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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu
Original article
a r t i c l e i n f o s u m m a r y
Article history:
Background & aims: Altered body composition is evident in school children with cerebral palsy (CP). Fat
Received 31 July 2013
free mass and fat mass amounts differ according to functional ability and compared to typically devel-
Accepted 8 February 2014
oping children (TDC). The extent to which body composition is altered in preschool-aged children with
CP is unknown. We aimed to determine the fat free mass index (FFMI) and body fat percentage (BF%) of
Keywords:
preschool-aged children with CP and investigate differences according to functional ability and compared
Body composition
Functional ability to TDC.
Children Methods: Eighty-ve children with CP (68% male) of all functional abilities, motor types and distributions
Cerebral palsy and 16 TDC (63% male) aged 1.4e5.1 years participated in this cross-sectional study. Body composition
was determined via isotope dilution. Children with CP were classied into groups based on their Gross
Motor Function Classication System (GMFCS) level. Statistical analyses were via ANOVA, ANCOVA, post-
hoc Tukey HSD tests, independent t-tests and multiple regressions.
Results: There were no signicant differences in FFMI or BF% when comparing all children with CP to
TDC. Children classied as GMFCS levels III, IV and V had signicantly lower FFMI levels compared to
children classied as GMFCS I and II (p < 0.05). Children of GMFCS IV and V had the highest mean (SD)
BF% of all children (24.6% (10.7%)), signicantly higher than children of GMFCS I and II (18.6% (6.8%),
p < 0.05).
Conclusions: Altered body composition is evident in preschool-aged children with CP, with a trend to-
wards lower FFMI levels and greater BF% across functional ability levels from GMFCS I to V. Further
Non-standard abbreviations: BF%, body fat percentage; BMI, body mass index; CP, cerebral palsy; DLW, doubly labelled water; DXA, dual energy X-ray absorptiometry;
FFM, fat free mass; FFMI, fat free mass index; GMFCS, Gross Motor Function Classication System; TDC, typically developing children.
q This material was presented as a free paper session at the following two conferences. (1) American Academy for Cerebral Palsy and Developmental Medicine 66th Annual
Meeting, 12the15th September 2012, Toronto, Canada. (2) Australasian Academy of Cerebral Palsy and Developmental Medicine 6th Biennial Conference, 27th May to 1st
June 2012, Brisbane, Australia.
* Corresponding author. Childrens Nutrition Research Centre, Queensland Childrens Medical Research Institute, The University of Queensland, Old Milk Kitchen, Building
916, Cnr Fourth and Back Rds (Southern Annexe of Edith Cavell Building), Herston, QLD 4029, Australia. Tel.: 61 07 3646 1981; fax: 61 07 3346 4684.
E-mail addresses: jacki.walker@hotmail.com (J.L. Walker), k.bell@uq.edu.au (K.L. Bell), RDS8Z@hscmail.mcc.virginia.edu (R.D. Stevenson), k.weir1@uq.edu.au (K.A. Weir),
r.boyd@uq.edu.au (R.N. Boyd), ps.davies@uq.edu.au (P.S.W. Davies).
1
Tel.: 61 07 3646 5542.
2
Tel.: 1 434 924 8184.
3
Tel.: 61 07 3636 1978.
4
Tel.: 61 07 3365 5315.
5
Tel.: 61 07 3646 1981.
http://dx.doi.org/10.1016/j.clnu.2014.02.007
0261-5614/ 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Please cite this article in press as: Walker JL, et al., Differences in body composition according to functional ability in preschool-aged children
with cerebral palsy, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.02.007
2 J.L. Walker et al. / Clinical Nutrition xxx (2014) 1e6
research is required to determine optimal body composition parameters and investigate contributing
factors.
Clinical trial registry: Australian New Zealand Clinical Trials Registry (ANZCTR) number:
ACTRN12611000616976.
2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Please cite this article in press as: Walker JL, et al., Differences in body composition according to functional ability in preschool-aged children
with cerebral palsy, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.02.007
J.L. Walker et al. / Clinical Nutrition xxx (2014) 1e6 3
2.3. Gross motor functional ability were calculated based on age and gender using the Centers for
Disease Control data26 and incorporating the LMS method. Mea-
Gross motor functional ability for the children with CP was sures of age, weight and height were compared between all chil-
determined independently by two research physiotherapists, using dren with CP and the TDC via independent t-tests. Measures of age,
an internationally accepted and validated classication, the weight and height were compared between functional ability
GMFCS.23 Children were classied into one of ve functional cate- groups and TDC using one-way ANOVA and post-hoc Tukey HSD
gories (IeV), which were then condensed into three groups: GMFCS tests to adjust for multiple comparisons. Body composition mea-
I and II, GMFCS III and GMFCS IV and V. sures (FFMI and BF%) were compared between all children with CP
and TDC via multiple regression, correcting for the inuence of age.
2.4. Anthropometry Body composition measures (FFMI and BF%) were compared be-
tween functional ability groups and TDC using one-way ANCOVA,
Weight was measured to the nearest 100 g using portable correcting for the inuence of age and using the Bonferroni
electronic scales (Homemaker Ltd, Australia) or chair scales (Seca correction for multiple comparisons.
Ltd, Germany). If the child was unable to stand or sit on their own,
they were weighed together with a parent. The parent was then
weighed separately and this weight subtracted from the combined 3. Results
weight to obtain a value for the child. Height or length (for children
under two years of age or those unable to stand correctly) was A convenience sample of 85 children with CP (68% male) with a
measured to the last completed millimetre using a portable length mean age (SD) of 2.6 (0.8) years participated in the study.
measuring board (Shorr Productions, Maryland, USA). In children Children ranged in age from 1.5 to 4.2 years. The distribution of
where a direct measure of height or length was not possible, knee GMFCS levels was as follows: I 42, II 10, III 13, IV 9, V 11,
height was measured to the last completed millimetre with an and with the exception of the inclusion of slightly more children
anthropometer (Holtain Ltd, Dyfed, UK). Knee height was then used classied as GMFCS I, is representative of a larger population of
to predict height using published, validated equations developed children with CP.27 Predominant motor impairments were: spas-
previously from a population of children with CP.5 All measure- ticity (n 72), dystonia (n 2), athetosis (n 3) and hypotonia
ments were taken by one of three trained dietitians. (n 8). Feeding method was via tube in 7 children (8%), all of whom
were classied as GMFCS IV or V. Epilepsy was present in 15 chil-
2.5. Ethics dren (18%), the majority of whom were classied as GMFCS III, IV or
V (n 11, 73%). The comparison group consisted of a convenience
This study was conducted as part of a larger project investigating sample of 16 TDC (63% male) with a mean age of 3.7 (0.5) years,
the growth, nutrition and physical activity of preschool-aged chil- range 3.0e4.5 years. All children were in good health at the time of
dren with CP (funded by the National Health and Medical Research the study.
Council (NHMRC) 569605) (Australian New Zealand Clinical Trials Descriptive data are included in Table 1. The use of z-scores
Registry (ANZCTR) number: ACTRN12611000616976).24 Ethical accounted for the differences in gender and age. Children with CP
approval for this study was obtained from the Childrens Health were younger, lighter and shorter than the TDC (p < 0.05). Children
Services District Ethics Committee (HREC/08/QRCH/112/AM01 and classied as GMFCS III and GMFCS IV and V had lower weight and
HREC/09/QRCH/124), The University of Queensland Medical height z-scores respectively when compared to those who were
Research Ethics Committee (2008002260 and 2009001869), the GMFCS I (p < 0.02). There were no differences, however, in weight
Cerebral Palsy League of Queensland Ethics Committee (CPLQ- and height z-scores between children classied as GMFCS III and
2000/2010-1029), the Gold Coast Health Service District Human those who were GMCFS IV and V.
Research Ethics Committee (HREC/09/QGC/88), the Townsville Body composition measures for all groups of children are
Health Service District Human Research Ethics Committee (HREC/ detailed in Table 2. Overall there were no signicant differences in
09/QTHS/96), the Central Queensland Human Research Ethics FFMI or BF% between the children with CP and the TDC after ac-
Committee (SSA/10/QCQ/13), and the Mater Health Services Human counting for differences in age. Children classied as GMFCS III had
Research Ethics Committee (1520EC). signicantly lower FFM and FFMI values when compared to those
who were GMFCS I and II (mean difference (MD) 1.2 kg
2.6. Power calculations and 1.3 kg/ht2 respectively, p < 0.05) despite smaller sample sizes
than predicted due to recruitment difculties. Children classied as
Using data from a previous study which investigated BF% in 77 GMFCS IV and V had similar values for all body composition pa-
TDC aged between 1.5 and 4.5 years, 1-SD of BF% was taken as 6%.25 rameters when compared to children classied as GMFCS III.
In order to detect a 6% difference between groups in the current Children classied as GMFCS IV and V had the lowest values of
study, a total of 16 children with CP for each functional ability group FFMI (signicantly lower than both those who were GMFCS I and II
and 16 TDC were required, which was statistically signicant with (MD 1.5 kg/ht2, p < 0.001) and TDC (MD 1.5 kg/ht2,
80% power and 5% signicance. A 1-SD difference was concluded to p < 0.01)) and highest BF% of all children involved in the study
be biologically and clinically signicant, as this represents the dif- (signicantly higher than children of GMFCS I and II (MD 5.6%,
ference between a child classied in the 16th percentile compared p 0.026)). Overall there was a trend towards lower FFMI (r 0.4,
to the 50th percentile, or the 50th percentile compared to the 84th p 0.000) and greater BF% (r 0.3, p 0.008) cross-sectionally
percentile. across GMFCS levels from I to V, accounting for differences in age
of the children. The GMFCS level or functional ability of a child
2.7. Statistical analyses contributed to 16% of the variability in FFMI, independent of the
inuence of age (p < 0.001). The contribution of GMFCS level to BF%
Statistical analyses were performed using Statistical Package for was minimal at 8%. Subsequent analysis of all data in Tables 1 and 2
the Social Sciences (SPSS) Version 20 (IBM SPSS Statistics 20.0). excluding those children who were partially or completely tube-fed
Children with CP were grouped according to functional ability, and did not signicantly alter any outcomes and produced similar
the fourth group consisted of the TDC. Weight and height z-scores results.
Please cite this article in press as: Walker JL, et al., Differences in body composition according to functional ability in preschool-aged children
with cerebral palsy, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.02.007
4 J.L. Walker et al. / Clinical Nutrition xxx (2014) 1e6
Table 1
Anthropometric and demographic measures for children with cerebral palsy according to gross motor functional ability and typically developing children.a
GMFCS I and II (n 52) GMFCS III (n 13) GMFCS IV and V (n 20) All children with CP (n 85) TDC (n 16)
Age (year) 2.63 0.79b 2.04 0.47b 2.94 0.86b,c 2.61 0.81d 3.69 0.48
Weight (kg) 13.6 2.2b 11.2 1.5b,e 13.0 3.4b 13.1 2.6d 16.9 1.7
Weight z-score 0.1 1.0 1.2 1.3b,e 1.1 1.9b,e 0.5 1.4d 0.6 0.6
Height (cm) 91.2 7.5b 83.2 5.1b,e 89.8 7.5b,c 89.6 7.7d 101.9 5.3
Height z-score 0.0 1.0 1.0 1.1b,e 1.0 1.3b,e 0.4 1.2d 0.5 0.7
Tube-fed (n) 0 0 7 7 0
Birth weight (g) 2641 1207 1841 853 2344 1291 2471 1206 NA
Gestational age (weeks) 36.0 4.9c 30.2 4.3 36.0 5.3c 35.1 5.3 NA
CP, cerebral palsy; GMFCS, Gross Motor Function Classication System; NA, not available; TDC, typically developing children.
a
All values are means SDs.
b
Signicantly different from the TDC (p < 0.05) by one-way ANOVA and post-hoc Tukey HSD tests.
c
Signicantly different from the GMFCS III group (p < 0.05) by one-way ANOVA and post-hoc Tukey HSD tests.
d
Signicantly different from the TDC (p < 0.001) via independent t-tests.
e
Signicantly different from the GMFCS I and II group (p < 0.05) by one-way ANOVA and post-hoc Tukey HSD tests.
When considering the feeding method of the children with se- ranging from 3.11 to 2.36 and 4.87 to 3.07 respectively. Children
vere CP (Table 3), there was a trend toward lower FFMI (p 0.07) classied as GMFCS IV and V have changes in body composition
for those children who were tube-fed compared to orally-fed, that have the potential to persist throughout childhood and impact
despite no difference in age. This result, however, was not statis- negatively on their overall health if the trend continues. Health
tically signicant. concerns may include the development of cardiovascular, respira-
tory and musculoskeletal problems, and a decrease in functional
4. Discussion status (incorporating mobility and the ability to complete self-care
tasks).28
The aim of this study was to investigate and evaluate the dif- A major factor that is hypothesised to contribute to the current
ferences in body composition according to gross motor functional study results is the GFMCS level of the children and their resulting
ability in preschool-aged children with CP and compare to TDC. In physical activity levels. Although physical activity was not reported
the absence of validated measures to accurately estimate body in the current study, children with greater functional impairment
composition in the clinical setting, assessment of body composition and hence activity limitations may not increase FFM due to reduced
in children with CP remains difcult. A variety of anthropometric levels of physical activity, unlike their counterparts who are less
measures (for example weight-for-height and skinfold thicknesses) restricted (those children classied as GMFCS I, II and III). The total
have been shown to be poor predictors of BF% when compared to amount of physical activity appears to be an important factor, as
measurements via dual energy x-ray absorptiometry (DXA) in FFMI increases as functional ability improves, to the point where
children with moderate to severe CP.9 It is benecial to measure children classied as GMFCS I and II have similar levels of FFMI to
body composition via a criterion standard such as isotope dilution TDC.
techniques or DXA9 as per the current study. Previous literature reported that overfeeding tube-fed children
As an overall population, ndings regarding similar amounts of who were classied as GMFCS IV and V (median age 9.0 years)
FFMI and BF% when compared to TDC are consistent with previous relative to their estimated energy requirements resulted in
literature.9,11,14 This study, however, has also described differences increased amounts of body fat.15 Further investigations determined
between preschool-aged children of varying functional levels. that the use of a low-energy enteral feed in a similar population, the
Altered body compositions were evident in this young age group prescribed volume of which did not exceed 75% of estimated en-
across the spectrum of functional abilities, particularly in those ergy requirements, did not result in adverse effects on body
children who were classied as GMFCS IV and V. The trend towards composition.16 Whether a higher relative fat intake contributes
lower FFMI and greater BF% with declining gross motor functional greatly to increases in BF%, especially in children classied as
ability reaches statistical signicance in those children who were GFMCS IV and V who are orally-fed, dependent or independent of
classied as GMFCS III or GMFCS IV and V. This is despite no sig- energy intake, is yet to be determined. The trend towards greater BF
nicant differences in height and weight z-scores between children % and absolute body fat in all children of GMFCS IV and V in the
who were classied as GMFCS III and those who were GMFCS IV current study, regardless of feeding method, is clinically important.
and V, attributed to large standard deviations in the GMFCS IV and A tendency towards adiposity is a risk factor for the development of
V group. This indicates the inclusion of children of varying body obesity, which is now a health concern amongst all children with
sizes at either extremes, with individual height and weight z-scores CP,6,7 particularly in those with greater functional impairment who
Table 2
Body composition measures for children with cerebral palsy according to gross motor functional ability and typically developing children.a
GMFCS I and II (n 52) GMFCS III (n 13) GMFCS IV and V (n 20) All children with CP (n 85) TDC (n 16)
b,c b,c d
FFM (kg) 11.0 1.5 9.0 1.5 9.6 1.9 10.4 1.8 13.0 1.4
FFMI (kg/ht2) 13.0 1.5 11.8 1.9c 11.4 1.4b,c 12.4 1.7 12.7 1.0
Body fat (kg) 2.7 1.4 2.1 0.8 3.4 2.0 2.8 1.5 3.9 0.7
Body fat (%) 18.6 6.8 19.1 7.1 24.6 10.1c 20.1 8.1 23.0 3.6
CP, cerebral palsy; FFM, fat free mass; FFMI, fat free mass index; GMFCS, Gross Motor Function Classication System; TDC, typically developing children.
a
All values are means SDs.
b
Signicantly different from the TDC (p < 0.05) by one-way ANCOVA, accounting for the inuence of age and using the Bonferroni correction for multiple comparisons.
c
Signicantly different from the GMFCS I and II group (p < 0.05) by one-way ANCOVA, accounting for the inuence of age and using the Bonferroni correction for multiple
comparisons.
d
Signicantly different from the TDC (p < 0.01) via multiple regression, accounting for the inuence of age.
Please cite this article in press as: Walker JL, et al., Differences in body composition according to functional ability in preschool-aged children
with cerebral palsy, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.02.007
J.L. Walker et al. / Clinical Nutrition xxx (2014) 1e6 5
Please cite this article in press as: Walker JL, et al., Differences in body composition according to functional ability in preschool-aged children
with cerebral palsy, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.02.007
6 J.L. Walker et al. / Clinical Nutrition xxx (2014) 1e6
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Please cite this article in press as: Walker JL, et al., Differences in body composition according to functional ability in preschool-aged children
with cerebral palsy, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.02.007