Common medical comorbidities associated with cerebral palsy

Assessment of somatosensory profiles by quantitative sensory testing in children and adolescents with and without cerebral palsy and chronic pain

OBJECTIVE

We investigated differences in somatosensory profiles (SSPs) assessed by quantitative sensory testing in children and adolescents with cerebral palsy (CCP) with and without chronic pain and compared these differences to those in a group of typically developed children and adolescents (TDC) with and without chronic pain.

METHOD

All included subjects were consecutively recruited from and tested at the same outpatient orthopedic clinic by the same investigator. The subjects had their reaction times tested. The SSP consisted of the following tests: warmth (WDT), cool (CDT), mechanical (MDT), and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; wind-up ratio (WUR); dynamic mechanical allodynia (DMA) and cold pressor test (CPT) using a conditioned pain modulation (CPM) paradigm.

RESULTS

We included 25 CCP and 26 TDC. TDC without chronic pain served as controls. In TDC with chronic pain, WDT, HPT, HPT intensity, and PPT were higher than in controls. No differences in SSPs between CCP with and without chronic pain were observed. In CCP, the MDT, WDT, CDT, and HPT intensity were higher than in controls. CCP had longer reaction times than TDC. There were no differences regarding the remaining variables.

DISCUSSION

In CCP, the SSPs were independent of pain status and findings on MR images. In all CCP the SSPs resembled TDC with chronic pain, compared to TDC without chronic pain. This suggests that CCP do not have the normal neuroplastic adaptive processes that activate and elicit functional changes in the central and peripheral nervous systems.

The cost of respiratory hospitalizations in children with cerebral palsy

AIM

To establish the burden of respiratory illness in cerebral palsy (CP) on the Western Australian health care system by quantifying the costs of respiratory hospitalizations in children with CP, compared with non-respiratory hospitalizations.

METHOD

A 2-year (2014-2015) retrospective study using linked hospital data (excluding emergency department visits), in a population of children with CP in Western Australia aged 18 years and under (median age at hospitalization 7 years; interquartile range 5-12 years).

RESULTS

In 671 individuals (57% male) there were 726 emergency hospitalizations, and 1631 elective hospitalizations. Although there were more elective hospitalizations, emergency hospitalizations were associated with longer stays in hospital, and more days in an intensive care unit, resulting in a higher total cost of emergency hospitalizations than elective hospitalizations (total costs: emergency AU$7 748 718 vs elective AU$6 738 187). 'Respiratory' was the leading cause of emergency hospitalizations, contributing to 36% of all emergency admission costs. For a group of high-cost inpatient users (top 5% of individuals with the highest total inpatient costs) the most common reason for hospitalization was 'respiratory'. Where non-respiratory admissions were complicated by an additional respiratory diagnosis, length of stay was greater.

INTERPRETATION

Respiratory hospitalizations in CP are a significant driver of health care costs. In the paediatric group, they are a burden for a subgroup of children with CP.

WHAT THIS PAPER ADDS

Respiratory illness is the most costly area for unplanned, emergency hospitalizations for children and young people with cerebral palsy. The top 5% of individuals with the highest total inpatient costs account for a disproportionate amount of health care costs.

Evidence from Finland and Sweden on the relationship between early-life diseases and lifetime childlessness in men and women

The percentage of people without children over their lifetime is approximately 25% in men and 20% in women. Individual diseases have been linked to childlessness, mostly in women, yet we lack a comprehensive picture of the effect of early-life diseases on lifetime childlessness. We examined all individuals born in 1956-1968 (men) and 1956-1973 (women) in Finland (n = 1,035,928) and Sweden (n = 1,509,092) to the completion of their reproductive lifespan in 2018. Leveraging nationwide registers, we associated sociodemographic and reproductive information with 414 diseases across 16 categories, using a population and matched-pair case-control design of siblings discordant for childlessness (71,524 full sisters and 77,622 full brothers). The strongest associations were mental-behavioural disorders (particularly among men), congenital anomalies and endocrine-nutritional-metabolic disorders (strongest among women). We identified new associations for inflammatory and autoimmune diseases. Associations were dependent on age at onset and mediated by singlehood and education. This evidence can be used to understand how disease contributes to involuntary childlessness.

The effect of functional independence levels on sleep and constipation in children with cerebral palsy

OBJECTIVE

The study aimed to examine the effect of functional independence levels on sleep behavior and constipation in children with cerebral palsy.

METHODS

This cross-sectional observational single-center study was carried out in a special rehabilitation center in Istanbul. Inclusion criteria were those aged between 4 and 18 years with Gross Motor Function Classification System III-IV-V functional independence levels. Those who had surgery concerning intestinal health, had a chronic infectious bowel disease, had congenital intestinal anomalies, had received botox treatment in the last 6 months, had uncontrolled epileptic seizures, had complained of constipation in the last 6 months, and had cardiopulmonary disease were excluded from the study. The sociodemographic characteristics of the participants and the Gross Motor Function Classification System were recorded. Pediatric Functional Independence Scale (Functional Independence Measure for Children) was used to measure the functional independence level, Pediatric Sleep Questionnaire was used to measure the level of sleep problems, and Constipation Severity Scale was used to measure constipation severity.

RESULTS

A total of 60 children who were diagnosed with cerebral palsy were included. According to Gross Motor Function Classification System, 46.7% of the cases were Level III, 35% were Level IV, and 18.3% were Level V. There was a negative moderate significant correlation between Functional Independence Measure for Children and Pediatric Sleep Questionnaire (r=-0.303; p=0.019) and between Functional Independence Measure for Children and Constipation Severity Scale (r=-0.342; p=0.007).

CONCLUSION

We described that lower functional independence levels were related to worse sleep and constipation symptoms. The results suggest that effective strategies for developing functional independence levels may be beneficial for both sleep and constipation symptoms in the concept of cerebral palsy management.

Comorbidities in children with cerebral palsy: a single-centre cross-sectional hospital-based study from India

OBJECTIVE

To describe the comorbidities in children with cerebral palsy (CP) and determine the characteristics associated with different impairments.

DESIGN

Cross-sectional study.

SETTING

Tertiary care referral centre in India.

PATIENTS

Between April 2018 and May 2022, all children aged 2-18 years with a confirmed diagnosis of CP were enrolled by systematic random sampling. Data on antenatal, birth and postnatal risk factors, clinical evaluation and investigations (neuroimaging and genetic/metabolic workup) were recorded.

MAIN OUTCOME MEASURES

Prevalence of the co-occurring impairments was determined using clinical evaluation or investigations as indicated.

RESULTS

Of the 436 children screened, 384 participated (spastic CP=214 (55.7%) (spastic hemiplegic=52 (13.5%); spastic diplegia=70 (18.2%); spastic quadriplegia=92 (24%)), dyskinetic CP=58 (15.1%) and mixed CP=110 (28.6%)). A primary antenatal/perinatal/neonatal and postneonatal risk factor was identified in 32 (8.3%), 320 (83.3%) and 26 (6.8%) patients, respectively. Prevalent comorbidities (the test used) included visual impairment (clinical assessment and visual evoked potential)=357/383(93.2%), hearing impairment (brainstem-evoked response audiometry)=113 (30%), no understanding of any communication (MacArthur Communicative Development Inventory)=137 (36%), cognitive impairment (Vineland scale of social maturity)=341 (88.8%), severe gastrointestinal dysfunction (clinical evaluation/interview)=90 (23%), significant pain (non-communicating children's pain checklist)=230 (60%), epilepsy=245 (64%), drug-resistant epilepsy=163 (42.4%), sleep impairment (Children's Sleep Habits Questionnaire)=176/290(60.7%) and behavioural abnormalities (Childhood behaviour checklist)=165 (43%). Overall, hemiparetic and diplegic CP and Gross Motor Function Classification System ≤3 were predictive of lesser co-occurring impairment.

CONCLUSION

CP children have a high burden of comorbidities, which increase with increasing functional impairment. This calls for urgent actions to prioritise opportunities to prevent risk factors associated with CP and organise existing resources to identify and manage co-occurring impairments.

TRIAL REGISTRATION NUMBER

CTRI/2018/07/014819.

The effects of weight gain over time on gait in children with cerebral palsy: Comparison to a matched healthy weight cerebral palsy control group

BACKGROUND

Children with cerebral palsy (CP) have demonstrated higher rates of overweight and obesity than their typically developed peers. Limited studies have assessed how being overweight or obese affect lower limb kinematics during gait in these children.

RESEARCH QUESTION

How are lower limb kinematics during gait affected in children with CP who progress from a healthy weight to being overweight or obese compared to a well-matched healthy weight CP control group?

METHODS

A retrospective analysis of the movement analysis laboratory database was conducted.Children with CP were included if they were aged between 4 and 17 years at baseline,had a follow-up assessment with a minimum of 12 months between assessments, and had no orthopaedic interventions between assessments. A matched control group of children with CP with the same inclusion criteria, except for a requirement of healthy BMI at follow-up, was included. Temporal-spatial and full 3-dimensional lower limb kinematic data were examined.

RESULTS

Normalized speed and step length reduced from baseline to follow-up for both groups,with no difference in the amount of change between groups. Children with increased BMI demonstrated increased external hip rotation during stance at follow-up not evident in the control group.

SIGNIFICANCE

Results demonstrated similar changes over time between groups. Increased external hip rotation in children with increased BMI was considered small and within the threshold of error associated with transverse plane kinematics. Our results suggest that being overweight or obese does not result in a meaningful change in lower limb kinematics in children with CP.

Parental caregivers' perception of their transition from hospital to home in children with cerebral palsy who have undergone orthopedic surgery

PURPOSE

Evaluate parental perception of the quality of discharge teaching, readiness for discharge, and the impact of these on post discharge coping difficulty and resource utilization in children with cerebral palsy (CP) following surgery.

DESIGN AND METHODS

Prospective cohort study conducted from September 2017-March 2021 at a pediatric academic medical center. Demographics were collected pre-operatively. Parents completed the Readiness for Hospital Discharge Scale (RHDS) and Quality of Discharge Teaching Scale (QDTS) within four hours of discharge. Four weeks post-discharge, parents completed the Post-discharge Coping Difficulty Scale (PDCDS). Utilization of healthcare resources were extracted from the electronic health record for 90 days post-operatively. Associations among demographics, RHDS, QDTS, PDCDS and resource utilization were assessed using general linear models; PDCDS's open-ended questions were analyzed using directed content analysis.

RESULTS

114 parental caregivers participated. Post discharge coping was significantly associated with additional resource utilization: length of stay (p = 0.046), readmissions (p = 0.001), emergency department visits (p = 0.001), clinic calls (p = 0.001) and unplanned clinic visits (p = 0.006). PDCDS was negatively correlated with the QDTS Quality of Teaching Delivered subscale (r = -0.32; p = 0.004) and three of five RHDS subscales: 1) Child's Personal Status (r = -0.24; p = 0.02); 2) Knowledge (r = -0.30; p = 0.005); and 3) Coping Ability (r = -0.39; p < 0.001). Four themes explicated parental coping difficulties.

CONCLUSION

Parents experiencing coping difficulties were more likely to have difficulty managing their child's care needs at home and required additional health care resources.

PRACTICE IMPLICATIONS

Recognizing that parents' readiness for discharge may not reflect their coping abilities post-discharge requiring nurses to coordinate pre- and post-discharge education and support services.

Gastro-oesophageal reflux disease in children with neurological impairment: a retrospective cohort study

OBJECTIVES

To determine the incidence and prevalence of gastro-oesophageal reflux disease (GERD) diagnosis and treatment in children with neurological impairment (NI) along with relationship to key variables.

DESIGN

This is a population-based retrospective cohort study.

SETTING

This study takes place in Alberta, Canada.

PATIENTS

Children with NI were identified by hospital-based International Classification of Diseases (ICD) codes from 2006 to 2018.

MAIN OUTCOME MEASURES

Incidence and prevalence of a GERD diagnosis identified by: (1) hospital-based ICD-10 codes; (2) specialist claims; (3) dispensation of acid-suppressing medication (ASM). Age, gender, complex chronic conditions (CCC) and technology assistance were covariates.

RESULTS

Among 10 309 children with NI, 2772 (26.9%) met the GERD definition. The unadjusted incidence rate was 52.1 per 1000 person-years (50.2-54.1). Increasing numbers of CCCs were associated with a higher risk of GERD. The HR for GERD associated with a gastrostomy tube was 4.56 (95% CI 4.15 to 5.00). Overall, 2486 (24.1%) of the children were treated with ASMs of which 1535 (61.7%) met no other GERD criteria. The incidence rate was 16.9 dispensations per year (95% CI 16.73 to 17.07). The prevalence of gastrojejunostomy tubes was 1.1% (n=121), surgical jejunostomy tubes was 0.7% (n=79) and fundoplication was 3.4% (n=351).

CONCLUSIONS

The incidence of GERD in children with NI greatly exceeds that of the general paediatric population. Similarly, incidence rate of medication dispensations was closer to the rates seen in adults particularly in children with multiple CCCs and gastrostomy tubes. Further research is needed to determine the appropriate use of ASMs balancing the potential for adverse effects in this population.

The Co-Occurrence of Autism Spectrum Disorder and Cerebral Palsy and Associated Comorbid Conditions in Children and Adolescents

BACKGROUND

Comorbidity is the co-occurrence of two or more disorders in the same person.

AIM

This study investigated the frequency of comorbid conditions, in children and adolescents, with autism spectrum disorder (ASD), cerebral palsy (CP), and a comorbid diagnosis of ASD and CP.

METHOD

Ninety-six children and adolescents with ASD, CP, and both ASD and CP aged between 4 and 18 years participated in this study. Parents completed the Gastrointestinal Symptom Inventory, Children's Sleep Habits Questionnaire, Child Behavior Checklist, Social Communication Questionnaire, and the Vineland Adaptive Behavior Scales.

RESULTS

Results of ANOVA analyses revealed significant group differences in sleep problems, social communication difficulties, and adaptive behavior. Regression analysis found that the presence of an intellectual disability significantly predicted levels of adaptive behavior.

CONCLUSION

This research demonstrated the importance of studying comorbidities in children and adolescents with CP alone, ASD alone, and combined ASD and CP.

Hospital Burdens of Patients With Cerebral Palsy Undergoing Posterior Spinal Fusion for Scoliosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF.

METHODS

Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost.

RESULTS

Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 (P < .001) with a 2.07-day greater LOS (P < .001) than patients without CP.

CONCLUSION

Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.

Determinants of Manual Abilities of Children with Cerebral Palsy: A National Registry-Based Study

PURPOSE

This cross-sectional study aimed to identify determinants of manual abilities of children with cerebral palsy (CP), as measured by the Manual Ability Classification System (MACS), in terms of intrinsic (child-related) and extrinsic (service-related) variables.

METHODS

The participants were 106 children with a confirmed diagnosis of CP (aged 4-16 years). Two ordinal logistic regression models were conducted to identify intrinsic and extrinsic determinants of manual abilities.

RESULTS

Four child-related (intrinsic) variables were found to be significant determinants of manual abilities: bimanual ability, ability to maintain and assume chair sitting, presence of seizures, and gross motor function, and only one service-related (extrinsic) significant variable was identified, which was receiving spasticity medications.

DISCUSSION

The results highlight several determinants that should be considered when assessing and intervening to improve manual abilities of children with CP. The findings are discussed in relation to the intervention approach, contextual modification, and assistive device prescription.

Epidural Analgesia Versus Lumbar Plexus Blockade After Hip Reconstruction Surgery in Children With Cerebral Palsy and Intrathecal Baclofen Pumps: A Comparison of Safety and Efficacy

BACKGROUND

Epidural analgesia is commonly used for pain control after reconstructive hip surgery, but its use is controversial in the presence of an intrathecal baclofen pump (ITB). The purpose of this retrospective study was to investigate the rate of serious anesthetic and postoperative complications as well as the efficacy of epidural analgesia compared with lumbar plexus blocks (LPBs) for pain management after neuromuscular hip reconstruction in children with cerebral palsy (CP) and ITB.

METHODS

Pediatric patients with CP and ITB undergoing hip reconstructive surgery from 2010 to 2019 were retrospectively identified. Patients receiving epidural analgesia were compared with those receiving LPB. Morphine milligram equivalents per kilogram were used as a surrogate measure for pain-related outcomes, as pain scores were reported with wide ranges (eg, 0 to 5/10), making it unfeasible to compare them across the cohort. Postoperative complications were graded using the modified Clavien-Dindo classification.

RESULTS

Forty-four patients (26/44, 59% male) underwent surgery at an average age of 10.3 years (SD=3.4 y, range: 4 to 17 y). The majority utilized LPB (28/44, 64%) while the remaining utilized epidural (16/44, 36%). There were no differences in rates of serious complications, including no cases of ITB malfunction, damage, or infection. During the immediate postoperative course, patients who received LPB had higher morphine milligram equivalents per kilogram requirements than patients who received epidural analgesia.

CONCLUSIONS

In patients with CP undergoing hip reconstruction surgery with an ITB in situ, epidural anesthesia was associated with improved analgesia compared with LPB analgesia, with a similar risk for adverse outcomes. Epidural catheters placed using image-guided insertion techniques can avoid damage to the ITB catheter while providing effective postoperative pain control without increasing rates of complications in this complex patient population.

LEVEL OF EVIDENCE

Level III.

Vision Abnormalities in Children and Young Adults With Cerebral Palsy; A Systematic Review

AIM

The current study was designed to provide detailed information on the prevalence of ocular abnormalities in patients with cerebral palsy (CP).

METHODS

Four international online scientific databases, including Web of Science, PubMed, Scopus, and Google Scholar were systemically searched. First, the titles of the articles were evaluated, and if relevant, their abstracts and full texts were reviewed. The quality of the studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

RESULTS

A total of 147 articles were found in the initial search. After applying the exclusion criteria, 65 articles were chosen for further review, from which 17 articles, comprising a total of 1734 patients with CP ranging in age from birth to 22 years, passed the STROBE quality check and were included in this review. The prevalence of ocular abnormalities in the CP patients reported in the evaluated studies ranged between 34% to 100%, with refractive error, strabismus, and nystagmus exhibiting the greatest overall prevalence at 52%, 48%, and 11%, respectively in this population.

CONCLUSION

Early ocular assessment of children with CP is essential for an accurate diagnosis, personalized rehabilitation and performing early interventions to improve their visual function.

Validation of actigraphy for sleep measurement in children with cerebral palsy

Objectives:

Sleep issues are common in children with cerebral palsy (CP), although there are challenges in obtaining objective data about their sleep patterns. Actigraphs measure movement to quantify sleep but their accuracy in children with CP is unknown. Our goals were to validate actigraphy for sleep assessment in children with CP and to study their sleep patterns in a cross-sectional cohort study. Methods: We recruited children with (N = 13) and without (N = 13) CP aged 2–17 years (mean age 9 y 11mo [SD 4 y 10mo] range 4–17 y; 17 males, 9 females; 54% spastic quadriplegic, 23% spastic diplegic, 15% spastic hemiplegic, 8% unclassified CP). We obtained wrist and forehead actigraphy with concurrent polysomnography for one night, and home wrist actigraphy for one week. We developed actigraphy algorithms and evaluated their accuracy (agreement with polysomnography-determined sleep versus wake staging), sensitivity (sleep detection), and specificity (wake detection).

Results:

Our actigraphy algorithms had median 72–80% accuracy, 87–91% sensitivity, and 60–71% specificity in children with CP and 86–89% accuracy, 88–92% sensitivity, and 70–75% specificity in children without CP, with similar accuracies in wrist and forehead locations. Our algorithms had increased specificity and accuracy compared to existing algorithms, facilitating detection of sleep disruption. Children with CP showed lower sleep efficiency and duration than children without CP.

Conclusions:

Actigraphy is a valid tool for sleep assessment in children with CP. Children with CP have worse sleep efficiency and duration.

"Your Child Has Cerebral Palsy": Parental Understanding and Misconceptions

IMPORTANCE

Caregivers of children with cerebral palsy can best help their child if they understand the disorder and the correct terminology.

OBJECTIVE

To assess caregiver understanding of cerebral palsy.

DESIGN

This was a cross-sectional study from a large tertiary medical center in Boston, to assess understanding of the term cerebral palsy by primary caregivers of children and adolescents with cerebral palsy. All cases were obtained from hospital electronic medical records. Telephone surveys were conducted. Caregiver understanding of cerebral palsy was assessed by open-ended responses (50%) and success in answering true/false questions about cerebral palsy (50%).

PARTICIPANTS

Primary caregivers of children 18 years and younger with cerebral palsy.

RESULTS

Thirty-three percent of caregivers denied ever being told that their child had cerebral palsy. Most caregivers identified cerebral palsy as a brain problem (79%), lifelong condition (73%), often caused by a perinatal (60%) or gestational (40%) insult. Fifty-two percent knew that cerebral palsy was nonprogressive. Sixty-two percent of caregivers believed they had a good, very good, or excellent understanding of cerebral palsy, whereas the investigators found 69% of caregivers had a good, very good, or excellent understanding of cerebral palsy (P = .006). Most caregivers rated very good or excellent the setting where cerebral palsy was discussed (58%), the explanations provided (55%), and the amount of time spent (45%), yet using a Pearson correlation coefficient, most important was the time spent (r = 0.53).

CONCLUSIONS

Following discussion with their child's physician, most primary caregivers of children with cerebral palsy have a good, very good, or excellent understanding of cerebral palsy. Most critical to a good understanding of cerebral palsy was the time spent in explaining the diagnosis.

The progression of BMI status over time in Irish ambulant children with cerebral palsy

BACKGROUND

An increasing prevalence of overweight and obesity in children has been reported globally. Most studies examining the trajectory of BMI in children over time have tended to focus on children with typical development. Our group previously reported static prevalence rates in children with cerebral palsy. However, concern remains within our multi-disciplinary team that progression into higher BMI categories is apparent as children with cerebral palsy age.

AIMS

To examine the progression of BMI status as children with cerebral palsy age and determine the severity of obesity.

METHODS

A retrospective analysis was conducted of the National Movement Laboratory database yielding 574 participants that met inclusion criteria. BMI was calculated retrospectively, and age adjusted BMI centiles were used for analysis. A chi-square test for homogeneity was used to compare differences in proportions. Differences in age, weight and height between assessments were assessed using a Wilcoxon signed rank test. Statistical significance was set at p < 0.05.

RESULTS

No statistically significant differences were present in proportions for any BMI classifications between first and repeat assessments. Small increases were evident in both the obesity (7.8 to 11.5%) and overweight (10.8 to 12.4%) categories. Eighty percent of children remained in a normal BMI category between assessments while 56% remained either overweight or moved into a category of obesity.

CONCLUSION

The majority of children with cerebral palsy who presented with a normal BMI at first assessment maintained this BMI classification at follow-up. The results of this study highlight the importance of maintaining a healthy BMI status.

Experiences and Needs of Parents Caring for Children with Cerebral Palsy: A Systematic Review

OBJECTIVE

Caregiver burden of parents of children with disabilities is negatively associated with parental quality of life and psychosocial well-being and has been identified as a public health concern. Reviews have consolidated the experiences of these parents, but little is understood about the unique challenges faced by parents of children with cerebral palsy (CP). We aim to conduct an in-depth synthesis of the experiences and needs of parents of children with CP to better support them.

METHODS

Six electronic databases were searched systematically for qualitative research, and a thematic synthesis was performed.

RESULTS

Seventeen studies from 1988 to 2019 encapsulating the experiences of 226 parents were included in this review. Four themes and 11 subthemes were identified: (1) self: the caregiver-parent trajectory (coming to terms with the fact, physical and emotional demands, and a nice outlet), (2) family: maintaining the family unit (juggling multiple children and parenting as a co-occupation), (3) society: social repercussions (facing public discrimination, rejection by extended family, and loss of freedom), and (4) parents' wish list (open communication and caring attitudes, funding and health care accessibility, social integration, and inclusivity). Apart from emotional adaptation and physical childcare difficulty, parents indicated a need for more information on health care services, funding, better attitudes and empathy from health care providers, properly trained educators, disability-friendly fixtures, and more public awareness.

CONCLUSION

The findings in this review provide insight into the true experiences and needs of parents caring for children with CP and will aid clinicians in the development of family-centered care pathways for these patients.

[Caregiver burden in patients with moderate-severe cerebral palsy. The influence of nutritional status]

INTRODUCTION

Patients with moderate-severe cerebral palsy require the support of their caregivers to carry out the activities of daily living (ADLs).

OBJECTIVES

To describe the comorbidities, need for care in children with cerebral palsy and to analyse the influence of the degree of motor involvement, nutritional status and other neurological disorders.

METHODS

Cross-sectional and observational study. Patients with cerebral palsy degrees III-IV-V according to the Gross Motor Function Classification System (GMFCS) have been studied. A record of comorbidities has been made and body composition has been studied using anthropometry and bioimpedance. In addition, a caregiver burden survey on ADLs has been carried out (10 items on the different actions: hygiene, clothing, transfers, sleeping and feeding). Which variables have the greatest influence on the perception of difficulty in performing ADLs have been studied.

RESULTS

A total of 69 patients (50.7% women, mean age 10.46 ± 0.4 years) were analysed, with GMFCS grades: grade III 36.2% (N=25), grade IV 29.0% (N=20), grade V 34.8% (N=24). A relationship was found between the caregiver burden score and GMFCS grade (P=0.003) and intellectual disability (P<0.001). However, regardless of the degree of GMFCS and intellectual disability, there is greater difficulty in performing ADLs in relation to lower values in weight (Z-score) (P=0.028), fat mass (kg) (P=0.035), fat mass (%) (P=0.094), body mass index (Z-score) (P=0.086).

CONCLUSIONS

In addition to the degree of clinical impairment, nutritional status is a factor that influences the caregiver's difficulty in performing the ADLs in cerebral palsy patients on which we can act to improve this problem.

Team Approach: The Perioperative Management of Reconstructive Hip Surgery for the Non-Ambulatory Child with Cerebral Palsy and Spastic Hip Disease

Cerebral palsy (CP) is the leading cause of physical disability in children. Although physical disability is the hallmark of CP, children with CP also often have complex medical comorbidities. Spastic hip subluxation is the second most common orthopaedic deformity in children with CP, and the incidence increases with the severity of CP. Hip surveillance should be implemented in children with CP to monitor hip stability over time. A reconstructive surgical procedure is recommended when the migration percentage is >40%. Perioperative care of children undergoing a hip reconstructive surgical procedure is a multidisciplinary endeavor requiring the expertise of professionals with different backgrounds. The core team should comprise orthopaedic surgeons, nurses, nurse practitioners, pediatricians, nurse case managers, anesthesiologists, and physical therapists. Additional team members include nutritionists, clinical pharmacists, social workers, child life therapists, and consulting specialty services. This review describes the team approach to the perioperative care of non-ambulatory children with spastic hip subluxation undergoing a reconstructive hip surgical procedure, utilizing a case scenario of a 7-year old girl with CP and complex associated medical comorbidities.

Prevalence of overweight and obesity in Irish ambulant children with cerebral palsy

BACKGROUND

Children with cerebral palsy may be at greater risk of being overweight or obese than their typically developed peers due to a number of biomechanical, behavioural, or medical issues that restrict participation. It has been a concern of our multi-disciplinary team that a greater number of children with cerebral palsy were presenting as overweight or obese. However, there are conflicting results in the literature as to prevalence and trends of overweight and obesity in these children.

AIMS

To assess the prevalence of overweight and obesity in children with cerebral palsy presenting to our movement analysis laboratory over a 20-year time period.

METHODS

A retrospective analysis was conducted of the laboratory database. Inclusion criteria were ambulatory children with a diagnosis of spastic cerebral palsy aged between 4 and 17 years inclusive. Height, weight, physical classification of cerebral palsy and functional level of impairment were extracted. Body mass index was calculated and data were analysed according to 4- × 5-year time periods.

RESULTS

There were 1021 children included in this study. There were no significant findings for increasing trends of overweight and obesity across time. Prevalence of obesity and combined overweight and obesity in the most recent time period (2015-2019) was 7.1% and 20% respectively.

CONCLUSIONS

Prevalence of overweight and obesity is not increasing in Irish ambulatory children with cerebral palsy. However, a higher prevalence of overweight and obesity was evident when compared with their typically developed Irish peers. It is therefore important that prevalence and trends are monitored.

Why individuals with cerebral palsy are at higher risk for respiratory complications from COVID-19

Respiratory dysfunction is a leading cause of morbidity and mortality in individuals with cerebral palsy (CP). In children and adults with CP, movement and physical function is always affected. Yet, many clinicians overlook potential for impaired movement and function of the diaphragm muscle (DIAm) in individuals with CP. Since individuals with pre-existing respiratory disorders are at greater risk for respiratory complications if they contract COVID-19, understanding potential risks to individuals with CP is important. In this review we present research on respiratory function and DIAm force generation in children with CP. We compare this clinical work to basic science research investigating phrenic motor neuron and DIAm motor unit dysfunction in an animal model with CP symptoms, the spa mouse. Finally, we integrate the clinical and basic science work in respiratory function in CP, discussing potential for individuals with CP to have severe respiratory symptoms from COVID-19.

Comorbidities in cerebral palsy: a patient registry study

AIM

To describe the total burden of disease in individuals with cerebral palsy (CP) in Norway.

METHOD

A comprehensive set of disorder categories were extracted from the Norwegian Patient Registry using International Statistical Classification of Diseases, 10th Revision diagnosis codes for individuals born between 1996 and 2010 who received specialist healthcare between 2008 and 2017 (0-21y). Individuals with CP were identified through a validation study in cooperation with the Cerebral Palsy Registry of Norway. Risk differences (proportions of individuals recorded with each disorder) were used to compare individuals with CP with the general population without CP.

RESULTS

The study included 966 760 individuals. Among these, 2302 (0.24%) had CP (1330 males, 972 females). Of the individuals with CP, 95.0% were recorded with one or more comorbidity, and the risks of medical, neurological, and mental/behavioural disorders were higher compared with the risks in the general population. The most common neurological and mental/behavioural disorders were cocausal, i.e. attributed to the same injury to the developing brain that caused CP, while medical disorders were most often complications of CP or coincidentally co-occurring with CP.

INTERPRETATION

Individuals with CP have a considerably higher burden of medical, neurological, and mental/behavioural disorders compared with the general population, including disorders that are not directly caused by, or complications to, the brain injury.

WHAT THIS PAPER ADDS

Nearly all individuals with cerebral palsy (CP) had one or more comorbidity. Fifty-two per cent had at least one comorbidity attributed to the same cause as CP, complications of CP, and coincidentally co-occurring with CP. Risks of medical, neurological, and mental/behavioural disorders were considerably higher than in the general population.

A Critical Evaluation of Current Concepts in Cerebral Palsy

Spastic cerebral palsy (CP), despite the name, is not consistently identifiable by specific brain lesions. CP animal models focus on risk factors for development of CP, yet few reproduce the diagnostic symptoms. Animal models of CP must advance beyond risk factors to etiologies, including both the brain and spinal cord.

FOOD INTAKE, NUTRITIONAL STATUS AND GASTROINTESTINAL SYMPTOMS IN CHILDREN WITH CEREBRAL PALSY

BACKGROUND

Cerebral palsy may be associated with comorbidities such as undernutrition, impaired growth and gastrointestinal symptoms. Children with cerebral palsy exhibit eating problems due to the effect on the anatomical and functional structures involved in the eating function resulting in malnutrition.

OBJECTIVE

The aim of this study was to investigate the association between food intake, nutritional status and gastrointestinal symptoms in children with cerebral palsy.

METHODS

Cross-sectional study that included 40 children with cerebral palsy (35 with spastic tetraparetic form and 5 with non-spastic choreoathetoid form of cerebral palsy, all requiring wheelchairs or bedridden) aged from 4 to 10 years. The dietary assessment with the parents was performed using the usual household food intake inquiry. Anthropometric data were collected. Gastrointestinal symptoms associated with deglutition disorders, gastroesophageal reflux and chronic constipation were also recorded.

RESULTS

The median of height-for-age Z-score (-4.05) was lower (P<0.05) than the median of weight-for-age (-3.29) and weight-for-height (-0.94). There was no statistical difference between weight-for-age and weight-for-height Z-scores. Three patients with cerebral palsy (7.5%) exhibited mild anemia, with normal ferritin levels in two. Symptoms of dysphagia, gastroesophageal reflux, and constipation were found in 82.5% (n=33), 40.0% (n=16), and 60.0% (n=24) of the sample, respectively. The patients with symptoms of dysphagia exhibited lower daily energy (1280.2±454.8 Kcal vs 1890.3±847.1 Kcal, P=0.009), carbohydrate (median: 170.9 g vs 234.5 g, P=0.023) and fluid intake (483.1±294.9 mL vs 992.9±292.2 mL, P=0.001). The patients with symptoms of gastrointestinal reflux exhibited greater daily fluid intake (720.0±362.9 mL) than the patients without symptoms of gastroesophageal reflux (483.7±320.0 mL, P=0.042) and a greater height-for-age deficit (Z-score: -4.9±1.7 vs 3.7±1.5, P=0.033). The patients with symptoms of constipation exhibited lower daily dietary fiber (9.2±4.3 g vs 12.3±4.3 g, P=0.031) and fluid (456.5±283.1 mL vs 741.1±379.2 mL, P=0.013) intake.

CONCLUSION

Children with cerebral palsy exhibited wide variability in food intake which may partially account for their severe impaired growth and malnutrition. Symptoms of dysphagia, gastroesophageal reflux, and constipation are associated with different food intake patterns. Therefore, nutritional intervention should be tailored considering the gastrointestinal symptoms and nutritional status.

Associations of Coexisting Conditions with Healthcare Spending for Children with Cerebral Palsy

OBJECTIVE

To determine which coexisting conditions have the strongest associations with healthcare use and spending among children with cerebral palsy (CP).

STUDY DESIGN

Retrospective analysis of 16 695 children ages 0-18 years with CP - identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes - using Medicaid from January 1, 2013 to December 31, 2013 from 10 states in the Truven MarketScan Medicaid Database. Using generalized linear models, we assessed which coexisting conditions (including medical technology) identified with Agency for Healthcare Research and Quality's Chronic Condition Indicators had the strongest associations with total healthcare spending across the healthcare continuum.

RESULTS

Median per-patient annual Medicaid spending for children with CP was $12 299 (IQR $4826-$35 582). Most spending went to specialty (33.1%) and hospital (26.7%) care. The children had a median 6 (IQR 4-10) coexisting conditions; epilepsy was the most common (38.1%). Children with epilepsy accounted for 59.6% ($364 million) of all CP spending. In multivariable analysis, the coexisting conditions most strongly associated with increased spending were tracheostomy (median additional cost per patient = $56 567 [95%CI $51 386-61 748]) and enterostomy (median additional cost per patient = $25 707 [95%CI $23 753-27 660]).

CONCLUSIONS

Highly prevalent in children with CP using Medicaid, coexisting conditions correlate strongly with healthcare spending. Tracheostomy and enterostomy, which indicate significant functional impairments in breathing and digestion, are associated with the highest spending. Families, providers, payers, and legislators may leverage these findings when designing policies positioned to enable the best health and care for children with cerebral palsy.

Child's quality of life and mother's burden in spastic cerebral palsy: a topographical classification perspective

Objective

To evaluate the child’s quality of life (QoL), mother’s burden, and correlation between these parameters in children with spastic cerebral palsy (CP).

Methods

Children with spastic CP (n = 120; mean age: 8.64 ± 3.45 years; range: 2–17 years) were classified into three groups of diplegia, hemiplegia, and quadriplegia based on topographical classification. The Pediatric Quality of Life Inventory and Zarit Burden Interview were used to determine the child’s QoL and the mother’s burden scores, respectively.

Results

Children’s QoL scores were lower in the quadriplegia group than in the hemiplegia and diplegia groups (except for emotional functioning). The mother’s burden was lower in the quadriplegia group than in the other groups, and it was lower in the diplegia group than in the hemiplegia group. Increases in children’s QoL scores were associated with decreases in the mothers’ burden scores.

Conclusion

Children’s QoL is associated with the mother’s burden in spastic CP, and quadriplegic children and their mothers are more affected. The burden of mothers ranked the highest in the quadriplegia group, followed by the diplegia group and the hemiplegia group. Topographical classification is a good indicator for children’s QoL and the mother’s burden in spastic CP.

Clinical outcomes of non-surgical management of detrusor leak point pressures above 40 cm water in adults with congenital neurogenic bladder

AIMS

Neurogenic bladders (NGB) with detrusor leak point pressures >40 cm H₂ O (dLPP > 40) have been associated with deterioration of renal function in children with myelomeningocele. For these children, careful pressure management preserves renal function. However, similar evidence is lacking in adult congenital urology (ACU) patients with NGB. We describe renal functional outcomes of non-surgical management of adults with dLPP > 40 or premicturition detrusor pressure (PMDP) >40 cm H₂ O, consisting of close follow-up with urodynamic studies (UDS) and renal ultrasound (RUS), paired with adjustments to clean intermittent catheterization (CIC) frequency, anticholinergics, and addition of onabotulinumtoxinA toxin (BTX) injection.

METHODS

We retrospectively reviewed the UDS of all patients at an ACU clinic from 2011 to 2016. Patients with dLPP/PMDP > 40 cm who elected for non-surgical management were included. We describe their management and renal functional outcomes.

RESULTS

A total of 33/42 patients with dLPP/PMDP > 40 elected for non-surgical management. 28/33 (85%) were successfully managed without bladder augmentation or urinary diversion at follow-up of nearly 3 years. The median index dLPP/PMDP was 49 cm H₂ O (IQR 44, 63) and final dLPP/PMDP was 28 (IQR 18, 43). There was a significant decrease in dLPP/PMDP and increase in bladder compliance between index and final UDS (P < 0.001). No patients advanced their CKD stage and 6/10 with baseline hydronephrosis had improvement or resolution of hydronephrosis with non-surgical management.

CONCLUSIONS

A non-surgical protocol for ACU patients with NGB and dLPP/PMDP > 40, utilizing CIC, anticholinergics, and BTX is safe and effective when coupled with coordinated care and close follow-up.

Comparing emergency department presentations among children with cerebral palsy with general childhood presentations: a data linkage study

AIM

The aims of this study were to estimate the proportion of emergency department presentations attributable to children with cerebral palsy (CP), investigate the frequency of emergency department presentations in a CP cohort, and compare emergency department presentations among children with CP with those of other children.

METHOD

This was a retrospective cohort study. The Victorian Cerebral Palsy Register was linked to the Victorian Emergency Minimum Dataset. Data on emergency department presentations for the CP cohort occurring between 2007 and 2014 and population control data were obtained.

RESULTS

The CP cohort (n=1748) had 7015 emergency department presentations during the 7-year period, accounting for 0.4% of the 1.69 million age-specific presentations during that time. The number of annual presentations per 1000 children rose with increasing CP severity. Compared with presentations among the general population, higher proportions of presentations among the CP cohort were preceded by ambulance arrivals (27% vs 8%), triaged as urgent (66% vs 32%), and required hospital admission (38% vs 12%).

INTERPRETATION

The marked differences in presentations between the CP cohort and the general population in the proportions that were urgent and required ambulance arrivals and hospital admissions was an important finding. Strategies to ensure appropriate use of services, including encouragement to seek earlier assistance from primary care providers, may prevent problems escalating to the need for urgent care.

WHAT THIS PAPER ADDS

Children with cerebral palsy (CP) account for 0.4% of childhood emergency department presentations. More emergency department presentations among children with CP require ambulance arrival. More CP emergency department presentations are urgent and require hospital admission. Traditional emergency department triage scales seem less accurate for this group.

Sleep: An underemphasized aspect of health and development in neurorehabilitation

Sleep deficiency has unique causes and implications for children with neonatal brain injury; contributing to the development or exacerbation of neurodevelopmental impairments and yet it is an underemphasized aspect of health and development. There is very little research evidence to guide the management of sleep disorders in children with cerebral palsy, a common neurodevelopmental disability of childhood. This paper is a comprehensive review and analysis of the literature regarding what is known about sleep quantity and quality in children with cerebral palsy. The specific implications for children with cerebral palsy are explored including the adverse effects of sleep deficiency on general child development, physical health and growth, and mental functioning. The consequences for the family are also discussed. Finally, the assessment and management of sleep problems are summarized to provide guidance to clinicians who work in neurodevelopmental medicine.

Translation, cross-cultural adaptation and validation of the ABILHAND-Kids for the Brazilian Portuguese

ABSTRACT This study aimed to translate, to adapt cross-culturally and to validate the ABILHAND-Kids for the Brazilian Portuguese. ABILHAND-Kids was translated to Brazilian Portuguese and translated back by two certified translators in each phase. After the expert committee approval, the pre-test version was applied in 40 parents of children with cerebral palsy in order to verify item comprehension. Twenty-one volunteers were enrolled in the psychometric properties analysis. Reproducibility was verified by interrater and intrarater reliability and the validity was tested by investigating Box and Block Test, Purdue Pegboard Test and grip strength correlations. ABILHAND-Kids showed strong intrarater (ICC=0.91) and interrater (ICC=0.97) reliability and high internal consistency (Cronbach’s alfa: 0.99). ABILHAND-Kids showed significant correlations with Box and Block Test (performed by dominant upper extremity), Purdue Pegboard Test and grip strength. The Brazilian Portuguese version of ABILHAND-Kids is a reliable tool to measure upper extremities function of children with cerebral palsy, based on the perception of their parents.

Hospital admissions in children with cerebral palsy: a data linkage study

AIM

The overall aim was to investigate the feasibility and utility of linking a cerebral palsy (CP) register to an administrative data set for health services research purposes. We sought to compare CP hospital admissions to general childhood population admissions, and identify factors associated with type and frequency of admissions in a CP cohort.

METHOD

The CP register for Victoria, Australia was linked to the state's hospital admissions database. Data pertaining to the admissions of a CP cohort (n=1748) that took place between 2007 and 2014 were extracted. Population data were also obtained.

RESULTS

Overall, 80% of the CP cohort (n=1401) had at least admission between 2007 and 2014, accounting for 11 012 admissions or 1.5% of all admissions in their age group. Compared to general population admissions, CP admissions were more costly and more likely to be elective (66% vs 57%; p<0.001), medical (71% vs 57%; p<0.001), and to take place in metropolitan hospitals (92% vs 78%; p<0.001). Increased CP severity and complexity were associated with having more admissions and a higher proportion of admissions attributable to respiratory illness.

INTERPRETATION

By linking with administrative data sets, CP registers may be useful for health services research and inform health service delivery.

Asthma in intellectual disability: are we managing our patients appropriately?

People with intellectual disability are a vulnerable group of people with asthma that has, to date, largely been ignored in the medical literature. Although guidelines for medication management for people with intellectual disability suggest asthma is treated as for other populations, there are special considerations that should be taken into account when managing asthma in this group. Due to their cognitive impairment as well as comorbidities, they are likely to require support with asthma self-management, including inhaler use. Their varying degrees of autonomy mean that there is often a need to provide education and information to both the person and their caregivers.

EDUCATIONAL AIMS

To understand general principles of health of people with intellectual disability and how this affects the healthcare professional's approach to asthma management.To understand how intellectual disability affects cognition, autonomy and communication, and therefore the ability of a person to self-manage asthma.To recognise ways of mitigating respiratory disease risk in people with intellectual disability.To describe ways for healthcare professionals to support people with intellectual disability and their caregivers in asthma management.

A retrospective review of cyproheptadine for feeding intolerance in children less than three years of age: effects and side effects

AIM

Premature infants and those with brain injury often suffer from feeding intolerance and vomiting in the first several years of life. Cyproheptadine is a medication with antihistaminergic, antiserotonergic and anticholinergic effects, thought to increase gastric accommodation. We aimed to retrospectively review our experience using cyproheptadine for feeding intolerance and/or vomiting in children under the age of three.

METHODS

This is a retrospective chart review of 39 patients less than three years of age who were prescribed cyproheptadine for feeding intolerance or vomiting and had follow-up information available.

RESULTS

Starting dose ranged widely (from 0.069 to 0.825 mg/kg/day). Side effects such as sleepiness and constipation were rare. The medication had a significant positive effect, defined as resolution of vomiting, improved feeding tolerance or improved comfort with feeds, in 67% of children. An additional 28% showed possible improvement, defined as some improvement in vomiting or improvement in vomiting or feeding tolerance in conjunction with other changes in addition to cyproheptadine.

CONCLUSION

In our experience, cyproheptadine appears to be safe and effective in decreasing vomiting and feeding intolerance in children less than three years of age. A trial of cyproheptadine could be considered before invasive testing in infants with feeding issues.

Mental health problems in children with neuromotor disabilities

Mental health in children with neuromotor disorders is part of a dynamic system, including medical and developmental domains, family, school and community. Presentations are often complex and multifactorial, requiring a broad, individualized approach. A narrative overview of mental health symptoms in children with neuromotor disabilities is provided, along with recommendations for their assessment and management using the WHO's International Classification of Functioning framework.

Tertiary paediatric hospital admissions in children and young people with cerebral palsy

BACKGROUND

Many previous studies that have investigated hospital admissions in children and young people with cerebral palsy lack information on cerebral palsy severity and complexity. Consequently, little is known about factors associated with the frequency and type of hospital admissions in this population. This study used hospital admission data available for all children and young people known to a population-based cerebral palsy register to describe the patterns of use of tertiary paediatric hospital services over a 5-year period.

METHODS

This was a retrospective cohort analysis of routinely collected admission data from the two tertiary paediatric hospitals in the Australian state of Victoria. Data on admissions of individuals born between 1993 and 2008 registered on the Victorian Cerebral Palsy Register were analysed (n = 2183).

RESULTS

Between 2008 and 2012, 53% of the cohort (n = 1160) had at least one same-day admission, and 46% (n = 996) had one or more multi-day admissions. Those with a moderate to severe motor impairment and those with a co-diagnosis of epilepsy had more admissions, and for multi-day admissions, longer lengths of stay, P < 0.05. Across all severity levels, respiratory and musculoskeletal diseases were the most frequently reported reasons for medical and surgical admissions, respectively. All-cause readmission rates for urgent multi-day stays within 7, 30 and 365 days of an index admission were 10%, 23% and 63%, respectively.

CONCLUSIONS

The reasons for hospital admissions reported here reflect the range of comorbidities experienced by children and young people with cerebral palsy. This study highlights priority areas for prevention, early diagnosis and medical management in this group. Improved primary and secondary prevention measures may decrease non-elective hospital admissions and readmissions in this group and reduce paediatric inpatient resource use and healthcare expenditure attributable to cerebral palsy.

Tertiary paediatric emergency department use in children and young people with cerebral palsy

AIMS

The aim of this study was to describe the pattern of tertiary paediatric emergency department (ED) use in children and young people with cerebral palsy (CP).

METHODS

A retrospective analysis of ED data routinely collected at the two tertiary paediatric hospitals in Victoria, Australia, cross-matched with the Victorian Cerebral Palsy Register. Data pertaining to the ED presentations of 2183 registered individuals born 1993-2008 were obtained.

RESULTS

Between 2008 and 2012, 37% (n = 814) of the CP cohort had 3631 tertiary paediatric ED presentations. Overall, 40% (n = 332) of presenters were residing in inner metropolitan Melbourne; 44% (n = 356) in outer Melbourne; and 13% (n = 108) in regional Victoria. Presenters were more likely than non-presenters to be younger, non-ambulant and have epilepsy. In total, 71% of presentations were triaged as Australasian Triage Scale 1-3 (urgent), and 44% resulted in a hospital admission. Disorders of the respiratory, neurological and gastrointestinal systems, and medical device problems were responsible for 72% of presentations.

CONCLUSION

Many of the tertiary paediatric ED presentations in this group were appropriate based on the high admission rate and the large proportion triaged as urgent. However, there is evidence that some families are bypassing local services and travelling long distances to attend the tertiary paediatric ED, even for less urgent complaints that do not require hospital admission. Alternative pathways of care delivery, and strategies to promote the management of common problems experienced by children and young people with CP in non-paediatric EDs or primary care settings, may go some way towards reducing unnecessary tertiary paediatric ED use in this group.

Assessment of Abilities and Comorbidities in Children With Cerebral Palsy

This study examines major comorbidities in children with severe cerebral palsy and the feasibility of psychological tests for measuring abilities in a more impaired population. Eighty psychological evaluations of children with cerebral palsy aged 1.8 to 15.4 years (mean = 5.6) were analyzed. Major comorbid disorders were correlated with severity of motor disability. More than half of the cohort were diagnosed with severe cerebral palsy according to the Gross Motor Function Classification System. Multiple subtests were combined in order to assess the intellectual level. Normal intelligence was found in 22.5%, and 41.3% had moderate or severe intellectual impairment. Epilepsy occurred in 32.5% and attention-deficit hyperactivity disorder (ADHD) in 22.5%. Intellectual disability correlated with motor ability and with epilepsy. In a logistic regression model, epilepsy and motor ability score predicted 29.9% of IQ score variance. Intellectual impairment and epilepsy are common comorbidities. Subtests from different scales should be applied and interpreted with caution.

Sleep and Children with Cerebral Palsy: A Review of Current Evidence and Environmental Non-Pharmacological Interventions

Between 23%–46% of children with cerebral palsy experience sleep problems. Many of the sensory-motor and cognitive features of cerebral palsy (such as immobility, pain, and seizures) act as predisposing factors for sleep problems in this population. This paper presents the background related to the etiology and consequences of sleep problems in children with cerebral palsy. The relationship between pain and sleep is emphasized, as the risk of pain is highly prevalent in children with cerebral palsy. The review concludes with a discussion of the evidence-base for environmental non-pharmacological interventions based on light, temperature, sound and bedding to promote sleep for children with cerebral palsy.

Epidemiology of severe hearing impairment in a population-based cerebral palsy cohort

BACKGROUND

Comorbidities including hearing impairment occur commonly in individuals with cerebral palsy (CP).

METHODS

Hearing impairment was assessed in a registry-derived population-based sample of children with CP.

RESULTS

Hearing impairment was documented in 12.7% (27 of 212) with less than a quarter of these (or 2.7% overall [6 of 212]) having a severe hearing loss of greater than 70 dB bi-aurally. Those with severe hearing impairment were more likely to be nonambulatory (Gross Motor Function Classification System IV/V; 100% versus 34.0% in the registry; P < 0.001) and have a spastic quadriplegic or dyskinetic CP variant (100% versus 42%, P = 0.001). Severe neonatal hyperbilirubinemia necessitating exchange transfusion demonstrated a striking association with hearing impairment in the context of CP in spite of small observed numbers; three of three had severe hearing loss, accounting for 50% of cases of severe hearing loss.

CONCLUSIONS

These results suggest a specific CP context and antecedent conditions that necessitate a heightened vigilance for the detection and remediation of hearing impairment.

Orthopedic surgery and mobility goals for children with cerebral palsy GMFCS level IV: what are we setting out to achieve?

BACKGROUND

Multilevel orthopedic surgery is considered to be the gold standard treatment for ambulatory children with cerebral palsy (CP), classified at levels I, II, or III according to the Gross Motor Function Classification System (GMFCS). Hip enlocation and stability are the main goals of orthopedic intervention in the GMFCS level IV subgroup and are well researched; however, there is no evidence to date to support or challenge the effectiveness of orthopedic treatment to preserve functional mobility in this patient group. The aim of this study was to evaluate the results of orthopedic surgery to maintain or restore standing transfers and supported walking in children with CP at GMFCS level IV.

METHODS

Twenty-two children with CP GMFCS level IV who underwent orthopedic surgery to improve mobility between the years 2004 and 2008 were included in this study. A retrospective chart review was performed and a satisfaction questionnaire sent to all patients. The primary outcome measure was the attainment and maintenance of mobility goals 2 years post-surgery. The secondary outcome measures were family/patient satisfaction, Functional Mobility Scale (FMS), and complications.

RESULTS

The two goals identified by the patients and carers were standing transfers and supported walking. At the 2-year post-surgery assessment, 14 children (63.6 %) did not reach their pre-determined goals. In the questionnaire, 21.4 % of the families reported that surgery was not beneficial. The FMS score remained unchanged in 95.4 % of the patients. Fourteen patients (63.6 %) had at least one complication that prolonged their post-operative rehabilitation (e.g., neuropraxia).

CONCLUSION

This study suggests that orthopedic surgery in children with CP at GMFCS level IV is unlikely to maintain or restore mobility. Furthermore, it carries a significant risk of complications.

LEVEL OF EVIDENCE

Case series, Level IV.

Medical expenditures attributable to cerebral palsy and intellectual disability among Medicaid-enrolled children

This study estimated medical expenditures attributable to cerebral palsy (CP) among children enrolled in Medicaid, stratified by the presence of co-occurring intellectual disability (ID), relative to children without CP or ID. The MarketScan(®) Medicaid Multi-State database was used to identify children with CP for 2003-2005 by using the International Classification of Diseases, Ninth Revision; Clinical Modification (ICD-9-CM) code 343.xx. Children with ID were identified for 2005 by using ICD-9-CM code 317.xx-319.xx. Children without CP or ID during the same period served as control subjects. Medical expenditures were estimated for case and control children for 2005. The difference between the average expenditures for children with and without CP was used as a proxy for attributable expenditures for the condition. The attributable expenditures of co-occurring ID were calculated similarly as the difference in average expenditures among children with CP with and without ID. A total of 9927 children with CP were identified. Among them, 2022 (20.3%) children had co-occurring ID recorded in medical claims. Children with CP but without ID incurred medical expenditures that were $15,047 higher than those of control children without CP or ID. By contrast, children with CP and co-occurring ID incurred costs that were $41,664 higher, compared with control children, and $26,617 more than children with CP but without ID. Administrative data from a large, multistate database demonstrated high medical expenditures for publicly insured children with CP. Expenditures approximately tripled for children with CP and co-occurring ID.

Sleep problems in physically disabled children and burden on caregivers

AIM

The present study was implemented to investigate relationships between sleep problems in physically disabled children and sleep quality and perceived burden of caregivers.

METHODS

Subjects comprised 100 caregivers of disabled children, including 96 mothers, 2 fathers and 2 grandmothers. Questionnaires included demographic data for children and caregivers, sleep problems of children, and sleep quality (Pittsburgh sleep quality index (PSQI)) and perceived burden on caregivers (Japanese version of the Zarit Burden Interview (J-ZBI)). The sleep problems of children were evaluated according to the following five categories: "Problems initiating and maintaining sleep"; "Problems with sleep-related breathing"; "Problems with excessive somnolence"; "Problems with circadian rhythm"; and "Problems with sleep-related movement".

RESULTS

The children comprised 66 boys and 34 girls (age range, 1-17 years). Of these, 65 children could not sit up and 35 could. A total of 88 children were found to have one or more categories of sleep problems. The most common sleep problem was "Problems initiating and maintaining sleep" (64.8%), followed by "Problems with sleep-related movement" (59.1%). J-ZBI was significantly higher in caregivers of children with "Problems initiating and maintaining sleep". PSQI scores were significantly higher in caregivers of children with "Problems with sleep-related breathing" and "Problems with circadian rhythm". A significant correlation was identified between perceived J-ZBI and PSQI of the caregiver.

CONCLUSIONS

Increased focus on the sleep problems of disabled children is needed, particularly in relation to the sleep quality and perceived burden of caregivers.

Relação entre independência funcional e qualidade de vida na paralisia cerebral

INTRODUÇÃO: A paralisia cerebral (PC) pode limitar o desempenho de atividades funcionais e a qualidade de vida desses indivíduos. OBJETIVOS:Avaliar a relação entre independência funcional e qualidade de vida de crianças com paralisia cerebral. MATERIAIS E MÉTODOS: A amostra foi composta por 30 crianças com diagnóstico de PC. Para mensurar a qualidade de vida foi utilizado o Questionário de Saúde da Criança (CHQ-PF50) e, para avaliar a funcionalidade, a parte I (habilidades funcionais) do Inventário de Avaliação Pediátrica de Incapacidade (Pedi). O teste de correlação de Spearman foi utilizado para avaliar a relação entre essas variáveis. RESULTADOS: Foi encontrada correlação significativa entre os domínios de função física e limitação das atividades diárias graças aos aspectos emocionais e comportamentais com todas as áreas do Pedi (p < 0,05). O domínio de limitação das atividades diárias graças aos aspectos físicos e a percepção de saúde apresentaram relação com as áreas de autocuidado e função social (p < 0,05). A função global só apresentou relação significativa com o autocuidado, e a saúde mental apresentou relação inversa com a mobilidade (p < 0,05). CONCLUSÕES: Nenhum domínio do CHQ-PF50 apresentou forte correlação com as áreas do Pedi, o que mostra que esses questionários avaliam constructos diferentes. Tais resultados podem auxiliar no planejamento de estratégias de avaliação e intervenção para crianças com PC.

Genetic [corrected] insights into the causes and classification of [corrected] cerebral palsies

Cerebral palsy-the most common physical disability of childhood-is a clinical diagnosis encompassing a heterogeneous group of neurodevelopmental disorders that cause impairments of movement and posture that persist throughout life. Despite being commonly attributed to a range of environmental factors, particularly birth asphyxia, the specific cause of cerebral palsy remains unknown in most individuals. A growing body of evidence suggests that cerebral palsy is probably caused by multiple genetic factors, similar to other neurodevelopmental disorders such as autism and intellectual disability. Recent advances in next-generation sequencing technologies have made possible rapid and cost-effective sequencing of the entire human genome. Novel cerebral palsy genes will probably be identified as more researchers and clinicians use this approach to study individuals with undiagnosed neurological disorders. As our knowledge of the underlying pathophysiological mechanisms of cerebral palsy increases, so will the possibility of developing genomically guided therapeutic interventions.