Mustafa Ozturk, Selami
Akkus, Mehmet Ali Malas and Ahmet Nesimi Kisioglu
From the Department of
Public Health, School of Medicine, University of Suleyman Demirel,
Isparta, Turkey.
Correspondence to: Dr.
Mustafa Ozturk, Suleyman Demirel Universitesi, Tip Fakultesi, Halk
Sagligi Anabilim Dali 32040 Isparta, Turkiye
E-mail:
[email protected]
Manuscript received:
November 12, 2001, Initial review completed: December 20, 2001;
Revision accepted: March
1, 2002.
The aim of this study
was to evaluate growth status of the children with cerebral palsy (CP)
in Isparta Province, Turkey. Forty three children with CP (24 male 19
female; mean (SD) age 8.1±4.2 years) were included in this study.
32.6% of the children were quadriplegic, 44.2% diplegic and 14.0%
hemiplegic. All caregivers were interviewed and anthropometric
measurements of the children with CP were performed. The ratio of
weight for age and height for age z scores under 2 SD were higher
in males, 7-16 age groups, quagriplegics, and having oromotor
dysfunction. This study showed that the children with CP in our region
have suffered from growth failure.
Key words: Anthropometric
measurements. Cerebral palsy, Growth status.
Cerebral palsy (CP) is a disorder
especially affecting the ability to control movement and posture.
Depending on the location and extent of the damage, cerebral palsy can
be mild or severe. It is sometimes associated with other problems such
as seizures, mental retardation, hearing and vision problems,
communication problems, etc.
It has been well
documented in the literature that the children with CP are frequently
associated with poor growth. The main cause of growth failure in the
children with CP is inadequate nutritional intake resulting from feeding
difficulties(1-5). The majority of the studies on growth status of
children with CP have been performed in western countries. In this
study, we aimed to evaluate the anthropometric growth of the children
with CP in our region.
Subjects and Methods
Forty three children with
CP admitted to the Isparta Spastic Childrens Center were included. No
patient had any other chronic systemic illness (cardiac, renal), or
history regarding use of medication (e.g., steroids) that are
known to affect growth. The diagnosis of CP was based on a neurologic
examination. Severity of impairments were evaluated according to the
Gross Motor Function Classification System (GMFCS)(6).
All caregivers were
interviewed and informed consent obtained. Information on demographic
characteristics and feeding disorders was gathered using a
questionnaire. Patients with tongue thrust, fluid or food loss, coughing
and gagging during eating, excessive time requirement for meals, and
difficulty in consuming textured foods were considered to have oromotor
dysfunction(2-3). None of the children with CP were receiving feeds
through nasogastric tubes.
Measurements of weight,
height, lower-leg lengths and skinfold thickness (triceps, biceps,
suprailiac and subscapular) were performed using standard methods(7-8).
Weight was measured on an electronic scale. A Holtain skinfold caliper
was used to measure skinfold thickness. Percentage body fat, fat mass
and fat-free mass were calculated from two skinfold thicknesses (triceps
and subscapular) using the equations of Slaughter, et al.(9).
ANTHRO software program (Version 1.02, World Health Organization, Geneva
1999) that uses reference data of the National Center for Health
Statistics (NCHS) was used for calculation of z scores of weight for age
(WAz), height for age (HAz) and weight for height (WHz) . Statistical
analysis was completed on the Statistical Package for Social Sciences
(Version 7.51).
Results
The mean age of patients
was 8.1 ± 4.2 years (range 1.2 to 16.1 years); 55.8% were male. Of 43
patients, 32.6% had quadriplegia, 44.2% diplegia and 14.0% hemiplegia;
81.4% of all patients were spastic. There was no significant difference
between male and female children in the ratios of GMFCS level, while
frequency of oromotor dysfunction was higher in males (P < 0.01).
Table I
shows the mean anthropometric measurements and the variables derived
from skinfold thickness. The proportion of patients with WAz, HAz and
WHz scores below 2 SD was 34.9%, 30.2% and 9.3% respectively.
Table I Anthropometric Measurements
Measurement
|
Mean (n=43)
|
(SD)
|
Weight (kg)
|
22.3
|
(11.3)
|
Height (cm)
|
116.3
|
(22.3)
|
Weight for age Z score
|
1.5
|
(0.9)
|
Height for age Z core
|
1.6
|
(1.3)
|
Weight for height Z score
|
0.4
|
(1.2)
|
Biceps skinfold (mm)
|
4.0
|
(1.6)
|
Triceps skinfold (mm)
|
6.6
|
(2.6)
|
Subscapular skinfold (mm)
|
5.2
|
(2.3)
|
Suprailiac skinfold (mm)
|
4.3
|
(2.5)
|
Body fat (%)
|
11.2
|
(4.1)
|
Fat mass (kg)
|
2.7
|
(2.4)
|
Fat-free mass (kg)
|
19.6
|
(9.3)
|
Lower-leg lengths(8)
below the 2.5th centile was seen in 32.6% patients. There was a
significant correlation between height and lower-leg length (r = 0.83, P
< 0.001).
Table II
shows the distribution of mean z scores in relation to some
characteristics. Both HAz and WHz scores were significantly lower in
7-16 yr old (P < 0.05). Mean fat mass and body fat were higher in
females (P < 001). Similarly, the proportion of patients with WAz and
HAz scores under 2 SD were higher in males, patients 7-16 yr of age,
quadriplegics, having GMFCS levels III-V, and having oromotor
dysfunction.
Table II-WAz, HAz and WHz scores, and Body Fat Measurements in Relation to
Clinical Characteristics
|
Means
(SD)a
|
Characteristics
|
n
|
WAz
|
HAz
|
WHz
|
FM (kg)
|
FFM (kg)
|
BF (%)
|
Gender
|
Male
|
24
|
1.7(0.8)
|
1.8(1.1)
|
0.6(1.0)
|
2.0(1.0)
|
19.2(8.1)
|
9.7(2.1)
|
Female
|
19
|
1.3(0.9)
|
1.4(1.4)
|
0.2(1.4)
|
3.6(3.3)*
|
20.2(10.7)
|
13.2(5.1)**
|
Age groups
|
1-6 years
|
16
|
1.4(0.8)
|
0.9(1.2)
|
0.1(1.3)
|
1.4(0.3)
|
11.9(1.7)
|
10.4(1.7)
|
7-16 years
|
27
|
1.6(0.9)
|
2.0(1.1)*
|
1.0(0.9)*
|
3.5(2.7)**
|
24.2(8.8)***
|
11.7(4.9)
|
Diagnosis
|
Quadriplegia
|
14
|
1.8(0.9)
|
2.1(1.3)
|
0.6(1.0)
|
2.0(1.0)
|
19.4(8.0)
|
9.5(2.1)
|
Others
|
29
|
1.4(0.9)
|
1.4(1.2)
|
0.3(1.3)
|
3.1(2.8)
|
19.7(10.0)
|
12.0(4.5)*
|
GMFCS level
|
I-II
|
23
|
1.5(0.9)
|
1.4(1.0)
|
0.4(1.3)
|
2.9(2.5)
|
20.4(10.3)
|
11.5(4.6)
|
III-V
|
20
|
1.6(0.9)
|
1.9(1.5)
|
0.5(1.2)
|
2.5(2.3)
|
18.7(8.1)
|
10.8(3.4)
|
Oromotor dysfunction
|
Yes
|
23
|
1.7(1.0)
|
1.9(1.3)
|
0.5(1.2)
|
2.6(2.4)
|
19.0(8.6)
|
10.9(4.0)
|
No
|
20
|
1.3(0.7)
|
1.3(1.1)
|
0.3(1.2)
|
2.9(2.5)
|
20.3(10.2)
|
11.6(4.3)
|
Total
|
43
|
1.5(0.9)
|
1.6(1.3)
|
0.4(1.2)
|
2.7(2.4)
|
19.6(9.3)
|
11.2(4.1)
|
unpaired t test, *P<0.05, **P<0.01, ***P<0.001
WAz, HAz, WHz scores: weight for age, height for age, weight for height standard deviation scores.
FM: fat mass; FFM: free fat mass; BF: body fat
Discussion
Accurate measurement of
linear growth by height in children with CP may be difficult due to
frequent occurrence of joint contractures. It is suggested that linear
growth may be assessed using upper-arm and lower-leg lengths(8). We
found a significant correlation between height and lower leg length
measurements in our subjects.
Growth retardation in the
children with CP has been well documented in the literature. Stallings, et
al.(2), reported that there was a strong relationship between linear
growth measured with upper arm and lower leg length, neuromotor
involvement and nutritional status in the children with quadriplegic CP.
Among 171 patients attending a pediatric rehabilitation center, the mean
z scores of height and weight were found to be as 1.7 ± 1.9 and 1.6
± 1.8 respectively(10). The proportions of the children below the 2.5th
centile for normal height and weight were 38%, and 42%, respectively in
this study(10). Similar figures are reported by other workers(11).
It has been reported that
patients with CP have growth failure when compared with age and
sex-matched healthy children, and have different body compositions.
Stallings, et al(3) reported lower WAz and HAz scores, and body
fat, fat mass and fat-free mass in children with spastic quadriplegic CP
in comparison to normals. More children are malnourished in the
developing countries, including Turkey, as compared to the NCHS
reference population(12,13). Although we did not make a comparison
between the children with CP and a control group, we believe that the z
scores in our patients were significantly lower than healthy Turkish
children.
Krick and Van Duyn(14)
found that children with CP and oromotor dysfunction had significantly
reduced weight and height than their age-and sex-matched counterparts
without such impairment. Our results confirm those reported previously
since the proportion of patients with WAz and HAz scores below 2 SD
were higher in these with oromotor dysfunction.
Contributors:
MO coordinated the study and drafted the paper, he will act as the
guarantor for the paper. SA participated in data analysis and drafting
the paper. MAM participated in data collection and analysis. ANK
contributed in data analysis and drafting the paper.
Funding:
None.
Competing interests:
None stated.
|
Key
Messages |
Children with
cerebral palsy suffer from growth failure.
Qromotor dysfunction might
contribute to growth failure in some patients.
|
