|Year : 2018 | Volume
| Issue : 3 | Page : 156-160
Nutritional status in cerebral palsy: A Cross-sectional comparative survey of children in Kano, Nigeria
Adamu Sa'idu Adamu1, Umar Abba Sabo2, Garba Dayyabu Gwarzo2, Raymond O Belonwu2
1 Department of Paediatrics, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
2 Department of Paediatrics, College of Health Sciences, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||26-Sep-2018|
Adamu Sa'idu Adamu
Department of Paediatrics, Abubakar Tafawa Balewa University Teaching Hospital, Hospital Road, Off Yandoka Street, P.M.B 0117, Bauchi State
Source of Support: None, Conflict of Interest: None
Background: Cerebral palsy (CP) is a common neurodevelopmental motor disorder resulting from early childhood brain insult. Nutrition in children is very important for growth and development. This is more so in those with chronic illnesses such as CP. This study was conducted with the aim of assessing the anthropometry and anthropometric indices of CP children. Materials and Methods: This comparative, cross-sectional study recruited 150 children with CP matched for age and sex, with 150 children without CP (as controls). The participants' socio-demographic and CP-related data were collected using a pre-tested questionnaire designed for the study. The weight and height of the subjects were measured. Nutritional status was determined using the World Health Organization Z-scores. Results: Overall prevalence of malnutrition in CP subjects was 86%. This was significantly higher than in controls, whose prevalence was 55.3% (χ2 = 34.027,P < 0.0001). The prevalence of stunting, wasting and underweight in CP subjects was 53.3%, 57.5% and 66.9%, respectively. These were also significantly higher than those of controls who had prevalence of stunting being 16.7%, wasting 8.5% and underweight 14.8%. Conclusion: This study found a high prevalence of malnutrition (especially under-nutrition) and therefore underscores the need for more emphases on nutritional assessment, counselling and management in CP patients.
Keywords: Anthropometry, cerebral palsy, malnutrition, nutritional status
|How to cite this article:|
Adamu AS, Sabo UA, Gwarzo GD, Belonwu RO. Nutritional status in cerebral palsy: A Cross-sectional comparative survey of children in Kano, Nigeria. Niger Postgrad Med J 2018;25:156-60
|How to cite this URL:|
Adamu AS, Sabo UA, Gwarzo GD, Belonwu RO. Nutritional status in cerebral palsy: A Cross-sectional comparative survey of children in Kano, Nigeria. Niger Postgrad Med J [serial online] 2018 [cited 2018 Oct 19];25:156-60. Available from: http://www.npmj.org/text.asp?2018/25/3/156/242205
| Introduction|| |
Cerebral palsy (CP) is a common neurodevelopmental disorder affecting children worldwide, with an incidence of 2–2.5 per 1000 live births.,, It is one of the common paediatric neurologic disorders in low-income countries., Motor dysfunction is a cardinal feature of CP and plays a central role in the definition, classification and management of CP. It prevents patients from carrying out activities of daily living (including self-feeding) and causes oral motor dysfunction, predisposing them to under-nutrition. On the other hand, under-nutrition causes decrease in muscle strength, thereby worsening motor impairment in CP. High prevalence of malnutrition in children with CP was reported in high-income countries,, but these prevalence data are few and variable in low-income countries., The variability in the prevalence may be related to different anthropometric indices used in classifying the nutritional status of children with CP. Amongst these anthropometric indices, the World Health Organization (WHO) Growth Standard Chart got universal acceptance because it took cognizance of socio-economic and environmental factors affecting anthropometry. Nutritional assessment and appropriate intervention are critical in the care of children with CP., Unfortunately, routine nutritional assessment of children with CP is low, especially in low-income countries such as Nigeria where access to health-care services is limited and the prevalence of malnutrition in general population is high. This underscores the need for further research and intervention in CP patients. This study was undertaken to assess the nutritional status of children with CP in Kano, Nigeria, compared to children without chronic illnesses.
| Materials and Methods|| |
Ethical clearance was obtained from Aminu Kano Teaching Hospital Research Ethics Committee, Zaria Road, Kano, Nigeria. Approval was obtained on 17th July 2013 (Protocol Number: AKTH/MAC/SUB/12A/P-3/VI/1169). Voluntary, written informed consent to enrol the patient into the study was obtained from the parent(s) or the accompanying caregiver(s) of each child. Assent was obtained from children aged 7–12 years.
The minimum sample size (n) of patients required was calculated from the formula:
n = Minimum sample size
Z1−α= Standard normal deviation corresponding to probability of type 1 error at 5% = 1.96
Z1−β= Standard normal deviation corresponding to probability of type 2 error at power 80% = 0.84
P1 = Prevalence of malnutrition in CP children = 35.7% (0.36)
P2 = Prevalence of malnutrition in general population of children = 20.5% (0.21)
q1 = Complementary probability of P1= (1 – P1)
q2 = Complementary probability of P2= (1 − P2)
To allow for attrition, 10% of the sample size was added to the calculated minimum sample size: 136 + 14 = 150.
The sample size used for the study was 150 each for CP cases and control group, respectively. The total sample size was 300.
Study design and population
The study was a comparative, cross-sectional study conducted at the Paediatric Neurology Clinic of Aminu Kano Teaching Hospital Kano, Nigeria, from October 2015 to March 2016. It was conducted as a fellowship dissertation. There was a delay in obtaining approval from the fellowship-awarding institution and hence the delay in commencement of the study after obtaining an ethical approval. A total of 300 children aged 2–12 years, 150 each in CP and control group, were enrolled into the study. A case was considered CP if it fulfilled the definition agreed upon at the 2004 International Workshop on Definition and Classification of CP. Where a patient had motor dysfunction but a history suggestive of preceding non-progressive brain insult was not obtained, it was considered a case after excluding transient motor dysfunction, motor impairments with manifestations of progressive brain insult and motor dysfunctions from spinal abnormalities or injuries. Patients with other chronic ailment that predisposed them to under-nutrition (such as congenital cardiac disease and tuberculosis) and those with severe lower limb contractures that prevent proper height measurement were excluded from the study. The control group was children without CP or chronic ailment who presented with acute illnesses at the Paediatric Outpatient Department of the hospital. They were matched for age and sex with CP cases. A pre-tested questionnaire developed for the study was administered to obtain the socio-demographic and CP-related data of the study subjects.
Anthropometry (weight and height) were measured in accordance with the standard procedure. All measurements were carried out by the same person (the principal investigator). Weight was measured using a digital weighing scale with taring capability (Seca UNICEF). Tare weighing was used for subjects who could not stand, where accompanying parent or caregiver is weighed first. The scale is then tared to zero and then the parent/caregiver carried the children and the scale then displayed the child's weight. The measured weight was recorded to the nearest one decimal place (0.1 kg). Height was measured using a stadiometer (UNICEF). Recumbent length was measured in children who were unable to stand using the length board. Height/length measurements were recorded to nearest 0.1 cm. Anthropometric measurements obtained were converted into indices using the WHO Growth Standard Charts for Z-scores based on subjects' age and sex. Nutritional status was determined using Z-scores for weight-for-age (WAZ), weight-for-height (WHZ), height-for-age and body mass index (BMI)-for-age (BAZ). Z-scores of <−2 to −3 Z-score were considered malnourished, while scores <−3 severely malnourished. BAZ of >+1–2 were classified overweight, while scores of >+2 were considered obese. However, because of the age limitation of the WHO WAZ and WHZ charts, only 142 of subjects whose ages were 10 years and below had their WAZ done, and 106 of subjects whose ages were 5 years and below had their WHZ done.
The data generated were analysed using SPSS statistical software version 20 (IBM Corp. Armonk, NY, USA) and presented using tables. Quantitative variables were summarised and presented as means and standard deviations. Means were compared using t-test. Qualitative variables were presented as frequencies and percentages. Proportions were compared using Chi-square test. An α-level of significance was set at 5%; thus, P < 0.05 was accepted as statistically significant.
| Results|| |
There were 103 (68.7%) males and 47 (31.3%) females in each of the CP and control group, respectively. Male to female ratio was 2.2:1. The ages of subjects ranged from 2 to 12 years. The mean age of CP group was 4.57 ± 2.6 years. Although the mean of age of control was slightly lower than that of subjects with CPs (4.55 ± 2.4 years), they have the same sex and age distribution as they were matched with cases as seen in [Table 1]. Subjects aged 2 years constituted the highest percentage (34%) of the total sample population.
When compared, the mean weight, height and BMI of CP cases were significantly lower than those of control [Table 2]. However, there were no significant differences between the means of weight, height and BMI of males and females in both CP cases and controls as shown in [Table 3].
|Table 2: Mean weight, height and body mass index among the study participants|
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|Table 3: Mean weight, height and body mass index by gender among the study participants|
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The overall prevalence of malnutrition in CP cases was 86% (n = 129). Out of these, 119 (79.3%) had under-nutrition, while the remaining 10 (6.7%) had over-nutrition. The prevalence of malnutrition among the controls was 55.3% (n = 83). Sixty-eight subjects (45.3%) from the control group were under-nourished, while 15 (10%) had over-nutrition (11 overweight, 4 obesity). The difference between the prevalence of malnutrition in CP cases and controls was significant (χ2: 34.027. P < 0.0001). The prevalence of stunting (mild-to-moderate and severe forms) in CP cases was 53.3%. The CP group had higher prevalence of wasting, underweight and thinness, especially the severe forms, than the control group [Table 4]. Of the 106 participants assessed for wasting in each of the two arms, the CP group had 31.1% (n = 33) cases of severe wasting compared to 1.9% (n = 2) in control group (χ2: 32.887, P <0.0001). Conversely, the prevalence of over-nutrition (overweight and obesity) was higher in controls than in CP subjects. Overweight and obesity constituted 7.3% and 2.7% in the controls, respectively. None among CP cases was obese while 6.7% were overweight. However, there was no significant difference in the anthropometric indices between male and female CP subjects [Table 5].
|Table 5: Anthropometric Indices of cerebral palsy subjects between sexes|
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| Discussion|| |
The demographic characteristics of the 150 CP subjects in this study show male preponderance of 68.7%. Similar high proportion of male patients in CP (62.9%) was earlier reported in Kano, Nigeria, and England. The reason for this male preponderance is not clearly known. Some of the reasons hypothesised include more vulnerability of male preterm to white matter injury and intra-ventricular haemorrhages and the neuroprotective action of female sex hormone oestrogen., This study also shows that younger age (2–4 years) constituted 60% of the cases of CP. This was in keeping with earlier findings, and may be as a result of loss to follow-up and increased mortality with increasing age. A Nigerian study reported high follow-up default rate of over 88%.
The mean weight and height of the CP participants were 13.0 ± 5.2 kg and 97.2 ± 17.1 cm, respectively. This is lower than the finding of a Brazilian study where the mean weight was 15 ± 1.5 kg and mean height was 99.7 ± 4.6 cm. It is interesting to note that the subjects in the index study were older than those in the Brazilian study. However, the index study included all cases of CP irrespective of severity while the Brazilian study recruited only children with mild CP. This may explain the lower mean weight and height in this study because children with severe forms of CP tend to have lower height and weight. When compared to controls, the mean heights and weights of CP patients were lower than those of controls across all age categories. These findings are similar to those reported in other African studies., Studies have shown higher risk of under-nutrition in CP children.,
The overall prevalence of malnutrition was 86%, of which 79.3% had under-nutrition. Studies have shown a variable prevalence of under-nutrition amongst children with CP from African countries., Kakooza-Mwesige et al. reported prevalence of 52% in Ugandan children; Okeke and Ojinnaka reported the prevalence of 16.3% in Enugu, South-East Nigeria, while Tomoum et al. reported prevalence of 15.8% in Egypt. This study used similar method of nutritional assessment as the Ugandan study (WHO Z-score) which may explain the higher prevalence. The WHO growth standard chart was shown to be more sensitive in detecting malnutrition., Moreover, the higher prevalence in this study may be related to the regional variation of malnutrition in the general paediatric population. For instance, the Nigerian Demographic and Health Survey 2013 reported that Kano, North-West Nigeria, has a significantly higher prevalence of malnutrition in the general population than Egunu in the South-East. Malnutrition prevalence of 47.5% was also reported in Bosnian children with CP using the WHO Z-score. The prevalence was relatively lower (38.1%) in Greece when the WHO Z-score was used to assess nutritional status of children with CP. Generally, there is higher prevalence of under-nutrition amongst the general population in low-income countries such as Nigeria when compared to the high-income countries such as Greece. Our data also displayed a significantly higher prevalence of severe malnutrition in children with CP compared to children without chronic illness. Such findings had been previously reported. The higher proportion of severe stunting in the CP group can be explained by the chronicity of the disease and by extension of malnutrition.
| Conclusion|| |
The prevalence of malnutrition in children with CP is high in Kano, Nigeria. Severe forms of malnutrition are significantly higher in children with CP when compared with children without chronic illness. There is need for proactive routine nutritional assessment, management and regular follow-up of children with CP.
Some of the patients with contracture were excluded from the study because of difficulty in height measurement. This might have introduced a selection bias. Such subjects could have been enrolled into the study and a segmental weight measurement carried out. Not all study subjects had their nutritional status assessed using WAZ and WHZ because of age limitation of WHO Growth Standard Charts.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Winter S, Autry A, Boyle C, Yeargin-Allsopp M. Trends in the prevalence of cerebral palsy in a population-based study. Pediatrics 2002;110:1220-5.
Himmelmann K, Hagberg G, Beckung E, Hagberg B, Uvebrant P. The changing panorama of cerebral palsy in Sweden. IX. Prevalence and origin in the birth-year period 1995-1998. Acta Paediatr 2005;94:287-94.
Prevalence and characteristics of children with cerebral palsy in Europe. Dev Med Child Neurol 2002;44:633-40.
Lagunju IA, Okafor OO. An analysis of disorders seen at the paediatric neurology clinic, university college hospital, Ibadan, Nigeria. West Afr J Med 2009;28:38-42.
Belonwu RO, Gwarzo GD. The clinical spectrum of paediatric neurological disorders in Aminu Kano Teaching Hospital, Kano. Sahel Med J 2008;11:12-4. [Full text]
Stevenson RD, Conaway M, Chumlea WC, Rosenbaum P, Fung EB, Henderson RC, et al.
Growth and health in children with moderate-to-severe cerebral palsy. Pediatrics 2006;118:1010-8.
Russell DM, Leiter LA, Whitwell J, Marliss EB, Jeejeebhoy KN. Skeletal muscle function during hypocaloric diets and fasting: A comparison with standard nutritional assessment parameters. Am J Clin Nutr 1983;37:133-8.
Kuperminc MN, Stevenson RD. Growth and nutrition disorders in children with cerebral palsy. Dev Disabil Res Rev 2008;14:137-46.
Tomoum HY, Badawy NB, Hassan NE, Alian KM. Anthropometry and body composition analysis in children with cerebral palsy. Clin Nutr 2010;29:477-81.
Okeke IB, Ojinnaka NC. Nutritional status of children with cerebral palsy in Enugu Nigeria. Eur J Sci Res 2010;39:505-13.
de Onis M, Garza C, Victora CG, Onyango AW, Frongillo EA, Martines J, et al.
The WHO multicentre growth reference study: Planning, study design, and methodology. Food Nutr Bull 2004;25:S15-26.
Campanozzi A, Capano G, Miele E, Romano A, Scuccimarra G, Del Giudice E, et al
. Impact of malnutrition on gastrointestinal disorders and gross motor abilities in children with cerebral palsy. Brain Dev 2007;29:25-9.
Sullivan PB, Lambert B, Rose M, Ford-Adams M, Johnson A, Griffiths P, et al.
Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford feeding study. Dev Med Child Neurol 2000;42:674-80.
Kirkwood BR, Sterne JA. Essential Medical Statistics. 2nd
ed. New York: Blackwell Scientific Publication; 2003.
Odunayo SI, Oyewole AO. Risk factors for malnutrition among rural Nigerian children. Asia Pac J Clin Nutr 2006;15:491-5.
Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al.
A report: The definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007;109:8-14.
Jarvis S, Glinianaia SV, Arnaud C, Fauconnier J, Johnson A, McManus V, et al.
Case gender and severity in cerebral palsy varies with intrauterine growth. Arch Dis Child 2005;90:474-9.
Johnston MV, Hagberg H. Sex and the pathogenesis of cerebral palsy. Dev Med Child Neurol 2007;49:74-8.
Gibson CL, Gray LJ, Murphy SP, Bath PM. Estrogens and experimental ischemic stroke: A systematic review. J Cereb Blood Flow Metab 2006;26:1103-13.
Kakooza-Mwesige A, Tumwine JK, Eliasson AC, Namusoke HK, Forssberg H. Malnutrition is common in Ugandan children with cerebral palsy, particularly those over the age of five and those who had neonatal complications. Acta Paediatr 2015;104:1259-68.
Frank-Briggs AI, D Alikor EA. Pattern of paediatric neurological disorders in Port Harcourt, Nigeria. Int J Biomed Sci 2011;7:145-9.
Iloeje SO, Ejike-Orji I. Compliance by cerebral palsy (CP) patients attending a child neurology service, in a developing country: A preliminary study. West Afr J Med 1993;12:1-5.
Zonta MB, Agert F, Muzzolon SR, Antoniuk SA, Magdalena NI, Bruck I, et al
. Growth and anthropometry in hemiplegic cerebral palsy patients. Rev Paul Pediatr 2009;27:416-23.
Reilly S, Skuse D, Poblete X. Prevalence of feeding problems and oral motor dysfunction in children with cerebral palsy: A community survey. J Pediatr 1996;129:877-82.
Schwarz NG, Grobusch MP, Decker ML, Goesch J, Poetschke M, Oyakhirome S, et al
. WHO 2006 child growth standards: Implications for the prevalence of stunting and underweight-for-age in a birth cohort of Gabonese children in comparison to the Centers for Disease Control and Prevention 2000 Growth Charts and the National Center for Health Statistics 1978 Growth References. Public Health Nutr 2008;11:714-9.
Karagiozoglou-Lampoudi T, Daskalou E, Vargiami E, Zafeiriou D. Identification of feeding risk factors for impaired nutrition status in paediatric patients with cerebral palsy. Acta Paediatr 2012;101:649-54.
Melunovic M, Hadzagic-Catibusic F, Bilalovic V, Rahmanovic S, Dizdar S. Anthropometric parameters of nutritional status in children with cerebral palsy. Mater Sociomed 2017;29:68-72.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]