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Figure 6 Weight for length for boys aged 0 to 120 months. The solid line represent boys with quadriplegic cerebral palsy and the dotted line represents the National Center for Health Statistics standard curve for 10th, 50th and 90th percentiles.

growth, decreased muscle mass, and decreased fat stores on the affected side, and that the magnitude of the differences increases with age and functional severity. Gender, age, cognitive impairment, and ambulatory status have also been noted to contribute to the slow growth seen in this population.

Measurement of length or height for individuals with CP may require techniques and standards using arm span, lower leg length, or segmental measurements because of the difficulties encountered with joint contractures and/or scoliosis. The use of height age, rather than chronological age, is a common technique and is defined as the age at which the child's height crosses the 50th percentile on the National Center for Health Statistics chart.

The use of z scores for length-for-age, weight-for-age, and weight-for-length promotes an accurate evaluation of discrete changes from one measurement date to another. Percentile tables describe ranges, and consequently detection of movement within the range is difficult to describe. The z score denotes standard deviation units from the median and allows the practicing clinician and investigator to pinpoint precisely any given measurement.

For screening purposes, conventional length/height and weight measures can be completed and compared to the Centers for Disease Control and Prevention growth charts. Reference standards for body mass index for children with CP do not exist; therefore, one must use body mass index data in conjunction with body composition data to determine adequacy of growth. Samson-Fang and Stevenson recommend using the TSF as a screening for identifying suboptimal fat stores in children with CP.

When trying to obtain growth measurements, joint contractures, muscle spasms, and poor cooperation will impact accuracy. Upper extremity (arm) length, tibial length, and knee height are often noted in the literature as valid proxies for length in children with CP up to the age of 18 years. (See Table 2 for estimation of height using segmental measures.)

Researchers from the multicenter North American Growth in Cerebral Palsy Project suggest that a practical method to assess nutritional status in a child with CP is to measure body fat. This can be done in the form of either the triceps skin fold or

Table 2 Estimation of height from segmental measures

Age 0-12 years

(4.35 x UAL) + 21.8 (3.26 x TL) + 30.8 (2.68 x KH) + 24.2

Age 6-18 years

White male (2.22 x KH) + 40.54 Black male (2.18 x KH) + 39.60 White female (2.15 x KH) + 43.21 Black female (2.02 x KH) + 46.59

UAL, upper arm length; TL, tibia length; KH, knee height.

both the TSF and subscapular skin folds. However, patient cooperation with the measuring techniques, required for accuracy and safety, may be difficult to obtain or maintain. For some individuals with CP, the process may be difficult, and training is needed to learn the technique for body fat measures and segmental measures mentioned previously.

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