DOI: doi.org/10.21776/ub.ijds.2023.10.02.11
273
Enhancing Nutritional Status in Children with Cerebral Palsy: The Impact of Parental Feeding Rules
Counseling and Special Spoon Utilization
Arif Mansur, Universitas Andalas, Indonesia
Nining Sulistyawati, Sekolah Tinggi Ilmu Kesehatan Madani Yogyakarta, Indonesia Ira Mulya Sari, Universitas Andalas, Indonesia
Corresponding author:
Arif Mansur,
arifrohmanmansurphd@nrs.
unand.ac.id
Article history:
Received: 14 July 2023 Revised: 1 August 2023 Accepted: 5 October 2023
Published online at ijds.ub.ac.id
Copyright © 2023 Author(s) Licensed under CC BY NC.
Abstract
To evaluate the effect of Parental Feeding Rules, Counseling, and the utilization of Special Spoons on the Nutritional Status of children with cerebral palsy. Children with cerebral palsy (CP) experience nutritional deficiencies resulting from food intake challenges caused by brain and nervous impairments. However, parental implementation, such as counseling on feeding rules and specialized spoons, must be improved. Method: A pre-experimental design was used with a Group pre-test-posttest approach, focusing on counseling about feeding rules and using specialized spoons to assess their impact on children's food intake and nutritional status with cerebral palsy. The research was conducted in Bantul, with 18 parent-child pairs with cerebral palsy selected through purposive sampling. Data analysis was performed using bivariate analysis with the Paired t-test. Result: The child's weight and height have increased. The average weight score increased after (mean = 26.23; SD = 10.25) compared to before (mean = 24.75; SD
= 9.42), and this result was statistically significant (p = 0.004). The average height score increased after (mean = 135.21; SD = 16.58) compared to before (mean = 135.21; SD = 16.58), and this result was statistically significant (p = 0.001). Conclusion: The intervention counseling seemed to increase the weight and height indicators, but the nutritional status of BMI for age and height for age remained the same.
Keywords: Cerebral palsy, counseling, food intake, feeding rules, nutritional status, special spoons
1. Research Background
Every child is expected to go through stages of growth and development. They face challenges in their physical and emotional growth, which directly or indirectly affect their development (Kemenkes, 2010). Cerebral palsy (CP), which is the most common motor disability in childhood (Stavsky et al., 2017), is a leading cause of motor disabilities in children (Sadowska, Sarecka-Hujar, and Kopyta, 2020). Data obtained from the child
development division at seven teaching hospitals in Indonesia shows that CP is among the five most common impairments. Children with CP are most vulnerable to health problems (Kemenkes, 2010).
Adequate nutrition is essential for supporting children's development and maintaining body functions (Forde et al., 2021; Matonti, Blasetti, and Chiarelli, 2021).
Feeding problems, low energy intake, and wasting are common in children with cerebral palsy (Ahmad, Sharif and Karamat, 2020; Boudokhane et al., 2021). These children often experience dysphagia, constipation, and gastroesophageal reflux, leading to difficulties in feeding and prolonged meal times (Sørensen et al., 2021). Children who suffer from CP usually experience problems with feeding, causing delays in the child's growth (Dahlseng et al., 2012). Growth and nutrition disorders are secondary health conditions that commonly occur in children with cerebral palsy (CP). Malnutrition is a significant cause of inadequate growth, thus impacting health, including psychological and physiological functioning, utilization of health services, community participation, motor function, and survival (Kuperminc and Stevenson, 2008).
Children with cerebral palsy (CP) face challenges in nutrient fulfillment due to impaired brain function and nerve disorders, affecting movement, learning, hearing, vision, and thinking. These issues increase the risk of malnutrition and can impact bone density, muscle mass, quality of life, and healthcare utilization. Thorough nutritional assessment and treatment of gastrointestinal problems are essential for improved feeding and nutritional status. (Foster et al., 2020; Jesus and Stevenson, 2020).
Children with cerebral palsy (CP) are at risk of inadequate nutrient intake, leading to malnutrition. Feeding problems, such as oral-motor dysfunction and difficulties with food intake, are common in children with CP (Boudokhane et al., 2021; Kutbi et al., 2022).
Studies have shown that most children with CP are malnourished, with lower energy and carbohydrate intake. Keleinikova et al. (Keleinikova et al., 2021) found that most malnourished children without chronic disease have low energy intake due to deficiencies of all macronutrients, including proteins, fats, and carbohydrates. The results of research (Sugiarto and Setiawati EM, 2012) conducted at the Disabled Children Education Foundation (YPAC) Semarang with a total of 27 children aged 2-10 years gave the results:
the average calorie intake in children with CP 1133.96 kcal and the average intake its protein is 38.69 grams. Lower calorie intake was found in 81.5% of respondents, and lower protein intake was found in 33.3%. Poor nutritional status was found in 88.9% of respondents.
Efforts to improve the nutritional status of children are not enough to expand the reach of services; they need to be balanced with increasing the knowledge and skills of the community. Parental behavior in feeding children is essential to children's nutritional status (Murashima et al., 2012a; Rodgers et al., 2013a). The results of the study (Kadarhadi, Mexitalia, and Puruhita, 2012) stated that feeding rule counseling interventions could improve the nutritional status of toddlers on the height/age indicators; this was
reinforced by research (M. M. Darwati et al., 2014), which stated that feeding rule interventions for four months could improve indicators nutritional status of toddlers on the parameters of weight/age, height/age and weight/height significantly. Nutritional counseling was conducted for three months to see its effect on food intake and the patient's nutritional status (Yuniarti, Purba, and Pangastuti, 2013).
The results of research and findings of Hartini et al., who designed a spoon for people with cerebral palsy that has a curvature angle between the handle of the spoon and the head spoon of 135 degrees and is equipped with a finger rest bar made of snorkeling wood, make it easy to use by CP sufferers who experience finger stiffness, limited range of motion, and a lack of grasping and grasping abilities. People with cerebral palsy do not have trouble eating something. Even with this spoon, they can do it independently (Wicaksono, 2012).
Preliminary studies at the Griya Lare Utami Children's House through interviews with parents of children with cerebral palsy stated that they did not know about suitable feeding methods and not all of them used special spoons for CP sufferers as a tool in providing adequate food intake for their children who had cerebral palsy. As health workers, nurses have a role in fulfilling nutritional intake in children, including as an interdisciplinary health team and nutrition counselor (Ghalili et al., 2007). Special spoon for children with cerebral palsy in improving the nutritional status of children with cerebral palsy at two locations in Bantul. The approach needed to address complex problems in children with cerebral palsy to fulfill food intake and improve their nutritional status requires a combination of Counseling interventions for feeding rules to parents and special spoons for the nutritional status of children with cerebral palsy.
This study examines the effect of parental counseling on feeding rules and the use of a special spoon for cerebral palsy on the nutritional status of children with cerebral palsy. Counseling is carried out by providing feeding guidelines to parents and using a special cerebral palsy spoon.
2. Methodology
2.1 Design
This research is a Pre-Experimental Design with the Group pre-test-posttest approach. The research locations include two locations in Bantul. The study population consisted of pairs of parents and children who have cerebral palsy in both locations.
2.2 Sampling method
The sampling technique used is purposive sampling. The minimum sample required is 15 pairs of parents and children with cerebral palsy. Inclusion criteria include children with cerebral palsy who can swallow food through their mouths, communicate, have hand movements, and sit. Exclusion criteria included parents and children with cerebral palsy refusing to be research subjects.
2.3 Intervention
Counseling feeding rules and the use of special cerebral palsy spoons are efforts to assist parents of cerebral palsy children. Counseling was given as many as three sessions, each lasting for 30-40 minutes; this intervention consisted of 3 components of feeding guidelines which included schedules, environments, basic procedures for feeding practices in children and combined with the use of special spoons for children with cerebral palsy, intervention was given once a month for three months by the research team and carried out in three places, the two research locations and direct home visits to parents. Children are taught when eating to use a special spoon by holding and stamping the spoon firmly so that they can eat with their own dominant (right) hand and not use their fingers for food. The type of food given varies with a regular eating schedule, and only scheduled snacks are allowed.
2.4 Measurement and data collection
Previously, researchers asked for the willingness of research respondents to participate in this study by signing a consent sheet as respondents first. The collection of research data was carried out using an instrument in the form of a questionnaire to determine the demographic distribution of research respondents. The weight and height measurements were carried out (pre-test). After the counseling process is complete, a Post-test is carried out. Food intake and nutritional status were measured by weighing and measuring height using a Camry digital scale with an accuracy level of 0.1 and a capacity of 150 kg/330 lb/24 st to measure children's weight and a stature meter. A unique formula has been used for children with cerebral palsy who cannot stand up (Samson- Fang and KL, 2013) in estimating the height of children with cerebral palsy based on segmental measurements. The measurement results are used to determine nutritional status using the WHO Anthro and Anthro Plus software. The Cerebral Palsy Special Spoon has almost the same function as the spoon above, the difference is that there are no finger bars and the handle of the spoon is made of plastic, and the spoon is made of stainless steel.
Picture 1. A special spoon for cerebral palsy
2.5 Statistics
The nutritional status data is processed by utilizing the WHO z-score. Analysis of the research data was carried out quantitatively in accordance with the research objectives.
The data analysis used in this research used univariate analysis to analyze the research variables descriptively by presenting data in frequency distribution tables and narratives as explanations of the tables presented. Next, the Paired t-test was carried out, and a discussion of the results of the study was carried out.
2.6 Ethics
This research has obtained a research ethics permit from ethics committee of Health Polytechnic of the Ministry of Health Yogyakarta Number: LB.01.01/KE- 01/XXII/538/2017.
3. Results and Discussion
3.1 Characteristics of Research Subjects
Respondents in this study were 18 pairs of children with cerebral palsy and mothers from Children's House Griya Lare Utami Bantul 4 (22.2%), Special Need School Bantul 14 (77.7%), and research subjects. The characteristics of the research subjects are presented as follows.
Table 1. Results of Analysis of the Characteristics of Research Subjects (n=18)
Variable Frequency (n) Percentage (%)
Mother's Education Level
Base 7 35
Intermediate 7 35
Tall 4 20
Mother's Occupational Status
Work 7 35
Housewife 11 55
Family Income
< 1,125,000 8 44,4
1,125,000-2,500,000 9 50
˃2,500,000 1 5,6
Number of children
1 4 22,2
≤ 2 7 38,9
3 6 33,3
≥ 4 1 5,6
History of Disease During Pregnancy
There aren't any 13 65
TORCH 1 5
CMV 1 5
bedrest 1 5
Myoma 1 5
Etc 1 5
Consumption of drugs during pregnancy
As prescribed by the doctor/midwife 12 60
No Prescription/Herbs 1 5
There is not any 5 25
History of Pediatric Disease Before CP
Developmental Delays 6 30
Premature 3 15
Hydrocephalus 3 15
Virus Infection 3 15
There are not any 3 15
Based on table 3.1, it is identified that the level of mother's education for the category of primary and secondary education has the same percentage, namely 35%, working as a housewife 55%, income between (Rp.1,125,000-2,500,000)as much as 50%, having children less than or equal to two as much as 38.9%, not having a history of illness during pregnancy by 65%, taking drugs or vitamins during pregnancy only with a doctor's/midwife's prescription 60%, while for a history of childhood illnesses before getting the cerebral palsy history of childhood illness before getting cerebral palsy most of the 30% were detected experiencing developmental delays.
Weight-for-age, Stature-for-age, and BMI-for-age of Children with Cerebral Palsy Before and After Counseling Intervention Feeding Rules and Utilization of Special Spoons for Cerebral Palsy. Presentation of data in the form of Z-Score (Standard Deviation) results of calculations using the software "WHO Anthro and WHO Anthro Plus."
Table 2. Mean values (SD) of pre-test and post-test scores for Weight, Stature, and BMI (n=18).
Pre-test Post-test
Weight 24,75 (9,42) 26,23 (10,25) *
Height 135,02 (16,58) 135,21 (16,58) *
BMI-for-age (z-score) -2,79 (3,30) -2,66 (2,77)
Height-for-age -0,05 (1,93) -0,06 (1,83)
*p< 0.01 (Post-test versus pre-test score).
Normality test of Z-Score value of nutritional status on indicators of BMI/Age and Height/Age. Before conducting a bivariate analysis of the parametric paired t-test, a prerequisite test is needed to ensure that the data or z-score values for BMI for age and Height-for-age (WHO Multicentre Growth Reference Study, 2006) have a normal distribution. The normality test was conducted using the Shapiro-Wilk test with a p-value of 0.519 on the nutritional status indicators BMI-for-age and TB-for-Age of 0.361. Thus, the requirement to perform a parametric paired sample t-test can be carried out.
Table 3. Bivariate analysis of nutritional status before and after counseling on feeding rules and use of a special spoon for cerebral palsy
No Nutrition Status Z-Score t p-values
1 BMI-for-age -0,028 0.77
2 Stature-for-Age 0.604 0.55
Based on Table 3, it can be identified that there is a No. Significant effect of counseling on feeding rules and the use of a special spoon for cerebral palsy on the z-score value of the nutritional status of children with cerebral palsy after three months of
intervention on the BMI/U indicator, and there is no significant difference in the z value - score of nutritional status on indicators of height/age.
4. Discussion
The results showed that 15% of children with Cerebral Palsy had a history of premature birth. These results follow research (Stavsky et al., 2017), who stated that the risk of cerebral palsy is dependent on gestational age and is much more common among preterm neonates, especially those who are very preterm.
In this study, the effect of two interventions was measured, namely counseling feeding rules and using a unique spoon, on the nutritional status of children with cerebral palsy. The nutritional status assessment included three z-score indicators of nutritional status using Who Anthro and Who Anthroplus software. The results of calculating the Z- score value obtained complete data on the indicators of height/age and BMI/age, while the data obtained for the indicator of weight/age needed to be completed. So, the hypothesis test using the Paired T-Test was carried out on data on height/age and BMI/age, and the results showed that there was a statistically significant difference in the z-score indicator for BMI/Age nutritional status, which is a handy index for identifying overweight and obesity. Obesity. BMI/A and Weight/Height show very similar results. This result is in accordance with the opinion (Rebelo et al., 2022), which states that educational interventions can improve the eating skills of children with cerebral palsy.
The data showed that the majority of children with cerebral palsy in this study had nutritional status in the very thin category. This situation is in accordance with various research results in developing countries (Gangil et al., 2001; Zainah et al., 2001; Caram, Morcillo and Costa‐Pinto, 2008; Sjakti et al., 2008). This study was also reinforced by Sugiarto (2012), who explained that children with cerebral palsy have almost entirely lower calorie intake and higher protein intake than calorie needs and protein requirements, causing most children with cerebral palsy to have poor nutritional status.
The level of malnutrition in children with cerebral palsy is related to the severity of eating and drinking dysfunction and gross motor disorders (Zhao et al., 2023).
Children with cerebral palsy have poor nutritional status; various factors cause this condition. Overall assessment efforts are needed regarding feeding and nutritional status to start nutritional rehabilitation promptly to improve the nutritional status and quality of life of children with cerebral palsy (Gangil et al., 2001). About a third of parents of children with cerebral palsy tend not to realize their child has difficulty eating, so most children do not get enough calorie intake. This condition tends to cause children to have a thin and fragile nutritional status (Sjakti et al., 2008). Parents' awareness of the problem of feeding their children could be higher, and they overestimate the nutritional status of their children (Gangil et al., 2001). Parents tend to experience difficulty preparing nutritious food for children with CP with an adapted texture (Pinto et al., 2022).
In this study, it was also found that some children with cerebral palsy had an obese nutritional status, although the majority of CP children had a thin or very thin nutritional status. following research (Socrates et al., 2000) state that children with CP have inferior nutritional status, and weight for height, height for age and weight for age are much smaller than their siblings. This condition is affected by decreased motor function and increased provision of gastrostomy due to the availability of better healthcare facilities (Aggarwal, Chadha, and Pathak, 2015). The opinion (Snik et al., 2019) shows a considerable risk of malnutrition in children with Cerebral Palsy (CP) due to insufficient nutritional intake. The severity of malnutrition in children with CP tends to impair their development (Socrates et al., 2000).
Fulfillment of nutritional needs is an essential aspect of managing children with cerebral palsy. The impact of malnutrition on movement physiology, neurological and psychological functions is very diverse, such as damage to the immune system, cognitive problems, and neuromuscular paralysis. The results showed that improving nutritional status could improve the general health condition of children with cerebral palsy (Aggarwal, Chadha, and Pathak, 2015)
The leading cause of insufficient intake is feeding problems which are very prevalent in children with cerebral palsy (Snik et al., 2019). The use of a tool in the form of a special spoon for cerebral palsy is included in helping meet the nutritional needs of children with cerebral palsy, according to research results (Østensjø, Carlberg and Vøllestad, 2005) which states that out of 1075 assistive devices provided to 84 children with cerebral palsy, it is proven that 980 devices support mobility, self-care, and social functioning. Research results (Jahan et al., 2022) suggest interventions directly related to children's growth/eating have better outcomes than behavioral interventions. Individuals with severe disabilities and nonfunctional extremities often rely on others for feeding, limiting their decision-making and control (Wyckoff and Mitani, 2015). New instrumentation spoons have been developed to assess the self-feeding skills of children with cerebral palsy (Zuckerman et al., 2015). Spoons adapted with thickened handles have improved movement performance in people with tetraparesis CP without increasing spillage (Van Roon and Steenbergen, 2006).
The results of this study are in accordance with research studies (M. M. Darwati et al., 2014). Which state that feeding rules interventions can significantly increase indicators of the nutritional status of toddlers in the parameters of weight/height or BMI/age.
Parents, especially mothers, in feeding children have an essential role in the nutritional status of children (Murashima et al., 2012b; Rodgers et al., 2013b). Likewise, health professionals must pay full attention to the nutritional status of children with cerebral palsy (Snik et al., 2019).
The use of modified food utensils, such as special spoons, forks, and drinking cups, has been shown to have a positive effect on the eating skills of children with cerebral palsy (CP) (Hartini et al., 2021). Nutritional status in children with CP is associated with gross
motor function and can be influenced by factors such as low birth weight (Leandro, 2016).
Children with CP with better table tool handling skills tend to have better physical development and are likelier to eat various snacks (Zuckerman et al., 2015). Poor nutritional status is standard in children with CP and significantly impacts their health and well-being (Kim, Bae and Cho, 2009). Therefore, using special spoons for children with CP can improve their nutritional status by improving their eating skills and promoting a more varied and adequate food intake.
The impact of providing feeding rules counseling to parents of children with cerebral palsy shows a significant change in the z-score indicator of BMI/A nutritional status. The results of this study are in accordance with the previous study. (Darwati et al., 2014) which states that the intervention of feeding rules can significantly increase the indicators of the nutritional status of toddlers in the parameters of BB/TB or BMI/Age.
While the study provides valuable insights, there are some drawbacks worth noting.
One is the small sample size and the absence of comparison groups, the absence of direct and periodic monitoring of feeding practices. Therefore, there is a potential gap between the guidelines of counseling taught and daily practice.
5. Conclusion
After conducting counseling interventions on feeding rules and using special spoons for cerebral palsy for three months on the nutritional status of children with cerebral palsy, it can be concluded that there is an increase in the z-score value on the BMI/A nutritional status indicator. However, the nutritional status of Height/Age has remained the same.
6. Acknowledgments
Researchers would like to thank the Ministry of Research, Technology, and Higher Education Indonesia as research funders, patients, and managers at Special Need School 1 Bantul and Griya Lare Utami Children's House, and Universitas Andalas for facilitating research publication.
7. Funding Information
This work was funded by the Ministry of Research, Technology, and Higher Education in Indonesia.
8. Author Contribution
ARM and NS conceived and designed the experiments, conducted the experiments, and collected the data. ARM and IMS analyzed and interpreted results and prepared the first draft of the manuscript. All authors provided feedback and helped define the research, analysis, and manuscript.
9. Conflict of interest
The authors at this moment state that no institutions or people with whom this study has any conflicts of interest.
Bibliography
Aggarwal, S., Chadha, R. and Pathak, R. (2015) 'Nutritional status and growth in children with cerebral palsy: a review,' International Journal of Medical Science and Public Health, 4(6), pp. 737–744.
Ahmad, S., Sharif, F. and Karamat, I. (2020) 'Feeding Problems at Different Levels of Gross Motor Function in Children with Cerebral Palsy: JRCRS. 2020; 8 (2): 64-68', Journal Riphah College of Rehabilitation Sciences, 8(2), pp. 64–68.
Boudokhane, S. et al. (2021) ‘Feeding problems and malnutrition associated factors in a North African sample of multi-disabled children with cerebral palsy,' Research in Developmental Disabilities, 118, p. 104084.
Caram, A. L. A., Morcillo, A. M. and Costa‐Pinto, E. A. L. (2008) ‘Nutritional status of children with cerebral palsy in a Brazilian tertiary‐care teaching hospital’, Developmental Medicine & Child Neurology, 50(12), pp. 956–956.
Dahlseng, M. O. et al. (2012) 'Feeding problems, growth, and nutritional status in children with cerebral palsy,' Acta paediatrica, 101, pp. 92–98.
Darwati et al. (2014) ‘Pengaruh Intervensi Konseling Feeding Rules dan Stimulasi Terhadap Status Gizi dan Perkembangan Anak di Posyandu Kabupaten Jayapura’, 15(6).
Forde, C. G. et al. (2021) 'Nutritional considerations in children,' Nutrition and oral health, pp. 3–15.
Foster, B. A. et al. (2020) ‘The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy’, Hospital Pediatrics, 10(12), pp. 1087–1095. doi: 10.1542/hpeds.2020- 0177.
Gangil, A. et al. (2001) ‘Feeding problems in children with cerebral palsy’, Indian Pediatrics, 38(8), pp. 839–846.
Ghalili, R. A. et al. (2007) ‘Standards of practice for nutrition support nurses’, Nutrition in Clinical Practice, 22, pp. 458–465.
Hartini, S. et al. (2021) ‘The effects of using modified food utensils on the feeding skills of children with cerebral palsy’, Enfermería Clínica, 31, pp. 515–520. doi:
10.1016/j.enfcli.2020.10.040.
Jahan, I. et al. (2022) ‘Nutrition Interventions for Children with Cerebral Palsy in Low- and Middle-Income Countries: A Scoping Review’, Nutrients, 14(6), p. 1211. doi:
10.3390/nu14061211.
Jesus, A. O. and Stevenson, R. D. (2020) 'Optimizing Nutrition and Bone Health in Children with Cerebral Palsy,' Physical Medicine and Rehabilitation Clinics of North America, 31(1), pp. 25–37. doi: 10.1016/j.pmr.2019.08.001.
Kadarhadi, E., Mexitalia, M. and Puruhita, N. (2012) Pengaruh konseling dengan “feeding rules” terhadap status gizi anak dengan kesulitan makan. PhD Thesis. Fakultas Kedokteran.
Keleinikova, A. et al. (2021) 'Nutritional status of children with undernutrition without chronic diseases.' Clinical Nutrition ESPEN, 46, p. S733.
Kemenkes, R. I. (2010) ‘Pedoman Umum Perlindungan Kesehatan Anak Berkebutuhan Khusus’, Jakarta: Bakti Husada.
Kim, J.-D., Bae, Y.-K. and Cho, M.-S. (2009) ‘Eating patterns of children with cerebral palsy by table utensil-handling skills’, Journal of the Korean Dietetic Association, pp. 139–
151.
Kuperminc, M. N. and Stevenson, R. D. (2008) ‘Growth and nutrition disorders in children with cerebral palsy’, Developmental Disabilities Research Reviews, 14(2), pp. 137–
146. doi: 10.1002/ddrr.14.
Kutbi, H. A. et al. (2022) ‘Food neophobia and its association with nutrient intake among Saudi children’, Food quality and preference, 96, p. 104372.
Leandro, C. G. (2016) 'Nutritional status and gross motor function in children with cerebral palsy, and implications for Zika virus infection,' Developmental Medicine & Child Neurology, 58(9), pp. 893–894.
Matonti, L., Blasetti, A. and Chiarelli, F. (2021) 'Nutrition and growth in children.' MINERVA Pediatrics, 72(6), pp. 462–471. doi: 10.23736/S0026-4946.20.05981-2.
Murashima, M. et al. (2012a) ‘Feeding behaviors of low-income mothers: directive control relates to a lower BMI in children, and a nondirective control relates to a healthier diet in preschoolers’, The American Journal of clinical nutrition, 95(5), pp. 1031–1037.
Murashima, M. et al. (2012b) ‘Feeding behaviors of low-income mothers: directive control relates to a lower BMI in children, and a nondirective control relates to a healthier diet in preschoolers’, The American Journal of clinical nutrition, 95(5), pp. 1031–1037.
Østensjø, S., Carlberg, E. B. and Vøllestad, N. K. (2005) ‘The use and impact of assistive devices and other environmental modifications on everyday activities and care in young children with cerebral palsy’, Disability and Rehabilitation, 27(14), pp. 849–
861.
Pinto, C. et al. (2022) ‘Embracing the Nutritional Assessment in Cerebral Palsy: A Toolkit for Healthcare Professionals for Daily Practice’, Nutrients, 14(6), p. 1180. doi:
10.3390/nu14061180.
Rebelo, F. et al. (2022) ‘Dietary and nutritional interventions in children with cerebral palsy: A systematic literature review’, PloS One, 17(7), p. e0271993. doi:
10.1371/journal.pone.0271993.
Rodgers, R. F. et al. (2013a) 'Maternal feeding practices predict weight gain and obesogenic eating behaviors in young children: a prospective study,' International Journal of Behavioral Nutrition and Physical Activity, 10, pp. 1–10.
Rodgers, R. F. et al. (2013b) ‘Maternal feeding practices predict weight gain and obesogenic eating behaviors in young children: a prospective study’, Int J Behav Nutr Phys Act, 10(1), p. 24.
Sadowska, M., Sarecka-Hujar, B. and Kopyta, I. (2020) ‘Cerebral Palsy: Current Opinions on Definition, Epidemiology, Risk Factors, Classification and Treatment Options’, Neuropsychiatric Disease and Treatment, 16, pp. 1505–1518. doi:
10.2147/NDT.S235165.
Samson-Fang, L. dan B. and KL (2013) 'Assessment of growth and nutrition in children with cerebral palsy', European Journal of clinical nutrition, 67, pp. 5–8.
Shakti, H. A. et al. (2008) 'Feeding difficulties in children with cerebral palsy,' Paediatrica Indonesiana, 48(4), pp. 224–9.
Snik, D. A. C. et al. (2019) ‘Nutritional care: The “poor child” of clinical care in children with cerebral palsy’, Journal of Pediatric Rehabilitation Medicine, 12(2), pp. 133–138. doi:
10.3233/PRM-180537.
Socrates, C. et al. (2000) ‘Poor nutrition is a serious problem in children with cerebral palsy in Palawan, the Philippines’, International Journal of Rehabilitation Research.
Internationale Zeitschrift Fur Rehabilitationsforschung. Revue Internationale De Recherches De Readaptation, 23(3), pp. 177–184. doi: 10.1097/00004356-200023030- 00007.
Sørensen, S. J. et al. (2021) 'Nutritional screening of children and adolescents with cerebral palsy: a scoping review,' Developmental Medicine & Child Neurology, 63(12), pp. 1374–1381.
Stavsky, M. et al. (2017) ‘Cerebral Palsy—Trends in Epidemiology and Recent Development in Prenatal Mechanisms of Disease, Treatment, and Prevention’, Frontiers in Pediatrics, 5, p. 21. doi: 10.3389/fped.2017.00021.
Sugiarto, F. and Setiawati EM, M. (2012) Asupan makan dan status gizi anak dengan palsi serebralis. PhD Thesis. Fakultas Kedokteran.
Van Roon, D. and Steenbergen, B. (2006) ‘The use of ergonomic spoons by people with cerebral palsy: effects on food spilling and movement kinematics’, Developmental medicine and child neurology, 48(11), pp. 888–891.
WHO Multicentre Growth Reference Study (2006) ‘WHO Child Growth Standards: Methods and development: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age’, Geneva: World health organization.
Wicaksono, P. (2012) UGM Ciptakan Sendok Khusus untuk Cerebral Palsy - Gaya Tempo.co.
Available at: https://gaya.tempo.co/read/425921/ugm-ciptakan-sendok-khusus- untuk-cerebral-palsy (Accessed: 1 August 2023).
Wyckoff, E. and Mitani, M. (2015) ‘The Spoon late: A Self-Feeding Dev·ce’. Available at:
https://typeset.io/papers/the-spoon-late-a-self-feeding-dev-ce-58vo9qnriu (Accessed: 1 August 2023).
Yuniarti, Y., Purba, M. B. and Pangastuti, R. (2013) ‘Pengaruh konseling gizi dan penambahan makanan terhadap asupan zat gizi dan status gizi pasien HIV/AIDS’, Jurnal Gizi Klinik Indonesia, 9(3), pp. 132–138. doi: 10.22146/ijcn.15446.
Zainah, S. H. et al. (2001) 'Determinants of linear growth in Malaysian children with cerebral palsy,' Journal of pediatrics and child health, 37(4), pp. 376–381.
Zhao, Y. et al. (2023) ‘Relationship Between Nutritional Status and Severity of Cerebral Palsy: A Multicentre Cross-Sectional Study’, Journal of Rehabilitation Medicine, 55, p. jrm00367. doi: 10.2340/jrm.v55.4395.
Zuckerman, O. et al. (2015) 'Assisting caregivers of children with cerebral palsy: Towards a self-feeding assessment spoon,' in Proceedings of the Ninth International Conference on Tangible, Embedded, and Embodied Interaction, pp. 557–562.
