ARTICLE

Growth and Health in Children With Moderate-to-

Severe Cerebral Palsy
Richard D. Stevenson, MDa, Mark Conaway, PhDb, W. Cameron Chumlea, PhDc, Peter Rosenbaum, MDd, Ellen B. Fung, RD, PhDe,
Richard C. Henderson, MD, PhDf, Gordon Worley, MDg, Gregory Liptak, MDh, Maureen O’Donnell, MDi, Lisa Samson-Fang, MDj,
Virginia A. Stallings, MDk; of the North American Growth in Cerebral Palsy Study

Departments of aPediatrics and bPublic Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia; cDepartment of Community Health and
Pediatrics, Wright State University, Fairborn, Ohio; dDepartment of Pediatrics, McMaster University, Hamilton, Ontario, Canada; eDepartment of Pediatrics, Children’s
Hospital Oakland, Oakland, California; fDepartment of Orthopedics, University of North Carolina, Chapel Hill, North Carolina; gDepartment of Pediatrics, Duke University,
Durham, North Carolina; hDepartment of Pediatrics, University of Rochester, Rochester, New York; iDepartment of Pediatrics, University of British Columbia, Vancouver,
British Columbia, Canada; jDepartment of Pediatrics, University of Utah, Salt Lake City, Utah; kDepartment of Pediatrics, University of Pennsylvania, Philadelphia,
Pennsylvania

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
BACKGROUND. Children with cerebral palsy frequently grow poorly. The purpose of
this study was to describe observed growth patterns and their relationship to
www.pediatrics.org/cgi/doi/10.1542/
health and social participation in a representative sample of children with mod- peds.2006-0298
erate-severe cerebral palsy. doi:10.1542/peds.2006-0298
METHODS. In a 6-site, multicentered, region-based cross-sectional study, multiple Key Words
cerebral palsy, health status, growth,
sources were used to identify children with moderate or severe cerebral palsy. growth and nutrition, growth patterns
There were 273 children enrolled, 58% male, 71% white, with Gross Motor Abbreviations
Function Classification System levels III (22%), IV (25%), or V (53%). Anthro- CP— cerebral palsy
pometric measures included: weight, knee height, upper arm length, midupper NAGCPP—North American Growth in
Cerebral Palsy Project
arm muscle area, triceps skinfold, and subscapular skinfold. Intraobserver and KH— knee height
interobserver reliability was established. Health care use (days in bed, days in UAL— upper arm length
SUB—subscapular skinfold thickness
hospital, and visits to doctor or emergency department) and social participation TRI—triceps skinfold thickness
(days missed of school or of usual activities for child and family) over the preceding AMA—arm muscle area
GMFCS—Gross Motor Function
4 weeks were measured by questionnaire. Growth curves were developed and z
Classification System
scores calculated for each of the 6 measures. Cluster analysis methodology was CDC—Centers for Disease Control and
then used to create 3 distinct groups of subjects based on average z scores across Prevention

the 6 measures chosen to provide an overview of growth. Accepted for publication Mar 31, 2006
Address correspondence to Richard D.
RESULTS. Gender-specific growth curves with 10th, 25th, 50th, 75th, and 90th per- Stevenson, MD, Department of Pediatrics,
University of Virginia School of Medicine,
centiles for each of the 6 measurements were created. Cluster analyses identified Kluge Children’s Rehabilitation Center and
3 clusters of subjects based on their average z scores for these measures. The Research Institute, 2270 Ivy Rd, Charlottesville,
VA 22903. E-mail: rds8z@virginia.edu
subjects with the best growth had fewest days of health care use and fewest days
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
of social participation missed, and the subjects with the worst growth had the most Online, 1098-4275). Copyright © 2006 by the
days of health care use and most days of participation missed. American Academy of Pediatrics

CONCLUSIONS. Growth patterns in children with cerebral palsy were associated with
their overall health and social participation. The role of these cerebral palsy-
specific growth curves in clinical decision-making will require further study.

1010 STEVENSON et al
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
G ROWTH IS A fundamental and integral marker of
health and well-being in children. Normal growth
is an indicator of health, whereas abnormal growth may
dren with a history of genetic, metabolic, or neurode-
generative disease or other medical illnesses known to
influence growth were excluded. However, children
indicate illness, malnutrition, or something awry in the were not excluded on the basis of prematurity or low
child’s environment. Cerebral palsy (CP) is a common birth weight. Informed consent was obtained from the
neurologic condition that originates in early childhood parent or legal guardian, and assent was obtained when
but affects individuals throughout their life span. Chil- appropriate. The institutional review boards of each par-
dren with CP are known to grow poorly compared with ticipating site approved the study.
their peers, but it is unclear whether this poor growth is
“normal” for the population or a marker of some sec- Procedure
ondary condition that requires further evaluation and Subjects traveled to each study site to participate. At a
treatment. The basic clinical questions are: (1) does the single observation, trained observers performed a de-
observed “poor” growth negatively impact health and tailed anthropometric assessment of each child using
well-being of children with CP; and (2) if growth is standard techniques.1,7 Duplicate measures were ob-
improved, are health and well-being also improved? tained, and the average was used for analyses. Measures
This investigation addresses the first of these questions. included knee height (KH), upper arm length (UAL),
Growth assessment requires reliable measures and weight, midupper arm circumference, subscapular skin-
comparison reference data. Reliable alternative mea- fold thickness (SUB), triceps skinfold thickness (TRI),
sures of growth for children with CP have been widely and calculated arm muscle area (AMA). Duplicate mea-
adopted.1–3 However, appropriate reference growth sures were also used to calculate intraobserver and in-
curves for these children have not been clearly estab- terobserver reliability, and these are reported in Table 1.
lished. The objectives of this study are as follows: (1) to Reliability was comparable with other published reports
describe growth status in a region-based sample of chil- in children with CP.1 Sexual maturity ratings (Tanner
dren with moderate or severe CP enrolled in the North stages) and severity of CP were determined after observ-
American Growth in Cerebral Palsy Project (NAGCPP), ers were trained for these assessments.8 We have re-
(2) to develop growth curves and calculate z scores, and ported previously on sexual maturity ratings in this pop-
(3) to correlate growth with markers of health and social ulation.9 Severity of CP was assessed using the Gross
participation. Motor Function Classification System (GMFCS).6 The
GMFCS categorizes severity into 5 levels (I through V)
METHODS based on gross motor function, predominantly indepen-
The NAGCPP is a multicenter study designed to investi- dent mobility. This study enrolled subjects who were
gate growth, physical development, and nutritional sta- levels III, IV, and V, the more severe end of the spec-
tus in children with CP according to an established pro- trum. Older children who are level III can ambulate
tocol.4 The University of Virginia, Duke University, the independently with a walker (household ambulators)
University of North Carolina, the Children’s Hospital of but often use wheelchairs in the community; those at
Philadelphia, the University of Rochester, McMaster level IV cannot walk independently but can achieve
University, and the University of British Columbia were independent mobility in a motorized wheelchair; and
the participating sites, with Duke and University of those at level V have no independent mobility but,
North Carolina operating as a single site. rather, are transported.
Information regarding demographics, medical his-
Subjects tory, functional abilities, health care use, and social par-
The details of subject identification, recruitment, and
enrollment were fully described previously.4 The sub-
jects were a sample drawn from the 6 region-based sites, TABLE 1 Reliability of Anthropometric Measures
using multiple sources for identification: clinic samples, Variable Intraobserver Interobserver Error
parent organizations, local United Cerebral Palsy Asso- Error (N ⫽ 18)
ciations, school systems, public service announcements, (N ⫽ 307)a
physical therapists, local physicians, equipment vendors, TE CV TE CV
and newspaper advertisements. Each of the sites defined Weight 0.08 0.30 0.04 0.18
a geographical region with a population of ⬃500 000 Arm circumference 0.18 0.92 0.32 1.66
people. All of the children with CP5 between the ages of UAL 0.27 1.07 0.52 2.32
2 and 18 years in each region were eligible for recruit- KH 0.22 0.61 0.29 0.89
TRI 0.60 5.93 0.55 6.98
ment. All of the subjects of moderate or severe impair-
SUB 0.51 5.80 0.73 12.5
ment defined by Gross Motor Function Classification
TE indicates technical error ⫽ 公⌺ d2/2n, where d ⫽ difference between paired measures on
System levels III, IV, or V,6 who had clinically diagnosed n subjects; CV, coefficient of variation ⫽ 100 ⫻ (TE/mean of measures taken).
CP, were included. Medical history was reviewed. Chil- a Population measured includes some subjects excluded from other analyses in this study.

PEDIATRICS Volume 118, Number 3, September 2006 1011

Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
ticipation was collected by interview questionnaire. TABLE 2 Demographics of Enrolled Subjects (N ⴝ 273)
Questions regarding health and participation were Characteristic Enrolled,
adapted from the National Health Interview Survey of n (%)
the Centers for Disease Control and Prevention (CDC)10 Age, y 2–5 72 (26)
and referred to the 4 weeks preceding the measure- 6–12 107 (39)
ments. These questions asked how many days over the 13–19 94 (34)
Gender Male 157 (58)
previous 4 weeks were spent with the child at the emer-
Female 116 (42)
gency department, at the doctor’s office, overnight in the Race White 192 (70)
hospital, home from school, home in bed, home from Black 63 (23)
usual activities, or with a family member home and Other 18 (7)
missing usual activities. No attempt was made to validate GMFCS level III 56 (23)
IV 64 (25)
the caregiver’s recall. The original questions from Na-
V, no gastrostomy 73 (29)
tional Health Interview Survey asked similar questions V, with gastrostomy 62 (24)
but over the preceding 12 months. Other analyses of the Birth weight, g ⬍1500 52 (24)
NAGCPP population regarding general health status, nu- 1500–2400 53 (24)
tritional status, bone mineral status, fracture rate, and 2401–3300 61 (28)
⬎3300 53 (24)
health and participation have been published else-
Maternal height, percentile ⬍25th 49 (26)
where.4,11–13 25th to 75th 91 (47)
⬎75th 52 (27)
Data Analysis Numbers may not add to 273 because of missing values.
Cross-sectional data analysis was performed by the sec-
ond author (M. C.) at the coordinating center using
GAUSS 5.014 and SAS 9.1 (SAS Institute, Cary, NC)15 the healthy children were based on converting the CDC
software. The development of growth curves used meth- height charts16 to KH estimates using the formulas in
ods that were similar to those used for the current CDC Chumlea et al.19 Figures 3 and 4 show the weight curves
growth charts for healthy U.S. children.16,17 These CP- for boys and girls with CP superimposed on the weight
specific curves were used to calculate CP-based z scores curves for healthy children. All of these growth curves
or SD scores for further analysis. To relate body size and include the 10th, 25th, 50th, 75th, and 90th percentiles.
health, K-means cluster analysis18 was used to group The cluster analysis discriminated 3 groups of chil-
children according to their CP z scores for each of 6 dren based on their CP z scores for each of 6 anthropo-
measures of growth and body composition. These 6 metric assessments: KH, UAL, weight, TRI, SUB, and
measures were chosen a priori as a way to describe each midupper AMA. Each child is represented in only 1
child’s growth in a comprehensive fashion using KH group. Figure 5 depicts these 3 groups, with the y-axis
(lower extremity linear growth), UAL (upper extremity representing the average CP z score for each of the 6
linear growth), weight (body mass), TRI (extremity fat measures. For discussion, these groups will be referred to
stores), SUB (truncal fat stores), and midupper AMA as: Z⫺, the “smaller” group (bottom line in Fig 5; on
(skeletal muscle mass). The number of clusters (3) was average 1 SD below the mean); Z␾, the “middle” group
chosen empirically as a way to discriminate the sample, (middle line in Fig 5; on average at about the mean); and
and the cluster analysis program assigned subjects to the Z⫹, the “larger” group (top line in Fig 5; on average ⬃1
appropriate cluster based on the z scores on the 6 mea- SD above the mean). Of these children, 90 (35%) were
sures. Thus, the technique created a single 3-level com- in the Z⫺ group, 106 (42%) were in the Z␾ group, and
posite categorical variable of 6 separate continuous vari- 58 (23%) were in the Z⫹ group.
ables with each subject assigned to only 1 of the 3 These 3 groups were then correlated with markers of
clusters. health and social participation over the preceding 4
weeks (Fig 6 and Table 3). The x-axis in Fig 6 and the
RESULTS numbers in Table 3 represent number of days, so higher
The population is described in Table 2 and consisted of numbers indicate more days with health care use and
273 children, with 58% male and 71% white subjects. more days missed of school or usual activities. These
Gender-specific growth curves were constructed for all analyses demonstrate that the Z⫹ group had fewest days
of the anthropometric data, and 4 illustrative curves are of health care and fewest days missed of usual activities,
reproduced in the figures. Because a direct measure of and the Z⫺ group had the most days of health care and
recumbent length or stature could not be obtained in most activities days missed, with the Z␾ group falling in
these children, KH was used as a proxy for linear between. Although these results did not reach statistical
growth. Figures 1 and 2 show the KH curves for boys significance (at the P ⬍ .05 level; see Table 3), their
and girls with CP, superimposed on a comparison KH order, relative to each other, was consistent.
curve generated for healthy children. KH estimates for The 3 groups from cluster analysis did correlate with

1012 STEVENSON et al
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
FIGURE 1
KH centiles for Boys with CP versus healthy boys. A, KHs and estimated centiles for boys
with CP (n ⫽ 156). B, Estimated KH centiles for boys with CP (—) and healthy boys (哹).
KH estimates for the general population were based on converting the CDC height charts
using the formulas in Chumlea et al.19
functional severity. Table 4 displays GMFCS and feeding
tube status by group. There are significant (P ⬍ .001)
differences among the groups with respect to the GM-
FCS classifications, with the Z␾ and Z⫹ groups tending
to have fewer GMFCS level V children (most severely
impaired) and more GMFCS level 3 children (least se-
verely impaired) than the Z⫺ group. Negative binomial
regression models were fit to the health and participa-
tion measures to assess the effect of group membership
on these measures, adjusting for age, gender, and GM-
FCS/feeding tube status. The results of these analyses are
displayed in Fig 7. These 2 figures display the estimated
ratio of the health and participation measures from the
Z⫺ group, relative to the Z␾ and Z⫹ groups, respec-
tively, adjusting for age, gender, and GMFCS/feeding
tube status. As in the unadjusted analyses, children in
the Z⫺ group consistently had greater health care use
and lower social participation than children in the Z␾
and Z⫹ groups. Moreover, for 2 of the health and par-
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
FIGURE 2
KH centiles for girls with CP versus healthy girls. A, KHs and estimated centiles for girls
with CP (n ⫽ 114). B, Estimated KH centiles for girls with CP (—) and healthy girls (哹). KH
estimates for the general population were based on converting the CDC height charts
using the formulas in Chumlea et al.19
ticipation measures (days missed at school and days of
usual activity missed by family members) in the adjusted
analyses (see Fig 7B), these differences were statistically
significant (P ⬍ .05).
DISCUSSION
In pediatric practice, “poor” or subnormal growth is
equated with poor health. Poor growth is determined by
careful measurement (anthropometry) and comparison
of the results to appropriate reference standards. The
anthropometric assessment of children with CP has been
difficult because of difficulty acquiring reliable measure-
ments of stature (height or length) and lack of appropri-
ate reference data for comparison.2 Although the mea-
surement problem has been overcome through the use
of alternative measures (eg, UAL, lower leg length, and
skinfold thickness),1,3 the reference standard problem
remains. The use of general population standards for a
PEDIATRICS Volume 118, Number 3, September 2006 1013
FIGURE 3
Weight centiles for boys with CP versus healthy boys. A, Weights and estimated centiles
for boys with CP (n ⫽ 153). B, Estimated weight percentiles for boys with CP (—) and
healthy boys (哹). Weight centile estimates for the general population were based on the
CDC weight charts.16
group of nonambulatory, severely impaired children is
questionable.20
Most reference standards were established by mea-
suring a representative cross-section of the healthy pop-
ulation and creating growth charts.16 Such growth charts
are intended to encompass individual variability because
of genetic potential. The primary measures used are
stature (height or length), body mass (weight), and often
some measure of body proportion (body mass index
[BMI] or weight for height). An important feature of
most growth charts is that they are intended to be de-
scriptive of a population (“how they grew”) and are used
to monitor normal growth and screen for abnormal
growth. They are not intended to be prescriptive for
health (“how they should grow”).21 Growth charts help
clinicians determine the body size (stature and weight)
and relative proportions (BMI) of an individual child
compared with reference data from healthy children.
This is usually described in terms of the child’s growth
1014 STEVENSON et al
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
FIGURE 4
Weight centiles for girls with CP versus healthy girls. A, Weights and estimated centiles for
girls with CP (n ⫽ 113). B, Estimated weight centiles for girls with CP (—) and healthy girls
(哹). Weight centile estimates for the general population were based on the CDC weight
charts.16
percentile (50th percentile being “average”) or in SDs
(z score) from the mean. However, a child at the 10th
percentile weight for stature, for example, is not neces-
sarily less healthy than a child at the 50th percentile,
although clearly thinner. Although clinicians often con-
sider the 50th percentile weight for a particular height as
“ideal” (implying ideal for health), it is simply no more
than a statistical average for the population. Relatively
few data exist that actually link patterns of growth to
clinically meaningful health indicators.
Diagnosis-specific growth curves have been devel-
oped for other health conditions, such as Down syn-
drome and Turner syndrome,22–24 conditions in which
malnutrition is uncommon and the genetic abnormality
directly influences stature. Having a reference growth
curve for children with CP may be helpful to clinicians
and beneficial to children. However, any representative
sample of children with moderate or severe CP is likely
to include many children with differing degrees of acute
FIGURE 5
Cluster means and SEs of means from 3 clusters (n ⫽ 254 subjects
observed on all 6 anthropometric measures).
and chronic malnutrition and possibly growth hormone
deficiency.25,26 This limits the usefulness of a descriptive
reference growth chart for clinical management. What
would be useful for clinical practice is a “prescriptive”
growth curve, with statistical and clinically significant
links between body size and proportions and health and
social participation outcomes.
We developed CP-specific growth curves for measures
of linear growth, body mass, and body composition.
These growth curves, illustrated in the sample figures,
are similar in shape to other growth curves, both in
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
FIGURE 6
Anthropometric clusters and health and participation
for children with CP. N ⫽ 238 children with both anthro-
pometric and outcomes data. There are n ⫽ 82 children
in the “Z⫺ smaller” cluster (F), n ⫽ 104 in the “Z␾ mid-
dle” cluster (■) and n ⫽ 52 children in the “Z⫹ larger”
cluster (Œ).
typical children16 and in special populations.23,24 Of note
is a steady increase in growth throughout childhood
followed by a plateau in adolescence. The usual adoles-
cent growth spurt seems blunted in the CP curve per-
centiles compared with healthy children. On average,
the children with moderate or severe CP were smaller,
thinner, and lighter than their age- and gender-related
peers without CP. The differences are significant and
become more pronounced as children age. For example,
whereas the CP KH percentiles overlap with the percen-
tiles for typical children early in childhood, none of our
PEDIATRICS Volume 118, Number 3, September 2006 1015
 TABLE 3 Summary of Health and Participation Outcomes by Cluster Group
Variable Z⫺ Small (n ⫽ 82) Z␾ Medium (n ⫽ 104) Z⫹ Large (n ⫽ 52) P
Mean SE Range Mean SE Range Mean SE Range
Doctor visits 0.84 0.12 0–6 0.85 0.16 0–10 0.65 0.15 0–4 .35
Emergency department visits 0.18 0.08 0–4 0.06 0.02 0–1 0.06 0.03 0–1 .67
Hospital overnight 0.39 0.21 0–16 0.07 0.03 0–2 0.08 0.06 0–3 .22
Days in bed 0.49 0.22 0–15 0.40 0.27 0–28 0.06 0.06 0–3 .14
School days missed 1.38 0.40 0–25 0.95 0.32 0–28 0.38 0.16 0–5 .08
Child unable to do usual activities 1.01 0.27 0–15 0.92 0.31 0–21 0.52 0.19 0–7 .46
Family unable to do usual activities 0.79 0.20 0–10 0.82 0.32 0–28 0.25 0.12 0–5 .11
Data are the number days over the previous 4 weeks. P values from Kruskal-Wallis test.

TABLE 4 Cluster Membership by GMFCS

Variable Z⫺ (Smaller), Z␾ (Middle), Z⫹ (Larger), Total
n (%) n (%) n (%)
III 9 (11) 29 (30) 17 (31) 55
IV 21 (25) 21 (21) 15 (27) 57
V no gastrostomy 37 (44) 22 (22) 11 (20) 70
V with gastrostomy 17 (20) 26 (27) 12 (22) 55
Total 84 (100) 95 (100) 55 (100) 237
Values displayed are number of subjects and column percentages. Numbers do not add to 254 because of missing values on GMFCS/feeding
tube status. ␹2 test ⫽ 19.5; P ⬍ .0001.

FIGURE 7
Estimated percentage of health care use and participation measures for (A) the “Z⫺ small” cluster relative to the Z␾ cluster and (B) the Z⫺ cluster relative to the Z⫹ “large” clusters,
relative to the “medium” cluster. Values displayed are the estimates and 95% confidence intervals based on the negative binomial regression model, adjusting for age, gender, and
GMFCS/feeding tube status.

subjects was above the 5th percentile for their typical
peers by adolescence. These data are consistent with
previous reports that show an apparent worsening or
“falling off” of growth in children with CP over time
when compared with typical children.25,27–29
These CP-specific growth curves could be published
for clinical use, as other diagnosis-specific reference
curves have been,23,24,30 and our group debated this issue
pointedly. However, because the representative sample
of children with CP used to develop the curves likely
included children with confounding secondary condi-
tions of acute and chronic malnutrition and growth hor-
mone deficiency, we decided against the idea. We were
concerned that clinicians might use these growth curves
as “prescriptive” for the population. Therefore, we de-
cided to embark on further analyses to link physical
growth to health and participation outcomes. There is
clear precedent for this notion in child health research,
most notably in research related to obesity and cystic
fibrosis.31–33 In addition, research in adults supports a
relationship between underweight and excess mortality.34
To link physical growth with markers of health and

1016 STEVENSON et al
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
participation, cluster analyses were chosen to extract the
most information possible from the anthropometric data
collected. Although we considered using simpler mea-
sures of proportion, such as weight for height or BMI,
these children were so varied in body proportions that
overall patterns of growth and body composition would
be misrepresented or not captured entirely. Our intent
was to take a broad “snapshot” of physical growth. Not
unexpectedly, and as illustrated in Table 4, growth cor-
related with neurologic severity and the presence of a
feeding gastrostomy. A large proportion of the smallest
growth group (Z⫺) was made up of the most severely
impaired children (GMFCS level V), particularly those
without a gastrostomy. However, every level of severity
was represented in each of the anthropometric groups.
Thus, whereas neurologic severity accounted for a por-
tion of the variance in outcomes, it was only when we
controlled for severity (see Fig 7) that 2 of the analyses
reached statistical significance.
The markers of health that we chose were modified
from the National Health Information Survey by the
CDC.10 Although based on questionnaire responses from
parents, they address the construct of health and well-
being through the reported use of health services and
reported participation in school and usual activities. The
results of our analyses were consistent in that the best
growth correlated with the least use of health care ser-
vices and fewest days missed of usual activities, even
when neurologic severity was controlled. The consis-
tency of these results suggests that a larger sample size
would likely demonstrate more statistically significant
results. However, health and participation are influ-
enced by many different factors, only some of which
may be modifiable, and even a larger cross-sectional
sample would not confirm cause and effect relationships.
Understanding the impact of growth on health and par-
ticipation will require clinical trials in which growth is
modified (eg, nutritionally and/or hormonally) and out-
comes are carefully measured. Nevertheless, we feel that
the current data are suggestive and worthy of further
investigation.
What do these results mean, and where do we go
from here? These data and analyses represent the next
step in clarifying the relationship between growth and
health in children with CP. However, these data must be
viewed with caution. Although “better” health and “big-
ger” growth correlated strongly with one another, the
direction of causality is unclear. Children may be health-
ier because they are bigger, or they could be bigger
because they are in better health. Alternatively, because
the health and participation questions refer to the 4
weeks before measurement, it is conceivable that chil-
dren who had been ill (and missed school, etc) subse-
quently lost weight and were smaller. Further studies,
such as those recently published by Sullivan et al,35,36 are
essential to corroborate these findings and to evaluate
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
whether specific interventions that improve growth re-
sult in improved health and social participation. The
clinical goal is to optimize the health and well-being of
children with CP and their families through appropriate
management growth and nutrition.37
CONCLUSIONS
Children with moderate or severe CP have poor growth
compared with typical children. We developed growth
curves for children with moderate or severe CP and
correlated growth with markers of health and social
participation. Bigger children with CP had better health
and social participation than similar smaller children.
Further studies are needed to corroborate these findings
and to evaluate whether specific interventions can im-
prove growth, as well as health and social participation.
Determining the potential role of these growth curves in
clinical decision-making will require further study.
ACKNOWLEDGMENTS
This study was conducted as part of the North American
Growth in Cerebral Palsy Project. It was supported by
the Kluge Research Fund and the Children’s Hospital
Committee of the University of Virginia, the Genentech
Foundation for Growth and Development, the National
Center for Medical Rehabilitation Research (grants 5 R01
HD35739-04, 1 F32 HD08615-01A1, 1 R24 HD39631-01,
and K24-HD041504-01), and the University of Virginia
General Clinical Research Center (M01RR00847). In ad-
dition, this study was supported by the University of
North Carolina General Clinical Research Center (M01
RR00046) and the National Institute of Arthritis, Mus-
culoskeletal and Skin Diseases (K24 AR02132); the Gen-
eral Clinical Research Center (M01 RR00240) and the
Nutrition Center at the Children’s Hospital of Philadel-
phia; the Jones-Guerrero Fund at Duke University, the
Children’s Hospital Fund at the University of British
Columbia, and the General Clinical Research Center at
the University of Rochester (M01 RR00044).
We gratefully acknowledge the help and support of
the children and their families. We also give special
thanks to Vivienne Spauls, Jillian Bumler, Teresa Olsen,
and Candra Gerrick.
REFERENCES
1. Spender QW, Cronk CE, Charney EB, Stallings VA. Assessment
of linear growth of children in cerebral palsy: use of alternative
measures to height or length. Dev Med Child Neurol. 1989;31:
206 –214
2. Stevenson RD. Measurement of growth in children with de-
velopmental disabilities. Dev Med Child Neurol. 1996;38:
855– 860
3. Stevenson RD. Use of segmental measures to estimate stature
in children with cerebral palsy. Arch Pediatr Adolesc Med. 1995;
149:658 – 662
4. Liptak GS, O’Donnell M, Conaway M, et al. Health status of
children with moderate to severe cerebral palsy. Dev Med Child
Neurol. 2001;43:364 –370
PEDIATRICS Volume 118, Number 3, September 2006 1017
 5. Bax MCO. Terminology and classification of cerebral palsy. Dev
Med Child Neurol. 1964;6:295–307
6. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Ga-
luppi B. Development and reliability of a system to classify
gross motor function in children with cerebral palsy. Dev Med
Child Neurol. 1997;39:214 –223
7. Cameron N. The methods of auxological anthropology. In:
Falkner F, Tanner JM, eds. Human Growth: A Comprehensive
Treatise. 2nd ed. New York, NY: Plenum Press; 1986
8. Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Second-
ary sexual characteristics and menses in young girls seen in
office practice: a study from the pediatric research in office
settings network. Pediatrics. 1997;99:505–512
9. Worley G, Houlihan CM, Herman-Giddens ME, et al. Second-
ary sexual characteristics in children with cerebral palsy and
moderate to severe motor impairment: a cross-sectional sur-
vey. Pediatrics. 2002;110:897–902
10. National Health Interview Survey. National Center for Health
Statistics 1997. Available at: www.cdc.gov/nchs/about/major/
nhis/hisdesgn.htm. Accessed August 1, 2004
11. Samson-Fang L, Fung E, Stallings VA, et al. Relationship of
nutritional status to health and societal participation in chil-
dren with cerebral palsy. J Pediatr. 2002;141;637– 643
12. Henderson RC, Lark RK, Gurka MJ, et al. Bone density and
metabolism in children and adolescents with moderate to se-
vere cerebral palsy. Pediatrics. 2002;110(1). Available at: www.
pediatrics.org/cgi/content/full/110/1/e5
13. Stevenson RD, Conaway M, Barrington JW, Cuthill SL, Worley
G, Henderson RC. Fracture rate in children with cerebral palsy.
Pediatr Rehab. 2006; In press
14. Gauss Mathematical and Statistical System [computer program].
Version 5.0. Maple Valley, Washington: Aptech Systems, Inc;
2002
15. The SAS System [computer program]. Version 9.1. Cary, North
Carolina: SAS Institute Inc; 2004
16. Ogden CL, Kuczmarski RJ, Flegal KM, et al. Centers for Disease
Control and Prevention 2000 growth charts for the United
States: improvements to the 1977 National Center for Health
Statistics version. Pediatrics. 2002;109;45– 60
17. Cole T, Green P. Smoothing reference centile curves: the LMS
method and penalized likelihood. Stat Med. 1992;11:
1305–1320
18. Johnson R, Wichern J. Applied Multivariat Statistical Analyses.
3rd ed. Upper Saddle River, NJ: Prentice Hall; 1992
19. Chumlea WC, Guo SS, Steinbaugh ML. Prediction of stature
from knee height for black and white adults and children with
application to mobility-impaired or handicapped persons. J Am
Diet Assoc. 1994;94:1385–1388
20. Samson-Fang LJ, Stevenson RD. Identification of malnutrition
in children with cerebral palsy: poor performance of weight-
for-height centiles. Dev Med Child Neurol. 2000;42:162–168
1018 STEVENSON et al
Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018
21. Grummer-Strawn LM, Garza C, Johnson CL. Childhood
growth charts. Pediatrics. 2002;109:141–142
22. Styles ME, Cole TJ, Dennis J, Preece MA. New cross sectional
stature, weight, and head circumference references for Down’s
syndrome in the UK and Republic of Ireland. Arch Dis Child.
2002;87:104 –108
23. Myrelid A, Gustafsson J, Ollars B, Anneren G. Growth charts
for Down’s syndrome from birth to 18 years of age. Arch Dis
Child. 2002;87:97–103
24. Rongen-Westerlaken C, Corel L, van den BJ, et al. Reference
values for height, height velocity and weight in Turner’s syn-
drome. Swedish Study Group for GH treatment. Acta Paediatr.
1997;86:937–942
25. Stallings VA, Charney EB, Davies JC, Cronk CE. Nutrition-
related growth failure of children with quadriplegic cerebral
palsy. Dev Med Child Neurol. 1993;35:126 –138
26. Coniglio SJ, Stevenson RD, Rogol AD. Apparent growth hor-
mone deficiency in children with cerebral palsy. Dev Med Child
Neurol. 1996;38:797– 804
27. Rempel GR, Colwell SO, Nelson RP. Growth in children with
cerebral palsy fed via gastrostomy. Pediatrics. 1988;82:857– 862
28. Stallings VA, Cronk CE, Zemel BS, Charney EB. Body compo-
sition in children with spastic quadriplegic cerebral palsy. J Pe-
diatr. 1995;126:833– 839
29. Stevenson RD, Hayes RP, Cater LV, Blackman JA. Clinical
correlates of linear growth in children with cerebral palsy. Dev
Med Child Neurol. 1994;36:135–142
30. Krick J, Murphy-Miller P, Zeger S, Wright E. Pattern of growth
in children with cerebral palsy. J Am Diet Assoc. 1996;96:
680 – 685
31. Krebs NF, Jacobson MS, American Academy of Pediatrics Com-
mittee on Nutrition. Prevention of pediatric overweight and
obesity. Pediatrics. 2003;112:424 – 430
32. Borowitz D, Baker RD, Stallings V. Consensus report on nutri-
tion for pediatric patients with cystic fibrosis [review]. J Pediatr
Gastroenterol Nutr. 2002;35:246 –259
33. Sharma R, Florea VG, Bolger AP, et al. Wasting as an indepen-
dent predictor of mortality in patients with cystic fibrosis [see
comment]. Thorax. 2001;56:746 –750
34. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess
deaths associated with underweight, overweight, and obesity.
JAMA. 2005;293:1861–1867
35. Sullivan PB, Juszczak E, Bachlet AM, et al. Impact of gastros-
tomy tube feeding on the quality of life of carers of children
with cerebral palsy. Dev Med Child Neurol. 2004;46:796 – 800
36. Sullivan PB, Juszczak E, Bachlet AM, et al. Gastrostomy tube
feeding in children with cerebral palsy: a prospective, longitu-
dinal study. Dev Med Child Neurol. 2005;47:77– 85
37. Stevenson R. Beyond growth: gastrostomy feeding in children
with cerebral palsy. Dev Med Child Neurol. 2005;47:77– 85
 Growth and Health in Children With Moderate-to-Severe Cerebral Palsy
Richard D. Stevenson, Mark Conaway, W. Cameron Chumlea, Peter Rosenbaum,
Ellen B. Fung, Richard C. Henderson, Gordon Worley, Gregory Liptak, Maureen
O'Donnell, Lisa Samson-Fang and Virginia A. Stallings
Pediatrics 2006;118;1010
DOI: 10.1542/peds.2006-0298

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/118/3/1010
References This article cites 30 articles, 9 of which you can access for free at:
http://pediatrics.aappublications.org/content/118/3/1010.full#ref-list-
1
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Developmental/Behavioral Pediatrics
http://classic.pediatrics.aappublications.org/cgi/collection/developme
nt:behavioral_issues_sub
Growth/Development Milestones
http://classic.pediatrics.aappublications.org/cgi/collection/growth:dev
elopment_milestones_sub
Fetus/Newborn Infant
http://classic.pediatrics.aappublications.org/cgi/collection/fetus:newb
orn_infant_sub
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
https://shop.aap.org/licensing-permissions/
Reprints Information about ordering reprints can be found online:
http://classic.pediatrics.aappublications.org/content/reprints

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018

 Growth and Health in Children With Moderate-to-Severe Cerebral Palsy
Richard D. Stevenson, Mark Conaway, W. Cameron Chumlea, Peter Rosenbaum,
Ellen B. Fung, Richard C. Henderson, Gordon Worley, Gregory Liptak, Maureen
O'Donnell, Lisa Samson-Fang and Virginia A. Stallings
Pediatrics 2006;118;1010
DOI: 10.1542/peds.2006-0298

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/118/3/1010

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

Downloaded from http://pediatrics.aappublications.org/ by guest on January 22, 2018