‘Nutritional status of children with cerebral palsy in a Brazilian tertiary‐care teaching hospital’

Abstract

SIR–Malnutrition is a common and worldwide medical problem in children with cerebral palsy (CP).1–5 Pediatric gastroenterologists and nutritionists have seen an increasing number of patients with CP requiring nutritional support in Brazilian clinics in the last few years. Any evaluation of current nutritional condition in children with CP should take into consideration the fact that these children are usually smaller than children at the same age due to their muscle hypotrophy and contracture. There is a lack of information regarding the nutritional status of Brazilian children with CP. This study reports data on growth parameters recorded in patients with CP seen at gastroenterology, orthopaedic, and neurology pediatric units in a Brazilian tertiary-care teaching hospital, between January 2004 and March 2006, from 58 cities of three states of Brazil. Data and the anthropometric measurements were obtained by a trained nutritionist observer with validity measurements after Review Board approval and the caregivers gave informed consent. The weight, height, triceps skinfold thickness (TST), mid-upper arm muscle area (AMA), and mid-upper arm fat area (MAFA) were converted into z-scores, and malnutrition was defined when the z-score was ≤–2.6,7 Data were recorded in the SPSS. Most of the children (80.7%) were unable to assume and upright posture. Some of them had scoliosis, involuntary muscle spasms, and poor cooperation so the height was estimated on the basis of knee height.1 One hundred and fourteen children were measured, 65 (57%) males and 49 (43%) females, aged from 2 to 12 years 11 months (median age 7y 4mo). Spastic quadriplegic CP was the most frequent type, found in 78 (68.4%) children. Fifteen (13.2%) patients were neurologically classified as mixed type, 10 (8.8%) children had spastic hemiplegia CP, eight (7%) had spastic diplegia CP, and three (2.6%) were classified as athetoid. The ataxic type of CP was found only in children with the mixed type of CP. According to the Gross Motor Function Classification System,8 96 (84.2%) were classified as Level V, eight (7%) as Level IV, six (5.3%) as Level I, and four (3.5%) as Level II. Anthropometric indicators (z-scores) mean and standard deviation were: –2.19 (SD 2.48) for weight; –1.66 (SD 1.50) for height; –1.04 (SD 1.34) for TST: –1.03 (SD 1.73) for AMA; and –1.15 (SD 1.41) for MAFA. Children with quadriplegia showed the most frequent malnutrition: 42 (72%) for weight; 31 (68.9%) for height; 25 (71.4%) for TST; 24 (68.6%) for AMA; and 31 (75.6%) for MAFA. Mean weight/age z-scores were significantly lower in children with the athetoid and mixed type of CP. However the mean height/age z-scores were significantly higher in children with hemiplegic CP. Children with athetoid CP presented the lowest MAFA values (p<0.001), whereas no significant difference was found for mid upper AMA. There was no significant difference in the anthropometric indicators for sex. This study showed that Brazilian children with CP are severely malnourished when compared to children with CP in other countries.4,9,10 Weight, height, and MAFA were lower compared to the National Center for Health Statistics reference curves. Weight/age z-score ≤–2 was observed in 50.9% of the children, height in 38.6%, and adipose tissue in 35.1%. One-third of the children presented with malnutrition in other anthropometric parameters, including TST (30.7%) and mid upper AMA (29.8%). Malnutrition was more severe in quadriplegic children with dysphagia, as reported by others studies.11,12 Two other situations contributed to the malnutrition in this study: the socioeconomic status, which was more frequently in D class with 53 children (46.5%), and the use of gastrostomy feeding, which was very low, with only seven children (6.2%).