Subjective Global Nutritional Assessment: A Reliable Screening Tool for Nutritional Assessment in Cerebral Palsy Children – Correspondence Jogender Kumar & Amitabh Singh
The Indian Journal of Pediatrics ISSN 0019-5456 Indian J Pediatr DOI 10.1007/s12098-018-2694-0
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Author's personal copy The Indian Journal of Pediatrics https://doi.org/10.1007/s12098-018-2694-0
CORRESPONDENCE
Subjective Global Nutritional Assessment: A Reliable Screening Tool for Nutritional Assessment in Cerebral Palsy Children – Correspondence Received: 24 December 2017 / Accepted: 24 April 2018 # Dr. K C Chaudhuri Foundation 2018
To the Editor : We read the article by Minocha et al. [1] and would like to appreciate the authors for highlighting the important but under-recognized problem of malnutrition in cerebral palsy (CP) children. Authors first time used Subjective Global Nutritional Assessment (SGNA) method in CP children and found fair agreement with the objective nutritional assessment. However, there are certain points we would like to highlight which might bring more clarity to the assessment of nutritional status in this population. The authors used WHO growth charts for anthropometric parameters. However, there are a lot of studies which suggest that pattern of growth of children with CP is different from the general population. In given CP population subset also growth was greatly influenced by functional severity and feeding ability. So, it is advisable not to compare their anthropometric parameters with standard growth charts and one should use CP specific growth charts designed according to their Gross Motor Function Classification System (GMFCS) level. These growth charts show significant deviation from general population reference/ standard growth charts (CDC, WHO etc.) and this deviation increases with age and with the severity of functional disability [2, 3]. Dietary intake of children was recorded but it is not described whether that intake was compared with anthro pometry/ age-based normative intake for the general population or it was specific to cerebral palsy patients considering the fact that energy needs of these children may be different from the general population. Studies have shown that resting energy expenditure and total energy expenditure in children with spastic quadriplegic CP (55% in this study) are reduced in all the energy compartments (total, physical activity and resting). In the current study prevalence of malnutrition was 76.6% which is quite high and may be partly because of using standard caloric intake data into account. So, while assessing calorie intake and planning nutritional rehabilitation this must be considered [2, 4].
Authors found poor agreement with triceps skinfold thickness which may be because of the fact that anthropometric parameters underestimate percentage body fat in these children at GMFCS levels III to V. So, serial skinfold measurements over time using the individual as their own control rather than a single skinfold measurement is more useful [5]. Authors frequently stated that there was fair to moderate agreement between SGNA and objective measurements, however, reported k value falls in the zone of fair agreement only. The agreement is not so good because of the inherent deficit in SGNA, as it does not consider body habitus which is an important component determining nutritional intake and anthropometry in these children. Jogender Kumar1 and Amitabh Singh2 1
Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India; 2 Department of Pediatrics, VMMC & Safdarjung Hospital, New Delhi, India. E-mail:
[email protected]
References 1. 2.
3. 4. 5.
Minocha P, Sitaraman S, Choudhary A, Yadav R. Subjective global nutritional assessment: a reliable screening tool for nutritional assessment in cerebral palsy children. Indian J Pediatr. 2018;85:15–9. Scarpato E, Staiano A, Molteni M, Terrone G, Mazzocchi A, Agostoni C. Nutritional assessment and intervention in children with cerebral palsy: a practical approach. Int J Food Sci Nutr. 2017;68:763–70. Brooks J, Day S, Shavelle R, Strauss D. Low weight, morbidity, and mortality in children with cerebral palsy: new clinical growth charts. Pediatrics. 2011;128:e299–307. Stallings VA, Zemel BS, Davies JC, Cronk CE, Charney EB. Energy expenditure of children and adolescents with severe disabilities: a cerebral palsy model. Am J Clin Nutr. 1996;64:627–34. Kuperminc MN, Gurka MJ, Bennis JA, et al. Anthropometric measures: poor predictors of body fat in children with moderate to severe cerebral palsy: anthropometric measures of adiposity in children with CP. Dev Med Child Neurol. 2010;52:824–30.
Author's personal copy Indian J Pediatr
Authors' Reply To the Editor : We thank Kumar and Singh for comments on our paper published in January issue of IJP [1]. We agree with authors that there are cerebral palsy (CP) specific growth charts but our review did not find them uniformly appropriate in our children with CP. Charts described by Brooks et al. are based on US cohort [2]. Wright et al. described similar charts and they gathered the data from UK cohort [3]. CDC also developed growth charts for children with special need but in training module it is clearly stated BThese specialized growth charts provide useful growth references, but may have some limitations. Generally, they were developed from relatively small homogeneous samples and data used to develop the charts may have been obtained from inconsistent measuring techniques. For example, in some cases, chart reviews were used to collect data; in other cases, the measurement techniques were not clearly defined.^ The data on Indian cohort is unavailable to our knowledge. So we decided to go with WHO growth charts. Dietary intake was recorded and we took several factors into consideration while estimating energy needs, including age, activity level, growth rate, and muscle tone. In our study, prevalence of malnutrition was high. As we had already stated that generalised conclusions pertaining to nutritional status of children with CP from the community cannot be inferred from the above study, as this study provides nutritional profile of cerebral palsy children presenting to tertiary centre only.
In regard to skin fold thickness, this was a point time crosssectional study so we have taken single measurement. There is scope for further study on follow up of these children. Subjective global nutritional assessment (SGNA) was originally described by Baker et al. [4] and used in adults. It was considered as a useful clinical method in that cohort. The aim of our study was whether SGNA can be useful in CP children or not. We found many limitations of this method and we agree that there is only fair agreement between anthropometry and SGNA. Priyanka Minocha 1, Sadasivan Sitaraman1, Anita Choudhary1 and Rajiv Yadav2 1
Department of Pediatrics, SMS Medical College and Hospital, Jaipur, Rajasthan, India; 2 Department of Preventive and Social Medicine, SMS Medical College and Hospital, Jaipur, Rajasthan, India. E-mail:
[email protected]
References 1. 2. 3. 4.
Minocha P, Sitaraman S, Choudhary A, Yadav R. Subjective global nutritional assessment: a reliable screening tool for nutritional assessment in cerebral palsy children. Indian J Pediatr. 2018;85:15–9. Brooks J, Day S, Shavelle R, Strauss D. Low weight, morbidity, and mortality in children with cerebral palsy: new clinical growth charts. Pediatrics. 2011;128:e299–307. Wright CM, Reynolds L, Ingram E, Cole TJ, Brooks J. Validation of US cerebral palsy growth charts using a UK cohort. Dev Med Child Neurol. 2017;59:933-8. Baker JP, Detsky AS, Wesson DE, et al. Nutritional assessment: a comparison of clinical judgement and objective measurements. N Engl J Med. 1982;306:969-72.
