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. 2024 Mar 18;14:6494. doi: 10.1038/s41598-024-55730-1

Estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa: a systematic review with meta-analysis

Ermias Sisay Chanie 1,✉, Natnael Moges 2, Fikadie Dagnew Baye 1, Gebrehiwot Berie Mekonnen 1, Mengistu Melak Fekadie 1, Lakachew Yismaw Bazezew 2, Denekew Tenaw Anley 3, Melkamu Aderajew Zemene 3, Natnael Atnafu Gebeyehu 4, Getachew Asmare Adella 5, Gizachew Ambaw Kassie 6, Misganaw Asmamaw Mengstie 7, Mohammed Abdu Seid 8, Endeshaw Chekol Abebe 9, Molalegn Mesele Gesese 4, Kirubel Dagnaw Tegegne 10, Yenealem Solomon Kebede 11, Berihun Bantie 12, Sefineh Fenta Feleke 13, Tadesse Asmamaw Dejenie 14, Wubet Alebachew Bayih 15, Amare Kassaw 1, Anteneh Mengist Dessie 3, Melkalem Mamuye Azanaw 3, Sewunt Sisay Chanie 16
PMCID: PMC10948888  PMID: 38499717

Abstract

Malnutrition is more prevalent among children with cerebral palsy and a major factor for child morbidity and mortality in children with different co-morbidity, especially in Sub-Saharan Africa: The main aim of this systematic review and meta-analysis was to estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa. We searched PubMed, Web of Science, Google Scholar, Research Gate, and institutional repositories for papers that reported the proportion of malnutrition among children with cerebral palsy that were published between December 2010 and September 2023. Data were retrieved using the standardized JBI data extraction checklist through Microsoft Excel, and then exported to STATA 17 for further analysis. DerSimonian and Laird’s estimator was used to calculate the pooled effect size in the random-effects model. Statistics such as the Cochran Q test and I2 test were employed to measure heterogeneity. Egger's test and the funnel plot were used to look for publication bias. This systematic review and meta-analysis used 16 studies from Sub-Saharan Africa to estimate the proportion of malnutrition among 2,120 children with cerebral palsy. The pooled proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa by using random-effects model analysis was found to be 59.7% (95% CI; 49.8–69.6). The proportion of malnutrition was also estimated by sample sizes categorized as ≤ 120 and > 120, and the proportion of malnutrition was found to be 54.0 (95% CI: 44.7–63.3) and 64.5 (95% CI: 50.5–78.5). Moreover, the proportion of malnutrition was estimated by accounting for the difference in the year of publication. In this regard, the study classified before ≤ 2017 and > 2017, and the proportion of malnutrition was found to be 53.7 (95% CI: 38.0–69.3) and 62.5 (95% CI: 49.7–75.3) in Sub-Saharan Africa respectively. Malnutrition among children with cerebral in Sub-Saharan Africa was found to be very high. Hence, enhancing and developing strategic guidelines for malnutrition screening, prevention, and nutritional support are crucial among children with cerebral palsy. Furthermore, systematic review, randomized control trials, and qualitative studies are recommended to understand the burden more among children with cerebral palsy in the continent.

Keywords: Children with cerebral palsy, Malnutrition, Sub-Saharan Africa

Subject terms: Molecular medicine, Neurology, Risk factors

Introduction

Cerebral palsy is a neurological disorder cause a lifelong physical disability1. With an estimated incidence of 17 million persons globally, cerebral palsy affects around 1 in 500 newborns2.

Children with cerebral palsy have a higher risk of developing malnutrition than other children because CP affects the muscles and movements involved in chewing, swallowing, and feeding3,4. It is a double burden for children with cerebral palsy to develop malnutrition since the problems are worsening each other and add challenges5,6.

The prevalence of malnutrition among children with cerebral palsy was 7.9–71.46%5,7, and malnutrition is more prevalent among children with cerebral palsy and a major factor for child morbidity and mortality in children with different co-morbidity, especially in Sub-Saharan Africa8.

Children with cerebral palsy are more susceptible to both the long- and short-term effects of malnutrition. Malnutrition lowers quality of life and social engagement, raises susceptibility to illness, and health care utilization, and lowers chances of survival5,6,9.

Therefore, malnutrition prevention, management, and nutritional support are very crucial and the stakeholders, government, and non-governmental organizations should be included in planning and implementing a package for children with cerebral palsy5,10,11.

Although some research has been done on the prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa in the past, the combined frequency is not well understood. This systematic review and meta-analysis aimed to determine the pooled prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa. This study may also draw new evidence from different heterogeneity of studies. Hence, this research is of paramount importance in providing evidence to policymakers, researchers, and clinicians to recognize the burden and can help the development of strategic guidelines, and enhance clinical decision-making and monitoring by integrating the recommendations of the study.

Methods

Data sources and search strategies

Review question

The review question of this systematic review and meta-analysis is: What is the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa?

Study selection

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (“PRISMA checklist” was used in the formulation of the systematic review methodology12. A registration request for the review methodology has been made to the PROSPERO database.

Articles were evaluated based on the inclusion and exclusion criteria from the perspective of the outcome variable (i.e., are they reporting the prevalence or epidemiology of malnutrition among children with cerebral palsy or not).

Search strategy

We searched PubMed, Google Scholar, Web Science, Cochrane databases, and other source that were conducted on malnutrition among children with cerebral palsy, and were published between January 2010 and September 2023. Since research involves constantly testing the hypotheses, staying updated with the latest publications will help us estimate the recent and updated burden of the problem.

The search was conducted using the following keywords: (Prevalence OR proportion OR Burden OR magnitude) AND (Children [MeSH Terms] OR Child OR infant OR Kids) AND (Cerebral palsy [MeSH Terms] OR Disability OR Impairment OR Special needs) AND (Sub-Saharan Africa) OR developing country OR resource-limited setting. The search terms were used separately and in combination using Boolean operators like “OR” or “AND”. The literature search conducted from April 01 to 17, 2023 by authors includes ESC, MAM, MAS, and SSC. All papers published until April 17, 2023, were included in this review.

Eligibility criteria

Inclusion criteria

  • Language: Articles published in English.

  • Study area: Only studies conducted in Sub-Saharan Africa were eligible for this study.

  • Study design: Observational studies (case-control, cohort, and cross-sectional study) that report the prevalence of malnutrition among children with cerebral palsy.

  • Publication year: Reports made from January 2010 onwards.

  • Publication condition: Peer-reviewed journal articles as well as articles from the university website.

  • Outcome of interests: Studies reported the prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa was considered.

Exclusion criteria

Due to the inability to evaluate the quality of publications without access to the complete text and to estimate the outcome variable, articles that were not fully accessed were excluded. Furthermore, studies that did not distinguish between children with cerebral palsy and those with other special needs/disability were excluded from the study.

Outcome measurement among children with cerebral palsy

There is one key outcome variable in this systematic review, which is the prevalence of malnutrition among children with cerebral palsy. The prevalence of malnutrition among children with cerebral palsy was calculated by multiplying the total number of children with cerebral palsy who had malnutrition by 100 and dividing that number by the total number of children with cerebral palsy.

Study selection and data extraction

All Studies reported the prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa were transferred to Zotero software, and duplicate articles were removed. The pertinent information, including the names of the authors, the study's design, sample size, study area, and the number of cases/proportions of malnutrition were independently extracted by four authors (ESC, NM, FDB, and GBM). Similar to the preceding step, disagreements were discussed during a consensus meeting with other reviewers (MAM, MAS, ECA, MMG, KDT, SSC, and YSK) for the final decision on which studies to include in the meta-analysis and systematic review.

Quality assessment

We evaluated the included studies' quality using the Joanna Briggs Institute Critical Appraisal instrument for use in JBI Systematic Reviews (JBI-MAStARI)13. For the cross-sectional, case–control, and cohort investigations, various items were used in the scale. This systematic review and meta-analysis study included five writers (TAD, WAB, AK, AMD, and MMA) who examined the included articles.

Statistical analysis

The authors verified the accuracy of the retrieved data in a Microsoft Excel sheet before exporting it into STATA 17 for further analysis. The STATA version 17 was used for all analyses in this study.

The degree of heterogeneity was evaluated using Cochrane Q-statistics and an I2 statistic with a p-value (< 0.05)14,15. The test for heterogeneity was high (75%) or moderate (50–74%)16. Using a random-effects model, the pooled prevalence of malnutrition among children with cerebral palsy was estimated.

Once we had determined that there was moderate or higher heterogeneity, we also looked into the cause of the heterogeneity using subgroup analysis and meta-regression17. Predetermined subgroups were taken into account for this, including the study sample size, study design, publication year, and study conditions.

The publication bias was estimated through a funnel plot and Egger test18 and sensitivity analysis was piloted to examine the effect of a single study on the overall estimation.

Results

Search result

We found 1374 studies from PubMed, Google Scholar, Web Science, Cochrane databases, and other source. There were 507 studies were excluded due to duplication. Of the remaining 867 studies, 523 studies were excluded through title and abstract screening. From a total of 344 full-text articles, 328 were excluded due to the outcome variable wasn’t reported. A total of 16 studies were finally included from 09 Sub-Saharan Africa such as Nigeria, Ghana, Uganda, Kenya, Sudan, Cameroon, Tanzania, Botswana, and Zambia (Fig. 1).

Figure 1.

Figure 1

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The PRISMA flow diagram of searching process.

Study characteristics and participants

This systematic review and meta-analysis examined 16 studies conducted in Sub-Saharan Africa to determine the prevalence of malnutrition among 2,120 children diagnosed with cerebral palsy. The review included a total of 16 cross-sectional studies with study design19–34.

Out of sixteen studies in this review, five were from Nigeria19,21,23,25,26,, three were from Ghana), two studies were from Uganda22,28, and the remaining seven studies were from Kenya30, Sudan20, Cameroon29, Tanzania33, Botswana27, and Zambia31.

The review found that the highest proportion of malnutrition among children with cerebral palsy was 90%22, while the lowest proportion was 37.3%23. The sample sizes varied significantly, with the largest study including 388 participants from Nigeria25, and the smallest study including only 16 participants from Zambia31 (Table 1).

Table 1.

Distribution of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

First author/year Country Study design Sample size Cases Malnutrition (%) Quality status
Adamu et al 2018 Nigeria Cross sectional 150 129 86 Low risk
Ali et al. 2022 Sudan Cross sectional 90 53 58.9 Low risk
Badaru et al. 2023 Nigeria Cross sectional 146 95 65.1 Low risk
Bambi et al. 2021 Uganda Cross sectional 224 202 90 High risk
Chidomere et al. 2023 Nigeria Cross sectional 169 63 37.3 Low risk
Donkor et al. 2019 Ghana Cross sectional 34 17 50 Low risk
Duke et al 2021 Nigeria Cross sectional 388 198 51 Low risk
Iloeje et al. 2017 Nigeria Cross sectional 100 37 38.1 Low risk
Johnson et al. 2017 Botswana Cross sectional 61 26 43 Low risk
Kakooza- et al. 2015 Uganda Cross sectional 135 57 42 Low risk
Kana et al. 2022 Cameroon Cross sectional 88 36 40.9 Low risk
Koriata et al. 2012 Kenya Cross sectional 140 98 70.3 Low risk
Nawa et al. 2022 Zambia Cross sectional 16 13 80.5 Low risk
Polack et al. 2018 Ghana Cross sectional 76 49 65 Low risk
Sissya et al. 2010 Tanzania Cross sectional 239 175 73.1 Low risk
Zuurmond et al. 2018 Ghana Cross sectional 64 40 63.1 Low risk
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Meta-analysis

The pooled proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa by using random-effects model analysis was found to be 59.7% (95%CI; 49.8–69.6) and showed in (Fig. 2).

Figure 2.

Figure 2

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Forest plot to test of malnutrition estimation among children with cerebral palsy in Sub-Saharan Africa.

Estimation of malnutrition burden by sub group analysis among children with cerebral palsy

The proportion of malnutrition was also estimated by considering the sample size difference. The sample sizes were categorized as ≤ 120 and > 120, and the proportion of malnutrition was found to be 54.0 (95% CI: 44.7–63.3) and 64.5 (95% CI: 50.5–78.5) in Sub-Saharan Africa respectively (Fig. 3). Moreover, the proportion of malnutrition was estimated by accounting for the difference in the year of publication. In this regard, the study classified before ≤ 2017 and > 2017, and the proportion of malnutrition was found to be 53.7 (95% CI: 38.0–69.3) and 62.5 (95% CI: 49.7–75.3) in Sub-Saharan Africa respectively (Fig. 4).

Figure 3.

Figure 3

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The proportion of malnutrition estimation among children with cerebral palsy by sample sizes categories.

Figure 4.

Figure 4

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The proportion of malnutrition estimation among children with cerebral palsy by year of publications categories.

Publication bias

Egger's regression test value showed that there is a statistically significant publication bias in this study (p < 0.044) (Table 2). Besides, a funnel plot showed an asymmetrical distribution which indicated the presence of publication bias (Fig. 5)). Moreover, the results of sensitivity analyses using the random effect model suggested were estimated (Fig. 6).

Table 2.

Egger's test of the study of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

Std_Eff Coefficient SE T P > t [95% CI]
Slope 89.32553 11.1347 8.02 0.000 65.44397 113.2071
Bias −6.563965 2.965408 −2.21 0.044 −12.92413 −0.2037975
Test of H0: no small-study effects P = 0.044, Root MSE = 4.62, Number of Studies = 16
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Figure 5.

Figure 5

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Funnel plot tests for the proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

Figure 6.

Figure 6

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The sensitivity test for the proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

Discussion

This systematic review and meta-analysis study provides representative data on the estimation of malnutrition among children with CP in Sub-Saharan Africa.

The study suggests that an estimated pooled malnutrition burden among children with cerebral in Sub-Saharan Africa was found to be 57.4% (95% CI; 46.7–68.2).

The finding of this review, the proportion of malnutrition among children with CP is higher than the study conducted in Saudi Arabia11, U.S.A7, Argentine10, Bangladesh35, Nepal36, Turkey37, Vietnam38, and systematic review and meta-analysis Asia 40%39.

This difference might be due to the limited healthcare services, healthcare providers, infrastructure, and limited social support for the optimization of health among children with cerebral palsy by preventing, controlling, and managing malnutrition in Sub-Saharan Africa as compared to other continents40,41.

Moreover, food insecurity, overpopulation, low educational status, and wars can contribute to malnutrition is too high, particularly in resource-limited settings and vulnerable groups such as children with cerebral play in Sub-Saharan Africa40–43.

However, the proportion of malnutrition is lower than in the study conducted in Colombia9, and a Systematic Review and Meta-Analysis Arabic speaking countries5. This difference might be due to the reference standards cut-off point to diagnosis malnutrition in Colombian and Arabic-speaking countries were included mild, modern, and severe classifications, whereas this study included moderate and severe to declare malnutrition only among children with cerebral palsy5,9.

The finding of this review will inform the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa for the planners, policymakers, healthcare providers, government and non-governmental organizations, and researchers’ up-to-date data. Additionally, this finding shows the impact of malnutrition in children with cerebral, so prevention and management through the integration of the recommendations to develop guidelines and improve the quality of service is very crucial for children with cerebral palsy in the continent.

The subgroup analysis conducted in this review aimed to estimate the proportion of malnutrition among children with cerebral palsy in various categories within the Sub-Saharan Africa region. One aspect that was examined was the difference in sample sizes, with participants categorized as ≤ 120 and > 120. The estimated proportions of malnutrition were found to be 54.0% (95% CI: 44.7–63.3) and 64.5% (95% CI: 50.5–78.5), respectively. Another factor considered was the variation in the year of publication, with studies classified as published before ≤ 2017 and > 2017. The estimated proportions of malnutrition were found to be 53.7% (95% CI: 38.0–69.3) and 62.5% (95% CI: 49.7–75.3), respectively. Taking into account the significance of a large sample size for accuracy, it is conceivable that the proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa might be higher than the findings of this study suggest. Moreover, recent studies focusing on this population in the region have shown that, there is an increment in the prevalence of malnutrition among children with cerebral palsy. It is crucial to take these subgroup analysis findings into account to avoid misleading conclusions influenced by confounding factors44.

The subgroup analysis findings emphasize the urgent requirement for interventions and targeted strategies to tackle the rising prevalence of malnutrition among children with cerebral palsy.

Limitations of the study

This systematic review and meta-analysis have some limitations. Firstly, the study did not assess the specific causes of malnutrition among children with cerebral palsy. Secondly, only quantitative observational studies published in English were included in the analysis, potentially excluding relevant studies in other languages. Thirdly, studies that did not differentiate between children with cerebral palsy and those with other disabilities were not considered in the analysis.

Conclusion

Malnutrition among children with cerebral in Sub-Saharan Africa was found to be very high. Hence, enhancing and developing strategic guidelines for malnutrition screening, prevention, and nutritional support are crucial among children with cerebral palsy. Furthermore, systematic review, randomized control trials, and qualitative studies are recommended to understand the burden more among children with cerebral palsy in the continent.

Supplementary Information

Supplementary Information. (69.6KB, pdf)

Acknowledgements

We would like to thank all authors of the studies included in this systematic review and meta-analysis.

Abbreviation

CP

Cerebral palsy

Author contributions

E.S.C., N.M., F.D.B., G.B.M., M.M.F., L.Y.B., D.T.A., M.A.Z., N.A.G., G.A.A., G.A.K., M.A.M., M.A.S., E.C.A., and S.S.C. developed the protocol and involved in the design, selection of study, and data extraction. Moreover, E.S.C., M.M.G., K.D.T., Y.S.K., B.B., S.F.F., T.A.D., W.A.B., A.K., A.M.D., and MMA performed the statistical analysis and developed the initial drafts of the manuscript. All authors prepared, read, and approved the final draft of the manuscript.

Data availability

All data generated or analyzed during this study are included in this published article.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-024-55730-1.

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