Original Paper

Ann Nutr Metab 2015;66:224232

DOI: 10.1159/000431330

Cerebral Palsy in Children as a Risk

Factor for Malnutrition
a, b b a
LidiaPerenc Grzegorz Przysada Jadwiga Trzeciak
a
Regional Hospital No. 2. St. Queen Jadwiga in Rzeszow, Regional Physical Therapy Education
b
Center for Children (RORE), and Medical Faculty, University of Rzeszow, Rzeszow, Poland
posture control and motor
function. Professionals
currently stress that these
symptoms are often
accompanied by sensory,
perception, cognition and
behavior impairments,
epilepsy and secondary
bone/muscle deformities.
Key Words (for BMI z-score <1.64, p = International Classification
Cerebral palsy Gender Gross motor function classification 0.0010). Conclusions: of Diseases, 10th Revision
scale Body mass index Blood hemoglobin Among children with CP,
(ICD-10), lists numerous
types of CP: spastic
malnourishment risk factors
diplegia, spastic tetraplegia
are male gen-der for anemia
Abstract and spastic hemiplegia,
and tetraplegia and high
Aim: The main aim of this study was to determine some mal- dyskinetic CP, ataxic CP,
GMFCS values.
nutrition risk factors among children with cerebral palsy (CP). other CP and unspecified
2015 S. Karger
Children with CP often require the assistance of physical ther- AG, CP. The severity of disability
Basel

apy centers. Experience suggests that, apart from physical in this pa-tient group is
disabilities, this group often suffers from malnutrition. Meth- diagnosed independently of
ods: Data were gathered in the hospital among 128 children Introduction ICP classifica-tion, and it is
aged 318 years who were suffering from CP. The children based on Gross Motor
were admitted from 2011 to 2013 to the Center for Neuro-logical Cerebral palsy (CP) is a Function Classifica-tion
Physical Therapy for children in the Regional Hospital No. 2. St. group of symptoms caused System (GMFCS) [2].
Queen Jadwiga in Rzeszow (RORE). Statistical analy-ses were by a permanent and non-
conducted for data on gender, age, type of CP, mo-tor functionprogressive damage to the
level according to Gross Motor Function Classifi-cation Scale brain (cerebrum,
(GMFCS), body mass index (BMI) and hemoglo-bin levels in cerebellum, brain stem)
blood. Results: The risk of anemia differs based on gender suffered at an early
the risk is 6 times greater among boys than among girls (p = development stage. The
0.0398). Risk of malnutrition is 3.5 times higher in children with incidence is stable at 1.53
tetraplegia than in children with di-plegia or hemiplegia (p = cases for 1,000 live births
0.0043). Higher GMFCS scores are connected to greater [1].
proportions of malnourished children CP is characterized by
abnormal muscle tone,
PL-35- @
205 u
E-Mail karger@karger.com Lidia Perenc, MD
Rzeszow n
2015 S. Karger AG, Basel 0250 www.karger.com/anm Medical Faculty, University (Poland) i
6807/15/06640224$39.50/0 of Rzeszow Ul. E-Mail v
Warszawska 26a
mieczrad .
rzeszow.pl
Data indicate that in this patient group physical dis-
ability is often accompanied by malnutrition. One of the
possible, simple ways of assessing malnutrition is to com-
pute body mass index (BMI) and refer it to norms that are
expressed in the form of percentile charts plotted for age
and gender [3]. Malnutrition is diagnosed when BMI val-
ues drop below the 5th percentile or 1.64 z-score [4].
Before the course of nutritional treatment, assessment of
nutritional condition is necessary. In Poland, addition-ally,
anthropological assessment, including calculating a BMI
index, is highly recommended [5].
Aim. The aim of the study is to diagnose malnutrition
risk factors among children with CP, by using basic data
gathered at admission to the hospital (Center for Neuro-
logical Physical Therapy for children).
Methods
Basic data were gathered during the hospital stays of 128 chil-
dren aged 318 years suffering from infantile CP. The children were
admitted from 2011 to 2013 to the Center for Neurological Physical
Therapy for children in the Regional Hospital No. 2. St. Queen
Jadwiga in Rzeszow (RORE). The average age of the par-ticipants
was 8.7 years. Descriptive statistics are presented in ta-ble 1. A total
of 52.3% of the children were boys and 47.7% were girls (table 1).
The group included children with different forms of CP as listed in
ICD-10. The tetraplegic form was most common (39.1%) followed by
diplegic (31.3%) and hemiplegic (25%) and unspecified (3.1%).
Dyskinetic form was not observed (table 1). GMFCS was used to
estimate motor function. The biggest propor-tion of children (32%)
was in the II level of GMFCS, and the small-est proportion were in the
III and IV (12.5% each). A total of 25% of the children were in the
highest level of motor function develop-ment (level I) and 18% of the
children were in the level V, that is, the level of weakest motor
function development (table 1). In order to simplify the statistical
analysis of results, levels I and II of GMFCS were joined as group A
and levels III and IV as group C. Nutrition indices for all participants
were available, including BMI (Quetelet II index) and blood
hemoglobin level, with reference to age group. For the studied
groups, the z-score was calculated based on means and SDs
representing norms for population of healthy children from Rzeszow
[6]. Most of the z-score values appear be-
= 0.63, Me+ 0.5), which means that BMI values are sig-low 0 (x
nificantly lower in the studied group than in the group of
healthy children. The prevalence of malnutrition among
children with CP is 22.7% (table 1).
Relationships between the chosen characteristics were ana-
lyzed. Distributions of those characteristics that were treated as
dependent are presented in reference to groups determined by
the characteristic that were treated as independent variables (e.g.
BMI according to gender, GMFCS according to the type of CP).
Numbers and percentages of specific answers to the chosen
questions in the compared groups are presented in cross-tabs. Sta-
tistical analyses were conducted in order to estimate, if the varia-tions
of answers between the groups are accidental or if they stem
from a specific pattern, characteristic of the whole population.
Since the variables were measured on nominal scales, the Chi-
square test was chosen as the appropriate test for the analyses.
For variables measured on ordinal scale (BMI and GMFCS), the
significance level was verified using Mann-Whitney test (2 groups)
or Kruskal-Wallis test (for more than 2 groups).
Results
Gender and BMI
Distributions of participants between the BMI z-score
according to gender are presented in a cross-table. At first
glance, BMI distributions among girls and boys seem sim-
ilar. This has been confirmed by Mann-Whitney test at a p
value of 0.8455, which tested the hypothesis that the BMI
z-score distribution was similar for both groups (table 2).
Mann-Whitney test allows the comparing of average
distributions of a given characteristic between 2 groups,
but it does not allow the identification of differences in
proportions of subgroups (e.g. malnourished or obese
children); so, for chosen categories, additional Chi-
square test was conducted. This allowed us to compare
the num-ber of boys and girls within subgroups. As
indicated by the data presented in table 2, the analysis
did not identify any differences between boys and girls
in their BMI. There are a similar number of obese and
malnourished children in both groups.
Gender and Blood Hemoglobin
A statistically significant difference between boys and
girls in terms of anemia risk was detected. In the research
group, the risk of anemia was 6 times greater among boys
in comparison to girls (10.4 vs. 1.6%; probability com-
puted with Chi-squared at p = 0.0398). Comparisons of
groups based on the level of GMFCS or ICP type failed to
detect differences in terms of anemia (table 2).
Gender and Type of ICP
No statistically significant difference between boys
and girls in terms of incidence of various types of CP
was detected. The distributions were similar in the 2
groups. This claim is supported by an insignificant
result of the Chi-square test (p = 0.3963; table 2).
Gender and Motor Function Development
According to GMFCS
No differences between genders were found in terms
of GMFCS classification. Since GMFCS is coded on an
ordinal scale, the Chi-square test was used to detect dif-
ferences between genders (p = 0.1673; table 2).
CP and Malnutrition in Children Ann Nutr Metab 2015;66:224232 225
DOI: 10.1159/000431330
Table 1. Characteristics of the study group

c c
Age, years x Me s 25 75 Min Max
8.7 8.0 4.2 5.0 12.5 3 18

n %
Gender
Male 67 52.3
Female 61 47.7
Type of CP
Diplegia 40 31.3
Tetraplegia 50 39.1
Hemiplegia 32 25.0
Extrapyramidal 2 1.6
Undetermined 4 3.1
GMFCS
A
I 32 25.0
II 41 32.0
B
III 16 12.5
C
IV 16 12.5
V 23 18.0
BMI (z-score range)
<1.64 (malnutrition) 29 22.7
1.64 to 1.0 (low body mass) 19 14.8
1.0 to 1.0 (norm) 68 53.1
1 to 1.64 (overweight) 8 6.3
>1.64 (obesity) 4 3.1
c c
BMI (z-score) x Me s 25 75 Min Max
0.63 0.51 1.33 1.48 0.20 4.96 3.81

n %
Level of hemoglobin
Low 8 6.3
Normal 120 93.8

Arithmetic mean (x), median (Me), standard deviation (s), percentile 25. (c25) i 75. (c75), minimal
(min) and maximal (max) value, GMFCS level of motor development assessed with GMFCS scale.
tetraplegic CP (Chi-
square test at p =
0.0000; table 3). Level of Motor
CP Type and Motor Function According Function
to GMFCS
Estimated by
A statistically significant relationship was
GMFCS and
found be-tween the type of CP and level of
Position on BMI
motor function develop-ment, diagnosed
using the GMFCS. The distributions of
z-Score
Higher levels of
GMFCS levels across the compared
motor function
groups are presented below, and the
estimated by GMFCS
analyses were done with the Chi-square
(poorer motor function)
test. Tetraplegic children constitute the
were connected to more
biggest propor-tion of the weakest, that is,
severe malnutrition (p =
levels IV and V of motor func-tion
0.0010; table 3). Among
development (group C). The highest
children with the poorest
GMFCS scores were reached for
motor function
development, 46.2% scored below 1.64 z-found in group C than in 0.0011; table 3).
score (malnutrition) and 64.1% below 1.0 both remaining groups,
z-score (malnutrition and low body mass). which is evidenced by
Much more cases of malnutrition werelower BMI val-ues (p =
226 Ann Nutr Metab 2015;66:224232 Perenc/Przysada/Trzeciak
DOI: 10.1159/000431330
Table 2. Results part I

Gender (p = 0.8455) Total

male, % female, %
Relationship between gender and BMI (Mann-Whitney test)
BMI (z-score)
<1.64 (malnutrition) 16(26.2) 13 (19.4) 29
1.64 to 1.0 (low body mass) 9(14.8) 10 (14.9) 19
1.0 to 1.0 (norm) 32(52.5) 36 (53.7) 68
11.64 (overweight) 2(3.3) 6(9.0) 8
>1.64 (obesity) 2(3.3) 2(3.0) 4
Total 61 67 128

BMI (z-score)
c c
n x Me s 25 75

Gender
Female 61 0.63 0.47 1.31 1.60 0.11
Male 67 0.62 0.52 1.36 1.41 0.21
p 0.8455
Gender (p = 0.0398 ) Total
*
male, % female, %
Relationship between gender and blood hemoglobin (Chi-square test)
Blood hemoglobin
Low 7(10.4) 1(1.6) 8
Normal 60 (89.6) 60 (98.4) 120
Total 67 61 128

Gender (p = 0.3963) Total

male, % female, %
Relationship between gender and type of CP (Chi-square test)
Type of CP
Diplegia 23(34.3) 17 (27.9) 40
Tetraplegia 27(40.3) 23 (37.7) 50
Hemiplegia 13(19.4) 19 (31.1) 32
Athetoid 2(3.0) 0(0.0) 2
Undetermined 2(3.0) 2(3.3) 4
Total 67 61 128

Gender (p = 0.1673) Total

male, % female, %
Relationship between gender and level of motor development presented in GMFCS scale (Chi-square test)
GMFCS
A 34(55.7) 39 (58.2) 73
B 11 (18.0) 5 (7.5) 16
C 16 (26.2) 23 (34.3) 39
Total 67 61 128

CP and Malnutrition in Children Ann Nutr Metab 2015;66:224232 227

DOI: 10.1159/000431330
Table 3. Results part II
c
25
c
25
Type of ICP (p = 0.0000)

diplegia tetraplegia hemiplegia athetotidc undetermined Total

Relationship between type of CP and level of motor development presented in GMFCS scale (Chi-square test)
GMFCS
A 32 (80.0) 9 (18.0) 30 (93.8) 1 (50.0) 1 (25.0)
B 6 (15.0) 6 (12.0) 2 (6.3) 0 (0.0) 2 (50.0)
73
C 2 (5.0) 35 (70.0) 0 (0.0) 1 (50.0) 1 (25.0)
Total 40 50 32 2 4
16
39
GMFCS (p = 0.0010) Total 128

A B C

BMI z-score
<1.64 (malnutrition) 9 (12.3) 2 (12.5) 18 (46.2) 29
1.64 to 1.0 (low body 10 (13.7) 2 (12.5) 7 (17.9) 19
mass) 1.0 to 1.0 (norm) 47 (64.4) 11 (68.8) 10 (25.6) 68
11.64 (overweight) 4 (5.5) 0 (0.0) 4 (10.3) 8
>1.64 (obesity) 3 (4.1) 1 (6.3) 0 (0.0) 4
Total 73 16 29 128

BMI z-score
s
n x Me

GMFCS
A 73 0.34 0.36 1.12 1.01 c
75
B 16 0.23 0.52 1.36 0.96
C 39 1.31 1.52 1.47 2.04
p 0.0011 0.28
0.37
Type of CP (p = 0.0547) Total 0.26
diplegia/ tetraplegia
hemiplegia

Relationship between selected BMI z-score and types of CP (Chi-square test)

BMI (z-score) (%) <
1.64 (malnutrition) 10 (13.9) 18 (36.0) 28
1.64 to 1.0 (low body 12 (16.7) 7 (14.0) 19
mass) 1.01.0 (norm) 44 (61.1) 20 (40.0) 64
11.64 (overweight) 4 (5.6) 4 (8.0) 8
>1.64 (obesity) 2 (2.8) 1 (2.0) 3
Total 72 50 122

BMI z-score
s
n x Me

Type of CP
Diplegia 40 0.46 0.50 1.10 1.13 c
75
Tetraplegia 50 0.96 0.99 1.57 1.87
Hemiplegia 32 0.65 0.65 1.10 1.24
p 0.1250 0.20
0.02
0.32

228 Ann Nutr Metab 2015;66:224232 Perenc/Przysada/Trzeciak

DOI: 10.1159/000431330
Table 3. (continued)

Type of CP
diplegia/ tetraplegia
hemiplegia
OR
Risk of malnutrition (OR) in children with tetraplegia (chi-square test)
BMI z-score
Malnutrition 10 (13.9) 18 (36.0) 3.49 (1.448.43)

Figures in parentheses are percentages. OR = Odds ratio.

dren grow up to be adults
CP Type and Position on BMI z-Score with poor physical and
The analysis is reduced to the 3 most common forms mental ability, and they
of CP appearing in children. Children with diplegia and suffer from chronic illnesses
hemiplegia were combined into one group because theymore often. Nutrition issues
represent a similar level of motor development in terms of that are often observed
the GMFCS scale. Remaining types of CP were omitted among disabled children
because of their small number. The comparison of such affect growth, development
constructed groups points at the existence of significant and functions of the
difference (p = 0.0547). Malnutrition occurs more often in nervous, digestive and
children with tetraplegia. In general, the BMI z-score immune system and
values are lower in this group of children; however, the cardiorespi-ratory
Kruskal-Wallis test did not confirm statistically signifi-cant endurance, which in turn
difference (p = 0.1250). The risk of appearance of affects prognosis [8, 9].
malnutrition in children with tetraplegia is 3.5 times Authors often
greater than in children with diplegia or hemiplegia (p = concentrate on reporting
0.0043; table 3). greater inci-dence of
malnutrition among
Blood Hemoglobin Level and Motor
disabled children and on
Function According to GMFCS finding risk factors
GMFCS level distributions in the 2 groups werefacilitating malnutrition. In
com-pared using the Chi-square test. The level of the stud-ies, malnutrition is
statistical significance was not reached (table 4). estimated using
anthropometric indi-ces
Blood Hemoglobin Level and CP Type
(body mass, height, BMI,
No statistically significant difference in anemia inci- arm circumference, triceps,
dence among children with various types of ICP was waist and subscapular
de-tected (Chi-square at p = 0.4017; table 4). skinfold thickness) or
biochemical indices (blood
hemoglobin, as well as
Discussion vitamin A, D, al-pha-
tocopherol, zinc, copper,
Numerous factors have been known to influence post-
calcium, magnesium, fer-
natal growth and differentiation. The list includes prena-tal,
ritin and iron levels) [10,
genetic, socioeconomic, psychosocial factors, urban-ization, 11].
climate, nutrition, physical activity, health and illnesses [7]. Neyestani et al. [12]
Physical, motor and cognitive developments are influenced examined 290 boys and
by correct nutrition. Malnourished chil- girls with disabilities of
various origins. The
children were aged 612
years and attended
schools for children with
special education needs in
Iran (Tehran). The study
indicated that malnutrition
is observed more often in
the group of disabled
children in comparison to
their healthy peers. Almost
90% had their body mass
and 70% had their height
below the third percentile.
Malnutrition was as-sumed
to be the cause of these
deficits. The childrens
daily energy intake was at
90% of suggested daily
energy needs, and it
covered 76% iron needs
and 59% calcium needs. In
comparison to boys, girls
received less protein,
calcium and riboflavin, and
their height was more often
below normal.
A study with 145
intellectually and/or
physically dis-abled girls
and boys aged 815
years was conducted in
South Africa. Data
indicated that the
childrens meal in-take
was lower in energy
value and protein and
microele-ment content
[8].
In Indian studies
conducted among 141
disabled chil-dren living in
Mumbai slums, eating
disorders were iden-tified as
risk factors for malnutrition.
The disabled chil-
CP and Malnutrition in Children Ann Nutr Metab 2015;66:224232 229
DOI: 10.1159/000431330
Table 4. Results part III

Blood hemoglobin (p = 0.3314) Total

low normal

Relationship between level of motor development presented in GMFCS scale and blood hemoglobin (Chi-square test)
GMFCS
A 4 (50.0) 69 (57.5) 73
B 0 (0.0) 16 (13.3) 16
C 4 (50.0) 35 (29.2) 39
Total 8 120 128

Hb
c c
n x Me s 25 75

GMFCS
A 73 13.1 12.9 0.9 12.4 13.6
B 16 12.9 12.9 0.8 12.3 13.4
C 39 12.9 12.9 0.9 12.4 13.4
p 0.8229

Type of CP (p = 0.4017) Total

diplegia tetraplegia hemiplegia athetoticd undetermined
Relationship between type of CP and blood hemoglobin (Chi-square test)
Blood hemoglobin
Low 1 (2.5) 3 (6.0) 3 (9.4) 0 (0.0) 1 (25.0) 8
Normal 39 (97.5) 47 (94.0) 29 (90.6) 2 (100.0) 3 (75.0) 120
Total 40 50 32 2 4 128

Figures in parentheses are percentages.

decreases the
effectiveness of unassisted
mentioned above, eating, difficulties with
dren had difficulties in eating; they were smaller,including Poland, belong communication, de-claring
weighed less and suffered from vitamin D, ferritin to this cate-gory. hunger or satiety [10].
and iron defi-ciencies [13]. There is data on A total of 90% of children
Studies conducted in Egypt included 639 boys and girls malnutrition incidence with CP suffer from oro-
with mental disabilities, aged 614 years. Malnutri-tion (BMI among chil-dren suffering motor dysfunction [16],
below the 5th percentile) was observed among 14.1% of the from central nervous gastroesophageal reflux and
children and was more common among boys. Muscle system disorders [15]. constipation, and due to
atrophy and fatty degeneration were also more common Quality of nutrition among frequent vomiting, lack of
among boys. Children of both genders suffered from vitamin children with neurolog-ical appe-tite and discomfort
and microelement deficiencies. There were no gender dysfunctions (as estimated while chewing and
differences in the blood hemoglo-bin level, vitamin A, alpha- with anthropometric pa- swallowing, they develop a
tocopherol, copper and mag-nesium levels, but boys rameters) is usually poorer dislike for eating [17]. Issues
suffered from anemia caused by iron and zinc deficiencies in comparison to the group with eating are especially
more often than girls [11]. of healthy peers. intense among children with
Admittedly, the population of disabled children is notMalnutrition risk increases bilateral hemiple-gia and
homogenous. Studies conducted in a physical therapywhen CP is ac-companied hypotonic CP [18]. The
center in Mexico city showed that children with ICP are in by oro-motor dysfunctions mentioned eating disor-ders
greatest danger of malnutrition among those with CP,and upper limb and hand are also more intense
spina bifida, Down syndrome or muscle atrophy [14]. dysfunctions. These among children with CP and
Malnutrition among the disabled children is believed to symptoms increase the
be a problem in developing countries. The countries time needed for meals and
 230 Ann Nutr Metab 2015;66:224232 Perenc/Przysada/Trzeciak
DOI: 10.1159/000431330
epilepsy [18]. Treatment of resistant epilepsy in children among children requiring long-term nutritional inter-vention,
is also a risk factor for the development of malnutrition nasogastric tube feeding should be used for short-term
connected to chewing and swallowing disorders, vomit- intervention and (4) anti-reflux procedures should be
ing and also to accompanying anorexia. Additionally, reserved for children with significant gastro-esophageal
an-tiepileptic drugs may also decrease appetite, change reflux [21]. Reports also indicate that there are positive
me-tabolism and daily activity [19]. therapeutic effects of nutritional rehabilitation and
Furthermore, the metabolism among children education and family therapy as they are significant
with CP is different, that is, simple activities and elements of the process [18]. Composition and calorific
mobility con-sume more energy [10]. value of meals should be determined for each individual
According to Stallings et al. [20], most children child [2]. It has been known for some time now that nu-
with ICP suffer from a decreased body mass and tritional therapy improves the quality of life of the dis-abled
height. The prevalence and intensity of malnutrition children and their families [2224]. Identification of risk
depends on the type of CP and severity of the illness. factors helps direct preventive and therapeutic in-
For example, chil-dren with bilateral hemiplegia are terventions in the group of children with CP.
smaller (in terms of height) as compared to children
with hemiplegia or diple-gia.
The authors aimed to show whether basic clinical Conclusions
data, such as gender, type of CP according to ICD-10
or sever-ity of motor dysfunction, correlate with the level Tetraplegic CP and high GMFCS scores
of mal-nutrition. The results are congruent with those by increase the danger of low BMI indices (below
Stall-ings et al. [20]. It turns out, that the highest levels 1.64 z-score). Male gender is a risk factor for
of GMFCS were observed in tetraplegia. Those anemia among children with CP.
suffering from tetraplegia had their BMI at a level below
the third percentile. The higher the level of GMFCS, the
greater the proportion of malnourished children. The Acknowledgments
greatest pro-portion of children with normal BMI was
All the authors have made substantial contributions and final
found among those with diplegia. Furthermore, in the
approval of all the conceptions, including drafting, and final ver-
researched group, the danger of anemia is 6 times sion. This study was self-funded. The positive attitudes and
greater among boys in comparison to girls. techni-cal assistance of the staff of Regional Hospital No. 2. St.
Data from western Turkey showed that among Queen Jadwiga in Rzeszow, Poland are greatly appreciated.
men-tally disabled children malnutrition increases
with age. Seventy-seven mentally disabled boys and
girls aged 10 18 years participated in the study [21]. Disclosure Statement
This observation has serious clinical implications
The authors declare that they have no competing interests.
diagnosing malnutri-tion requires therapeutic action
and a passive stance is not recommended.
Knowing the relationship between the type of CP (ac-
cording to ICD-10), severity of motor dysfunction (ac-
cording to GMFCS) and malnutrition (estimated basing on
BMI) allows the identification of those groups of pa-tients
who need special diagnostic and therapeutic proce-dures.
In 2009, Canadian Pediatric Society issued the fol-lowing
recommendations for children with neurological disorders:
(1) children at risk of nutrition-related prob-lems should be
identified early; (2) an assessment of nu-tritional status
should be performed during examination, and a
multidisciplinary team should be involved in the nutritional
intervention, which should be a part of an in-tegrated,
diversified therapy; (3) oral intake should be op-timized if
safe, and gastrostomy should be considered
 AACPDM: The definition and
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232 Ann Nutr Metab 2015;66:224232 Perenc/Przysada/Trzeciak
DOI: 10.1159/000431330
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