Measuring body composition and energy expenditure in children with severe neurologic impairment and intellectual disability

Treatment with brivaracetam has no apparent long-term effects on body weight in pediatric patients with epilepsy

OBJECTIVE

The objective of this study is to evaluate possible long-term effects of treatment with brivaracetam (BRV) on body weight in children with epilepsy.

METHOD

Post hoc analysis of data from patients (aged 1 month to <17 years) with ≥6 months of BRV treatment in a long-term, open-label trial (N01266 [NCT01364597]). Outcomes included body weight and body mass index (BMI) over time (z-score growth curves), and treatment-emergent adverse events (TEAEs). Previous/ongoing medical conditions that may affect body weight (gastrointestinal and metabolic/nutritional disorders); concomitant antiseizure medications (ASMs) were also evaluated.

RESULTS

Two hundred nine patients (mean [standard deviation] age 7.9 [4.6] years) were analyzed. Most (154 [73.7%]) had focal-onset seizures. At study initiation, median (range) BRV dose was 1.0 (0.4-7.5) mg/kg/day. Overall, 189 (90.4%) patients had a previous or ongoing medical condition (gastrointestinal disorders: 43 [20.6%]; metabolism/nutritional disorders: 26 [12.4%]). Most patients followed z-score curves for body weight and BMI during BRV treatment, although there were outliers in both directions. Incidences of appetite/weight-change TEAEs were low. Twenty-three (11.0%) patients had a TEAE of decreased appetite and 14 (6.7%) had a TEAE of weight decreased.

SIGNIFICANCE

Long-term adjunctive BRV was well tolerated in growing children with no indication of detrimental effects on body weight.

PLAIN LANGUAGE SUMMARY

Brivaracetam is an antiseizure medication (ASM) used to treat seizures in people with epilepsy. Some ASMs can lead to changes in people's appetite and weight. Knowing the effect a drug has on appetite and weight is particularly important in children. We looked at 209 children with epilepsy taking brivaracetam and studied changes in their body weight and body mass index over time. The number of reported side effects related to appetite or weight change was low. There was no apparent long-term effect on their body weight, even when taking their medical history and use of other ASMs into account.

Describing Energy Expenditure in Children with a Chronic Disease: A Systematic Review

Understanding energy expenditure in children with chronic disease is critical due to the impact on energy homeostasis and growth. This systematic review aimed to describe available literature of resting (REE) and total energy expenditure (TEE) in children with chronic disease measured by gold-standard methods of indirect calorimetry (IC) and doubly labeled water (DLW), respectively. A literature search was conducted using OVID Medline, Embase, CINAHL Plus, Cochrane, and Scopus until July 2023. Studies were included if the mean age of the participants was ≤18 y, participants had a chronic disease, and measurement of REE or TEE was conducted using IC or DLW, respectively. Studies investigating energy expenditure in premature infants, patients with acute illness, and intensive care patients were excluded. The primary outcomes were the type of data (REE, TEE) obtained and REE/TEE stratified by disease group. In total, 271 studies across 24 chronic conditions were identified. Over 60% of retrieved studies were published >10 y ago and conducted on relatively small population sizes (n range = 1-398). Most studies obtained REE samples (82%) rather than that of TEE (8%), with very few exploring both samples (10%). There was variability in the difference in energy expenditure in children with chronic disease compared with that of healthy control group across and within disease groups. Eighteen predictive energy equations were generated across the included studies. Quality assessment of the studies identified poor reporting of energy expenditure protocols, which may limit the validity of results. Current literature on energy expenditure in children with chronic disease, although extensive, reveals key future research opportunities. International collaboration and robust measurement of energy expenditure should be conducted to generate meaningful predictive energy equations to provide updated evidence that is reflective of emerging disease-modifying therapies. This study was registered in PROSPERO as CRD42020204690.

Intake levels and main sources of nutrients for Japanese children with motor or intellectual disabilities

Proper nutritional management is important for the growth and development of children with motor or intellectual disabilities; however, few studies have investigated the nutrient intake of children with disabilities. This study aimed to investigate the nutrient intake and food groups that are the main sources of nutrients for children with disabilities. This cross-sectional observational study included twenty-five children (mean age, 11⋅8 years) from five hospitals in Japan. Using a 3-d weighed dietary record, we estimated the daily nutrient intake and food and beverage sources that contributed to nutrient intake. The mean values of calcium, magnesium, iron, vitamin A, thiamine, riboflavin, and vitamin C intake were below the recommended dietary allowance, and those of dietary fiber and potassium were below the levels recommended by the Tentative Dietary Goal for Preventing Lifestyle-related Diseases (DG). In contrast, the mean intake values of fat, saturated fatty acids, and sodium were above the DG levels. Dairy products, meat, vegetables, and cereals were found to be the major contributors of nutrients. Increased intake of vegetables may help alleviate insufficient micronutrient intake in children with disabilities.

Validation study on a prediction formula to estimate the weight of children & adolescents with special needs aged 2-18 years old

BACKGROUND

This study aims to validate two predictive formulas of weight estimating strategies in children with special needs, namely the Cattermole formula and the Mercy formula.

METHODOLOGY

A cross-sectional study with a universal sampling of children and adolescents with special needs aged 2-18 years old, diagnosed with cerebral palsy, down syndrome, autism and attention-deficit/hyperactivity disorder was conducted at Community-Based Rehabilitation in Central Zone Malaysia. Socio-demographic data were obtained from files, and medical reports and anthropometric measurements (body weight, height, humeral length, and mid-upper arm circumference) were collected using standard procedures. Data were analysed using IBM SPSS version 26. The accuracy of the formula was determined by intraclass correlation, prediction at 20% of actual body weight, residual error (RE) and root mean square error (RMSE).

RESULT

A total of 502 children with a median age of 7 (6) years were enrolled in this study. The results showed that the Mercy formula demonstrated a smaller degree of bias than the Cattermole formula (PE = 1.97 ± 15.99% and 21.13 ± 27.76%, respectively). The Mercy formula showed the highest intraclass correlation coefficient (0.936 vs. 0.858) and predicted weight within 20% of the actual value in the largest proportion of participants (84% vs. 48%). The Mercy formula also demonstrated lower RE (0.3 vs. 3.6) and RMSE (3.84 vs. 6.56) compared to the Cattermole formula. Mercy offered the best option for weight estimation in children with special needs in our study population.

Measurement of body composition by deuterium oxide dilution technique and development of a predictive equation for body fat mass among severe neurologically impaired children

Introduction

Neurologically impaired (NI) children are at risk of malnutrition, which consequently impacts their health and quality of life. Accurate nutrition assessment is an important step in guiding appropriate nutrition support. Conventional anthropometric measurements among NI children have some limitations. Determining body composition requires more complex equipment, which is not routinely performed. This study was conducted to evaluate the association between anthropometric parameters and body composition assessed using the deuterium dilution technique (DDT) in NI children.

Methods

A cross-sectional study enrolled severe NI children aged 1-20 years who received home enteral nutrition for at least 3 months. Weight, length, and 4-site skinfold thickness were measured. Body composition was determined using DDT following the International Atomic Energy Agency (IAEA) protocol.

Results

A total of 37 NI children (56.76% male, median age 7.2 years) were enrolled. The prevalence of underweight, stunting, and overweight were 22, 38, and 35%, respectively. Body composition analysis showed the mean (SD) of total body water (TBW) and fat mass (FM) were 10.52 (4.51) kg and 9.51 (6.04) kg, respectively. Multivariate GLM analysis showed that the factors associated with FM were age (β = 0.07 [0.05,0.08]; p < 0.001), body mass index (BMI) (β = 0.82 [0.52, 1.12]; p < 0.001), biceps skinfold thickness (BSF) (β = 0.49 [0.23,0.75]; p = 0.001), and subscapular skinfold thickness (SSF) (β = -0.24 [-0.46,0.03]; p = 0.030). A predictive equation for FM was constructed.

Conclusion

A high prevalence of malnutrition was found among severe NI children despite enteral nutrition support. Our findings showed that age, BMI, BSF, and SSF were associated with FM. The predictive equation of FM was proposed and needed to be further validated and applied to clinical practice.

Tools for Nutrition Assessment of Adults with Cerebral Palsy: Development of a Gold Standard

PURPOSE OF REVIEW

Cerebral palsy (CP) is a group of disorders caused by non-stabilized cerebral lesions. Individuals with this disorder are at a higher risk of suffering from malnutrition and other related detrimental effects to their quality of life. For this reason, accurate methods of nutritional assessment are vital for people suffering from this condition. While assessment of nutritional status in children with CP has been extensively studied, very few studies have been carried out on adults. These limitations are due to the great anatomical-functional variability characteristic of this syndrome. Difficulties that derive from this variability in adult patients with CP mean that there remains an urgent need for certain standards of nutritional assessment for this population. The objective of this review is to compile the latest trends in nutritional assessment in adults with CP to guide the development of a conceptual framework for future research.

RECENT FINDINGS

With this aim, relevant studies have been identified. The most commonly used technique to evaluate nutritional status is the BMI because of its ease-of-use. However, its well-known limitations fail to adequately estimate the nutritional status in this population, with measurements of patients with CP yielding results that are much less accurate than those that already exist in the general population. Although more studies are needed, kinanthropometry is considered one of the most reliable techniques; nevertheless, the anatomical limitation characteristic of CP plays a limiting factor.

Neurological impairment and malnutrition in children: The role of home enteral nutrition in real life

Objective

Recent decades have brought an increased survival of children with Neurologic Impairment (NI) but malnutrition and digestive comorbidity remain important challenges to face. We designed the present study to assess the course of nutritional status following standardized Home Enteral Nutrition (HEN) program and to evaluate impact of changing mode of feeding, as a part of overall multidisciplinary management, on digestive co-morbidity as Gastro-Esophageal Reflux Disease (GERD), Oropharyngeal Dysphagia (OPD), constipation and airway aspiration.

Methods

We performed a retrospective analysis on NI children entered into Institutional HEN program due to NI disorders between January 2011 and 2019. Demographic, anthropometric characteristics (BMI z-score and weight for age z-score) and symptoms (GERD, OPD constipation and airway aspiration) were collected at the enrolment and during the follow up.

Results

We enrolled 402 patients (median age: 39 months); overall survival was 97%. Nutritional status was significantly improved by HEN; in particular growth profile significantly changed within the first 2 years following HEN beginning; GERD and airways aspirations decreased after HEN beginning. Constipation and OPD remained unchanged over time.

Conclusions

Malnutrition and digestive complaints are distinctive features of NI children. Nutritional status improve after 2 years from the beginning of standardized nutritional interventions. Overall multidisciplinary care, including standardized HEN protocols, seems to also impact on GERD and airway aspirations, which can decrease over time. It is possible that constipation and OPD, unchanged over time, are more dependent on underlying diseases than on overall treatments.

Equations based on anthropometric measurements for adipose tissue, body fat, or body density prediction in children and adolescents: a scoping review

PURPOSE

Assessing the body composition of children and adolescents is important to monitor their health status. Anthropometric measurements are feasible and less-expensive than other techniques for body composition assessment. This study aimed to systematically map anthropometric equations to predict adipose tissue, body fat, or density in children and adolescents, and to analyze methodological aspects of the development of anthropometric equations using skinfolds.

METHODS

A scoping review was carried out following the PRISMA-ScR criteria. The search was carried out in eight databases. The methodological structure protocol of this scoping review was retrospectively registered in the Open Science Framework ( https://osf.io/35uhc/ ).

RESULTS

We included 78 reports and 593 anthropometric equations. The samples consisted of healthy individuals, people with different diseases or disabilities, and athletes from different sports. Dual-energy X-ray absorptiometry (DXA) was the reference method most commonly used in developing equations. Triceps and subscapular skinfolds were the anthropometric measurements most frequently used as predictors in the equations. Age, stage of sexual maturation, and peak height velocity were used as complementary variables in the equations.

CONCLUSION

Our scoping review identified equations proposed for children and adolescents with a great diversity of characteristics. In many of the reports, important methodological aspects were not addressed, a factor that may be associated with equation bias.

LEVEL IV

Evidence obtained from multiple time series analysis such as case studies. (NB: dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Foods for Special Medical Purposes in Home Enteral Nutrition-Clinical Practice Experience. Multicenter Study

Background

Enteral nutrition (EN) with foods for special medical purposes (FSMP) is recommended for most patients on home enteral nutrition (HEN). Although there are disease-specific guidelines for energy, protein, and micronutrient provision, only a few studies are showing real-life experience in the long-term use of FSMP.

Methods

In a multicenter study, the influence of the FSMP composition and administration technique (bolus vs. continuous) on protein and energy provision in HEN was analyzed. Provision of vitamins and minerals was compared to recommended daily allowance (RDA) and upper tolerable limit (UL).

Results

Approximately, 772 patients on HEN, mostly (88.6%) with oncological and neurological diseases, were enrolled. The patients on standard FSMP received less protein and energy than those on hypercaloric and protein enriched despite receiving higher volumes of EN (p < 0.05). No differences were observed in jejunal feeding with oligomeric vs. polymeric FSMP in terms of energy, protein, and volume. Continuous gastric feeding provided more protein, energy, and volume vs. bolus feeding (p < 0.05). Significant number of patients received less than 100% RDA of vitamin D (50.5%), vitamin B3 (49%), vitamin K (21.8%), vitamin B5 (64.3%), vitamin B9 (60%). Majority of the patients received less than 100% RDA of sodium (80.2%), potassium (99%), chloride (98%), calcium (67%), magnesium (87%), fluoride (99%), and iodine (43%). Approximately, 43.63% of cancer and 49.9% of neurological patients received less than 1 g/kg/day of protein and 51.7% of cancer and 55.5% of neurological patients received less than 25 kcal/kg/day.

Conclusion

Awareness of the available compositions of FSMP and advantageous profiles of specific diets may lead to the implementation of recommendations for EN. HEN professionals need to analyze all the patient's needs and requirements to provide more tailored matching of nutritional support.

Assessment of Swallowing Disorders, Nutritional and Hydration Status, and Oral Hygiene in Students with Severe Neurological Disabilities Including Cerebral Palsy

BACKGROUND

Special needs schools (SNS) educate children and young people with major neurological disabilities who are at high risk of oropharyngeal dysphagia (OD) and malnutrition (MN). We aimed to assess the prevalence of OD, MN, dehydration (DH), and oral health (OH) in students at an SNS.

METHODS

A cross-sectional observational study was conducted at SNS L'Arboç, Catalonia, Spain. We assessed (a) demographics, health status, comorbidities, and gross motor function classification system (GMFCS), (b) swallowing function, oral-motor evaluation, masticatory capacity, and EDACS classification for eating and drinking abilities, (c) nutritional and DH status (anthropometry, bioimpedance and dietary records), and (d) OH (Oral Hygiene Index Simplified).

RESULTS

A total of 33 students (mean age 13.3 years; 39.4% level V of GMFCS) were included. Main diagnosis was cerebral palsy at 57.6%. All students presented OD, 90.6% had impaired safety, 68.7% were at levels II-III of EDACS, and 31.3% required PEG; furthermore, 89.3% had chronic MN, 21.4% had acute MN, 70% presented intracellular DH, and 83.9% presented impaired OH.

CONCLUSION

MN, DH, OD, and poor OH are highly prevalent conditions in students with cerebral palsy and other neurological disabilities and must be specifically managed through nutritional and educational strategies. The multidisciplinary team at SNS should include healthcare professionals specifically trained in these conditions.

Total energy expenditure among children with motor, intellectual, visual, and hearing disabilities: a doubly labeled water method

OBJECTIVE

Few studies have evaluated the total energy expenditure (TEE) of children with disabilities using the doubly labeled water (DLW) method; however, none have compared it by disability type. Furthermore, no large-scale studies have focused on the severity of motor disability (MD). We aimed to compare TEE in children with disabilities by disability type.

METHODS

In a cross-sectional study design, TEE was measured using the DLW method, anthropometry, and weighted food records. The following comparisons were made: (1) TEEs among four disability types and (2) TEEs of three subgroups classified by MD based on the Gross Motor Function Classification System (GMFCS).

RESULTS

In total, 256 children (138 boys; ages 6-15 years) were studied. The comparison between the four disability types for boys in all age categories revealed that TEE (kJ/d) was lowest in MD, followed by intellectual disability (ID), visual disability, and hearing disability (HD), in that order. TEE/fat-free mass (FFM) (kJ/FFMkg/d) was also lowest in MD and highest in HD. TEE (kJ/d) and TEE/FFM (kJ/FFMkg/d) were also lowest in MD and highest in HD in girls. For both boys and girls, TEE (kJ/d) and TEE/FFM (kJ/FFMkg/d) were higher in the MD subtype GMFCS I-II than in GMFCS III-IV and GMFCS V.

CONCLUSIONS

TEE differed, depending on the disability type, and was the lowest in MD and highest in HD for both boys and girls. Analysis by GMFCS classification revealed that greater severity of motor dysfunction resulted in lower TEE.

Parent-delivered interventions used at home to improve eating, drinking and swallowing in children with neurodisability: the FEEDS mixed-methods study

BACKGROUND

Eating, drinking and swallowing difficulties are common in young children with neurodisability. These difficulties may lead to inadequate calorie intake, which affects a child's nutrition, growth and general physical health.

OBJECTIVE

To examine which interventions are available that can be delivered at home by parents to improve eating, drinking and swallowing in young children with neurodisability and are suitable for investigation in pragmatic trials.

DESIGN

This was a mixed-methods study that included focus groups, surveys, an update of published systematic reviews of interventions, a systematic review of measurement properties of existing tools, evidence mapping, evidence synthesis, a Delphi survey and stakeholder workshops.

SETTING

The study was carried out in NHS hospitals, community services, family homes and schools.

PARTICIPANTS

Parents of children who had neurodisability and eating, drinking and swallowing difficulties. Professionals from health and education. Young people with eating, drinking and swallowing difficulties or young people who had previously experienced eating, drinking and swallowing difficulties.

DATA SOURCES

Literature reviews; national surveys of parents and professionals; focus groups with parents, young people and professionals; and stakeholder consultation workshops.

REVIEW METHODS

An update of published systematic reviews of interventions (searched July-August 2017), a mapping review (searched October 2017) and a systematic review of measurement properties using COnsensus-based Standards for the Selection of health status Measurement INstruments (COSMIN) methodology (searched May 2018).

RESULTS

Significant limitations of the available research evidence regarding interventions and tools to measure outcomes were identified. A total of 947 people participated: 400 parents, 475 health professionals, 62 education professionals and 10 young people. The survey showed the wide range of interventions recommended by NHS health professionals, with parents and professionals reporting variability in the provision of these interventions. Parents and professionals considered 19 interventions as relevant because they modified eating, drinking and swallowing difficulties. Parents and professionals considered 10 outcomes as important to measure (including Nutrition, Growth and Health/safety); young people agreed that these were important outcomes. Stakeholder consultation workshops identified that project conclusions and recommendations made sense, were meaningful and were valued by parents and professionals. Parents and health professionals were positive about a proposed Focus on Early Eating, Drinking and Swallowing (FEEDS) toolkit of interventions that, through shared decision-making, could be recommended by health professionals and delivered by families.

LIMITATIONS

The national surveys included large numbers of parents and professionals but, as expected, these were not representative of the UK population of parents of children with eating, drinking and swallowing difficulties. Owing to the limitations of research evidence, pragmatic decisions were made about interventions that might be included in future research and outcomes that might be measured. For instance, the reviews of research found only weak or poor evidence to support the effectiveness of interventions. The review of outcome measures found only limited low-level evidence about their psychometric properties.

CONCLUSIONS

Opportunities and challenges for conducting clinical trials of the effectiveness of the FEEDS toolkit of interventions are described. Parents and professionals thought that implementation of the toolkit as part of usual NHS practice was appropriate. However, this would first require the toolkit to be operationalised through development as a complex intervention, taking account of constituent interventions, delivery strategies, implementation and manualisation. Subsequently, an evaluation of its clinical effectiveness and cost-effectiveness could be undertaken using appropriate research methods.

FUTURE WORK

Initial steps include FEEDS toolkit development and evaluation of its use in clinical practice, and identification of the most robust methods to measure valued outcomes, such as Nutrition and Growth.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10454425.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 22. See the NIHR Journals Library website for further project information.

The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy

Children with cerebral palsy (CP) and other medical complexity comprise an outsized proportion of health care use. In this review, we describe the current science of assessment of nutritional status for children with CP, outline a systematic approach to assessing their nutritional status, delineate ramifications of malnutrition on hospitalization-associated outcomes, and identify knowledge gaps and means of addressing those gaps using quality improvement and clinical research tools. Methods to accurately assess body composition and adiposity in this population by using skinfolds, age, sex, and activity level are available but are not widely used. There are limitations in our current method of estimating energy needs in children with CP, who are at higher risk of both obesity and micronutrient deficiencies. There is some evidence of an association between malnutrition, defined as either underweight or obesity, and hospitalization-associated outcomes in children generally, although we lack specific data for CP. The gaps in our current understanding of optimal nutritional status and between current science and practice need to be addressed to improve health outcomes for this vulnerable patient population.

Top-ten tips for managing nutritional issues and gastrointestinal symptoms in children with neurological impairment

The prevalence of children with neurological impairment (NI) presenting feeding difficulties and gastrointestinal symptoms is rising. The most recent guidelines recommend early nutritional assessment and intervention in order to prevent undernutrition and growth failure, along with the proper diagnosis and treatment of some frequent gastrointestinal symptoms, such as gastroesophageal reflux disease (GERD) and constipation, which can further worsen the feeding process and nutritional status. Nonetheless, the nutritional issues and growth deficits of children with NI are often considered to be of low priority or under recognised by healthcare providers. The present article proposes ten top tips that highlight the major points along the nutritional management pathway of NI children. The implementation of these tips in all healthcare settings could potentially improve patient outcomes and reduce morbidity and mortality.

Optimizing Nutrition and Bone Health in Children with Cerebral Palsy

Children with cerebral palsy (CP) are at risk of growth and nutrition disorders. There are numerous challenges to measure and assess growth and nutritional status in children with CP. Addressing these challenges is imperative, because the consequences of poor growth and malnutrition range from decreased bone density, muscle mass, and quality of life to impacts on intellectual quotient, behavior, attention, social participation, healthcare utilization, and health care costs. In addition to discussing approaches to assess growth and nutrition, this article examines some of the methods of optimizing nutrition and bone health, including when preparing for and recovering from surgery.

Criterion validity of assessment methods to estimate body composition in children with cerebral palsy: A systematic review

BACKGROUND

Poor nutritional status is a problem in a high number of children with cerebral palsy (CP) and impairs their well-being. Therefore, periodic assessment of nutritional status and especially body composition is essential. However, we lack consensus on the best method to assess body composition in clinical practice.

OBJECTIVE

We aimed to systematically review the available evidence on the criterion validity of equation-based skinfold measurement and bioelectrical impedance analysis (BIA) to estimate body composition in children with CP.

METHODS

In a systematic review (MEDLINE, Cochrane Library and EMBASE), we identified studies that reported on the agreement between the estimation of body composition by equations of skinfold thickness or impedance values of BIA with a gold standard (isotope techniques or dual-energy-X-ray-absorptiometry [DXA]) in children with CP. We included only studies that provided correlations or agreement between estimations of body compartments (e.g., percentage body fat [%BF] or fat mass). Limits of agreement of 2.5%BF points were considered acceptable. Study quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies 2.

RESULTS

We included reports of 9 studies describing 3 skinfold equations and 4 equations to estimate body composition with BIA. Neither skinfold equations nor BIA could be reliably used to assess body composition in an individual child with CP at one point in time. On a population level, the Gurka skinfold equation was valid in ambulant children with CP, and the Kushner and Fjeld BIA equations were valid in a heterogeneous group of children with CP. Conclusions The future role of skinfold equations and BIA to assess and monitor body composition in an individual child with CP needs to be further investigated.

Nutritional care: The 'poor child' of clinical care in children with cerebral palsy

There is a considerable risk of malnutrition for children with Cerebral Palsy (CP) due to insufficient nutritional intake. The most important causes of insufficient intake are feeding problems which are highly prevalent in children with CP (depending on definition, age and heterogeneity of the researched population). Considering these facts, nutritional status should have the full attention of healthcare professionals but this is not yet the case. Evidence from research in clinical practice suggests that: 1) there is no consensus regarding who should perform the measurement and how often, 2) no standardised nutritional assessment is implemented, and 3) there is suboptimal communication and management about feeding and nutritional status in most healthcare networks. To overcome these problems, validated and practical tools for the screening and assessment of nutritional status should be a topic of research and subsequently made available and implemented in clinical practice. Because body composition is an objective indicator of available energy stores, research should focus on optimising measurement methods to determine body composition using anthropometric measures or bioelectrical impedance analysis (BIA). Furthermore, there is a definite need among health care providers for explicit and clear agreements on organisation and communication about nutritional care for children with CP.

Gastrointestinal and nutritional issues in children with neurological disability

Neurological disability is often associated with feeding and gastrointestinal disorders leading to malnutrition and growth failure. Assessment of nutritional status represents the first step in the clinical evaluation of children with neurological disability. The European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recently issued a consensus statement on gastrointestinal and nutritional management in children with neurological disability. Here we critically review and address implications of this consensus for clinical practice, including assessment and monitoring of nutritional status, definition of nutritional requirements, diagnosis and treatment of gastro-oesophageal reflux disease, and indications for and modalities of nutritional support. There is a strong evidence base supporting the ESPGHAN guidelines; their application is expected to lead to better management of this group of children.

WHAT THIS PAPER ADDS

Assessment of nutritional status in children with neurological disability should include the evaluation of body composition. Standard polymeric formula via gastrostomy tube is an effective, long-term nutritional intervention. Tube feeding should be started early, before the development of malnutrition.

Epicardial Fat Thickness in Non-Obese Neurologically Impaired Children: Association with Unfavorable Cardiometabolic Risk Profile

Background: Cardiovascular risk is reported in disabled children and epicardial fat (EF) is considered an independent predictor of cardiovascular disease (CVD). No data on the EF thickness (EFT) evaluation in disabled children have been published. Objective: We investigated EFT in neurologically impaired (NI) children; its relationship with their metabolic profile was also considered. Methods: Clinical data, body composition estimation, biochemical profile, and ultrasound-measured EFT were performed in 32 disabled patients (12.4 ± 6.3 years). Pathological parameters were defined using the following criteria: waist circumference >95th percentile, waist to height ratio (WHtR) >0.5, total cholesterol and triglycerides (TG) values >95th percentile, high density lipoprotein cholesterol <5th percentile, fasting blood glucose >100 mg/dL, homeostasis model assessment for insulin resistance (HOMA) >97.5th percentile, and EFT >3.6 mm. Results: EFT values in NI children were higher compared with control group values (p = 0.02). EFT correlated with gender (p < 0.001), age (p = 0.02), pubertal stage (p = 0.04), as well as WHtR (p = 0.03). A correlation between EFT and leptin was also noted (p = 0.04). EFT levels significantly correlated with pathological TG (p = 0.01) and HOMA-IR (p = 0.04). Conclusions: Higher EFT was observed in NI children compared with controls. EFT values correlated with clinical, metabolic, and endocrinological parameters. Ultrasound-measured EFT could be used to promptly detect subclinical CVD and to prevent adverse outcomes in disabled children.

The prevalence of undernutrition upon hospitalization in children in a developing country: A single hospital study from Malaysia

BACKGROUND

Undernourished children who require hospital care have a longer duration of hospitalization and respond poorly to modern medical therapy. The objective of the present study was to ascertain the nutritional status of children admitted to a pediatric tertiary center in Malaysia and the risk factors leading to undernutrition upon admission.

METHODS

In this cross-sectional, hospital-based study, anthropometric measurements [weight, length/height, mid-upper arm circumference (MUAC), triceps skinfold thickness were performed in 285 children aged from 3 months to 15 years who were admitted to University Malaya Medical Centre, Kuala Lumpur in November 2013. Acute (wasting) and chronic (stunting) undernutrition were defined as weight-for-height (WFH) and height-for-age (HFA) < -2 standard deviation (S.D.), respectively. Underweight was defined as weight-for-age < -2 S.D. For children aged between 1 and 5 years of age, World Health Organization definition for acute undernutrition (HFA < -2 S.D. and/or MUAC < 12.5 cm) was also noted.

RESULTS

Upon admission, the prevalence rates of acute and chronic undernutrition were 11% (n = 32) and 14% (n = 41), respectively. In addition, 7% (n = 21) had an MUAC of < 12.5 cm, 15% had body-mass index < -2 S.D., and 7% (n = 21) had triceps skinfold thickness < -2 S.D., while 17% (n = 47) were underweight. Using the World Health Organization definition of acute undernutrition, an additional eight patients were noted to have acute undernutrition (n = 40, 14%). No significant risk factors associated with undernutrition were identified.

CONCLUSION

The prevalence of undernutrition among children admitted to a tertiary hospital in Malaysia was 14%. Strategies for systematic screening and provision of nutritional support in children at risk of undernutrition as well as treatment of undernutrition in children requiring hospitalization are needed.

European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment

OBJECTIVES

Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment.

METHODS

Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.

ASSESSMENT OF NUTRITIONAL STATUS OF CHILDREN AND ADOLESCENTS WITH SPASTIC QUADRIPLEGIC CEREBRAL PALSY

ABSTRACT BACKGROUND: Due to several factors, such as gastrointestinal’s diseases and difficulty in feeding, children with Spastic Quadriplegic Cerebral Palsy tend to present nutritional deficits. OBJECTIVE: To assess the nutritional status of pediatric patients with Spastic Quadriplegic Cerebral Palsy according to reference curves for this population and with the measures of folds and circumferences, obtained by the upper arm circumference and triceps skin fold. METHODS: The data were obtained from: knee-height, estimated height, weight, upper arm circumference, and triceps skin fold. Values of folds and circumferences were compared with Frisancho, and specific curves for these patients were used as reference. The relationship between the values in the growth curve for healthy children, Z-Score, and comparison with the reference curve were verified by Fisher’s exact test. We adopted the significance level of 5%. RESULTS: We evaluated 54 patients. The mean age was 10.2 years, and 34 were male, 25 fed by gastrostomy and 29, orally. The frequency of low weight by the reference curve was 22.22%. More than half of the patients presented the parameters indicating lean mass below the 5th percentile. The height of all patients was classified as adequate for the age by the reference curve. CONCLUSION: Low weight was found in 22% of patients, and there is a greater tendency to present reduced muscle mass and increased fat mass, showing the need for evaluation and appropriate interventions for patients with Spastic Quadriplegic Cerebral Palsy.

Anthropometric Parameters of Nutritional Status in Children with Cerebral Palsy

INTRODUCTION

Patients with cerebral palsy (CP), besides the basic neurological damage, are also often undernourished. Adequate nutrition for children is very important during the period of intensive growth and development, which is of particular importance in patients with CP.

GOAL

To evaluate the nutritional status of patients with CP who are treated at the Pediatric Clinic, Clinical Centre of Sarajevo University and causes of malnutrition in these patients.

MATERIALS AND METHODS

Eighty patients with CP underwent anthropometric assessment (body weight, body height, body mass index, head circumference, subscapular skinfold thickness, triceps skinfold thickness and mid upper arm muscle circumference). Severity of CP was classified based on the Gross Motor Function Classification System (GMFCS). We compared the anthropometric parameters of our patients with normal values of healthy children, as well as with degree of motor impairment, oromotor dysfunction, feeding assistance, length of meals and daily feeding time.

RESULTS

There were significant differences in all monitored parameters in relation to normal values, with 38 (47.5%) malnourished patients in the total group, out of which 29 (63.0%) with severe motor impairment and with 9 (11.3%) obese patients in the total group. The presence of oromotor dysfunction and other monitored parameters had a significant impact on the nutritional status of these patients.

CONCLUSION

In severely disabled patients with CP there is a risk of profound malnutrition. Early identification and treatment of these patients is very important for their growth, development and health.

Nutritional status and metabolic profile in neurologically impaired pediatric surgical patients

BACKGROUND

Malnutrition is reported in pediatric neuromotor disability and impacts the child's health. We described the nutritional and metabolic status in neurologically impaired (NI) children undergoing surgery.

METHODS

Anthropometry, body composition, hormonal and nutritional evaluations were performed in 44 NI subjects (13.7±8.0 years). Energy needs were calculated by Krick's formula. Metabolic syndrome (MS) was defined applying the following criteria (≥3 defined MS): fasting blood glucose >100 mg/dL and/or homeostasis model assessment for insulin resistance (HOMA-IR) >97.5th percentile, trygliceride level >95th percentile, high-density lipoprotein (HDL)-cholesterol level <5th percentile, systolic/diastolic pressure >95th percentile; whilebody mass index - standard deviation score (BMI-SDS) <2 and biochemical malnutrition markers (≥2) defined undernutrition.

RESULTS

Energy intake was not adequate in 73.8% of the patients; no correlation between energy intake and BMI was noted. Undernutrition was noted in 34.1% of patients and MS in 11.36% of subjects. Fifty percent of the patients presented with insulin resistance, which was not related to BMI, body composition or other MS components.

CONCLUSIONS

Nutritional and metabolic monitoring of disabled children and young adults is recommended to prevent adverse outcomes associated with malnutrition.

Protein Requirements of the Critically Ill Pediatric Patient

This article includes a review of protein needs in children during health and illness, as well as a detailed discussion of protein metabolism, including nitrogen balance during critical illness, and assessment and prescription/delivery of protein to critically ill children. The determination of protein requirements in children has been difficult and challenging. The protein needs in healthy children should be based on the amount needed to ensure adequate growth during infancy and childhood. Compared with adults, children require a continuous supply of nutrients to maintain growth. The protein requirement is expressed in average requirements and dietary reference intake, which represents values that cover the needs of 97.5% of the population. Critically ill children have an increased protein turnover due to an increase in whole-body protein synthesis and breakdown with protein degradation leading to loss of lean body mass (LBM) and development of growth failure, malnutrition, and worse clinical outcomes. The results of protein balance studies in critically ill children indicate higher protein needs, with infants and younger children requiring higher intakes per body weight compared with older children. Monitoring the side effects of increased protein intake should be performed. Recent studies found a survival benefit in critically ill children who received a higher percentage of prescribed energy and protein goal by the enteral route. Future randomized studies should evaluate the effect of protein dosing in different age groups on patient outcomes, including LBM, muscle structure and function, duration of mechanical ventilation, intensive care unit and hospital length of stay, and mortality.

Systematic review of field-based physical fitness tests for children and adolescents with intellectual disabilities

BACKGROUND

Testing physical fitness in children and adolescents with intellectual disabilities (ID) can be challenging. This review provides an overview on psychometric properties of field-based physical fitness tests studied in children and adolescents with ID.

METHODS

A literature search was performed in March 2014. Studies were included if they evaluated feasibility, reliability and/or validity of a field-based physical fitness test in children and adolescents with ID.

RESULTS

Twenty-six papers met the inclusion criteria and described 18 tests on body composition (4), muscular strength (4), muscular endurance (6), and cardiorespiratory fitness (4). Best results on feasibility, reliability and/or validity were found for bioelectric impedance analysis, body mass index, grip strength, arm hang and distance run/walk tests. These results were mainly found in adolescents with mild to moderate ID.

CONCLUSION

Some tests were found feasible, reliable and/or valid in subgroups of children and adolescents with ID, but not in children and adolescents with all ages and levels of ID. Further assessment is needed before wider application in all children and adolescents with ID.

Body composition, diet, and physical activity: a longitudinal cohort study in preschoolers with cerebral palsy

BACKGROUND

Altered body composition in children with cerebral palsy (CP) could be due to differences in energy intake, habitual physical activity (HPA), and sedentary time.

OBJECTIVE

We investigated the longitudinal relation between the weight-for-age z score (WZ), fat-free mass (FFM), percentage of body fat (%BF), and modifiable lifestyle factors for all Gross Motor Function Classification System (GMFCS) levels (I-V).

DESIGN

The study was a longitudinal population-based cohort study of children with CP who were aged 18-60 mo (364 assessments in 161 children; boys: 61%; mean ± SD recruitment age: 2.8 ± 0.9 y; GMFCS: I, 48%; II, 11%; III, 15%; IV, 11%; and V, 15%). A deuterium dilution technique or bioelectrical impedance analysis was used to estimate FFM, and the %BF was calculated. Energy intake, HPA, and sedentary time were measured with the use of a 3-d weighed food diary and accelerometer wear. Data were analyzed with the use of a mixed-model analysis.

RESULTS

Children in GMFCS group I did not differ from age- and sex-specific reference children with typical development for weight. Children in GMFCS group IV were lighter-for-age, and children in GMFCS group V had a lower FFM-for-height than those in GMFCS group I. Children in GMFCS groups II-V had a higher %BF than that of children in GMFCS group I, with the exception of orally fed children in GMFCS group V. The mean %BF of children with CP classified them as overfat or obese. There was a positive association between energy intake and FFM and also between HPA level and FFM for children in GMFCS group I.

CONCLUSIONS

Altered body composition was evident in preschool-age children with CP across functional capacities. Gross motor function, feeding method, energy intake, and HPA level in GMFCS I individuals are the strongest predictors of body composition in children with CP between the ages of 18 and 60 mo.

Gastrointestinal and nutritional problems in neurologically impaired children

The current increasing survival of children with severe central nervous system damage has created a major challenge for medical care. Gastrointestinal and nutritional problems in neurologically impaired children have been recently recognized as an integral part of their disease, often leading to growth failure and worsened quality of life for both children and caregivers. Nutritional support is essential for the optimal care of these children. Undernourished handicapped children might not respond properly to intercurrent diseases and suffer unnecessarily. On the other hand, restoring a normal nutritional status results in a better quality of life in many. The easiest and least invasive method to increase energy intake is to improve oral intake. However, oral intake can be maintained as long as there is no risk of aspiration, the child is growing well and the time required to feed the child remains within acceptable limits. When oral intake is unsafe, insufficient or too time consuming, enteral nutrition should be initiated. Damage to the developing central nervous system may result in significant dysfunction in the gastrointestinal tract and is reflected in impairment in oral-motor function, rumination, gastro-oesophageal reflux (GER), with or without aspiration, delayed gastric emptying and constipation. These problems can all potentially contribute to feeding difficulty in disabled children, carrying further challenging long-term management issues.

Instruments for the evaluation of motor abilities for children with severe multiple disabilities: A systematic review of the literature

Based on a systematic review, psychometric characteristics of currently available instruments on motor abilities of children with disabilities were evaluated, with the aim to identify candidates for use in children with severe multiple (intellectual and motor) disabilities. In addition, motor abilities are essential for independent functioning, but are severely compromised in these children. The methodological quality of all studies was evaluated with the Consensus Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) Checklist; overall levels of evidence per instrument were based on the Cochrane Back Review Group strategy. As a result, 18 studies with a total of eight instruments, developed for children with cerebral palsy (CLA, GMFM-88 and LE85), spinal muscular atrophy (MHFMS), neuromuscular diseases (MFM), disabilities 0-6 years (VAB, WeeFIM), and one developed specifically for children with severe multiple disabilities (TDMMT) were found. Strong levels of evidence were found for construct validity of LE85 and MFM and for responsiveness of WeeFIM, but reliability studies of these instruments had a limited methodological quality. Up to now studies of the TDMMT resulted in limited and unknown evidence for structural validity due to the poor methodological quality of reliability studies. In a next step, the clinical suitability of the instruments for children with severe multiple disabilities will be evaluate.

Feasibility of bioelectrical impedance analysis in persons with severe intellectual and visual disabilities

BACKGROUND

Body composition measurements provide important information about physical fitness and nutritional status. People with severe intellectual and visual disabilities (SIVD) have an increased risk for altered body composition. Bioelectrical impedance analysis (BIA) has been evidenced as a reliable and non-invasive method to asses body composition in healthy persons and various patient populations; however, currently, there is no feasible method available to determine body composition in people with SIVD. In this study, therefore, we aimed to assess the feasibility of BIA measurements in persons with SIVD.

METHODS

In 33 participants with SIVD and Gross Motor Functioning Classification System (GMFCS) Scale I, II, III, or IV, two BIA measurements were sequentially performed employing Resistance and Reactance in Ohm and fat-free mass (FFM) in kg as outcome variables, utilizing the Bodystat(®) QuadScan 4000. Feasibility was considered sufficient if ≥ 80% of the first measurement was performed successfully. Agreement between two repeated measurements was determined by using the paired t-test and Intraclass Correlation Coefficient (ICC; two way random, absolute agreement). Bland-Altman analyses were utilized to determine limits of agreement (LOAs) and systematic error. Agreement was considered acceptable if LOAs were <10% of the mean of the first measurement.

RESULTS

The first BIA measurements were completed successfully in 88% of the participants. The paired t-test demonstrated no significant differences in Resistance, Reactance, and FFM between BIA Measurements 1 and 2 (P=0.140, 0.091, and 0.866). ICC was 0.965 (95% CI: 0.922-0.984) for Resistance; 0.858 (95% CI: 0.705-0.934) for Reactance; and 0.992 (95% CI: 0.982-0.996) for FFM. LOAs expressed as a percentage of the mean of Measurement 1 were 6.1% for Resistance, 17.6% for Reactance, and 3.8% for FFM.

CONCLUSIONS

The results of this study suggest that BIA measurements seem to be feasible in persons with SIVD. Although these results require confirmation in a more extensive sample of persons with SIVD, the findings of this study are an important first step in the assessment of applicability of BIA measurements for non-invasive monitoring of physical fitness and nutritional status of persons with SIVD.

Dietary Intakes and Nutritional Issues in Neurologically Impaired Children

Neurologically impaired (NI) children are at increased risk of malnutrition due to several nutritional and non-nutritional factors. Among the nutritional factors, insufficient dietary intake as a consequence of feeding difficulties is one of the main issues. Feeding problems are frequently secondary to oropharyngeal dysphagia, which usually correlates with the severity of motor impairment and presents in around 90% of preschool children with cerebral palsy (CP) during the first year of life. Other nutritional factors are represented by excessive nutrient losses, often subsequent to gastroesophageal reflux and altered energy metabolism. Among the non-nutritional factors, the type and severity of neurological impairment, ambulatory status, the degree of cognitive impairment, and use of entiepileptic medication altogether concur to determination of nutritional status. With the present review, the current literature is discussed and a practical approach for nutritional assessment in NI children is proposed. Early identification and intervention of nutritional issues of NI children with a multidisciplinary approach is crucial to improve the overall health and quality of life of these complex children.

Impact of Individualized Diet Intervention on Body Composition and Respiratory Variables in Children With Respiratory Insufficiency: A Pilot Intervention Study

OBJECTIVES

Diet modification may improve body composition and respiratory variables in children with respiratory insufficiency. Our objective was to examine the effect of an individualized diet intervention on changes in weight, lean body mass, minute ventilation, and volumetric CO2 production in children dependent on long-term mechanical ventilatory support.

DESIGN

Prospective, open-labeled interventional study.

SETTING

Study subjects' homes.

PATIENTS

Children, 1 month to 17 years old, dependent on at least 12 hr/d of transtracheal mechanical ventilatory support.

INTERVENTIONS

Twelve weeks of an individualized diet modified to deliver energy at 90-110% of measured energy expenditure and protein intake per age-based guidelines.

MEASUREMENTS AND MAIN RESULTS

During a multidisciplinary home visit, we obtained baseline values of height and weight, lean body mass percent by bioelectrical impedance analysis, actual energy and protein intake by food record, and measured energy expenditure by indirect calorimetry. An individualized diet was then prescribed to optimize energy and protein intake. After 12 weeks on this interventional diet, we evaluated changes in weight, height, lean body mass percent, minute ventilation, and volumetric CO2 production. Sixteen subjects, mean age 9.3 years (SD, 4.9), eight male, completed the study. For the diet intervention, a majority of subjects required a change in energy and protein prescription. The mean percentage of energy delivered as carbohydrate was significantly decreased, 51.7% at baseline versus 48.2% at follow-up, p = 0.009. Mean height and weight increased on the modified diet. Mean lean body mass percent increased from 58.3% to 61.8%. Minute ventilation was significantly lower (0.18 L/min/kg vs 0.15 L/min/kg; p = 0.04), and we observed a trend toward lower volumetric CO2 production (5.4 mL/min/kg vs 5.3 mL/min/kg; p = 0.06) after 12 weeks on the interventional diet.

CONCLUSIONS

Individualized diet modification is feasible and associated with a significant decrease in minute ventilation, a trend toward significant reduction in CO2 production, and improved body composition in children on long-term mechanical ventilation. Optimization of respiratory variables and lean body mass by diet modification may benefit children with respiratory insufficiency in the ICU.

Comparison of micronutrient levels in children with cerebral palsy and neurologically normal controls

OBJECTIVE

To measure levels of micronutrients in children with cerebral palsy and compare them with neurologically normal children of similar nutritional status.

METHODS

Fifty children with cerebral palsy (2-12 y) and 50 age and sex matched controls of similar nutritional status were enrolled. Detailed dietary history was recorded and nutritional status assessed. Venous blood (3 ml) was drawn for analysis. Micronutrient levels were measured as per standard technique.

RESULTS

Serum iron was 12.6 ± 5.9 and 20.9 ± 3.3 μmol/L in CP and controls respectively (P < 0.001). Mean copper levels were 106.2 ± 38.3 μg/dl in CP and 128.8 ± 20.2 μg/dl in controls (P < 0.001); magnesium levels were 1.97 ± 0.4 and 2.2 ± 0.3 mg/dl (P = 0.003). Zinc levels were similar in CP and controls (P = 0.979). The mean energy intake was significantly less in CP (P = 0.016). Mean protein intake did not vary significantly (P = 0.847). No correlation was found between energy intake and serum levels of micronutrients (P > 0.05). There was no difference in micronutrient levels with respect to gross motor functional classification system (GMFCS) grades and limb involvement (P > 0.05).

CONCLUSIONS

The serum levels of iron, copper and magnesium are significantly less in children with cerebral palsy, hence the need for supplementation.

Metabolic assessment and individualized nutrition in children dependent on mechanical ventilation at home

OBJECTIVE

To evaluate the nutritional and metabolic status and body composition of children on long-term mechanical ventilation using a home-based model.

STUDY DESIGN

Children on home mechanical ventilation, for at least 12 hours a day, were eligible. We performed anthropometry, bioelectrical impedance analysis (BIA), actual energy intake (AEI), and indirect calorimetry in the subject's home. Agreement between measured energy expenditure (MEE) from indirect calorimetry, and estimated energy expenditure by the Schofield equation and a novel volumetric carbon dioxide production-based equation was examined. Agreement between fat mass estimates from anthropometry and BIA was examined and compared with population norms.

RESULTS

We enrolled 20 children, 11 (55%) male; mean age 8.4 years (SD 4.8). Mean weight for age z-score was -0.26 (SD 1.48); 9/20 had z-scores <-1 or >+1. Thirteen were underfed (AEI:MEE <90%) or overfed (AEI:MEE >110%); 11 of 19 had protein intake that was less than recommended by guidelines. Fifteen subjects were hypo- or hypermetabolic. Mean (SD) fat mass % was 33.6% (8.6) by anthropometry, which was significantly greater than matched population norms (mean 23.0%, SD 6.1, P < .001). The estimated energy expenditure by a volumetric carbon dioxide production-based equation was in stronger agreement with the MEE than the Schofield equation (mean bias 0.06%, limits -15.98% to 16.16% vs mean bias -1.31%, limits -74.3% to 72%, respectively). BIA and anthropometric fat mass values were not in agreement.

CONCLUSION

A majority of children on home ventilation are characterized by malnutrition, altered metabolic status, and suboptimal macronutrient intake, in particular low protein intake. A multidisciplinary home-based model facilitates individualized energy and protein delivery and may improve outcomes in this cohort.

Nutritional management of children with cerebral palsy

Children with severe cerebral palsy and particularly those with oropharyngeal dysfunction are at risk of poor nutritional status. Determining the need and the mode of nutritional intervention is multifactorial and requires multiple methodologies. First-line treatment typically involves oral nutritional support for those children who are safe to consume an oral diet. Enteral tube feeding may need to be considered in children with undernutrition where poor weight gain continues despite oral nutritional support, or in those with oropharyngeal dysphagia and an unsafe swallow. Estimates for energy and protein requirements provide a starting point only, and ongoing assessment and monitoring is essential to ensure nutritional needs are being met, that complications are adequately managed and to avoid over or under feeding.

Well-being, health and fitness of children who use wheelchairs: feasibility study protocol to develop child-centred 'keep-fit' exercise interventions

AIM

To undertake the pre-clinical and modelling phases of the Medical Research Council complex intervention framework to underpin development of child-centred 'keep-fit', exercise and physical activity interventions for children and young people who use wheelchairs.

BACKGROUND

Children who use wheelchairs face many barriers to participation in physical activity, which compromises fitness, obesity, well-being and health. 'Keep-fit' programmes that are child-centred and engaging are urgently required to enhance participation of disabled children and their families as part of a healthy lifestyle. Nurses will likely be important in promoting and monitoring 'keep-fit' intervention(s) when implemented in the community.

DESIGN

Mixed-method (including economic analysis) feasibility study to capture child and family preferences and keep-fit needs and to determine outcome measures for a 'keep-fit' intervention.

METHODS

The study comprises three stages. Stage 1 includes a mixed-method systematic review of effectiveness, cost effectiveness and key stakeholder views and experiences of keep-fit interventions, followed by qualitative interviews with children, young people and their parents to explore preferences and motivations for physical activity. Stage 2 will identify standardized outcome measures and test their application with children who use wheelchairs to obtain baseline fitness data. Options for an exercise-based keep-fit intervention will then be designed based on Stage 1 and 2 findings. In stage 3, we will present intervention options for feedback and further refinement to children and parents/carers in focus groups. (Project funded October 2012).

DISCUSSION

At completion, this study will lead to the design of the intervention and a protocol to test its efficacy.

Accuracy of skinfold and bioelectrical impedance assessments of body fat percentage in ambulatory individuals with cerebral palsy

AIM

This study assessed the accuracy of measurements of body fat percentage in ambulatory individuals with cerebral palsy (CP) from bioelectrical impedance analysis (BIA) and skinfold equations.

METHOD

One hundred and twenty-eight individuals (65 males, 63 females; mean age 12y, SD 3, range 6-18y) with CP (Gross Motor Function Classification System [GMFCS] levels I (n=6), II (n=46), and III (n=19) participated. Body fat percentage was estimated from (1) BIA using standing height and estimated heights (knee height and tibial length) and (2) triceps and subscapular skinfolds using standard and CP-specific equations. All estimates of body fat percentage were compared with body fat percentage from dual-energy X-ray absorptiometry (DXA) scans. Differences between DXA, BIA, and skinfold body fat percentage were analyzed by comparing mean differences. Agreement was assessed by Bland-Altman plots and concordance correlation coefficients (CCC).

RESULTS

BMI was moderately correlated with DXA (Pearson's r=0.53). BIA body fat percentage was significantly different from DXA when using estimated heights (95% confidence intervals [CIs] do not contain 0) but not standing height (95% CI -1.9 to 0.4). CCCs for all BIA comparisons indicated good to excellent agreement (0.75-0.82) with DXA. Body fat percentage from skinfold measurements and CP-specific equations was not significantly different from DXA (mean 0.8%; SD 5.3%; 95% CI -0.2 to 1.7) and demonstrated strong agreement with DXA (CCC 0.86).

INTERPRETATION

Accurate measures of body fat percentage can be obtained using BIA and two skinfold measurements (CP-specific equations) in ambulatory individuals with CP. These findings should encourage assessments of body fat in clinical and research practices.

Differences in body composition according to functional ability in preschool-aged children with cerebral palsy

BACKGROUND & AIMS

Altered body composition is evident in school children with cerebral palsy (CP). Fat free mass and fat mass amounts differ according to functional ability and compared to typically developing 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 preschool-aged children with CP and investigate differences according to functional ability and compared to TDC.

METHODS

Eighty-five children with CP (68% male) of all functional abilities, motor types and distributions and 16 TDC (63% male) aged 1.4-5.1 years participated in this cross-sectional study. Body composition was determined via isotope dilution. Children with CP were classified into groups based on their Gross Motor Function Classification System (GMFCS) level. Statistical analyses were via ANOVA, ANCOVA, post-hoc Tukey HSD tests, independent t-tests and multiple regressions.

RESULTS

There were no significant differences in FFMI or BF% when comparing all children with CP to TDC. Children classified as GMFCS levels III, IV and V had significantly lower FFMI levels compared to children classified 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%)), significantly 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 towards lower FFMI levels and greater BF% across functional ability levels from GMFCS I to V. Further 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.

Measuring body composition in individuals with intellectual disability: a scoping review

BACKGROUND

Research shows obesity to be more prevalent amongst individuals with intellectual disability (ID) making correct measurement of body composition crucial. This study reviewed the validity and reliability of methods used for assessing body composition in individuals with ID.

METHODS

Authors conducted electronic searches through PubMed (1990 to present) and PsycINFO (1990 to present) and assessed relevant articles independently based on scoping review guidelines. Reviewers included primary research related to the validity and reliability of body composition measures on individuals with ID.

RESULTS

Searches identified six articles assessing body composition methods used on individuals with ID including body mass index (BMI), skinfold thickness, bioelectrical impedance analysis (BIA), waist circumference, tibia length, and anthropometric girth measurements. BMI and waist circumference appear suitable measures but skinfold thickness measurements may not be advisable due to participants' noncompliance resulting in a lack of precision and inaccurate results.

CONCLUSIONS

The current literature contains too few well-conducted studies to determine the precision and validity of body composition measures on individuals with ID. There may be a need to devise further regression equations that apply to individuals with specific types of ID in order to increase the reliability and validity of body composition measurements.