Nutrition 25 (2009) 620 626

www.nutritionjrnl.com
Applied nutritional investigation

Diet, feeding practices, and anthropometry of children and adolescents

with cerebral palsy and their siblings
Maria G. Grammatikopoulou, M.Sc., Efstratia Daskalou, B.Sc., and Maria Tsigga, Ph.D.*
Human Nutrition and Dietetics, Alexander Technological Educational Institute, Thessaloniki, Greece

Manuscript received August 17, 2008; accepted November 18, 2008.

Abstract Objective: We investigated growth and nutrition in children and adolescents with cerebral palsy
(CP) in comparison with their healthy siblings.
Methods: This was a case control, single observational investigation of 16 pairs of children with
CP and their healthy siblings. Stature, weight, skinfolds, and selected circumferences were mea-
sured, and Z-scores, percentage of body fat (calipers), and body mass index were calculated. Diet
and feeding practices were recorded for 3 d.
Results: No differences were observed in the macronutrient distribution of energy intake, with
participants with CP covering 75% of their energy requirements. Subjects with CP demonstrated low
vitamin A, biotin, folate, vitamin K, and copper intakes. The healthy siblings inadequately con-
sumed vitamin E and both groups followed diets low in zinc. Iron was marginal for the CP group,
but calcium was consumed adequately by all. The participants with CP demonstrated lower body
weight, body mass index, percentage of body fat, weight-for-age Z-score, and triceps skinfold (P
0.001), decreased height-for-age Z-score (P 0.008), lower body mass index Z-score (P 0.002),
and smaller circumferences. Praise rewards were more often used in children with CP (P 0.049)
but threats to withdraw food were applied only to the healthy siblings (P 0.021). When usual
intakes were considered, participants with a greater degree of motor impairment were closer to
meeting their energy needs.
Conclusion: The diets of participants with CP were in the majority energy deficient. The highest energy
intakes were demonstrated by the most severely impaired subjects. A tendency was recorded within each
household for the adequacy/inadequacy in energy intake, concerning both siblings. 2009 Published
by Elsevier Inc.

Keywords: Nutrition; Neurologic impairment; Macronutrient; Micronutrient; Body fat

Introduction impairment tend to follow diets poorer in terms of energy

Children and adolescents with cerebral palsy (CP) in the
majority encounter feeding problems that have an impact on
nutrient status and growth [13]. Dietary monitoring is
warranted in neurologic impairment because affected chil-
dren are at increased risk for nutrition-related morbidity and
mortality [4]. Henderson et al. [5] demonstrated that
residential-care living has a significant positive association
with all growth and nutrition variables compared with living
at home; as in the first environment, tube feeding is more
common. In general, children with a greater degree of motor
* Corresponding author. Tel/fax.: 30-231-0791584.
E-mail address: mtsigga@nutr.teithe.gr (M. Tsigga).
and micronutrients [6]. This is explainable considering that
these children are more dependent on the time and eager-
ness of their caretakers [1].
Cross-sectional studies comparing the diets of non-
institutionalized children with CP with those of the healthy
population have demonstrated decreased energy consump-
tion in participants with CP. This was attributed to their
inability to communicate their hunger, food preferences,
and satiety [7,8], leaving the responsibility of their dietary
intake on their caretakers [1]. However, these results could
have been biased by the overall differences in the home
environment, because neurologically impaired and healthy
participants were not nurtured by the same families. This
methodologic problem would have been encountered only

0899-9007/09/$ see front matter 2009 Published by Elsevier Inc.

doi:10.1016/j.nut.2008.11.025
 M. G. Grammatikopoulou et al. / Nutrition 25 (2009) 620 626
by comparing pairs of healthy children with children with
CP within the same household.
Thus, the present case-control study was designed to
observe differences in the dietary and feeding practices of
non-institutionalized children and adolescents with CP com-
pared with their healthy siblings.
Materials and methods
Participants
This research took place in Ioannina, a city in northwest-
ern Greece, during November 2007. The participating fam-
ilies were recruited by telephone through the Ioannina
school for children with special needs. Sixteen families
agreed to participate, all of which had one child with CP and
at least a non-affected one. Because some participating
families included more than one healthy child, the one
closer to the age of the child with CP was chosen for the
study. The final sample included 16 pairs of children with
CP (11 boys and 5 girls, mean age 10.1 2.9 y) and their
healthy siblings (8 from each sex, mean age 9.4 3.9 y).
The healthy children formed the control group. No differ-
ence was recorded in the age of the examined groups (P
0.582). The neurologic disabilities of participants with CP
are presented in Table 1; the gross-motor function classifi-
cation system [9] was omitted, because severity in accor-
dance to the Oxford Feeding Study II [2] was easier to
perform and more understandable by non-experts. Partici-
pants with CP were classified as having mild (little or no
difficulty in walking), moderate (difficulty in walking but
without the need of aids/helper), or severe (needs aids
and/or a helper or cannot walk) neurologic disability [2].
Approval for the investigation was obtained from the Ioan-
nina public health supervisor, our institute, the head princi-
pal and teachers of the school of children with special needs,
and the parents/guardians of all participants.
Table 1
Neurologic characteristics of participants with CP (n 16)
Type of CP
Spastic
Hypotonic
Dystonic/athetotic
Mixed type
Distribution of motor impairment
Hemiplegia
Diplegia
Quadriplegia 12 (75.0%)
Seriousness
Minimal
Mild
Severe
CP, cerebral palsy
621
Dietary assessment
Parents were instructed on how to record their childrens
food intake for 3 consecutive days, including a weekend
day. None of the children with CP was fed with tube
feedings partially or in total and all of them abstained from
drugs affecting growth (e.g., steroids). The mean dietary
intake of the 3 recorded days was calculated with the USDA
19 HealtheTec SR computer program and compared with
the latest dietary reference intake (DRI) values for children
[10]. Intakes lower than 70% of the DRI were considered
inadequate [6,11]. Nutrient intake percentiles were calcu-
lated through SPSS 12.0 (SPSS Inc., Chicago, IL, USA) as
approximate estimates of usual intake, as suggested by
Carriquiry [12]. Due to the wide range of age distribution
between samples, only macronutrients expressed per kilo-
gram of body weight were selected for the usual intake
calculation. The calculation of percentiles of nutrient intake
was performed on the intakes that derived from the 3-d
dietary records, i.e., from 48 (3 d for 16 subjects) daily
intakes for each nutrient, in each participating group. Basic
metabolic rate was calculated in accordance to the U.S.
Institute of Medicine [10] for the healthy children and as
suggested by Marchand et al. [1] for the children with CP.
Total energy expenditure was calculated as with Institute of
Medicine equations [10], with respect to the physical activ-
ity of each participant. The nutrient content of Greek recipes
was calculated as suggested by Trichopoulou [13].
Feeding practices
Parental strategies used at childrens mealtimes were
recorded by an experienced dietitian, with the use of a
questionnaire by Orrell-Valente et al. [14]. The dietitian
observed one evening meal per participating child and re-
corded the place of dining, the presence of a parent or of all
the family, and whether the child watched television or
played during mealtime. Parents were not aware that the
dietitian was recording feeding practices, but only the con-
sumed meals volume. Parental strategies were identified
as neutral prompts (e.g., Dont forget to eat your meal),
pressure/demand to eat (e.g., Eat now), reasoning (e.g.,
Have some salad, its good for you), food reward (e.g., If you
finish your meal you can have some ice cream), praise (e.g.,
Well done! You ate all your food!), food restrain/portion
9 (56.3%)
5 (31.3%) control (e.g., No more chips), threat to withdraw food (e.g.,
0 (0.0%) If you dont finish your meal, there will be no lemonade!),
2 (12.5%) threat to withdraw play privileges (e.g., If you dont eat,
there will be no play with the neighbors), or offer of play
0 (0.0%)
rewards (e.g., When you finish your meal, you can play with
4 (25.0%)
your brother) [14].
3 (18.8%) Anthropometry
4 (25.0%)
9 (56.3%)
Stature and body weight were measured with a scale
(SECA 789, Hamburg, Germany) with an attached stadiom-
622 M. G. Grammatikopoulou et al. / Nutrition 25 (2009) 620 626

eter. When standing height was difficult to measure due to Table 2

scoliosis or contractures, length was recorded in the supine Comparison of daily macronutrient and fat component intakes
position with a common measuring tape. Outcome measure- With CP Without CP P
ments included wrist, arm, waist, and hip circumferences (n 16) (n 16)
and triceps, subscapular, and calf skinfolds. Growth was EI
evaluated with the use of EPI Info computer software (Cen- MJ 5.6 1.4 6.5 1.5 0.105
ters for Disease Control and Prevention, Bethesda, MD, kJ/kg BW 269.3 122.2 209.6 75.8 0.129
Needs 0.75 0.18 0.86 0.23 0.108
USA). Body fat was calculated with equations from Slaugh-
Protein
ter et al. [15] for girls and boys, with the use of Lange g/kg BW 2.8 1.4 2.3 1.1 0.357
calipers (Beta-Technology Inc., Santa Cruz, CA, USA). %EI 17.4 5.7 19 5.9 0.417
Body mass index (BMI), fat mass index (FMI), and fat-free Carbohydrate
mass index (FFMI) were calculated for each participant as g/kg BW 7.6 3.7 5.6 2.3 0.073
%EI 47.0 10.0 44.8 9.6 0.526
body, fat mass, or fat-free mass weight (kilograms) divided
Fat
by height (meters) squared [16]. The same experienced g/kg BW 2.6 1.2 2.0 1.0 0.155
physician performed all measurements in the morning %EI 35.6 7.8 36.1 7.5 0.808
hours. Fiber (g) 12.9 6.7 13.8 7.6 0.600
Cholesterol (g) 0.17 0.07 0.26 0.14 0.014*
MUFAs (g) 16.6 8.2 23.7 11.7 0.007*
Statistical analyses PUFAs (g) 6.3 4.6 8.7 4.6 0.071
Trans fatty acids (g) 1.1 0.8 1.7 2.7 0.347
Saturated fatty acids (g) 21.6 9.3 26.6 10.7 0.109
Paired t tests were performed for all continuous scale
data. McNemars test was applied on the recorded feeding BW, body weight; CP, cerebral palsy; EI, energy intake; MUFAs,
practices of each group. Independent-samples t test was monounsaturated fatty acids; PUFAs, polyunsaturated fatty acids
* Statistically different between siblings with and without CP (paired t
performed for each distribution of motor impairment (diplegia/
test).
quadriplegia) and the calculated Z-scores. Analysis of vari-
ance with Bonferronis correction was used for assessing
differences in anthropometric indices between groups of
to expenditure was correlated to the macronutrient content
seriousness of impairment. Bivariate correlations were per-
of the diet expressed per kilogram of body weight (P
formed between the ratio of energy intake to expenditure
0.025, r 0.559, for protein; P 0.022, r 0.568, for fat;
and the anthropometric characteristics of the participants
P 0.004, r 0.677, for carbohydrate), to the consumed
with CP. Medians of energy and macronutrient intakes
saturated fatty acids (P 0.010, r 0.621), and to the ratio
between subjects with CP and their healthy siblings were
of vegetable to animal protein (P 0.022, r 0.566; Table 2).
tested with the Mann-Whitney test, and differences in the
Percentiles of macronutrient intake are presented in Ta-
medians of macronutrient intake among groups of serious-
ble 3. No differences were observed in the medians of the
ness of impairment were assessed with the Kruskal-Wallis
examined variables between siblings with and without CP
test. SPSS 12.0 (SPSS Inc.) was used for statistical analysis.
according to the Mann-Whitney test. Participants with CP
demonstrated wider ranges in their energy and macronutri-
ent intakes; however, the healthy siblings exhibited higher
Results percentiles for the ratio of energy intake to expenditure.
When the median values were calculated for each category
Dietary intake of seriousness of impairment, differences were demon-
strated only for the ratio of energy intake to expenditure
Energy intake was inadequate in both groups, but not (0.63 for mild, 0.62 for moderate, and 0.81 for severe
statistically different (5.6 1.4 versus 6.5 1.5 MJ/d for impairment) according to the Kruskal-Wallis test (H
participants with and without CP, respectively, P 0.105), 9.119, P 0.010).
with children with CP covering 74.6% of their energy re- In terms of micronutrient intake, the two groups did not
quirements and non-affected participants consuming 85.8% exhibit differences in the adequacy of DRI. However, the
of their energy needs. The macronutrient distribution of the participants with CP presented low vitamin A (66.8%),
diet in children with CP comprised 47% carbohydrate, biotin (66.7%), folate (56.7%), vitamin K (65.4%), and
35.6% fat, and 17.4% protein (1.1 1.0 vegetable/animal), copper (52.3%) intakes. Non-affected subjects consumed
whereas the healthy siblings consumed 44.8% carbohydrate, less vitamin E than recommended (47.9%) and all siblings
36.1% fat, and 19% protein (0.9 0.5 vegetable/animal). followed diets low in zinc (59.3% for those with CP and
No difference was recorded in the macronutrient and fiber 59.1% for those without CP). Iron was marginally con-
contents of the recorded diets; however, cholesterol was sumed by the subjects with CP (70.4%), but calcium was
significantly higher in the diet of the healthy siblings (P adequate in the diet of all siblings (97.4% for those with CP
0.014). For participants with CP, the ratio of energy intake and 95.5% for those without CP).
 M. G. Grammatikopoulou et al. / Nutrition 25 (2009) 620 626 623

Table 3
Usual intake distributions for energy and macronutrient of siblings with and without CP
Percentiles Participants with CP (n 16) Participants without CP (n 16)

Energy EI/EE Protein Carbohydrate Fat Energy EI/EE Protein Carbohydrate Fat
(kJ/kg BW) (g/kg BW) (g/kg BW) (g/kg BW) (kJ/kg BW) (g/kg BW) (g/kg BW) (g/kg BW)

5 121.1 0.31 1.3 3.5 0.9 106.8 0.49 0.8 2.3 0.6
10 141.8 0.39 1.5 4.3 1.1 121.1 0.61 1.0 2.7 1.0
25 195.0 0.59 1.9 5.5 1.6 148.5 0.72 1.4 3.6 1.1
50 248.1 0.74 2.7 6.8 2.5 201.5 0.83 2.2 5.2 1.8
75 343.1 0.96 3.5 9.5 3.3 259.1 0.98 3.0 7.2 2.8
90 429.0 1.10 4.3 11.5 4.6 307.3 1.16 3.4 8.9 3.4
95 450.2 1.11 5.1 13.8 5.1 359.9 1.28 4.3 10.1 3.8

BW, body weight; CP, cerebral palsy; EI/EE, energy intake/energy expenditure

Anthropometry diplegia. BMI and arm circumference were significantly dif-

Table 4 presents the anthropometric indices of all siblings.
Participants with CP had statistically lower body weight, BMI,
FMI, percentage of body fat (%BF), weight-for-age Z-score,
and triceps skinfold compared with their siblings (P 0.001),
lower height-for-age Z-score (P 0.008), BMI Z-score
(BMIZ), and FFMI (P 0.002), and smaller wrist, arm, waist,
and hip circumferences (P 0.005, P 0.006, P 0.018, and
P 0.007, respectively). No differences were recorded for
height, weight-for-height Z-score, and waist-to-hip ratio be-
tween subjects and controls. When Z-scores were analyzed for
diplegia or quadriplegia, BMIZ was significantly lower in
quadriplegia (P 0.044), although all Z-scores were higher in
ferent among the three groups of seriousness of impairment
(minimal/mild/severe, P 0.044 and P 0.047), but %BF
was similar among all types (P 1). Bonferronis correction
revealed differences in FFMI and BMIZ between subjects with
mild and severe impairment (P 0.028 and P 0.037). The
healthy siblings demonstrated significantly higher %BF (P
0.036), BMI (P 0.001), FMI (P 0.003), FFMI (P
0.005), triceps skinfold (P 0.033), weight-for-age Z-score
(P 0.001), BMIZ (P 0.001), and arm circumference
compared with subjects with severe impairment.
No correlations were observed between the ratio of en-
ergy intake to expenditure and the Z-scores, percentage of
fat, or circumferences of the participants with CP. Although

Table 4
Comparison of growth and anthropometric characteristics between subjects with CP and their healthy siblings
Seriousness of impairment CP total Non-CP P
(n 16) (n 16) (paired t test)
Mild Moderate Severe
(n 3) (n 4) (n 9)

Stature (m) 1.22 0.11 1.30 0.14 1.30 0.17 1.28 0.15 1.38 0.26 0.156
Weight (kg) 24.7 2.5 26.6 7.9 21.2 7.6 23.2 7.1 35.8 17.8 0.008*
Fat mass (kg) 3.4 0.4 5.1 2.8 3.3 2.7 3.7 2.5 8.3 5.9 0.002*
Fat-free mass (kg) 21.3 2.2 21.5 5.1 17.8 5.4 19.4 5.0 27.4 12.6 0.018*
Body fat (%) 13.7 0.1 17.6 6.5 14.1 6.3 14.9 5.7 21.9 6.7 0.001*
BMI (kg/m2) 17.0 4.8 15.7 3.4 12.2 1.9 14.0 3.4 17.9 3.1 0.001*
FMI (kg/m2) 2.3 0.7 2.9 1.5 1.8 1.0 2.2 1.1 4.0 1.7 0.001*
FFMI (kg/m2) 14.7 4.2 12.8 2.1 10.4 1.2 11.8 2.7 13.9 2.1 0.002*
Waist/hip ratio 1.01 0.03 0.95 0.02 0.98 0.07 0.98 0.05 0.95 0.05 0.117
Triceps skinfold (mm) 9.0 1.0 10.5 3.9 8.8 3.8 9.3 3.4 14.2 4.9 0.001*
Z-scores
Height-for-age 3.06 1.87 0.07 3.20 1.56 2.95 1.47 2.86 0.69 1.56 0.008*
Weight-for-age 2.24 1.68 0.08 2.00 4.29 3.31 3.03 3.07 0.46 1.16 0.001*
BMI 0.63 2.46 1.46 2.46 5.49 3.72 3.57 3.81 0.20 1.37 0.002*
Circumferences (cm)
Wrist 14.6 0.3 14.5 1.3 13.5 0.8 14.0 1.0 15.1 1.7 0.005*
Arm 18.2 1.5 21.5 3.1 17.7 2.1 18.7 2.7 21.5 3.8 0.006*
Waist 56.3 6.3 61.3 9.7 55.5 6.5 57.1 7.3 66.1 15.2 0.018*
Hip 55.8 7.5 64.8 10.6 56.7 8.0 58.6 8.9 69.6 16.0 0.007*

BMI, body mass index; CP, cerebral palsy; FFMI, fat-free mass index; FMI, fat mass index
* Statistically different between siblings with and without CP (paired t test).

Statistically different compared with participants with severe CP (Bonferronis test, P 0.05).

Statistically different compared with participants with severe CP (Bonferronis test, P 0.005).
624 M. G. Grammatikopoulou et al. / Nutrition 25 (2009) 620 626

Table 5
Feeding practices
With CP (n 16) Without CP (n 16) P

Kitchen Living room Kitchen Living room

Place of dining (kitchen/living room) 10 (62.5%) 6 (37.5%) 11 (68.8%) 5 (31.2%) 0.655

Yes No Yes No

Does the child watch TV while eating? (yes/no) 8 (50%) 8 (50%) 11 (68.8%) 5 (31.2%) 0.083
Is there a parent present when the child eats? (yes/no) 16 (100%) 0 (0%) 14 (87.5%) 2 (12.5%) 0.157
Does the family eat all together? (yes/no) 13 (81.3%) 3 (18.7%) 13 (81.3%) 3 (18.7%) 1.000
Does the child play/walk/move about during mealtime? (yes/no) 2 (12.5%) 14 (87.5%) 4 (25%) 12 (75%) 0.317
Parental strategies during mealtime
Neutral prompts 4 (25%) 12 (75%) 8 (50%) 8 (50%) 0.157
Pressure/demand to eat 4 (25%) 12 (75%) 3 (18.7%) 13 (81.3%) 0.564
Reasoning 5 (31.2%) 11 (68.8%) 7 (43.8%) 9 (56.3%) 0.414
Food reward 4 (25%) 12 (75%) 5 (31.2%) 11 (68.8%) 0.705
Praise 13 (81.3%) 3 (18.7%) 8 (50%) 8 (50%) 0.025*
Food restraint/portion control 1 (6.2%) 15 (93.8%) 3 (18.7%) 13 (81.3%) 0.317
Threat to withdraw food 0 (0%) 16 (100%) 4 (25%) 12 (75%) 0.046*
Threat to withdraw play privileges 2 (12.5%) 14 (87.5%) 3 (18.7%) 13 (81.3%) 0.655
Offer of play rewards 9 (56.3%) 7 (43.7%) 7 (43.7%) 9 (56.3%) 0.480

CP, cerebral palsy

* Statistically different between siblings with and without CP (McNemars test).

the ratio of energy intake to expenditure was not correlated
in sibling pairs, for 10 of the pairs (62.5%), adequacy and
inadequacy in energy intake coincided in CP and non-CP.
Feeding practices
Feeding practices are presented in Table 5. No differ-
ences were recorded regarding the place of dining, watching
television, the presence of a parent, or playing during meal-
time between participants with and without CP. Praise re-
wards were used more often in affected children (p 0.025)
and threats to withdraw food were applied only to the
healthy siblings (P 0.046). Parents did not use food-
restraint methods after the healthy children reached the age
of 8 y, and food rewards and praise stopped when the
healthy children became 10 y old.
Discussion
The macronutrient distribution in the energy intake of
participants agreed with DRI recommendations [9]; how-
ever, the caloric intake was inadequate in the majority of
subjects with CP. Where children with spastic quadriplegic
CP are concerned, energy intakes as low as 61 15% of the
DRI are common in the literature and do not suspend
growth, because lean body mass in these children and con-
sequently resting energy expenditure are lower compared
with unaffected children [1,17,18].
A major finding of the present investigation was that
energy needs were similarly met for healthy controls and
their siblings with CP, which was demonstrated in 62.5% of
the examined couples. This finding suggests the existence of
a family-related tendency for adequacy/inadequacy in en-
ergy intake. According to the cutoff points for energy intake
to expenditure (0.76 1.24) [19], ratios below 0.76 might be
attributed to under-recording or undereating [20]. However,
usually adolescents tend to under-report, whereas for the
younger children, reporting is the responsibility of a parent/
caregiver, and there is likely to be less access to unsuper-
vised eating [20]. The inadequate energy intake in young-
sters with CP has been attributed to undereating due to the
long duration needed for a patient with CP to be fed, often
exceeding the tolerance and attention of the patient and the
caregiver [18,21,22]. Caregivers often underestimate the
energy needs of a disabled child and, due to the extended
duration needed to feed these children, the amount of food
provided is often insufficient to meet the childs growth
needs [1,18]. In an effort to increase energy and food intake,
parents used praise more often than in their healthy children.
In addition, threats to withdraw food were not recorded for
participants with CP, but only for the healthy siblings.
The majority of nutritional studies use the mean of sev-
eral days of daily intake for each individual, a method that
is likely to result in inaccurate estimates of the usual intake
distribution, because day-to-day variability in consumption
can greatly inflate the variance of the distribution of indi-
vidual means [12]. Thus, habitual intakes deriving from
repeated measurements have been suggested as a more
accurate method for evaluating under-reporting [12,20]. In
the present study, a higher median energy intake to expen-
diture was demonstrated by the severely impaired partici-
pants, a finding that suggests the consumption of a diet
denser in energy. It is possible that parents of children with
severe impairment choose more energy-dense foods to eas-
ily meet caloric requirements in the minimum possible time
 M. G. Grammatikopoulou et al. / Nutrition 25 (2009) 620 626
needed to feed their child. In a larger CP sample, Hillesund
et al. [6] suggested a lower energy intake in children with
greater degrees of motor impairment; however, their data
derived from the mean intake of 4 d, whereas the present
data are based on the usual intakes, a method suggested to
be more valid [12]. Of course, with 16 pairs of participants,
usual intake estimates deriving from a 3-d dietary record are
likely to be imprecise and even methods such as the use of
SIDE software (Software for Intake Distribution Estima-
tion, Iowa State University, Ames, IA, USA) would not
compensate for imprecision due to the small sample [12].
However, the present data are available for further analysis
with the use of specific software to determine whether this
would have a significant impact on usual intake estimates.
Correlations between macronutrient intake and percent-
age of coverage of the caloric requirements indicate that, in
youngsters with CP, the macronutrient content of the diet
follows the energy intake. The higher cholesterol content in
the diet of non-affected siblings could be explained by their
ability to buy food and eat outside the home, a factor that
was not assessed by the present study.
Previous research has suggested micronutrient deficien-
cies in children with developmental disabilities concerning
thiamin, riboflavin, and vitamin C; however, in the present
study, adequacy was recorded for all participants [21]. Vi-
tamin A and zinc were consumed in amounts lower than
recommended, but this can be explained by the difficulties
encountered when consuming meat, as reported by parents
of children with CP, due to delayed swallowing, difficulty in
chewing solids, or coughing and choking during meals
[1,2,8]. Because milk and byproducts form the basic diet
cluster of energy intake for the majority of children with
severe disabilities, the calcium intake of the present sample
was optimal [2]. Iron was adequately consumed by all
siblings, although previous studies have suggested the op-
posite [2,21].
The participants with CP appear to grow inadequately,
with the majority of Z-scores being below the 2 SD
margins. In general, Z-score deficits correlate well in neu-
rologically impaired children, suggesting that nutritional
factors contribute to the observed growth failure [22]. The
height-for-age Z-score was significantly lower in siblings
with CP and this has been attributed to the worsening of
scoliosis or contractures over time [22]. Overall, the Z-
scores revealed stunting and wasting in all subjects with CP
and this phenomenon was aggravated in participants with
quadriplegia. According to Stevenson et al. [23], the exis-
tence of seizures or spastic quadriplegia is associated with
lower height-related Z-scores compared with children who
lack these disabilities. Diminished growth is prevalent in
children with quadriplegia irrespective of the family envi-
ronment, because the healthy siblings appear to grow ade-
quately [6,24]. The body composition analysis revealed
significantly lower %BF, FMI, and FFMI in affected sib-
lings due to the fat loss incurred in CP [1]. FMI and FFMI
have been suggested as indices capable of diagnosing ex-
625
cessive leanness and fatness [16]; thus, the significantly
different results between healthy and affected participants
demonstrate the degree of difference in body composition.
Compared with recent research on neurologically impaired
children and adolescents in Greece [25], the present partic-
ipants with CP demonstrated lower %BF, BMI, FMI, FFMI,
and Z-scores. The healthy siblings presented similar %BF,
BMI, FMI, FFMI, and Z-scores to healthy Greek children
and adolescents [26], indicating that the control group was
representative of the studied population. According to the
percentiles created from data on healthy American children
and adolescents, the present controls exhibited normality
in their fat mass and fat-free mass corresponding to the 50th
percentile, whereas the subjects with CP demonstrated ex-
cessive leanness corresponding to the 10th percentile [27].
All participants in the present investigation were orally
fed. Oral feeding has been proved stressful for the parents,
time consuming (often reaching 3 to 6 h/meal), and inef-
fective in covering the energy requirements of the affected
children [3,8,28]. When adequate dietary energy is provided
by enteral tube feedings, nutritional therapy leads to weight
gain and linear growth; however, for the majority of fami-
lies, the idea of gastrostomy is difficult to accept because
they perceive this approach as a failure on their part to feed
their child [29,30]. Enteral feeding requires decision-
making on the positioning and oral therapy, behavioral
modification, the type, route, and method of formula admin-
istration, and possible feeding intolerances [1,25,31]. Re-
search has demonstrated that neurologic diseases may
adversely affect linear growth even in the absence of un-
dernutrition and, consequently, growth failure may not be
corrected completely with nutritional therapy [1]. However,
nutritional status has a stronger effect on the linear growth
of subjects with CP; thus, the observed differences concern-
ing the nutritional status of healthy and affected siblings
would have been belittled [3].
Conclusions
The present survey was the first to compare pairs of
children and adolescents with CP with their healthy sib-
lings. Data on dietary intake indicate that no differences
exist in the macronutrient content of the diets of the sibling
pairs, although different feeding practices are being applied
by the parents. The diets of children with CP were in the
majority energy deficit; however, a tendency was recorded
within each household for adequacy/inadequacy in energy
intake concerning both siblings. In addition, subjects with
severe impairment were closer to meeting their caloric re-
quirements based on their usual intakes. Anthropometry, in
contrast, demonstrated decreased growth in participants
with CP, with the majority of skinfolds, circumferences, and
Z-scores being significantly lower compared with the results
of the healthy siblings.
626 M. G. Grammatikopoulou et al. / Nutrition 25 (2009) 620 626
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