Energy expenditure of children and adolescents ...

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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