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Am J

l

Nu i r

1996 :64 :62 7-3 4 . P rin te d in U SA . U 1996 Am eric an So ciety for C lin ica l N u trit ion

62 7

Energy expend itu re o f ch ild ren and ado lescen ts w ith

seve re d is ab ilit ies : a ce reb ra l p a lsy m ode l

V irg in ia A S ta llings B a be tte S Zem el Ja vn e C D av ies C hr istine E C ronk an d E dw ard B C h arize

A B S T R A C T

Spa stic q uad rip leg ic ce reb ral p alsy SQ CP ) is a

severe disab il ity tha t is a sso cia ted w ith ab norm a l phy sic al activ ity ,

body com pos ition , an d food in tak e and w ith frequen t m alnu trition .

T his stu dy exam in ed the p atte rn o f d ie tary in ta ke, an thro pom e try ,

an d en erg y exp end itu re in a g rou p of sub jects w ith SQ CP ag ed

2-I 8 y and a n orm al con tro l g roup . T he en ergy expend itu re pa tte rn

w as de te rm ined from res tin g energy expend itu re REE , n = 61

SQCP : 37 con tro l g ro up) by us ing ind irec t ca lo rim etry and

from to ta l en ergy ex pend itu re TEE , n

= 32

SQCP ; n

32

con tro l

g rou p) by u sin g the do ubly la beled w ater m ethod . Phy sic al a ctiv -

ity , in clu d in g the chro n ic sp ast ic ity of SQ C P, w as est im a ted from

the ra tio o f TEE to R EE . A bno rm al g row th an d body com pos ition

w ere comm on and d ie ta ry in take w as m ark ed ly o verreported in the

ch ild ren w ith SQC P. C hild ren w ith SQC P w ere d iv ided acco rd ing

to body fa t s to res de te rm ined by triceps-sk in fo ld -th ickness m ea-

surem en ts. Th e ch ild ren w ith low fa t s to re s had a low e r R EE

ad jus ted fo r fa t-free m ass com pared w ith the SQCP and con tro l

g roups

w ith ad equ ate fat s to res.

TEE was s ig n ifican tly low er fo r

the SQCP group than fo r the con tro l g roup . T he ra tio o f TEE to

REE , ind icat ing en erg y for n on basal n eed s, w a s sign ifican tly

low e r in the SQC P ch ild ren than in the con tro l g rou p , w ith the

ad eq ua te ly n ourished SQCP ch ild ren hav ing low er ra tios than th e

m ore poo rly nou rished SQC P grou p . T he nonbasa l energy exp en-

d itu re, such as fo r p hys ica l ac tiv ity an d sp as tic ity , o f ch ild ren w ith

SQC P w as low . T he nu tritio n -re la ted grow th fa ilu re and ab norm al

p a tte rn of REE a re like ly re la ted to inadeq ua te energ y in take .

Am

J C /in N u ir 1996;64 :627-34 .

K E Y W O R D S D ev e lo p m en ta l d isa b ilitie s cereb ra l pa lsy ,

res ting energy expend itu re , to ta l energy expend itu re , nu tr i-

t ion al s ta tu s, body com pos ition , d ie ta ry in tak e

I N T R O D U C T I O N

Pro v id ing op tim al ca re fo r pa tien ts w ith sev ere d isab ilitie s is

a cha lleng e tha t is becom ing increas in g ly reco gn ized by the

lega l, e th ica l, an d c lin ica l ca re g roups in the d isab ility fie ld

1 -8 ). O ne ofthe m o st basic com ponen ts o fca re is p rov is io n of

ad eq ua te food to m ee t n u trition al requ irem en ts . Y e t, fo r pa-

tien ts w ith m any severe d isab ilities , m arked aberra tions in

phys ical activ ity , b ody com pos ition , an d foo d in tak e render the

energy recomm end ations d er iv ed from hea lthy popu la tions po-

ten tia lly use less . In add ition , cu rren t na tio na l an d in te rna tiona l

energy in take recomm enda tio ns fo r h ea lthy ch ild ren and ad o-

lescen ts a re und er rev iew becau se som e age-g roup recomm en-

da tions appear to be h ig her than needed fo r usua l phy sica l

act iv i ty of ch ild ren in deve loped na tions 9-14). T h e en erg y

in take issue is even m ore critica l fo r pa tien ts w ith severe

d isab ilitie s because o f the ir inab ility to c lea rly comm un ica te

hunger and sa tie ty , w h ich leaves them dep enden t on a varie ty

of ca reg ivers to define and pro v ide op tim al in tak e w ithou t

d isease -sp ec ific d ie ta ry gu ide lines. T he o ra l m oto r dy sfun ction

tha t o ccu rs in m any pa tien ts w ith severe d isab ility resu lts in

ex tended tim e requ ired fo r m ea ls , p oor feed ing sk ills, frequen t

foo d re fusa l, cou gh ing , asp ira tion , re flux , and vom iting . T here -

fo re , these pa tien ts a re a t h ig h r isk fo r nega tive energ y ba lance

inc lud ing g en eral un dernu tritio n , ab norm al body com pos ition ,

and g row th failu re w ith inadequa te in take .

S pas tic q uadrip leg ic ce reb ra l p alsy SQCP ) is an exam ple of

a comm on perm anen t, severe d isab ility u sua lly w ith m ark ed ,

decreased cogn ition and am bula tion . P a tien ts w ith SQCP ex-

h ib it ab norm al phys ica l ac tiv ity , body com pos ition , and food

in take , w ith frequen t m aln u trition 1 5-2 6). B y us in g SQC P as

the m ode l o f a severe d isab ility , th is stud y exam ined the

pa tte rns o f d ie ta ry in take and energy expen d itu re in a group of

sub jec ts aged 2 -18 y w ith SQCP and a group of sim ilar ly sized

hea lthy ch ild ren . T he energ y expend itu re pa tte rn w as d ete r-

m ined from res ting energy expend itu re REE ) b y us in g ind irec t

ca lo rim etry and to ta l en ergy expen d itu re TEE ) b y using the

d oub ly labe led w ate r m ethod . T hese m easurem en ts a lso p ro -

v id ed an es tim ate o f the energy expend ed fo r phy sica l ac tiv ity ,

inc lud ing the ch ron ic sp as ticity o f SQ CP . T h e purp ose of th is

s tudy w as to m easure TEE and R EE and to de te rm ine the effec t

o f m alnu trition on the pa tte rn of en ergy expen d itu re .

S U B J E C T S A N D M E T H O D S

Six ty -o ne ch ild ren aged 2-1 8 y w ith a d iagnos is o f SQC P

w ere enro lled from two un iv ersity -based , te rtia ry care cereb ra l

I From the D iv isions of Gastroen te ro logy an d N utrition and Ch ild D c-

v e lo pm ent and R ehab ilita tion M ed ic ine . T he Ch ild re s H osp ita l

o f P hil-

ade lph ia . an d the D ep artm en t of P ed iatr ics, U n ive rsity of P enn sy lvan ia

Sch oo l of M ed icine, P h i lade lph ia .

2

Suppo rted by the Un ited C ereb ral P a lsy F ounda tio n , T he C hild ren s

Seashore House , the G ene ral C lin ic R e sea rch C ente r N IH RR - )0240) . and

th e N u trition C en te r

of The C hild ren s H osp ita l o f Ph ilad elp h ia .

3 A ddress rep rin t req uests to V A S ta ll in gs . D iv is io n of Gastroen te ro logy

and N utr itio n . Th e C hild re s H osp ita l o f Ph ilad elp h ia , 34 th S treet and

C iv ic C ente r Boulevard , Ph ilad elp h ia . PA 19104 . E -m ail : sta llingsv@

email .chop .edu .

R ece ived Feb rua ry 5 . 19 96 .

Accep ted

fo r pub lic atio n Jun e 3 . 1 996 .

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62 8

S T A L L IN G S E T A L

p alsy cen te rs : th e C h ild ren s S eash o re H o u se (T h e C h ild ren s

H o sp ital o f Ph ilad e lp h ia) an d th e A l d u Po n t In s titu te in W ilm -

in g to n , D E . T h e d iag n o sis o f S Q C P w as b ased o n a n eu ro lo g ic

ex am in atio n b y a d ev e lo p m en tal p ed iatric ian o r p ed iatric n eu -

ro lo g ist. S Q C P w as d e f in ed as sev ere in v o lv em en t o f b o th

u p p er an d lo w er ex trem itie s. C h ild ren w ith S Q C P w ere ex -

c lu d ed f ro m th e s tu d y if th ey h ad an y o th er ch ro n ic illn e sses

(eg , card iac , ren al, g astro in te stin al, o r co n g en ital sy n d ro m es)

o r u sed an y m ed icatio n (eg , ste ro id s , th y ro x in e ) k n o w n to

af f ect g ro w th o r b o d y co m p o s itio n . M o s t ch ild ren w ere en -

ro lled d u rin g a ro u tin e o f f ice v isit w ith f o llo w -u p co n tac t to

sch ed u le th e o v ern ig h t ad m iss io n an d m easu rem en ts. S o m e

ch ild ren w ere en ro lled b y a te lep h o n e call f ro m th e ir d ev elo p -

m en tal p ed iatric ian o r c lin ical co o rd in ato r to a p aren t w h en

th ere w as n o co n v en ien t c lin ic v is it sch ed u led . T h ere w as n o

recru itm en t s trateg y b ased o n race , sex , n u tritio n al s tatu s , o r

d isease sev erity . C h ild ren w ere c lassif ied as d y sk in e tic w h en

th ey h ad ch o re if o rm o r ath e to tic m o v em en ts . T h irty -sev en

h ealth y ch ild ren f ro m th e g en eral h o sp ital co m m u n ity an d

sib lin g s o f th e S Q C P su b jec ts w ere recru ited as co n tro l su b -

jec ts. B ecau se th e p rim ary aim o f th e in v estig atio n w as to

co m p are p atte rn s o f en erg y ex p en d itu re , th e g ro u p o f co n tro l

ch ild ren w ere se lec ted to b e s im ilar in sex , b o d y w e ig h t, an d

d istrib u tio n o f f at-f ree b o d y m ass to th e ch ild ren w ith S Q C P.

E x c lu sio n crite ria f o r co n tro l su b jec ts w ere th e sam e as f o r th e

ch ild ren w ith S Q C P. In f o rm ed co n sen t w as o b tain ed f ro m th e

ch ild ren s p aren ts o r leg al g u ard ian s an d th e p ro to co l w as

ap p ro v ed b y th e In stitu tio n al R ev iew B o ard at T h e C h ild ren s

H o sp ital o f Ph ilad elp h ia. T h e s tu d y w as co n d u c ted in th e

N u tritio n an d G ro w th L ab o rato ry an d th e G en eral C lin ical

R esearch C en te r o f T h e C h ild ren s H o sp ital o f Ph ilad e lp h ia

d u rin g an 1 8 -h o v ern ig h t ad m iss io n an d d u rin g th e 2 w k af te r

th is ad m iss io n.

N u tritio n al asse ssm en t in c lu d ed m easu rem en t o f w e ig h t, u p -

per-arm c ircu m f eren ce , an d sk in f o ld th ick n esses (tricep s an d

su p railiac) b y u sin g th e m e th o d s o f C am ero n (2 7 ). A H o ltain

sk in f o ld calip er (C ry m y ch , U n ited K in g d o m ) w as u sed to m ea-

su re sk in f o ld th ick n esses. Fat-f ree m ass, f at m ass, an d p ercen t-

ag e b o d y f at w ere calcu lated b y u s in g th e sex - an d p u b ertal

s tag e -ap p ro p riate p red ic tio n eq u atio n s o f S lau g h te r e t al (2 8 ) .

U p p er-arm c ircu m f eren ce w as tak en b y u s in g a p las tic In ser-

T ap e (R o ss L ab o rato rie s, C o lu m b u s, O H ) an d w e ig h t w as

m easu red b y elec tro n ic scale . L in ear g ro w th in ch ild ren w ith

SQ CP w as assessed b y u sin g a H o ltain an th ro p o m e te r to m ea-

su re u p p er-arm an d lo w er-leg len g th s (2 7 , 2 9 ). H e ig h t in th e

co n tro l su b jec ts w as m easu red b y u sin g a s tad io m e te r (2 7 ).

T w o rep licates o f each m easu rem en t w ere tak en an d th e m ean

v alu e u sed in th e an aly ses . A ll an th ro p o m e tric m easu rem en ts

w ere o b tain ed b y tw o in v estig ato rs (JC D an d B S Z ) . Pu b ertal

d ev e lo p m en t w as assessed an d each ch ild w as assig n ed a

p u b ertal stag e (3 0 ). W h ee lch air-b ased am b u lato ry statu s w as

c lass if ied as e ith er ass isted o r e lec tric . C o g n itiv e ab ility w as

b ased o n ed u catio n al c lass if icatio n an d recen t d ev e lo p m en tal

testing.

B ecau se o f th e co n trib u tio n o f o ral m o to r f u n c tio n to f o o d

in tak e (2 5 , 2 6 ), o ral m o to r ab ility w as assessed b y in terv iew

w ith th e careg iv er. T h e resu lts w ere scaled f ro m 0 to

5

or

g reate r, 0 in d icatin g n o ab n o rm alitie s an d 5 in d icatin g th e

p resen ce o f all th e f eed in g d if f icu ltie s asse ssed . T h ese in c lu d ed

to n g u e th ru s t, f lu id o r f o o d lo ss d u rin g eatin g , co u g h in g o r

g ag g in g d u rin g eatin g , ex cess iv e tim e req u ired f o r m eals , an d

d if f icu lty in co n su m in g tex tu red f o o d s (2 1 ).

N u trien t in tak e w as estim ated f ro m a w e ig h ed , 3 -d d ie tary

reco rd . T h e d ie tary d ata w ere c larif ied w ith th e careg iv er w h en

n eed ed an d an aly z ed b y o n e in v estig ato r. Pap er f o o d m o d e ls , a

f o o d scale (# 1 8 5 ; S u n b eam O ste r. S h u b u ta, M S ), an d a m ea-

su rin g cu p w ere d istrib u ted to each f am ily an d w ere u sed to

d e te rm in e f o o d p o rtio n s iz es . D ie t reco rd s w ere an aly z ed b y a

co m p u te r p ro g ram (FO O D PR O C E S S O R II, E sch a C o . E u -

g en e , O R ) an d m ean en erg y in tak e f o r th e 3 d w as rep o rted an d

co m p ared w ith 1 9 8 9 reco m m en d ed d ie tary allo w an ces (R D A s)

f o r ag e an d sex (3 1 ).

R est i n g ener gy expend i t u r e

REE was m easu r ed b y o p en -c ircu it in d irec t calo rim e try . In

p rep aratio n , each ch ild w as ad m itted to th e G en eral C lin ical

R esearch C en te r th e p reced in g af te rn o o n an d g iv en an ev en in g

m eal p ro v id in g 4 0 % o f th e to tal d aily en erg y b ased o n th e R D A

f o r ag e g ro u p , sex , an d b o d y w eig h t as 4 0 % f ro m carb o h y d rate ,

2 0 % f ro m p ro tein , an d 4 0 % f ro m f at. E ach ch ild f as ted an d

sto p p ed all m ed icatio n f o r 1 2 -1 4 h b ef o re th e R E E m easu re-

m en t. In th e early m o rn in g th e ch ild w as aw ak en ed , a n o rm al

ax illary tem p eratu re w as d o cu m en ted , an d th e ch ild w as tran s-

p o rted b y w h ee lch air f o r th e m easu rem en t o f R E E . A co m p u t-

e riz ed m e tab o lic cart (G o u ld 2 9 0 0 o r S en so rM ed ic 2 9 0 0 Z ;

S en so rM ed ic s, Y o rb a L in d a, C A ) w as u sed to m easu re R E E f o r

6 0 m m in a q u ie t, th e rm o n eu tral ro o m w h ile th e ch ild re s ted in

a su p in e p o sitio n . A larg e , c lear v en tilated h o o d w as p laced

o v er th e su b jec ts h ead f o r sam p lin g resp irato ry g ases. T h e

m o d if ied W eir eq u atio n (3 2 ) w as u sed to calcu late en erg y

eq u iv alen cy f ro m o x y g en co n su m p tio n an d carb o n d io x id e

p ro d u c tio n . T h e f irst 1 0 m m w ere d ev o ted to en v iro n m en tal

ad ju s tm en t b y th e ch ild an d w ere e lim in ated f ro m calcu latio n s.

REE data w er e com par ed

w ith p red ic ted v alu es f ro m W o rld

H ealth O rg an iz atio n (W H O ) b asal m e tab o lic rate eq u atio n s ,

w h ich are w e ig h t-, ag e- , an d sex -sp ec if ic (3 3 ).

T otal ener gy expend i t u r e and tot al b od y w ater

T E E w as m easu red b y th e d o u b ly lab e led w ater m e th o d w ith

th e s tab le iso to p es d eu te riu m (2 H ) as d eu te riu m o x id e an d i80

in w ate r w h ile th e su b jec ts m ain tain ed th e ir u su al f o o d in tak e

an d d aily activ ity p atte rn . T h e d o se w as 0 .1 4 g 2 H 2 O /k g esti-

m ated to tal b o d y w ater o f 9 9 .8 ato m p ercen t d eu te riu m (A l-

d rich , M ilw au k ee) . T h e d o se o f 18 0 in w ate r w as 0 .3 0 g

H 2 1 8 0 /k g es tim ated to tal b o d y w ater o f 1 4 -1 5 ato m p ercen t

i80 E G G M ound , M iam isbu r g, O H )

(23) .

T h e m eth o d is

accu rate to 5 % in su b jec ts in f ree -liv in g co n d itio n s (34-37) .

O n the day of

ad m iss io n , f as tin g b eg an at 1 8 3 0 an d a

b ase lin e u rin e sam p le w as co llec ted . U rin e sam p les f ro m in -

co n tin en t su b jec ts w ere co llec ted in d iap ers w ith an ex tra lay er

o f co tto n b attin g . Fo r co n tin en t su b jects u rin e w as co llec ted b y

s tan d ard m e th o d s . A t 2 0 0 0 , th e iso to p es w ere ad m in is te red b y

n aso g astric tu b e o r o rally d ep en d in g o n th e o ral m o to r sk ills o f

th e ch ild . O v ern ig h t u rin e an d th e f irs t u rin e v o id o f th e

m o rn in g (d ay 1 ) w ere co llec ted an d p o o led to ad ju s t f o r iso to p e

lo sse s . T h e seco n d u rin e v o id o f d ay 1 w as co llected to d e ter-

m in e to tal b o d y w ater an d to b eg in th e T E E m etab o lic p erio d

(3 8 ). A t h o m e , th e f irs t u rin e v o id o f d ay s

5 8 , 1 1, and 1 5 w as

co llec ted . U rin ary 2 H an d iso to p ic ab u n d an ces w ere m ea-

su red b y iso to p e ratio -m ass sp ec to m e try (S ch o elle r, U n iv ers ity

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N U T R IT IO N A N D C E R E B R A L PA L S Y

62 9

o f C h icag o ). S tan d ard eq u atio n s f o r calcu latio n o f T E E w ere

u sed , w ith ad ju s tm en t f o r o v ern ig h t lo ss af te r d o s in g . T h e

e lim in atio n rates f o r 80 (k ,,) an d 2 H (k H ) w ere d ete rm in ed b y

u sin g th e tw o -p o in t m e th o d . T h e 1 4 -d m e tab o lic p erio d w as

d e f in ed b y th e d if f e ren ce b e tw een d ay 1 an d d ay 1 5 . If th e

en erg y ex p en d itu re d if f e red

>

1 0 % b e tw een d ay 1 1 an d d ay

1 5 , d ata f o r th at su b jec t w ere ex c lu d ed f ro m f u rth er an aly sis .

T h e resp irato ry q u o tien t (R Q ) f o r th e T E E p erio d w as esti-

m ated as 0 .8 4 . T h is w as s im ilar to th e R Q es tim ated f ro m

ex am in atio n o f th e 3 -d reco rd s f ro m a su b set o f th ese su b jects .

T E E d ata w ere co m p ared w ith th e R D A f o r en erg y f o r ch ild ren

by ag e g ro u p an d sex (3 1 ) .

D at a analy si s

G ro w th m easu res, h e ig h t. w eig h t, an d lo w er-leg an d u p p er-

arm len g th , w ere ex p ressed as S D s o r Z sco res b y u s in g ag e -

an d sex -sp ec if ic re f e ren ce d ata to p erf o rm th e co m p u tatio n s .

R e f e ren ce d ata f o r h eig h t an d w e ig h t w ere o b tain ed f ro m th e

N atio n al C en te r f o r H ealth S tatistic s (3 9 ) an d co m p u ted b y

u sin g th e C en te rs f o r D isease C o n tro l an d Prev en tio n C A S P-

A N T H R O so f tw are p ro g ram (A tlan ta). R e f e ren ce d ata f o r lo w -

er-leg an d u p p er-arm len g th w ere o b tain ed f ro m S p en d er e t al

(29) . B ecau se o f th e k n o w n sk ew n ess in sk in f o ld th ick n esses

an d o th er so f t tissu e m easu res, p ercen tag es o f th e m ed ian s

w ere u sed in s tead o f

Z

sco res to calcu late ag e - an d sex -sp ec if ic

sco res f o r g ro u p co m p ariso n s . R e f e ren ce d ata f o r tricep s sk in -

f o ld th ick n ess , arm c ircu m f eren ce , u p p er-arm m u scle area, an d

u p p er-arm f at area w ere f ro m Frisan ch o (4 0 ) . T h e N atio n al

C en te r f o r H ealth S tatis tics ref eren ce stan d ard s f o r su b scap u lar

sk in f o ld th ick n ess w ere also u sed (4 1 ). R E E w as ex p ressed as

kJ /d . k J / k g b o d y w t, an d kJ /kg f at-f ree m ass . R E E as a p er-

cen tag e o f p red ic ted v alu es w as co m p u ted b y u sin g th e ag e -

an d sex -sp ec if ic eq u atio n s f ro m th e W H O (3 3 ). E n erg y in tak e

w as ex p ressed sim ilarly (k J/d an d k J k g b o d y w t d ), an d

as a p ercen tag e o f th e R D A as en erg y in tak e p er d ay an d

en erg y in tak ek g b o d y w t d

Fo r p u rp o ses o f an aly s is. ch ild ren w ere g ro u p ed as S Q C P o r

co n tro l g ro u p . T h e S Q C P g ro u p w as f u rth er an aly z ed as tw o

su b g ro u p s: ad eq u ate su b cu tan eo u s f at sto re s , in d icatin g cu r-

ren tly ad eq u ate n u tritio n al statu s , o r lo w su b cu tan eo u s f at

sto res , in d icatin g a p o o rly n o u rish ed statu s. T h e 2 5 th cen tile f o r

tricep s sk in f o ld th ick n ess w as ch o sen (4 0 ) to ass ig n th e S Q C P

ch ild ren in to th e ad eq u ate f at s to re s (> 2 5 th cen tile ) co m p ared

w ith lo w f at s to re s ( 2 5 th cen tile) g ro u p s . T h is w as to en su re

th at th o se su b jec ts c lassif ied as w e ll-n o u rish ed h ad ad eq u ate

en erg y in tak e d u rin g th e recen tly p as t tim e in te rv al re su ltin g in

ad eq u ate su b cu tan eo u s f at s to re s. D if f e ren ces b e tw een all

S Q C P ch ild ren an d co n tro l ch ild ren w ere ev alu ated b y a te st.

A n aly s is o f v arian ce w as u sed to co m p are ad eq u ate ly an d

p o o rly n o u rish ed S Q C P ch ild ren an d co n tro l ch ild ren . Fo r

so m e an aly se s . an aly s is o f co v arian ce (A N C O V A ) w as u sed ,

so th at co m p ariso n am o n g g ro u p s co u ld b e m ad e af ter th e

b io lo g ically re lev an t v ariab le s su ch as w eig h t, f at-f ree m ass , o r

sex w ere co n tro lled f o r (4 2 ). In te rac tio n te rm s w ere te sted in

th e m o d e ls to d e te rm in e w h eth er th e re latio n s b e tw een th ese

variables an d en erg y ex p en d itu re w ere d if f e ren t am o n g g ro u p s.

T h e S ch ef f d tes t w as u sed to te st f o r d if f e ren ces b e tw een g ro u p

m ean s . M u ltip le -reg ressio n m o d e ls w ere u sed to p red ict R E E .

A ll s tatis tical an aly se s w ere p erf o rm ed w ith S A S (S A S In s ti-

tu te , C ary . N C ) o n a V A X

4000

m in i-m ain f ram e co m pu te r.

RESUL TS

Sam pl e ch ar act er i st ics

T h e su b jec ts f ro m b o th S Q C P n 6 1 ) an d n o rm al co n tro l

ii

= 37 ) group s w ere sim ilar in sex d istribu tio n; th e

SQCP

g ro u p w as S 1 % f em ale an d th e co n tro l g ro u p w as 5 2 % f em ale .

E th n ic an d rac ial rep resen tatio n v aried b e tw een th e tw o g ro u p s,

w ith th e S Q C P g ro u p b e in g 5 3 % A f rican A m erican , 3 9 %

w h ite , 5 % H isp an ic , an d 3 % A sian . T h e co n tro l g ro u p w as

9 2 % w h ite, an d 8 % A f rican A m erican . S u b jec ts w ith S Q C P

in c lu d ed 2 8 % w ith a d y sk in e tic m o v em en t d iso rd er, 5 6 % w ith

a se iz u re d iso rd er, an d 2 2 % w ith a v en tricu lo p erito n eal sh u n t.

A m b u latio n w as w ith assis ted w h eelch air f o r 9 5 % o f th e su b -

jects , th e rem ain in g u sed an e lec tric w h ee lch air. A ll su b jects

w ith S Q C P h ad co g n itiv e d e lay w ith 6 % class if ied at th e lev e l

o f ed u cab le m en tal re tard atio n , 3 8 % w ith train ab le m en tal

re tard atio n . an d 5 6 % w ith sev ere m en tal re tard atio n . M o s t

su b jec ts w ith S Q C P h ad ab n o rm al f eed in g sco res , in c lu d in g

6 6 % w ith sev ere f eed in g p ro b lem s . T w en ty - f o u r p ercen t h ad

f eed in g tu b es in p lace at th e tim e o f th e stu d y . Pu b ertal d ev e l-

o p m en t f o r th e ch ild ren in th e S Q C P g ro u p w as c lassif ied as

6 7 % p rep u b ertal. 1 3 % p erip u b ertal (8 % T an n er s tag e 2 , 3 %

stag e 3 , 2 % stag e 4 ), an d 2 % p o stp u b ertal. E ig h teen p ercen t o f

th e su b jec ts w ere u n c lassif ied . A ll o f th e co n tro l g ro u p su b jec ts

w e re p re pu be rt al.

G r ow th , n u t r i t i on al st at us, and bod y com posi t i on

G ro w th m easu rem en ts f o r ch ild ren w ith S Q C P an d th e n o r-

m al co n tro l g ro u p are sh o w n in

T ab le 1. T he con t r ol gr oup

T A B L E

1

G ro w th in d ex es

of c hildre n w ith ce reb ral palsy and co ntrol c hildre n

C ereb ral p alsy g ro u p

C o ntro l g rou p

ll L ow f at sto res

A d eq u a te f at s to re s

A g e (y ) 9 .0

4.3 6 1 12 9 .1

4 .4 1471 2 8 .5

4.1 1 14 1 6.2

2 .2 137 1

W eig ht (k g ) 18 .8 7.7 1 611 2

18.0

6 .6 14 7 1 2 2 1 .4

lO .4 1 14 1 2 2.0

5. 2 1371

W eig ht. Z score

-2.5

1 .1 1 61 12

2. 8

1.014 71 2 1 .8 1 .1 14 12 3 0.1 0.81371

H eig ht, Z score

- -

0.2

0 .8 1 3 7 1

L o w er leg , Z sco re -2 .0 1 .5 1 561 -2 .0 1 .5 1 431 -2 .3 1 .4 (1 31

-

U ppe rarm .Z sc ore -1 .6 1.3 15 91 -1 .6 1.314 51 -1 .5 1.21141

S D :

ii

i n b ra ck e ts .

2

S ig nif icantly d if f e ren t f ro m co ntrol gro up . P