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Review Article
The Open Access Journal of Science and Technology
Vol. 3 (2015), Article ID 101174, 11 pages
doi:10.11131/2015/101174

Nutritional Status of Children with Autism Spectrum Disorders, Cerebral Palsy and Down Syndrome: A Scoping Review

Noor Safiza Mohamad Nor, Nur Shahida Abdul Aziz, Cheong Siew Man, Rashidah Ambak, and Mohd Azahadi Omar

Institute for Public Health, Ministry of Health Malaysia, Jalan Bangsar, 50590 Kuala Lumpur, Malaysia

Received 1 July 2015; Accepted 7 September 2015

Academic Editors: Enzo Grossi and Renato Millioni

Copyright © 2015 Noor Safiza Mohamad Nor et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction: Autism Spectrum Disorders (ASD), Down Syndrome (DS) and Cerebral Palsy (CP) are the most common disabilities among children. Nutritional status assessment is important as these children are at risk of underweight, overweight or obesity. Therefore, the objectives of this review were to identify evidence on the prevalence of nutritional status of children with DS, CP and ASD, and to determine tools and indicators to measure the nutritional status of these children. Methods: This scoping review was conducted using a framework suggested by Arksey and O'Maley. A comprehensive search was performed to identify published and unpublished works, reviews, grey literature and reports. Inclusion criteria for the search were articles in English published from 1990 to 2014 and related to children with ASD, DS and CP. Titles, abstract, and keywords for eligibility were examined independently by the researchers. Results: A total of 305,268 titles were extracted from electronic databases and other resources. Based on the inclusion criteria, 21 articles were selected for review. The prevalence of overweight or obese children with DS ranged from 33.5% to 43.5%. The prevalence of underweight children with CP was 22.2% to 78.2%. Children with ASD at a younger age were more likely to be overweight or obese compared with normal developing children. The common nutritional indicators used were z-scores for weight-for-age, height-for-age, body mass index-for-age, and head circumference-for-age. Conclusions: Overall, there is emerging evidence on the nutritional status of children with ASD, DS and CP although this is still very limited in developing countries including Malaysia. The evidence shows that children with CP were at risk of being underweight, while children with DS and ASD were at risk of being overweight or obese.

1. Introduction

Disability is defined as “difficulties in three areas of human functioning, which include i) impairments, ii) activity limitations, and iii) participation restrictions” [1]. Disability is a complex condition because it varies according to age, gender, socioeconomic status, cultural background, geographical area and health condition [2]. The degree of disability for any individual with disability also depends upon the relationship between various environmental factors [3]. Indeed, children with disabilities and their families may require a variety of services whereby the economic and social cost can be substantial [4]. According to the United Nations Children's Fund (UNICEF), it was estimated that the number of children with disabilities under 18 years old was approximately 150 million [5]. This included children with Autism Spectrum Disorders (ASD), Cerebral Palsy (CP), Down syndrome (DS), Learning Disabilities and other types of disabilities.

T1

Table 1: Key terms in the scoping review.

T2

Table 2: Prevalence of the nutritional status of children with DS, CP, and ASD.

T3

Table 3: Summary of measurements, instruments, and indicators used to determine the nutritional status of children with disability aged 0 to 18 years.

Nutritional status is an important indicator of the overall health status and wellbeing of children with disability. It portrays the physical growth of children and whether they are at risk of being underweight, overweight or obese. The impact of poor nutritional status and poor growth among children with disability may eventually lead to poor motor function, bone health, social participation and healthcare utilisation [6]. For example, the consequences of overweight and obesity problems in children with DS are the increased risk of developing adult obesity and non-communicable diseases such as diabetes and hypertension [7]. Malnutrition among children with CP can lead to poor growth and nutrient deficiencies such as iron and vitamin deficiency [8]. However, evidence on the nutritional status of children with DS, CP, and ASD is still limited and little is known on the overall prevalence of the nutritional status of these children, including the methods, tools and indicators to assess this. Various tools may be required to assess the nutritional status of children with disability due to the disparities in their health conditions, growth and development stage. Good knowledge and understanding are required among health care professionals in order to monitor the health status of these children, so that further treatment or intervention could be planned for this group.

Therefore, the present review will explore evidence on the nutritional status among children with disability, particularly among children with DS, CP, and ASD. It is hoped that these findings will support future research on the nutritional status for children with disability and the future planning of health interventions/programmes for this population.

F1
Figure 1: Flow chart of scoping review (based on framework by Arskey and O’Malley 2005).

2. Methods

The design of the present study was scoping review. Scoping review aims “to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available especially when an area is complex or has not been reviewed comprehensively before” [9]. Scoping review seeks to provide wide coverage of available literature depending on the purpose of the review. For the purpose of this topic, the scoping review was performed to; i) determine the extent and nature of research on the nutritional status of children ASD, CP, and DS; ii) describe the details of the evidence in terms of the prevalence of nutritional status, methods and tools used to determine nutritional status particularly for children with ASD, CP, and DS. In this review, nutritional status is defined as obesity, underweight, stunting and wasting.

The 5 stages of the scoping review framework by Arskey and O'Maley [9] include `identifying the research questions', `identifying relevant studies', `study selection', `charting the data' and `collating, summarising and reporting the results'. Consultation with programme managers and stakeholders from the Family Health Division, Ministry of Health Malaysia and health professionals (medical doctors, dietitians and paediatricians) at government hospitals were also conducted to enhance the review work undertaken by the research team members. The study was registered under the National Medical Research Registry Malaysia (NMRR) and the protocol was approved by the Medical Research and Ethics Committee (MREC) Malaysia (ID: NMRR -1495-19402).

2.1. Identifying the research questions

The review questions were: i) what is the prevalence or rate of nutritional status of children with ASD, CP, and DS aged 18 years and below? And, ii) what are the tools, indicators and measurements used to assess nutritional status of children with ASD, CP, and DS?

2.2. Identifying relevant studies

The purpose of performing the scoping review was to conduct a comprehensive search to identify primary studies (published and unpublished work), reviews, grey literature and annual reports. The research team members adopted a strategy for searching the evidence using different sources which included electronic databases of Medline Embase/Ovid, Pubmed, Highwire Press, Scopus, and Google Scholar, relevant research websites such as Disability Clearing House, World Health Organizations (WHO), and Welfare Department of Malaysia. The searches also involved hand-searching of relevant peer reviewed journals (Asia Pacific Public Health Journal, Journal of Developmental Disabilities, Journal of Autism and Developmental Disorders (JADD), Child: Care, Health and Development, Paediatrics, Research in Developmental Disorders, Human Nutrition and Dietetics, Malaysian Journal of Nutrition and Malaysian Medical Journal), bibliographic search of reference lists in books, reports, summaries, newsletters, and references from selected articles or bulletins from the World Health Organizations, Ministry of Health Malaysia, Ministry of Education Malaysia, Statistics department and Welfare Department of Malaysia.

The researchers decided to set the coverage of the review based on the time span and language of the articles. Inclusion criteria for the search were articles in English from 1990 to 2014 and related to children with ASD, CP, and DS who were below 18 years old. The commencement date of 1990 was chosen in order to cover a wide range of evidence and it was felt that the evidence on the nutritional status of children with disability was limited especially in Asian countries including Malaysia. Titles, abstract, keywords for eligibility were examined independently by the researchers. All types of studies were included in the search strategy. Foreign language articles were excluded due to the cost and time that would be required to translate these documents. Key terms used in the search of articles were shown in Table 1. Endnote software and Microsoft Excel programmes were used to manage the records via searching, keeping track of articles, checking the duplication of records and sorting reference lists. The researchers then compiled these records and made a summary.

2.3. Study selection

The study selection was based on the objectives of the study. The review only focused on documents related to the nutritional status of children with ASD, CP, and DS. The search strategy identified a large number of studies which were not relevant in answering the specific objectives. Thus, the researchers eliminated irrelevant articles based on the inclusion and exclusion criteria and those articles that did not answer the research questions. Four research team members screened the titles and retrieved the relevant abstracts. Abstracts that did not capture fully the scope of the study were excluded. Based on the eligible abstracts, copies of full articles were retrieved. The full articles were then checked by the researchers as to whether they appeared to answer the research question of the study. Selected full articles were then read by the researchers in order to select the final full articles for the review.

2.4. Charting the data

General and specific information about the studies were charted which include author(s), year of publication, objectives or aims of the study, country or study location, study population, sample characteristics, design, sample size including comparison group (if any), instruments and indicators used in the study and findings that were relevant to the objectives of the review.

2.5. Collating, summarising, and reporting the results

The characteristics of the results from the selected articles from various countries were described based on the design, types and outcomes of each study. The findings of the review were presented in two ways. First, tables of evidence on the nutritional status of children with Down, Syndrome, Cerebral Palsy and ASD were presented. Second, a summary table of the measurements, instruments and indicators were used to describe the various approaches or methods used to measure nutritional status. This included: types, categories of measurements, indicators, and availability of tools for measuring weight, height, length, and head circumference. Limitations of several studies and research gaps were also identified in order to make useful recommendations to the stakeholders and programme managers.

3. Results

A total of 305,268 titles were extracted from selected electronic databases and other resources. As shown in Figure 1, 107 abstracts were included after the initial screening process and the rest were excluded as they were irrelevant with regards to the types of disability, non-English articles, and duplicates. Only 21 studies met the inclusion criteria. Among these 21 articles included in the review, 10 articles were studies among children with CP, 4 among children with DS, 6 among children with ASD and 1 study among children with more than one type of disability. Countries of origin of the studies included developed and developing countries such as Mexico, United Kingdom, United States of America, Saudi Arabia, Argentia, Netherland and Malaysia.The majority of studies were cross-sectional (19 studies, 90%) and some studies used retrospective data. Only 2 out of 21 studies (10%) were prospective longitudinal studies. Sample size of the studies ranged from 50–400 children with CP, DS, and ASD aged from birth until 18 years old. The study population was recruited from various sources which included clinical settings (hospital and specialist clinics) and community settings (rehabilitation centres, universities, public schools, nurseries and households).

3.1. Nutritional status among children with CP, DS, and ASD

Overall, the majority of studies found that children with CP were at risk of being underweight, while children with DS and ASD tend to be at risk of being overweight or obese [Table 2].

3.2. Down syndrome

Several studies have shown that children with DS were shorter than the standard references of typically developing children, but they had comparable weights. The prevalence of at-risk-for- overweight or overweight or obesity among children with DS aged between 3 to 18 years old ranged from 33.5% to 43.5% [10,11,12,13,14].

3.3. Cerebral palsy

Several studies reported that the prevalence of underweight or undernutrition for children with CP aged 2 to 20 years old were within the range of 22.2% to 78.2% [15,16,17,18,19]. At the same time, the prevalence of being overweight or obese among this group of children ranged from 4.0% to 29.1%. A large proportion of children with CP had poor nutritional status. These studies also revealed that ambulatory children showed a higher prevalence of being overweight compared to non-ambulatory children [15,16,17,18,19].

3.4. Autism spectrum disorders

According to the 7 studies investigating the nutritional status of children with ASD [Table 2], children at a younger age were more likely to be overweight or obese as compared to the general population [20,21,22,23,24,25,26].

A narrative review was then conducted to summarise the instruments, measurements and indicators to determine the nutritional status of children with disablitiy. Overall, the most common anthropometric measurements used for children with CP, DS, and ASD were body weight, body height or length, body mass index, and head circumference (Table 3). The most commonly used nutritional indicators were Weight-for-Age, Height-for-Age, Body Mass Index-for-Age, Head Circumference-for-Age and subcutaneous fat percentage. The majority of the studies used z-scores to interprete the nutritional status of children.Growth curves were also applied. There were variety of tools utilised to conduct the anthropometric assessments which included weighing scale, sit balance scale, bone caliper for knee height estimation, spine- length measuring board, stadiometer, measuring tape and skinfold calipers.

4. Discussion

Based on the evidence in this review, there is emerging literature reporting the nutritional status of children with DS, CP, and ASD over the past 15 years. Several important aspects of the nutritional status among these children have been identified:

Firstly, children with DS, CP, and ASD have underweight, overweight and obesity problems and these were regularly reported by the published studies. However, the rates and prevalence varied between studies. There are several reasons for these inconsistent findings including the differences in the study design, sample size, recruitment procedures, choice of comparison groups or data and methods used to assess nutritional status. Secondly, it appears that the instruments and techniques of measurement used to measure weight, height and length of children with disability were also varied depending on the child's development and health condition. For example, Lopes et al [19] used estimates of weight and height for children with CP because it is rather difficult to measure the physical condition of a CP child, especially among those with hemiplegia and tetraplegia. In their study the parents were weighed using light clothing and then they were weighed with their child on the lap. Children with DS also grow in a different way and their growth is characterised by an earlier onset of growth spurt and reduced linear velocity. Therefore, DS children have shorter stature than the general population [11,12,13,14]. Common indicators used to assess the nutritional status of children with DS were weight-for-age percentile, height-for-age percentile and BMI-for-age percentile. Subcutanous fat estimate was also used to determine the nutritional status of children with DS. The measurement of the Triceps Skinfold Thickness (TSFT) was performed using the skinfold calipers [11]. Thirdly, findings from this scoping review have demonstrated that children with CP were at risk of being underweight, while children with DS and ASD were at risk of being overweight or obese. Malnutrition is common among children with CP and their nutritional status must be monitored regularly by health professionals [19]. Past studies have also shown that feeding difficulties is likely to become a determining factor in the nutritional status of children with DS, CP, and ASD. Feeding difficulties were associated with poor health and nutritional status [26,19]. Lopes et al [19] reported that children with CP especially those who were tetraplegic had a higher prevalence of difficulties in swallowing and chewing. Children with ASD also have various feeding problems including constipation, diarrhoea and abdominal pain which affect the nutritional status of these children [20,21,22,23,24,25,26]. Therefore, early identification of feeding difficulties and other related symptoms should be conducted by health professionals in order to monitor their nutritional status and to plan for proper dietary intervention.

Finally, this scoping review also found that there was no clear evidence on the nutritional status of children with DS, CP, and ASD in developing countries including Malaysia. Only one study in Malaysia by Zainah et al. [18] was identified. The study only compared the linear growth and nutritional parameters of a group of Malaysian children with cerebral palsy (CP) against a group of controls. The limitation of this study was that the data was collected from selected resources. The overall prevalence of nutritional status of children with CP, DS, and ASD in developing studies is not reported in this study. Therefore, future researches need to be conducted in developing countries in order to address the prevalence of underweight, overweight and obesity among these children. Collaborative research efforts between the Ministry of Health, universities and other government agencies is one of the strategies that need to be implemented to provide evidence on the nutritional status of children with disability. Trained professionals are also needed to conduct these studies and interventions for this group. For example in Malaysia, trained professionals and health experts to conduct the anthropometric measurements for children with disability and research in this area are also limited.

In conclusion, there is emerging evidence on the nutritional status of children with ASD, DS, and CP, although this is still very limited in developing countries including Malaysia. Findings of this scoping review demonstrated that children with CP were at risk of being underweight, while children with DS and ASD were at risk of being overweight or obese. It is hoped that these findings will support the planning of future researches and health interventions/programmes for this population.

Conflict of Interest Statement

The authors declare that they have no competing interests.

Acknowledgements

The authors would like to thank the Director General, Ministry of Health Malaysia for the permission to publish this paper. This scoping review was funded by the National Institutes of Health, Ministry of Health Malaysia. The authors would like to thank Dr Tahir Aris, Director of the Institute for Public Health for his support and supervision.

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Review Article
The Open Access Journal of Science and Technology
Vol. 3 (2015), Article ID 101174, 11 pages
doi:10.11131/2015/101174

Nutritional Status of Children with Autism Spectrum Disorders, Cerebral Palsy and Down Syndrome: A Scoping Review

Noor Safiza Mohamad Nor, Nur Shahida Abdul Aziz, Cheong Siew Man, Rashidah Ambak, and Mohd Azahadi Omar

Institute for Public Health, Ministry of Health Malaysia, Jalan Bangsar, 50590 Kuala Lumpur, Malaysia

Received 1 July 2015; Accepted 7 September 2015

Academic Editors: Enzo Grossi and Renato Millioni

Copyright © 2015 Noor Safiza Mohamad Nor et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction: Autism Spectrum Disorders (ASD), Down Syndrome (DS) and Cerebral Palsy (CP) are the most common disabilities among children. Nutritional status assessment is important as these children are at risk of underweight, overweight or obesity. Therefore, the objectives of this review were to identify evidence on the prevalence of nutritional status of children with DS, CP and ASD, and to determine tools and indicators to measure the nutritional status of these children. Methods: This scoping review was conducted using a framework suggested by Arksey and O'Maley. A comprehensive search was performed to identify published and unpublished works, reviews, grey literature and reports. Inclusion criteria for the search were articles in English published from 1990 to 2014 and related to children with ASD, DS and CP. Titles, abstract, and keywords for eligibility were examined independently by the researchers. Results: A total of 305,268 titles were extracted from electronic databases and other resources. Based on the inclusion criteria, 21 articles were selected for review. The prevalence of overweight or obese children with DS ranged from 33.5% to 43.5%. The prevalence of underweight children with CP was 22.2% to 78.2%. Children with ASD at a younger age were more likely to be overweight or obese compared with normal developing children. The common nutritional indicators used were z-scores for weight-for-age, height-for-age, body mass index-for-age, and head circumference-for-age. Conclusions: Overall, there is emerging evidence on the nutritional status of children with ASD, DS and CP although this is still very limited in developing countries including Malaysia. The evidence shows that children with CP were at risk of being underweight, while children with DS and ASD were at risk of being overweight or obese.