moderate to vigorous activity was inversely related to fat mass.
Malnutrition and nutritional deficiencies in children with cerebral palsy: a systematic review and meta-analysis
2022, Public Health
Citation Excerpt :
There was a predominance of cross-sectional cohort studies (68.65%; n = 46).1,3,6–9,14–17,19,20,22–24,26,36,39–41,44–47,52–61,63,65,67–70,76–79 Regarding the methodological quality, for the studies with a cross-sectional design, it was verified that 78.26% (n = 36) of the publications1–3,6,7,9,15–17,20,22,24,26,35,36,39,40,44,46,52,54,55,58–61,63,65,67,69,74–79 clearly presented the criteria for inclusion in the sample. No study was excluded because of its methodological quality.
This systematic review study and meta-analysis sought to estimate the prevalence of malnutrition and nutritional deficiencies in children with cerebral palsy (CP).
This is a systematic review and meta-analysis.
The systematic review was conducted according to the PRISMA guidelines. The articles were chosen using the PubMed, Embase, Scopus, Web of Science, Cochrane Library, SciELO, and Lilacs databases and the bibliographical reference lists of the articles. No limitations were placed on the time of publication, but the articles had to include children from 0 to 18 years old with CP who presented the prevalence of malnutrition and nutritional deficiencies. The methodological quality of the articles was assessed using the verification list for analytical cross-sectional studies, the Newcastle–Ottawa scale, and the Cochrane Collaboration tool for randomized studies. The meta-analysis of proportions was conducted based on the prevalence data for malnutrition or nutritional deficiencies. The study is registered in PROSPERO under CRD number 42020175068.
Sixty-seven articles (N = 453,804) published between 1986 and 2019 were included. Most of the articles presented a low risk of bias and no publication was excluded for quality reasons. The most widely used anthropometric index for diagnosing nutritional status was weight-to-age and the estimated prevalence of malnutrition was 40% (95% CI = 28.0–53.0). Nutrient deficiency was investigated by nine publications, with hypocalcemia and reduced serum concentrations of zinc, copper, and vitamin D being reported the most.
We found a high rate of malnutrition in the population in this review, moreover, we suggest that some nutritional deficiencies are associated with food deficit and that the socio-economic and age factors of these children may relate with the poor nutritional outcome. This makes monitoring and personalized nutritional management necessary, in accordance with the characteristics and particularities of children with CP.
Feeding problems and malnutrition associated factors in a North African sample of multidisabled children with cerebral palsy
2021, Research in Developmental Disabilities
In European and North American countries, stunting and malnutrition are common in children with cerebral palsy (CP), especially those with multiple disabilities. The extent of this problem in children with CP in North African countries is still unknown.
To evaluate feeding problems and growth in a sample of North African multidisabled children with CP and to determine the factors associated with malnutrition in this population.
We conducted a cross-sectional study including multidisabled children with severe CP. Anthropometric measurements (body weight, height, mid-upper arm circumference and triceps skinfold thickness) were performed. In addition, a thorough nutritional survey was conducted including feeding time and the presence of signs in favor of gastrointestinal problems.
We included 40 children, mainly boys (60 %) with a mean age of 6.4 ± 3.7 (range 2–16 years). The nutritional survey had revealed the presence of dysphagia, constipation and gastroesophageal reflux in 55 %, 67.5 % and 70 % of cases, respectively. Sixty-five percent of children had a mealtime over 30 min. Based on World Health Organization (WHO) growth charts, 67.5 % of children were underweight. Forty percent of the children had their weight below the 20th percentile, 5 % and 7.5 % had their height and BMI below the 5th percentile according to CP specific growth charts. Triceps skinfold thickness and mid-upper arm circumference were below the 5th percentile in 50 % and 55 % of cases, respectively. Age (p = 0.047) and constipation (p = 0.003) were identified as predictors of malnutrition.
Growth parameters and nutritional status are significantly altered in in our sample of North African multidisabled children with CP with a high prevalence of feeding problems represented especially by dysphagia, constipation and GER. Among the studied factors age and constipation may predict the existence of undernutrition.
Criterion validity of assessment methods to estimate body composition in children with cerebral palsy: A systematic review
2021, Annals of Physical and Rehabilitation Medicine
Poor nutritional status is a problem in a high number of children with cerebral palsy (CP) and impairs their well-being. Therefore, periodic assessment of nutritional status and especially body composition is essential. However, we lack consensus on the best method to assess body composition in clinical practice.
We aimed to systematically review the available evidence on the criterion validity of equation-based skinfold measurement and bioelectrical impedance analysis (BIA) to estimate body composition in children with CP.
In a systematic review (MEDLINE, Cochrane Library and EMBASE), we identified studies that reported on the agreement between the estimation of body composition by equations of skinfold thickness or impedance values of BIA with a gold standard (isotope techniques or dual-energy-X-ray-absorptiometry [DXA]) in children with CP. We included only studies that provided correlations or agreement between estimations of body compartments (e.g., percentage body fat [%BF] or fat mass). Limits of agreement of 2.5%BF points were considered acceptable. Study quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies 2.
We included reports of 9 studies describing 3 skinfold equations and 4 equations to estimate body composition with BIA. Neither skinfold equations nor BIA could be reliably used to assess body composition in an individual child with CP at one point in time. On a population level, the Gurka skinfold equation was valid in ambulant children with CP, and the Kushner and Fjeld BIA equations were valid in a heterogeneous group of children with CP. Conclusions The future role of skinfold equations and BIA to assess and monitor body composition in an individual child with CP needs to be further investigated.
Nutritional red flags in children with cerebral palsy
2020, Clinical Nutrition
Citation Excerpt :
Low fat reserves assessed by skinfold measurements were also noted in the study of Samson-Fang et al., who found an association between low fat stores and increased health care use and impaired social participation [2]. Low TSF but not SSF in comparison to typically developing peers were also observed by Tomoum et al., who also found a significantly lower whole body fat mass as determined by bioelectrical impedance measurements [16]. Low upper arm muscle mass (AMA < 10th centile) was present in respectively 18.5% and 39.7% of the GMFCS 4 and 5 patients.
Children with cerebral palsy (CP) are at risk for under-nutrition. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines identified anthropometric nutritional red flags for neurologically impaired children: weight for age z-score (WFA) < −2, triceps skinfold (TSF) or arm muscle area (AMA) < 10th centile and faltering weight. This study aimed to (1) evaluate the nutritional status of Flemish children and adolescents with CP using different anthropometric indicators; (2) assess the prevalence of nutritional red flags and (3) identify risk factors for low anthropometric parameters.
This study was a prospective, longitudinal observational study recruiting children and adolescents with CP (2–20 years) in 9 specialized Flemish centres. Measurements were performed at baseline (t₁, n = 325), after 6 (t₂, total n = 268) and 12 months (t₃, total n = 191). WFA z-scores were based on Flemish growth charts; TSF, subscapular skinfolds (SSF) and AMA compared with US reference data. Weight faltering was defined as ≥0.5 decrease in weight SDS at t₂ or t₃.
At t₁ 50 patients (15.4%) were classified as gross motor function classification system (GMFCS) 1, 95 (29.2%) as GMFCS 2, 49 (15.1%) as GMFCS 3, 54 (16.6%) as GMFCS 4, and 77 (23.7%) as GMFCS 5. The overall median (Q1; Q3) age was 11.7 (8.2; 15.9) years; 61.5% were boys and 22 (6.8%) had a gastrostomy (17 (22.1%) of GMFCS 5 group). The median (Q1; Q3) WFA z-score was −1.13 (−2.6; −0.1); 71.4% of the GMFCS 5 children had a WFA z-score < −2. The median (Q1; Q3) MUAC z-score was 0.17 (−0.7; 1.0); 16.9% of the GFMCS 5 children had MUAC z-score < −2. Median (Q1; Q3) TSF and SSF z-scores were respectively −0.01 (−0.8; 0.9) and 0.27 (−0.3; 0.9). All anthropometric indices tended to decrease with increasing GMFCS (p < 0.001). At t₁ 42.1% had at least one nutritional red flag, at t₂ 40.3% and at t₃ 41.4%. Of those with at least one nutritional red flag at t₁ or t₂, respectively 14.7% and 18.8% suffered weight loss 6 months later. A GMFCS >2 and dysphagia were associated with a higher risk for lower scores of nearly all nutritional indices.
Underweight was detected in almost three quarters of CP patients with GMFCS 5 classification, whereas deficits in subcutaneous fat and arm muscle reserve were observed in one fifth. Nutritional red flags, present in about 40% of the Flemish CP children, were apparently not successfully addressed in clinical practice, since up to one-fifth of CP patients with warning signs lost even further weight in the following 6 months. Beside a GMFCS >2, dysphagia was one of the most common conditions influencing the presence of low nutritional indices.

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^☆: The work was done in the departments of Pediatrics, and Clinical pathology, Faculty of Medicine, Ain Shams University and was not supported by any grant.

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Original ArticleAnthropometry and body composition analysis in children with cerebral palsy☆

Summary

Background & aims

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Statistical analysis

Results

Discussion

Conflict of interest statement

Acknowledgment

Gastrointestinal disorders in children with neurodevelopmental disabilities

Dev Disabil Res Rev

Serum leptin levels in children with cerebral palsy: relationship with growth and nutritional status

Neuro Endocrinol Lett

Feeding dysfunction is associated with poor growth and health status in children with cerebral palsy

J Am Diet Assoc

Total energy expenditure in adults with cerebral palsy as assessed by doubly labeled water

J Am Diet Assoc

Validation of tetrapolar biolectrical impedance method to assess human body composition

J Appl Physiol

Development and reliability of a system to classify gross motor function in children with cerebral palsy

Dev Med Child Neurol

Analytic and reporting guidelines: the third national health and nutrition examination survey, NHANES III (1988–94)

Use of segmental measures to estimate stature in children with cerebral palsy

Arch Pediatr Adolesc Med

Pattern of growth in children with cerebral palsy

J Am Diet Assoc

Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty

Arch Dis Child

Assessment of fat free mass using bioelectrical impedance measurements of the human body

Am J Clin Nutr

Total body water in health and disease: have anthropometric equations any meaning?

Nephrol Dial Transplant

Reduced body protein in children with spastic quadriplegic cerebral palsy

Am J Clin Nutr

Growth patterns in a population of children and adolescents with cerebral palsy

Dev Med Child Neurol

Determination of basal metabolic rate and body composition with bioelectrical impedance method in children with cerebral palsy

J Child Neurol

Nutrition-related growth failure of children with quadriplegic cerebral palsy

Dev Med Child Neurol

The effects of non-nutritional factors on growth in cerebral palsy

Dev Med Child Neurol

Original Article
Anthropometry and body composition analysis in children with cerebral palsy☆