reprint requests to VA Stallings. Division of ... STALLINGS. ET. AL palsy centers: the. Children's. Seashore. House. (The. Children's ...... MI, Carpenter. WH,.
Energy expenditure severe disabilities: Virginia
A Stallings,
ABSTRACT
Spastic
severe
disability
body
composition,
This
study
and
energy
2-I
8 y and
was
Babette
that
S Zemel,
quadriplegic
is associated
and
food
examined
the
intake
in
a normal from
resting
palsy
of
energy
is a
expenditure
expenditure
of
aged
pattern
(REE,
n =
issue
is
and
satiety, to
that
more
because
caregivers
of which
fore,
by
using
the
the ratio were
the
of TEE
common with
to body
fat
to REE.
Abnormal
SQCP.
for with
children
fat-free
mass fat
the SQCP group REE, indicating in
the
than
SQCP
for
fat
control than
SQCP
was
low.
The
of
REE
are
Nuir
1996;64:627-34.
from
body
as for physical
The
a lower
the
ratio
control
and spasticity,
nutrition-related
growth
hibit
to
with
the
ratios than the energy expenof children
failure
and
to inadequate
related
decreased
REE
of TEE
with
abnormal
energy
intake.
disabilities, cerebral energy expenditure,
palsy, nutri-
are at high
cognition
intake,
with
of
patterns subjects
of dietary aged 2-18
healthy mined
children. from resting
tional
WORDS energy
Developmental expenditure, total body
status,
composition,
dietary
Providing
optimal
(1-8).
One
ofthe
adequate tients
food with
physical energy tentially energy lescents dations Am
J Cliii
care
for patients
with
that is becoming increasingly and clinical care groups most
basic
to meet
many
activity,
body
useless.
In addition,
Nuir
to
and
current
be
higher
1996:64:627-34.
than Printed
Yet,
marked from
food
the field of
for
pa-
aberrations intake
healthy
is by
is provision
requirements.
derived
intake recommendations are under review because appear
ofcare
disabilities,
composition,
recommendations
disabilities
recognized in the disability
components
nutritional
severe
severe
in
render
the
populations
national
and
po-
international
needed in USA.
for
usual
U 1996
physical
American
Society
results
energy body
is an example
Patients body this
intake and energy y with SQCP and
with with
By study
and using
exfood
SQCP
as
examined
the
expenditure in a group of a group of similarly sized
The energy expenditure pattern was deterenergy expenditure (REE) by using indirect
AND
spasticity TEE and
using the also proactivity,
of SQCP. The purpose of this REE and to determine the effect
pattern
of energy
expenditure.
METHODS
children
enrolled
of
marked, SQCP
composition,
( 1 5-26).
balance
composition,
usually
ambulation.
in
frequent There-
aged
from
two
2-18
y with
university-based,
a diagnosis
of SQCP
tertiary
care
cerebral
I From velopment
the Divisions of Gastroenterology and Nutrition and Child Dcand Rehabilitation Medicine. The Childre&s Hospital of Phil-
adelphia.
and
School
the
Department
of Medicine,
of
Pediatrics,
University
of
Pennsylvania
Philadelphia.
2 Supported by the United Cerebral Palsy Foundation, The Children’s Seashore House, the General Clinic Research Center (NIH RR-()0240). and the Nutrition Center of The Children’s Hospital of Philadelphia. 3 Address reprint requests to VA Stallings. Division of Gastroenterology
and
Nutrition.
Civic
for healthy children and adosome age-group recommen-
disability
disability
disability,
on the
Sixty-one were
a challenge legal, ethical,
without
dysfunction
calorimetry and total energy expenditure (TEE) by doubly labeled water method. These measurements vided an estimate of the energy expended for physical
SUBJECTS
INTRODUCTION
motor
for negative
malnutrition
including the chronic study was to measure
intake
oral
abnormal
activity,
a severe
of malnutrition KEY resting
and
physical frequent
model
risk
severe
on a variety intake
inadequate intake. cerebral palsy (SQCP)
permanent,
abnormal
the
with
dependent
severe
severe
poor feeding skills, reflux, and vomiting.
undernutrition,
growth failure Spastic quadriplegic
mea-
significantly
group,
patients general
a common
and control lower for
was
having lower The nonbasal
and
in the according
the SQCP significantly
needs,
in
activity
likely
had
these
including
composition
divided
stores
group.
SQCP children SQCP group.
pattern
J C/in
low
nonbasal
children
such
activ-
overreported
were
compared with TEE was
diture,
Am
SQCP
Physical estimated
by triceps-skinfold-thickness
for the
adequately nourished more poorly nourished
and
stores.
energy
was
markedly
with
with
adequate
method.
growth was
determined
The
water
of SQCP,
intake
Children
stores
surements.
lower
labeled spasticity
and dietary
children
adjusted groups
doubly
chronic
with
for meals, aspiration,
energy
communicate
optimal The
The with
The
Center
Childre&s
Boulevard,
Hospital Philadelphia.
of
Philadelphia,
PA
19104.
34th E-mail:
Street
and
stallingsv@
email.chop.edu. Received
February
Accepted
for
for Clinical
5. 1996.
publication
Nutrition
June
3. 1996.
627
Downloaded from www.ajcn.org by guest on July 14, 2011
group)
them
provide
patients
patients
to clearly
guidelines.
in many
extended time required food refusal, coughing,
including
inability
and
(9-14).
for
leaves
define
SQCP: ‘z 37 control group) by using indirect calorimetry and from total energy expenditure (TEE, n = 32 SQCP; n 32 control ity,
nations
critical
their
dietary
occurs
B Charize’
in developed even
disease-specific 61
Edward
of children
activity
hunger
SQCP
with
and
disabilities
anthropometry, with
E Cronk,
intake
activity,
malnutrition.
intake, subjects
The energy
Christine
(SQCP)
physical
frequent
of dietary
group.
C Davies,
abnormal
and with
a group
control
Javne
cerebral with
pattern
expenditure
determined
of children and adolescents a cerebral palsy model13
STALLINGS
628 palsy
centers:
Hospital
the
ington,
DE.
The
examination
diagnosis
SQCP
upper
and
cluded
was
lower
from
used
study
renal,
any growth
or
during
a routine
children mental
overnight
were
enrolled
no
had
healthy
children
siblings
of the
from
Because
compare
patterns
children
were criteria
children
with
children’s approved
by the
Hospital
of
Research during
an
the
body
mass
for control
subjects
Informed or
and
the
Review
Board
Laboratory
Center
of
18-h
overnight
The
and
Children’s
and
by
skinfold sure
included
circumference,
suprailiac) skinfold
the
Upper-arm
(Crymych,
(Ross
were
was the
was
assessed
taken
scale.
by
by using
fat mass,
and
using
obtained
development
was
pubertal
stage
classified based
(30).
as either on
two
investigators
assessed
and
(JCD each
assisted
was
or electric.
classification
recent
with greater, presence tongue
the
of the contribution 26), oral motor caregiver.
The
0 indicating
no
of all the feeding thrust,
fluid
or
results
were
scaled
abnormalities difficulties food
loss
and
from
eating,
a
status
was
ability
was
child
(Gould
the
clear
fasted
REE
a normal
child
was
2900Z;
hood
used
to
REE rested
was
respiratory
was
trans-
A comput-
SensorMedic
ventilated
and
measure-
used to measure while the child
sampling
(32)
carbohydrate,
of REE. or
was room
an evening on the RDA
awakened,
and
2900
for
equation
was
In
Clinical
child the
measurement
head
for in
placed
gases.
calculate
The energy
from oxygen consumption and carbon dioxide The first 10 mm were devoted to environmental by the
which
are
child
weight-,
Total
energy
5 or the
included
coughing
was
stable
and
age-,
were
and
expenditure measured
isotopes while
eliminated
from
sex-specific
the
and
total
calculations.
(33). body
by the doubly deuterium
(2H)
subjects
maintained
estimated
the
day
baseline
urine
continent of cotton
subjects batting.
standard
methods.
labeled
water
mine (38).
their
tube
The
sured
oxide usual
dose
of
total
body
water
in
180
admission,
second
was
fasting
were collected For continent At 2000, or orally
The conditions
Urinary by isotope
2H and ratio-mass
g
percent method
is
(34-37).
1830
samples
and from
a in-
in diapers with an extra layer subjects urine was collected by
the
isotopes
depending
void
at
esti(Al0.30
atom
(23).
were
of day
administered
on the oral
urine and the first collected and pooled urine
was
14-15
Urine
i80
intake
g 2H2O/kg deuterium
began
collected.
food
water
of
with and
1 was
motor
isotopic spectometry
by skills
of
urine void of the to adjust for isotope collected
to deter-
total body water and to begin the TEE metabolic At home, the first urine void ofdays 5, 8, 1 1, and
collected. or
of
method
as deuterium
The
sample
the child. Overnight morning (day 1) were losses.
water
pattern. The dose was 0.14 water of 99.8 atom percent
Milwaukee).
nasogastric
to food interview 0 to
These
documented,
A large,
On
Pubertal
5 indicating
assessed. during
the
was
subject’s Weir
from
Each
i80 (EG&G Mound, Miamisburg, OH) accurate to ± 5% in subjects in free-living
developmental
of oral motor function ability was assessed by
(RDAs)
General
h before
morning
cart
fat.
12-14
position.
the
H2180/kg
testing. Because intake (25,
for
as 40%
from
a supine
drich,
in the (27).
assigned
Cognitive and
Euand
calorimetry.
to the
weight
40%
for the
and daily activity mated total body
with
BSZ). was
body
over
in water
to mea-
ambulatory
to by a
allowances
indirect
admitted
CA)
TEE
and the mean measurements
and child
Wheelchair-based
educational
weight
anthropometer
were
dietary
SensorMedics, Yorba Linda, 60 mm in a quiet, thermoneutral
the
Inser-
lengths (27, 29). Height by using a stadiometer
replicates of each measurement were taken used in the analyses. All anthropometric by
percent-
in children
Two value
analyzed
to mea-
a plastic and
growth
a Holtain
and lower-leg was measured
used
OH)
Linear
and
the sex- and pubertal of Slaughter et al (28).
Columbus,
electronic
sure upper-arm control subjects
mass,
by using equations
were
used
REE data were compared with predicted values from World Health Organization (WHO) basal metabolic rate equations,
A Holtain
was
early
equivalency production.
up-
(triceps
and
medication
In the
modified
2 wk after
(27).
Kingdom)
Fat-free
calculated prediction
Laboratories, by
was
all
metabolic
the
Philadelphia
thicknesses
a mea-
were
PROCESSOR II, Escha Co. intake for the 3 d was reported
was
and
erized
of weight,
of Cameron
United
circumference
measured
skinfold
sex,
as for the
Clinical
measurement
methods
thicknesses.
age body fat stage-appropriate
SQCP
and
using
caliper
Tape
stopped
adjustment assessment
and
and
records
by open-circuit
protein,
by wheelchair
admission. Nutritional
per-arm
group,
ported
General the
MS),
family
recommended
child
SQCP.
Children’s
of
each
temperature
protocol
during
dietary
expenditure
axillary
in
Hospital
admission
3-d
and
the caregiver when Paper food models, a
Shubuta,
Diet
meals,
(31).
measured
from
ment.
and
conducted
the
20%
to
from
at The
was
was
for age
of control
same
guardians study
and
with
the
1989
sex
sizes.
for
Research Center the preceding afternoon and given meal providing 40% of the total daily energy based
sub-
weight,
obtained
The
when
group
was
Institutional
REE preparation,
was
children
were
consent
legal
Growth
to the
portion
energy
or
as control
body
with and
no
community
the
compared age
with
to each
program (FOOD and mean energy
Resting
Thirty-seven
in sex,
Oster.
distributed
computer gene, OR)
was
investigation
expenditure,
Philadelphia.
and
of
to be similar
SQCP.
parents
Nutrition
aim
of energy selected
of fat-free
Exclusion
this
primary
Sunbeam
were food
status,
as dyskinetic
recruited
(21). a weighed,
determine
for
when
There
hospital
required
foods from
data were clarified by one investigator.
(#185;
cup
time
textured estimated
develop-
nutritional
movements. were
to Some
a parent
scheduled.
general
en-
their
to
classified
subjects
the
distribution
the
SQCP
were
dietary analyzed
scale
suring
contact
from
The and
excessive
abundances (Schoeller,
were
period 15 was
mea-
University
Downloaded from www.ajcn.org by guest on July 14, 2011
jects.
were
food
to
measurements.
sex,
athetotic
ex-
known
children
call
visit
both
syndromes)
follow-up
coordinator race,
of were
eating,
in consuming intake was
record. needed
neu-
illnesses
thyroxine)
and
on
or
chronic
with
clinic
Children
other
Most
visit
clinical
choreiform
SQCP
steroids,
by a telephone
based
severity.
they
any
with
during
difficulty Nutrient
on a neurologic or pediatric
AL
gagging
in Wilm-
or congenital
office
convenient
Children’s
involvement
composition.
strategy
disease
had
(eg,
or
based
severe
admission
pediatrician was
as
if they
body
the
recruitment
was
Children
medication
(The Institute
pediatrician
gastrointestinal,
affect schedule
House
Al duPont
of SQCP
defined
rolled
there
the
extremities.
the
cardiac,
or
Seashore and
by a developmental
rologist.
(eg,
Children’s
of Philadelphia)
ET
NUTRITION of Chicago). used,
Standard
with
elimination using
rates
the
defined
for
the
calculation
and
loss 14-d
of TEE
were
dosing.
The
after
2H (kH)
The between
were
determined
by
period
was
15.
If the
metabolic
day
1 and
day
differed > 10% between subject were excluded from
were
records
compared
group
and
sex
from
with
a subset
the RDA
CEREBRAL
of these
for energy
intake
adequate
children
Analysis
of
poorly that
the
subjects.
analysis
Growth arm
measures,
length,
and sex-specific Reference data National
height.
were
expressed reference for height
Center
using
the
software
(29).
Statistics
Disease
Control
program
and upper-arm Because of the
lower-leg
data to perform and weight were
Health
for
and
or Z scores
(Atlanta).
length known
and
by
and
Prevention
were obtained from skewness in skinfold
scores
group
for
comparisons. arm
upper-arm Center skinfold
fat for Health thickness
kJ/d.
were
data
upper-arm
from
Frisancho
wt,
kJ/kg
and
statistical
tute,
Cary.
Sample
for low-
(ii
For
purposes
of analysis.
rently
adequate
stores, triceps
indicating skinfold
nutritional
status,
a poorly thickness
and
National
those
TABLE Growth
subjects
or
grouped
low
classified
day
28%
a seizure
disorder,
with
and
as SQCP
or
as two cur-
subcutaneous
fat
the
mass, tested
relations
between
different
among
or in
these groups.
between
group
to predict
REE.
used with
had
with
SAS
(SAS
Insti-
computer.
3, 2%
were
Growth mal
between
feeding
with
4), and unclassified.
time
2%
39% was
with
disorder,
SQCP
56%
with shunt.
for 95%
6%
38%
at the
level mental
retardation. Most scores, including
Twenty-four study.
percent Pubertal
group was (8% Tanner
postpubertal.
sub-
subjects
trainable
mental feeding of the
of the All
classified with
children in the SQCP 1 3% peripubertal
stage
groups,
wheelchair.
problems.
were
the two
Subjects
wheelchair
at the
female.
a ventriculoperitoneal
retardation,
in place
SQCP
52%
African American, The control group
an electric delay
control the
classified as stage 2, 3%
Eighteen
All of the control
had devel-
percent
group
of
subjects
prepubertal.
Growth,
adequate
with
normal
was
movement
assisted
cognitive
severe
group
American.
22%
and
distribution;
53% Asian.
and 56% with severe SQCP had abnormal
tubes
subjects
61) sex
varied
used
mental with
(n
the control
African
with
SQCP
stage
centile for the SQCP
had
was
opment for the 67% prepubertal.
(> 25th centile) compared groups. This was to ensure
as well-nourished
after
the
in
a dyskinetic and
remaining
educable
the
8%
with
the
retardation. subjects
and
analyzed indicating
The 25th to assign
made
used,
were
SQCP
representation
and
included
jects,
control
nutritional
status,
measurements group
and
body
for children are
shown
in Table
composition with
SQCP 1. The
and
the
control
norgroup
1
indexes
of children
with
cerebral
palsy
and
control
children’
Cerebral All Age
racial
Ambulation as
as a per-
per
be
For
was
mini-mainframe
similar
white,
skin-
area,
for subscapular was expressed
further fat stores,
nourished status. was chosen (40)
children into the adequate fat stores with low fat stores ( 25th centile) that
were was
both
were
S 1 % female
and
feeding
children
SQCP group subcutaneous
from
92%
triceps
intake
and
for differences
4000
for
REE
a’ test.
children.
were
performed
on a VAX
groups
was
Ethnic
66%
control group. The subgroups: adequate
were
the SQCP group being 5% Hispanic, and 3%
The
control (ANCOVA)
models
with white,
mass.
energy
to test
of the medians and sex-specific
as a percentage energy intakekg
as d.
NC)
37)
group
of
the RDA body wt
used
by
adequately
could
whether
analyses
subjects
=
centage of predicted values was computed by using the ageand sex-specific equations from the WHO (33). Energy intake was expressed similarly (kJ/d and kJ . kg body wt d ), and of
was
evaluated
such as weight, fat-free Interaction terms were
expenditure
in all
characteristics
The
Spender et al thicknesses
(40).
fat-free
test
and
groups
Multiple-regression
All
CASP-
muscle
Statistics reference standards were also used (41). REE
body
kJ/kg
Reference
circumference,
area
computed data
among
resulting between
compare
of covariance
to determine
Scheffd
were to
children
variables for (42).
interval
RESULTS
(39)
Reference
children used
SQCP
energy
time
Differences
agethe
soft tissue measures, percentages instead of Z scores to calculate age-
thickness,
upper-
the computations. obtained from
and other were used fold
and by using
was
past
stores.
(y)
Weight
(kg)
Weight.
Zscore
Height,
Z score
Lower
6112
9.1
18.8
± 7.7
16112
18.0
±
2.8
±
1.1 16112 -
-2.0
Upperarm.Zscore
SD:
± 4.3
±
-1.6±
± 4.4
14712
6.6 14712 1.014712
:
2
Significantly
different
from
control
3
Significantly
different
from
children
Adequate
fat stores
8.5
1141
21.4
± 1.5 1561
-2.0
1.31591
-1.6±
group. with
P
