Growth Charts for Children with Cerebral Palsy: Weight and Stature Percentiles by Age, Gender, and Level of Disability

  • Steven M. Day
  • Jordan Brooks
  • Sharon Shumway
  • David Strauss
  • Lewis Rosenbloom


Growth charts for the general population, whether reference charts from the CDC or standards for healthy children developed by the WHO, are of limited use for children with cerebral palsy (CP), whose weight-for-age and stature-for-age often track below the 5th percentiles on such charts. In this chapter we review previous work on CP-specific growth patterns and growth charts and present new weight-for-age and stature-for-age growth charts for CP. The new charts are based on data comprising over 100,000 measurements of weight and height of children with CP who received services from the California Department of Developmental Services from 1988 to 2002. The charts are stratified by Gross Motor Function Classification System (GMFCS) level. The percentile curves in the new charts are based on methodology recommended by the WHO (the Box–Cox power-exponential distribution with four parameters was used to construct the percentile curves). The resulting curves show 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles of weight-for-age and stature-for-age separately for boys and girls and GMFCS levels I–V, with level V further separated according to presence of a feeding tube. Very low percentiles of weight (5th or 20th percentile, depending on GMFCS level), below which mortality rates are elevated, are identified in the charts. The format of the charts is similar to that of the CDC general population reference charts for children aged 2–20. The new charts confirm earlier work showing that percentiles of weight-for-age and stature-for-age in CP are substantially lower than corresponding percentiles in the general population. The charts also confirm that weight and stature in CP are strongly associated with level of gross motor functioning. Among the most severely affected children with CP (GMFCS level V), weight and stature percentiles are higher for those with feeding tubes. The chapter reviews evidence from earlier studies linking very high or very low weights in CP to other health outcomes and examines these links relative to percentiles of weight-for-age on the new GMFCS-level-specific growth charts. Practical considerations for using the new charts are discussed and cautionary notes provided. The chapter includes a brief discussion of how the information presented here might apply to other neurological disorders or medical conditions.


Cerebral Palsy Down Syndrome Growth Chart Gross Motor Function Classification System Percentile Curve 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



American Association on Mental Deficiency


Body mass index


Centers for Disease Control and Prevention


Client Development Evaluation Report


Cerebral palsy


Department of Developmental Services


Generalized additive models for location, scale, and shape


Gross Motor Function Classification System


National Center for Health Statistics


World Health Organization



Provision of data from the California Department of Developmental Services and Bureau of Vital Statistics is gratefully acknowledged.


  1. Al Husain M. Growth charts for children with Down’s syndrome in Saudi Arabia: birth to 5 years. Int J Clin Pract. 2003;57:170–4.PubMedGoogle Scholar
  2. Brooks J, Day SM, Shavelle RM, Strauss DJ. Low weight, morbidity, and mortality in children with cerebral palsy: new clinical growth charts. Pediatrics. Published online July 18, 2011 (10.1542/peds.2010–2801).Google Scholar
  3. California Department of Developmental Services. Client development evaluation report manual. Sacramento: State of California Health and Welfare Agency; 1986.Google Scholar
  4. California Department of Developmental Services. Fact book, eleventh edition. (2010a). Accessed 9 Mar 2010.
  5. California Department of Developmental Services. Information about developmental disabilities. (2010b). Accessed 9 Mar 2010.
  6. Cremers MJ, van der Tweel I, Boersma B, Wit JM, Zonderland M. Growth curves of Dutch children with Down’s syndrome. J Intellect Disabil Res. 1996;40(Pt 5):412–20.PubMedCrossRefGoogle Scholar
  7. Cronk CE. Growth of children with Down’s syndrome: birth to age 3 years. Pediatrics. 1978;61:564–8.PubMedGoogle Scholar
  8. Cronk C, Crocker AC, Pueschel SM, Shea AM, Zackai E, Pickens G, Reed RB. Growth charts for children with Down’s syndrome: 1 month to 18 years of age. Pediatrics. 1988;81:102–10.PubMedGoogle Scholar
  9. Day SM, Strauss DJ, Shavelle RM, Reynolds RJ. Mortality and causes of death in persons with Down syndrome in California. Dev Med Child Neurol. 2005;47:171–6.PubMedCrossRefGoogle Scholar
  10. Day SM, Strauss DJ, Vachon PJ, Rosenbloom L, Shavelle RM, Wu YW. Growth patterns in a population of children and adolescents with cerebral palsy. Dev Med Child Neurol. 2007;49:167–71.PubMedCrossRefGoogle Scholar
  11. Dibley MJ, Goldsby JB, Staehling NW, Trowbridge FL. Interpretation of Z-score anthropometric indicators derived from the international growth reference. Am J Clin Nutr. 1987;46:736–48.PubMedGoogle Scholar
  12. Fung EB, Samson-Fang L, Stallings VA, Conaway M, Liptak G, Henderson RC, Worley G, O’Donnell M, Calvert R, Rosenbaum P, Chumlea W, Stevenson RD. Feeding dysfunction is associated with poor growth and health status in children with cerebral palsy. J Am Diet Assoc. 2002;102:361–73.PubMedCrossRefGoogle Scholar
  13. Hamill PV, Drizd TA, Johnson CL, Reed RB, Roche AF. NCHS growth curves for children, birth-18 years: United States. Vital Health Stat. 1977;11(i–iv):1–74.Google Scholar
  14. Hamill PV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM. Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr. 1979;32:607–29.PubMedGoogle Scholar
  15. Henderson RC, Grossberg RI, Matuszewski J, Menon N, Johnson J, Kecskemethy HH, Vogel L, Ravas R, Wyatt M, Bachrach SJ, Stevenson RD. Growth and nutritional status in residential center versus home-living children and adolescents with quadriplegic cerebral palsy. J Pediatr. 2007;151:161–6.PubMedCrossRefGoogle Scholar
  16. Henderson RC, Lark RK, Gurka MJ, Worley G, Fung EB, Conaway M, Stallings VA, Stevenson RD. Bone density and metabolism in children and adolescents with moderate to severe cerebral palsy. Pediatrics. 2002;110:e5.PubMedCrossRefGoogle Scholar
  17. Horton WA, Rotter JI, Rimoin DL, Scott CI, Hall JG. Standard growth curves for achondroplasia. J Pediatr. 1978;93:435–8.PubMedCrossRefGoogle Scholar
  18. Hurvitz EA, Green LB, Hornyak JE, Khurana SR, Koch LG. Body mass index measures in children with cerebral palsy related to gross motor function classification: a clinic-based study. Am J Phys Med Rehabil. 2008;87:395–403.PubMedCrossRefGoogle Scholar
  19. Isojima T, Yokoya S, Ito J, Horikawa R, Tanaka T. New reference growth charts for Japanese girls with Turner syndrome. Pediatr Int. 2009;51:709–14.PubMedCrossRefGoogle Scholar
  20. Kennedy Krieger Institute. Growth references for children with quadriplegic cerebral palsy. (2009). Accessed 3 Aug 2009.
  21. Koenker R, Ng P, Portnoy S. Quantile smoothing splines. Biometrika. 1994;81:673–80.CrossRefGoogle Scholar
  22. Krick J, Van Duyn MA. The relationship between oral-motor involvement and growth: a pilot study in a pediatric population with cerebral palsy. J Am Diet Assoc. 1984;84:555–9.PubMedGoogle Scholar
  23. Krick J, Murphy-Miller P, Zeger S, Wright E. Pattern of growth in children with cerebral palsy. J Am Diet Assoc. 1996;96:680–5.PubMedCrossRefGoogle Scholar
  24. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL. CDC growth charts: United States. Adv Data. 2000;314:1–27.Google Scholar
  25. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat. 2002;11:1–190.Google Scholar
  26. Kuperminc MN, Stevenson RD. Growth and nutrition disorders in children with cerebral palsy. Dev Disabil Res Rev. 2008;14:137–46.PubMedCrossRefGoogle Scholar
  27. Laron Z, Lilos P, Klinger B. Growth curves for Laron syndrome. Arch Dis Child. 1993;68:768–70.PubMedCrossRefGoogle Scholar
  28. Lin PP, Henderson RC. Bone mineralization in the affected extremities of children with spastic hemiplegia. Dev Med Child Neurol. 1996;38:782–6.PubMedCrossRefGoogle Scholar
  29. Motion S, Northstone K, Emond A, Stucke S, Golding J. Early feeding problems in children with cerebral palsy: weight and neurodevelopmental outcomes. Dev Med Child Neurol. 2002;44:40–3.PubMedCrossRefGoogle Scholar
  30. 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.PubMedCrossRefGoogle Scholar
  31. Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content validity of the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurol. 2008;50:744–50.PubMedCrossRefGoogle Scholar
  32. Piro E, Pennino C, Cammarata M, Corsello G, Grenci A, Lo Giudice C, Morabito M, Piccione M, Giuffre L. Growth charts of Down syndrome in Sicily: evaluation of 382 children 0–14 years of age. Am J Med Genet Suppl. 1990;7:66–70.PubMedGoogle Scholar
  33. Rigby RA, Stasinopoulos DM. Smooth centile curves for skew and kurtotic data modelled using the Box-Cox power exponential distribution. Stat Med. 2004;23:3053–76.PubMedCrossRefGoogle Scholar
  34. Roberts CD, Vogtle L, Stevenson RD. Effect of hemiplegia on skeletal maturation. J Pediatr. 1994;125:824–8.PubMedCrossRefGoogle Scholar
  35. Rogozinski BM, Davids JR, Davis RB, Christopher LM, Anderson JP, Jameson GG, Blackhurst DW. Prevalence of obesity in ambulatory children with cerebral palsy. J Bone Joint Surg. 2007;89:2421–6.PubMedCrossRefGoogle Scholar
  36. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, Dan B, Jacobsson B. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109:8–14.PubMedGoogle Scholar
  37. Saito T, Mizuta K, Hishikawa S, Kawano Y, Sanada Y, Fujiwara T, Yasuda Y, Sugimoto K, Sakamoto K, Kawarasaki H. Growth curves of pediatric patients with biliary atresia following living donor liver transplantation: factors that influence post-transplantation growth. Pediatr Transplant. 2007;11:764–70.PubMedCrossRefGoogle Scholar
  38. Samson-Fang L, Fung E, Stallings VA, Conaway M, Worley G, Rosenbaum P, Calvert R, O’Donnell M, Henderson RC, Chumlea WC, Liptak GS, Stevenson RD. Relationship of nutritional status to health and societal participation in children with cerebral palsy. J Pediatr. 2002;141:637–43.PubMedCrossRefGoogle Scholar
  39. Sanchez-Lastres J, Eiris-Punal J, Otero-Cepeda JL, Pavon-Belinchon P, Castro-Gago M. Nutritional status of mentally retarded children in north-west Spain: anthropometric indicators. Acta Paediatr. 2003;92:747–53.PubMedCrossRefGoogle Scholar
  40. Sempe M, Hansson Bondallaz C, Limoni C. Growth curves in untreated Ullrich-Turner syndrome: French reference standards 1–22 years. Eur J Pediatr. 1996;155:862–9.PubMedCrossRefGoogle Scholar
  41. Shapiro BK, Green P, Krick J, Allen D, Capute AJ. Growth of severely impaired children: neurological versus nutritional factors. Dev Med Child Neurol. 1986;28:729–33.PubMedCrossRefGoogle Scholar
  42. Shim ML, Moshang T Jr, Oppenheim WL, Cohen P. Is treatment with growth hormone effective in children with cerebral palsy? Dev Med Child Neurol. 2004;46:569–71.PubMedCrossRefGoogle Scholar
  43. Spender QW, Cronk CE, Stallings VA, Hediger ML. Fat distribution in children with cerebral palsy. Ann Hum Biol. 1988;15:191–6.PubMedCrossRefGoogle Scholar
  44. Stallings VA, Charney EB, Davies JC, Cronk CE. Nutrition-related growth failure of children with quadriplegic cerebral palsy. Dev Med Child Neurol. 1993a;35:126–38.PubMedCrossRefGoogle Scholar
  45. Stallings VA, Charney EB, Davies JC, Cronk CE. Nutritional status and growth of children with diplegic or hemiplegic cerebral palsy. Dev Med Child Neurol. 1993b;35:997–1006.PubMedCrossRefGoogle Scholar
  46. Stallings VA, Cronk CE, Zemel BS, Charney EB. Body composition in children with spastic quadriplegic cerebral palsy. J Pediatr. 1995;126:833–9.PubMedCrossRefGoogle Scholar
  47. Stevenson RD. Use of segmental measures to estimate stature in children with cerebral palsy. Arch Pediatr Adolesc Med. 1995;149:658–62.PubMedCrossRefGoogle Scholar
  48. Stevenson RD, Conaway M. Growth assessment of children with cerebral palsy: the clinician’s conundrum. Dev Med Child Neurol. 2007;49:164.PubMedCrossRefGoogle Scholar
  49. Stevenson RD, Hayes RP, Cater LV, Blackman JA. Clinical correlates of linear growth in children with cerebral palsy. Dev Med Child Neurol. 1994;36:135–42.PubMedCrossRefGoogle Scholar
  50. Stevenson RD, Roberts CD, Vogtle L. The effects of non-nutritional factors on growth in cerebral palsy. Dev Med Child Neurol. 1995;37:124–30.PubMedCrossRefGoogle Scholar
  51. Stevenson RD, Conaway M, Barrington JW, Cuthill SL, Worley G, Henderson RC. Fracture rate in children with cerebral palsy. Pediatr Rehabil. 2006a;9:396–403.PubMedGoogle Scholar
  52. Stevenson RD, Conaway M, Chumlea WC, Rosenbaum P, Fung EB, Henderson RC, Worley G, Liptak G, O’Donnell M, Samson-Fang L, Stallings VA. Growth and health in children with moderate-to-severe cerebral palsy. Pediatrics. 2006b;118:1010–8.PubMedCrossRefGoogle Scholar
  53. Stewart L, McKaig N. Nutrition and growth: assessment and monitoring. In: Sullivan PB, editor. Feeding and nutrition in children with neurodevelopmental disability. London: Mac Keith Press; 2009. pp. 21–34.Google Scholar
  54. Sullivan PB. Feeding and nutrition in children with neurodevelopmental disability. London: Mac Keith Press; 2009.Google Scholar
  55. Szudek J, Birch P, Friedman JM. Growth charts for young children with neurofibromatosis 1 (NF1). Am J Med Genet. 2000;92:224–8.PubMedCrossRefGoogle Scholar
  56. Tobis JS, Saturen P, Larios G, Posniak AO. Study of growth patterns in cerebral palsy. Arch Phys Med Rehabil. 1961;42:475–81.PubMedGoogle Scholar
  57. Toledo C, Alembik Y, Aguirre Jaime A, Stoll C. Growth curves of children with Down syndrome. Ann Genet. 1999;42:81–90.PubMedGoogle Scholar
  58. Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics. 2005;116:e125–44.PubMedCrossRefGoogle Scholar
  59. Witt DR, Keena BA, Hall JG, Allanson JE. Growth curves for height in Noonan syndrome. Clin Genet. 1986;30:150–3.PubMedCrossRefGoogle Scholar
  60. World Health Organization. WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization; 2006.Google Scholar
  61. World Health Organization. Nutrition for Health and Development. WHO child growth standards: head circumference-for-age, arm circumference-for-age, triceps skinfold-for-age and subscapular skinfold-for-age: methods and development. Geneva: World Health Organization; 2007.Google Scholar
  62. Zainah SH, Ong LC, Sofiah A, Poh BK, Hussain IH. Determinants of linear growth in Malaysian children with cerebral palsy. J Paediatr Child Health. 2001;37:376–81.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Steven M. Day
    • 3
  • Jordan Brooks
    • 1
  • Sharon Shumway
    • 1
  • David Strauss
    • 1
  • Lewis Rosenbloom
    • 2
  1. 1.Life Expectancy ProjectSan FranciscoUSA
  2. 2.Royal Liverpool Children’s NHS Foundation TrustWest Derby, LiverpoolUK
  3. 3.Mortality Research & ConsultingNewport BeachUSA

Personalised recommendations