The neurologically handicapped child almost invariably experiences nutritional problems.1 They more commonly present as malnutrition, but obesity and overnutrition can also be found. Parameters to assess malnutrition and over-nutrition in the handicapped child have to be adjusted. Height is a proper parameter for growth and nutritional status, but difficult in children with malformations and spasticity.2-4 Also, disproportionate development of the head, rump and extremities makes assessment of height as a parameter of nutritional status difficult.5-7 Therefore, crown-rump length, width, crown-heel length, distal femoral length and distal arm length (Spender growth curve) have been developed to assess growth and to relate height to developmental abnormalities or to nutrition.8 It is clear that the Quetelet index or body mass index (BMI) have to be used with care in these children.
Different etiologies result in different growth abnormalities during development in childhood.9
Children with Down's syndrome, which is a genetic chromosomal disorder, have height and bone development retardation from birth. The rump or sitting height is normal in these children. The height development becomes relatively shorter each year up to the age of 15. The skull development stops at the age of 3. The growth deficit is more pronounced in height than in width and they appear microcephalic when they get older.
Children with multiple congenital anomalies, with specific histories of drug therapy, irradiation and viral infections early in gestation, and which could be considered as an environmental insult, have height curves that are normal until the age of 5 for both sexes, and then start to lag behind. By the age of 10, they slow down and seem to miss their adolescent growth spurt. Many children in this group become microcephalic, and usually there are more deficits in width than height.
In children with hypoxia, severe or prolonged deprivation of oxygen at the time of birth, in essence cerebral palsy with motor function impairment, height and trunk measurements are normal for 10 years and then slow down, perhaps reflecting a failure of the adolescent growth spurt. Head circumferences lag behind over all ages. On the other hand, children whose neurological deficit is minimal brain damage (attention deficit hyper-activity disorder, children with school and learning problems and no definite impairment of motor function), have their heights and weights within normal ranges. Therefore, body weight and BMI (kg/m2) are more appropriate for evaluation of malnutrition in these children.
In a study on more than 2000 institutionalized children with a handicap in Tokyo, Japan,3 height and weight were measured in four distinct groups. Groups were divided into deaf children; blind children; mentally retarded children, some of whom were completely ambulatory and 15% of whom needed crutches; and physically handicapped children, of whom 65% were non-ambulatory. Height more than 3 standard deviations below the mean was present in 2% of deaf children, 10% of blind children, 15% of children with mental retardation and 45% of physically handicapped children. Underweight more than 2 standard deviations below the mean was present in 1% of deaf children, 4% of blind children, 5% of children with mental retardation and 24% of physically handicapped children. Overweight more than 2 standard deviations above the mean was present in 8% of deaf children, 7.5% of blind children, 17% of mentally retarded children and 9% of physically handicapped children.10 In a Finnish study of patients up to the age of 20, the BMI showed that underweight (BMI <20kg/m2) was present in 30%, overweight in 10% and severe overweight in 7% (BMI > 32 kg/m2).11 Also, more than 20% of children being overweight was found in another survey of more than 1100 children.12,13 Although the studies report height and weight reduction of almost 1 standard deviation in large cohorts of handicapped children, it seems more appropriate to relate the chance of malnutrition to mental retardation (5%) or physical handicap (25%). A height reduction of more than 3 standard deviations occurs in 1% of deaf children, 5% of blind children, 2% of mentally retarded children and 6% of physically handicapped children. This proportion of stagnation in height development in chromosomal, toxic and hypoxic disorders was not easily explained by nutritional depletion. Also, disproportionate development in the head, trunk and extremities were not in keeping with nutritional problems.
In the normal child, undernutrition or overnutri-tion is obviously undesirable. In the handicapped child, however, a proper nutritional status is of crucial importance, as it supports the ability to employ all nutrients necessary for normal body functions in biological, physiological and psychological ways. 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.
Assessment of nutritional status requires a proper follow-up of height, body weight and assessment of the standard deviation score. By so doing, negative changes are easily discovered and appropriate nutritional intervention can be initiated. Spender et al8 showed that upper arm length and lower leg length were as appropriate as height measurements in these children and had the same technical intra- and interobserver errors as the measurements of height, usually difficult to obtain in these children. In practice, they are easier to perform and have a better compliance for regular follow-up measurements. Triceps skin fold as indication of body fat and arm circumference as indication of muscle mass, should be measured in conjunction with height and body weight with the highly variable muscle mass in these children.14
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