BMI does not capture the high fat mass index and low fat-free mass index in children with cerebral palsy and proposed statistical models that improve this accuracy

Feasibility and reliability of measured glomerular filtration rate with [I125]-iothalamate among young adults with mild-to-moderate cerebral palsy

Objective

Despite the need, measuring glomerular filtration rate (mGFR) is not routinely performed for adults with cerebral palsy (CP), possibly due to unknown feasibility given the secondary complications of CP. This study aimed to assess the feasibility and reliability of mGFR and explore factors associated with eGFR-mGFR discordance among young adults with mild-to-moderate CP.

Methods

This single-center, cross-sectional study included 18- to 40-year-olds with CP gross motor function classification system (GMFCS) I-III. The participants were excluded if they were pregnant/lactating, had cognitive impairments, or had contraindications to mGFR. A routine clinical protocol for mGFR and eGFR was used. mGFR feasibility was assessed based on the number of participants who completed testing. mGFR reliability was assessed using the coefficient of variation (CV) across the four 30 min intervals. The association between age, sex, and GMFCS and the percentage of eGFR-mGFR discordance was assessed.

Results

Of the 19 participants enrolled, 18 completed the testing [mean age (SD), 29.9 (7.4) years, n = 10 female participants, n = 10/3/5 for GMFCS I/II/III] and most (n = 15) of the participants had an mGFR >90 mL/min; 14 participants (77.8%) had a CV <20%, 2 had a CV between 20 and 25%, and 2 had a CV >50%. eGFR overestimated mGFR by a median (interquartile range) of approximately 17.5% (2-38%); the full range of mis-estimation was -20.5 to 174.3%. Increasing age and GMFCS levels exhibited notable, but weak-to-modest, associations with a larger eGFR-mGFR discordance.

Discussion

Obtaining mGFR was feasible and reasonably reliable within this small sample. eGFR overestimated mGFR by a notable amount, which may be associated with patient-level factors.

Elevated blood pressure in children with cerebral palsy and its relationship with adiposity and physical activity

BACKGROUND

There is a high prevalance of hypertension in adults with with cerebral palsy (CP). However, less is known about blood pressure in children with CP.

OBJECTIVE

The aim was to determine if blood pressure is elevated in children with CP and whether it is related to adiposity and physical activity.

METHODS

Thirty children with spastic CP (5-11 y) and 30 age-, sex-, and race-matched typically developing control children were studied. Resting systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate were measured, and mean arterial pressure (MAP) was calculated. Visceral fat mass and total body fat mass index (FMI) were determined using dual-energy X-ray absorptiometry. Physical activity was assessed using accelerometer-based monitors.

RESULTS

Children with CP had higher DBP and heart rate than controls (p < 0.05). DBP percentile and MAP were also higher in children with CP when BMI was statistically controlled. Children with CP and elevated blood pressure or hypertension (n = 8) had 56% more visceral fat mass than children with CP and normal blood pressure (n = 22; p < 0.05). In the groups combined, blood pressure was directly related to visceral fat mass and FMI, and inversely related to physical activity (p < 0.05). However, in children with CP alone, only visceral fat mass was related to blood pressure (p < 0.05).

CONCLUSIONS

Children with CP have higher resting blood pressure than typically developing children. The higher blood pressure is related to higher visceral adiposity. Careful blood pressure screening should start during childhood in individuals with CP.

Body mass index is not suitable for assessing body composition in children with spastic cerebral palsy

PURPOSE

To measure body composition by using bioelectrical impedance analysis (BIA) and body mass index (BMI) and to investigate the correlation and agreement between BMI and fat mass percentage in children with spastic Cerebral Palsy.

MATERIALS AND METHODS

BIA was used to assess fat mass percentage and BMI was determined from body weight and height. BMI and fat mass percentage were both categorized into five categories. The association between fat mass percentage and BMI was assessed using Pearson's correlation coefficient. Agreement between BMI and fat mass percentage was investigated with weighted Cohen's kappa coefficient.

RESULTS

One hundred and three children with CP across all Gross Motor Function Classification Levels (61% boys, mean age 9 years) were included. Mean BMI was 18.3 kg/m2 and mean fat mass was 24.9%. A large inter-subject variability was found with a weak correlation between BMI and fat mass percentage in children with a BMI < 20 kg/m2. Little agreement (k = 0.299, CI 0.16-0.44) between the categorization of children based on BMI and based on fat mass percentage was found.

INTERPRETATION

The large inter-subject variability in fat mass percentage combined with little agreement between the BMI and BIA categories suggests that BMI is not a suitable measure of fat mass in children with CP.IMPLICATIONS FOR REHABILITATIONUsing body mass index (BMI) and instead of fat mass percentage increases the risk of misclassifying body composition in children with spastic Cerebral Palsy.Children with a BMI < 20 kg/m2 are more at risk to be misclassified for body composition.

The evolution of nutrition management in children with severe neurological impairment with a focus on cerebral palsy

Nutritional management of children with severe neurological impairment (SNI) is highly complex, and the profile of this population is changing. The aim of this narrative review was to give the reader a broad description of evolution of the nutritional management of children with SNI in a high resource setting. In the last decade, there has been an emphasis on using multiple anthropometric measures to monitor nutritional status in children with SNI, and several attempts at standardising the approach have been made. Tools such as the Feeding and Nutrition Screening Tool, the Subjective Global Nutrition Assessment, the Eating and Drinking Ability Classification System and the Focus on Early Eating and Drinking Swallowing (FEEDS) toolkit have become available. There has been an increased understanding of how the gut microbiome influences gastrointestinal symptoms common in children with SNI, and the use of fibre in the management of these has received attention. A new diagnosis, 'gastrointestinal dystonia', has been defined. The increased use and acceptance of blended food tube feeds has been a major development in the nutritional management of children with SNI, with reported benefits in managing gastrointestinal symptoms. New interventions to support eating and drinking skill development in children with SNI show promise. In conclusion, as the life expectancy of people with SNI increases due to advances in medical and nutrition care, our approach necessitates a view to long-term health and quality of life. This involves balancing adequate nutrition to support growth, development and well-being while avoiding overnutrition and its associated detrimental long-term effects.

The age-related association between serum creatinine and cardiorespiratory morbidity and mortality and fractures among adults with cerebral palsy

PURPOSE

Serum creatinine may be an objective biomarker of salient health issues in adults with cerebral palsy (CP). The objective was to assess the age-related association between serum creatinine with 3-year risk of cardiorespiratory morbidity/mortality and fracture among adults with CP.

PATIENTS AND METHODS

This retrospective cohort study used medical records between Jan. 1, 2012 and Oct. 2, 2022 from adults ≥18 years old with CP. The association between baseline serum creatinine with the 3-year risk of all-cause mortality, respiratory/cardiovascular morbidity/mortality, and fracture was assessed by age and sex using logistic regression. The discriminative ability of serum creatinine alone and in conjunction with other variables was assessed.

RESULTS

Over the 3-year follow-up, 8.3% of 1368 adults with CP had all-cause mortality, 25.6% had respiratory morbidity/mortality, 12.4% had cardiovascular morbidity/mortality, and 8.9% sustained a fracture. The association between serum creatinine with outcomes was dependent on age. For younger adults, lower creatinine had a higher odds ratio (OR) for all-cause mortality, respiratory morbidity/mortality, and fracture. For 51-60 year olds, higher creatinine had a higher OR for cardiovascular morbidity/mortality. Serum creatinine alone had modest prediction of outcomes, and generally improved prediction when added to models that included sex and co-occurring intellectual disabilities and epilepsy (c-statistic range, 0.54-0.84).

CONCLUSIONS

Lower serum creatinine may reflect frailty while higher levels may reflect kidney dysfunction, helping to explain the differential associations by age. Serum creatinine may be a useful biomarker as part of risk prediction models for these salient health issues for adults with CP.

5-year fracture risk among children with cerebral palsy

BACKGROUND

Epidemiologic evidence documenting fracture risk as children with cerebral palsy (CP) age throughout growth is lacking to inform on when to implement fracture prevention strategies. The objective was to characterize the 5-year risk of fractures by each year of age among <1-13 year olds with CP and effects by patient-level factors.

METHODS

This retrospective cohort study used commercial administrative claims from 01/01/2001 to 12/31/2018 from children <1-13 years old with ≥5 years of insurance enrollment. Fractures were examined during the 5-year follow-up. For the CP cohort, the association between 5-year fracture rate and patient-level factors was assessed using Cox regression.

RESULTS

Children with (n = 5559) vs. without (n = 2.3 million) CP had a higher 5-year fracture risk at the vertebral column, hip, and lower extremities at almost each year of age, but lower 5-year fracture risk at the upper extremities after 6 years old (all P < 0.05). Among children with CP, the 5-year fracture rate was elevated for co-occurring neurological conditions and non-ambulatory status at the vertebral column, hip, and lower extremities (hazard ratio [HR] range, 1.44-2.39), and higher for males at the upper extremities (HR = 1.29) (all P < 0.05).

CONCLUSIONS

This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age for children with CP.

IMPACT

This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age across important developmental stages for children with vs. without cerebral palsy (CP). Children with vs. without CP were more likely to fracture at the vertebral column, hip, lower extremities, and humerus and less likely to fracture at the forearm and hands. The age-related 5-year fracture risk was associated with clinically relevant patient-level factors, but in different ways by fracture region. Study findings may be used to enhance clinical detection of at-risk children and strategize when to implement fracture prevention efforts for children with CP.

Cardiometabolic Risk and Its Relationship With Visceral Adiposity in Children With Cerebral Palsy

Context

Adults with cerebral palsy (CP) display a higher prevalence of cardiometabolic disease compared with the general population. Studies examining cardiometabolic disease risk in children with CP are limited.

Objective

The purpose of this study was to determine if children with CP exhibit higher cardiometabolic risk than typically developing children, and to examine its relationship with visceral adiposity and physical activity.

Methods

Thirty ambulatory children with CP and 30 age-, sex-, and race-matched typically developing control children were tested for blood lipids, glucose, and the homeostatic model assessment of insulin resistance (HOMA-IR). Visceral fat was assessed using dual-energy x-ray absorptiometry. Physical activity was assessed using accelerometer-based monitors.

Results

Children with CP had higher total cholesterol, low-density lipoprotein cholesterol, and non-high-density lipoprotein cholesterol (non-HDL-C), glucose, prevalence of dyslipidemia, prevalence of prediabetes, and visceral fat mass index (VFMI) and lower physical activity than controls (all P < .05). In the groups combined, non-HDL-C and glucose were positively related to VFMI (r = 0.337 and 0.313, respectively, P < .05), and non-HDL-C and HOMA-IR were negatively related to physical activity (r = -0.411 and -0.368, respectively, P < .05). HOMA-IR was positively related to VFMI in children with CP (r = 0.698, P < .05), but not in controls. Glucose was not related to physical activity in children with CP, but it was negatively related in controls (r = -0.454, P < .05).

Conclusion

Children with CP demonstrate early signs of cardiometabolic disease, which are more closely related to increased visceral adiposity than decreased physical activity.

Body Composition in Outpatient Children with Cerebral Palsy: A Case-Control Study

Purpose

The purpose of this study was to identify quantitative (BMI z-score and BMI percentile) and qualitative (BC) differences between high functioning outpatient children with CP (GMFCS levels I/II) vs TD children, using BIA. We hypothesized that: 1) BMI z-score and BMI percentile will be lower in children with CP compared with their TD peers; and 2) body components (BC) directly associated with muscle mass (including fat free mass (FFM%) and skeletal muscle mass (SMM) and predicted muscle mass (PMM)) in children with CP will be lower than in their TD peers.

Patients and Methods

Ninety children with CP (GMFCS levels I/II) aged 8-16 years were enrolled in this study. Due to the fact that there is lack of normative values of particular body components in the pediatric population, ninety typically developing (TD) peers were used as references. The examination consisted of two parts: 1) the height measurement and 2) body composition assessments, both using the bioelectric impedance analysis (BIA).

Results

Average values for height, weight, BMI z-score, and BMI percentile in children with CP were significantly statistically lower than in the reference group. BC's directly associated with muscle mass (including FFM%, SMM, and PMM) in children with CP were lower than those in their TD peers.

Conclusion

Altered body compositions were evident in children with CP.

Body Composition and Spasticity in Children with Unilateral Cerebral Palsy-A Case-Control Study

The aim of this study was to identify the correlations between segmental body composition and the spasticity level of the affected lower limb in children with unilateral cerebral palsy (spastic hemiplegia). Additionally, an attempt was made to identify the differences in composition between the affected and unaffected lower limbs using segmental body composition analysis. This case-control study included 31 children with spastic hemiplegia aged 8 to 16 years with differing severities of spasticity in the lower limbs. The reference group consisted of a control group which included 31 peers with corresponding age and sex to the tested group. Negative correlations obtained in the statistical analysis showed that higher spasticity level in the iliopsoas muscle is associated with lower limb fat-free mass and lower limb muscle mass. Our results showed that children with spastic hemiplegia have worse parameters of body composition in the affected limb than in the unaffected one. To confirm the importance of these results, further studies are needed in a larger population which includes non-ambulatory children.

5-year risk of “adult-onset” chronic diseases during childhood and adolescent transitioning for individuals with cerebral palsy

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“Adult-onset” chronic diseases may begin in childhood for individuals with CP.

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5-year disease risk was < 64.3-fold higher for < 1–13 year olds with vs without CP.

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5-year chronic disease risks were elevated for CP across all developmental stages.

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Patient factors impacted disease risk variably for children with CP.

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Findings may inform when to implement prevention efforts and who is more at-risk.

Epidemiologic evidence documenting risk of chronic diseases as children with cerebral palsy age throughout growth is lacking to inform prevention strategies. The objective was to characterize the 5-year risk of chronic diseases that are typically associated with advanced aging among < 1–13 year olds with cerebral palsy and effects by patient-level factors. This retrospective cohort study used nationwide commercial administrative claims from 01/01/2001–12/31/2018 from children < 1–13 years old with ≥ 5 years of mostly continuous insurance enrollment. The 5-year risk of chronic diseases was examined for the entire cohort with and without cerebral palsy and then by baseline age group (<1–2, 3–5, 6–8, 9–11, 12–13 years old), including cardiorespiratory, metabolic, kidney, and liver diseases, cancer, depression, and osteoarthritis. For cerebral palsy, the association between 5-year chronic disease rate and patient-level factors was assessed using Cox regression. Children with (n = 5,559) vs without (n = 2.3 million) cerebral palsy had a higher 5-year risk of all chronic diseases when comparing the entire cohorts (relative risk, 1.19 to 64.26, all P < 0.05) and most chronic diseases when comparing cohorts for each age group. Among children with cerebral palsy, there were effects by gender, co-occurring intellectual disabilities and/or epilepsy, and wheelchair use for some chronic diseases, which can help to identify at-risk children. This study provides novel epidemiologic evidence of 5-year risk of “adult-onset” chronic diseases for children with cerebral palsy during important developmental stages, and associated patient-level factors (to enhance clinical detection). Findings may inform when to implement prevention strategies and who may be more at risk.

Body Fat Distribution in Children and Adolescents With Cerebral Palsy

To evaluate the body fat distribution in children with cerebral palsy (CP). The present study focusses on a monocentric retrospective analysis of body fat distribution from children diagnosed with CP. The children participated in a rehabilitation program. Reference centiles were calculated based on data from the National Health and Nutrition Examination Survey (NHANES, 1999-2004). Z-scores for trunk-to-leg fat ratio were calculated. Further, fat mass index (FMI) was evaluated based on percentiles that have already been published. 237 males and 194 females with CP were considered (mean age: 11 years and 11 months [SD 3 years]). These were compared to 1059 males and 796 females from the NHANES (mean age: 14 years and 7 months [SD 3 years and 4 months]). The z-scores for trunk-to-leg fat ratio showed the following values: mean -0.47 (SD 1.50) for males, -0.49 (SD 1.11), for females, -0.48 (SD 1.34) for all. The z-scores for FMI showed the following values: mean -0.29 (SD 0.70) for males, -0.88 (SD 2.0) for females, -0.55 (SD 1.46) for all. The results showed rather a gynoid fat distribution and a lower FMI in children with CP than in the reference population (NHANES 1999-2004).

Infectious Complications and Operative Management of Intrathecal Baclofen Pumps in the Pediatric Population: A Systematic Review and Meta-Analysis of 20 Years of Pooled Experience

BACKGROUND

Intrathecal baclofen (ITB) is a treatment modality used to improve the quality of life of patients with intractable spasticity and dystonia. Although it is an effective solution in patients failing oral interventions, it is associated with potential infectious complications. It is known that pediatric patients with ITB have significantly higher infection rates compared with adult patients. The cause of these higher rates in pediatric patients remains unclear. In the present study, we performed a meta-analysis focusing on the incidence of infection, and clarification of potential risk factors for infection in pediatric patients with ITB.

METHODS

This meta-analysis was performed in accordance with the PRISMA guidelines. An electronic database search was performed through PubMed, Web of Science, Embase, and Cochrane Library databases. Eligibility criteria and bias assessment were applied before statistical analysis.

RESULTS

The 17 studies identified yielded 2238 pediatric patients treated with implanted ITB pumps between 1994 and 2014. Infection comprised 34% of observed complications, second only to catheter malfunction. Pediatric ITB primary infection ranged between 0% and 44% among included studies (interquartile range, 4.85%-18.85%). A linear mixed-effects regression model showed that subfascial implantation had 12% lower primary infection rates compared with subcutaneous implantations across the literature. The relative risk of infection was 56% lower in pediatric patients with subfascially implanted ITB pumps.

CONCLUSIONS

Surgeons and clinicians should use these data to better assess patient risk-benefit when considering ITB pump implantation.

Preventive Care for Adults With Cerebral Palsy and Other Neurodevelopmental Disabilities: Are We Missing the Point?

Preventive care techniques are cornerstones of primary care for people with neurodevelopmental disabilities such as cerebral palsy (CP). However, well-established methods evaluating health constructs may not be applied in the same way for adults with CP, as compared to the general population, due to differences in anatomy/physiology, leading to missed opportunities for interventions, medication modifications, and other primary/secondary prevention goals. One barrier to care prevention comes from misinterpretation of values to capture health constructs, even when measurements are accurate. In this Perspective, we emphasize the need for differential interpretation of values from commonly used clinical measures that assess for well-known medical issues among adults with CP obesity risk, bone health, and kidney health. We provide technical, but simple, evidence to showcase why the underlying assumptions of how some measures relate to the health construct being assessed may not be appropriate for adults with CP, which may apply to other neurodevelopmental conditions across the lifespan.

Nutritional screening of children and adolescents with cerebral palsy: a scoping review

AIM

To examine nutritional screening methods for children and adolescents with cerebral palsy.

METHOD

A scoping review was performed using established methodologies. In June 2020 we searched PubMed, Embase, CINAHL Complete, and the Cochrane Central Register of Controlled Trials to identify articles on tools/methods for nutritional screening of our target groups.

RESULTS

Thirty studies were included, containing various tools/methods used to identify under- and/or overnutrition by weight/height, circumferences, skinfolds, questionnaires, and/or technically advanced or invasive methods. Questionnaires, weight/height, circumferences, and skinfolds were considered feasible based on clinical utility, whereas bioelectrical impedance analysis and blood samples were not.

INTERPRETATION

We identified two screening tools for undernutrition that include no physical measurements, but did not find any screening tools for overweight and obesity. Most of the studies recommended one or more methods, indicating that determining nutritional status most likely includes a combination of methods, not all of which may be feasible in clinical practice. What this paper adds No nutritional screening tool using anthropometry or body composition was discovered. Heterogenous methods to identify under- and/or overnutrition are recommended. Preferable methods for nutritional screening include assessment of body composition. A validated nutritional screening tool for identification of overweight is warranted.

Degree of Accuracy of the BMI Z-Score to Determine Excess Fat Mass Using DXA in Children and Adolescents

Obesity is caused by fat accumulation. BMI Z-score is used to classify the different degrees of weight status in children and adolescents. However, this parameter does not always express the true percentage of body fat. Our objective was to determine the degree of agreement between the fat mass percentage measured by DXA and the stratification of weight according to BMI Z-score in the pediatric age group. We designed a descriptive cross-sectional study. The patients were classified as underweight/normal weight with Z-scores between −2 and +0.99, overweight from 1 to 1.99, obese from 2 to 2.99, and very obese ≥3. We included 551 patients (47% girls), with a mean age of 11.5 ± 2.8 years (3.7–18 years). Higher BMI Z-scores were associated with a higher percentage of total fat (p < 0.001). However, there were important overlaps between both parameters, such that the BMI Z-score classified patients with the same percentage of total fat mass as having a different nutritional status classification. In conclusion, the stratification of weight status according to BMI Z-score revealed that 46.7% of patients had a fat percentage that did not correspond to their classification. For a more accurate weight assessment in clinical practice, we recommend combining anthropometric indices with diagnostic tools that better correlate with DXA, such as electrical bioimpedance.

Factors associated with walking activity in adults with cerebral palsy

BACKGROUND

This prospective study used instrumented gait analysis, patient-reported outcomes, and portable accelerometers to examine walking activity in adults with cerebral palsy (CP).

RESEARCH QUESTION

This study aimed to provide objective data and evaluate factors associated with walking activity in adults with CP.

METHODS

Participants with CP (ages 25-45 years) completed instrumented gait analysis and patient-reported outcomes, including the Patient Reported Outcome Measurement Information System (PROMIS) and Satisfaction with Life Score (SWLS), and wore a StepWatch for 8 days. Average strides per day, stratified by Gross Motor Function Classification System (GMFCS), were compared with nondisabled adults ages 30-39 years utilizing Welch's t-tests with Bonferroni corrections. Correlation coefficients and stepwise multiple linear regression analyses examined relationships between walking activity and GMFCS, gait deviation index (GDI), gait velocity, PROMIS physical function, SWLS, body mass index (BMI), and employment.

RESULTS

Participants included 109 adults with CP, ages 29 ± 4 years, classified at GMFCS levels I/II (73 %) and III/IV (27 %). Compared with nondisabled adults, daily stride count was significantly lower in both groups of adults with CP (p < 0.00025), with a progressive decline according to GMFCS level. Walking activity correlated with PROMIS physical function (r = .42), GDI (r = .48), and gait velocity (r = .58). Association for employment was lower (r = 0.27) but significant, while age, SWLS, and BMI were not individually correlated with walking activity. Stepwise, multiple linear regression modeled with Akaike information criterion explained 40.9 % of the observed variability in walking activity in this cohort of adults with CP.

SIGNIFICANCE

Physical function, as classified by GMFCS or measured by PROMIS and self-selected walking velocity, has the strongest association with and is the most significant predictor of walking activity in adults with CP. After accounting for physical function, a small amount of the variation in walking activity can be explained by GDI, employment, and age.

The Association Between Kidney Disease and Mortality Among Adults With Cerebral Palsy-A Cohort Study: It Is Time to Start Talking About Kidney Health

Objective: Recent evidence shows that adults with cerebral palsy (CP) have an increased risk for kidney disease, but nothing is known about how kidney disease integrates with their overall health. To begin understanding the importance of kidney health, the objective was to determine if kidney disease is associated with mortality among adults with CP after accounting for comorbidities common to CP and kidney disease.

Methods: Data from 2016 to 2018 from adults ≥18 years with CP were used from a random 20% sample fee-for-service Medicare database. Kidney disease in 2016 was ascertained as chronic kidney disease (CKD) stages 1–4, end stage kidney disease (ESKD), nephritic and nephrotic syndrome, and renal osteodystrophy. A modified version of the Whitney Comorbidity Index (modWCI) was used, which includes 24 comorbidities relevant to CP and kidney disease. Mortality rate ratio (MRR) through the year 2018 was estimated for each kidney disease and Cox regression estimated the hazard ratio (HR) of mortality after adjusting for demographics, co-occurring neurological conditions, and the modWCI.

Results: Prevalence of kidney disease was 7.3% among 16,728 adults with CP. MRR was elevated for any kidney disease (MRR = 3.14; 95%CI = 2.76–3.58) and most subtypes (MRR = 2.21–3.56; all p < 0.05). The adjusted HR of mortality remained elevated for any kidney disease (HR = 1.25; 95%CI = 1.09–1.45) and ESKD (HR = 1.38; 95%CI = 1.10–1.74).

Discussion: Kidney disease, especially ESKD, is associated with mortality among adults with CP independent of comorbidities that are relevant to CP and kidney disease. Findings suggest that nephrology care should be considered as part of routine clinical care for this population.

Navigating the Pathway to Care in Adults With Cerebral Palsy

As individuals with cerebral palsy (CP) age, they face unique challenges which complicate their ability to access and receive appropriate health care. These problems exist at the level of the health care system, the clinician, and the individual. At the system level, there is an inadequate number of professionals who are informed of and interested in the care of adults with CP. Pediatric clinicians prefer treating children, and adult caregivers are not knowledgeable about and may feel less competent about CP. Pediatric care does not translate well to the adult population, and information about best practices for adults is just starting to develop. Differences in the physiologic development of individuals with CP render well-established clinical protocols for risk screening of chronic diseases less effective. Moreover, lack of supportive resources decreases a caregiver's sense of self-efficacy in treating this population. The patient's ability to navigate these barriers is complicated by the high prevalence of comorbid cognitive impairment and mental health issues including anxiety, depression, and other psychiatric disorders; a bidirectional relationship between challenges in navigating care/needs and comorbid mental health conditions appears likely. Many patients have additional barriers related to social determinants of health, such as access to transportation, accessible health care facilities, and other personal and environmental factors that may impede health maintenance and wellness. Increasing and disseminating knowledge, harnessing the power of new technologies such as telemedicine, and addressing mental health issues are some of the methods that are available to help adults with CP navigate this road.

Polypharmacy is a risk factor for mortality, severe chronic kidney disease, and liver disease among privately insured adults with cerebral palsy

BACKGROUND: Adults with cerebral palsy (CP) have an increased risk for polypharmacy, premature mortality, and early development of several morbidities, including conditions associated with excess medication exposure, such as chronic kidney disease (CKD) and liver disease. To date, very little is known about the consequence of polypharmacy for adults with CP. OBJECTIVE: To determine if polypharmacy is associated with an increased risk for mortality, severe CKD, and liver disease among adults with CP, before and after adjusting for comorbid neurodevelopmental disabilities (NDDs) and multimorbidity. METHODS: This is an exploratory treatment effectiveness study. Data from the Optum Clinformatics Data Mart were used for this retrospective cohort study. Adults aged 18 years or older with a diagnosis of CP and without severe CKD (stages IV+) and liver disease were identified from the calendar year 2013 and were subsequently followed from January 1, 2014, to death, severe CKD, liver disease, loss to follow-up, or end of study period (December 31, 2017). Diagnosis codes were used to identify NDDs (intellectual disabilities, epilepsy, autism spectrum disorders, spina bifida) and 24 relevant morbidities at baseline (i.e., calendar year 2013). Polypharmacy was defined as ≥ 5 medications and hyperpolypharmacy was defined as ≥ 10 medications at baseline. Cox regression models were developed to examine the association (as HR and 95% CI) between polypharmacy and hyperpolypharmacy with mortality, severe CKD, and liver disease separately, before and after adjusting for covariates (demographics, NDDs, multimorbidity). Exploratory analyses examined the mediating effect of incident severe CKD or liver disease on the association between the exposure (polypharmacy or hyperpolypharmacy) on outcomes. RESULTS: Of the 9,238 adults with CP, 58.5% had polypharmacy and 29.5% had hyperpolypharmacy. The fully adjusted HR for mortality was 2.14 (95% CI = 1.59-2.89) for polypharmacy and 1.65 (95% CI = 1.31-2.09) for hyperpolypharmacy. The fully adjusted HR for severe CKD was 1.66 (95% CI = 1.17-2.36) for polypharmacy and 1.67 (95% CI = 1.27-2.19) for hyperpolypharmacy. The fully adjusted HR for liver disease was 1.57 (95% CI = 1.27-1.94) for polypharmacy and 1.72 (95% CI = 1.42-2.08) for hyperpolypharmacy. Incident liver disease mediated 5.37% (polypharmacy) and 7.54% (hyperpolypharmacy) of the association between the exposure with incident severe CKD for nonelderly (aged < 65 years), while incident severe CKD mediated 7.05% (polypharmacy) and 6.64% (hyperpolypharmacy) of the association between the exposure with incident liver disease for elderly (aged ≥ 65 years). CONCLUSIONS: Polypharmacy and hyperpolypharmacy are robust risk factors for risk of mortality, severe CKD, and liver disease among privately insured adults with CP. While incidence of severe CKD and liver disease had negligible effects on the association between polypharmacy with mortality, there is evidence that they mediate a considerable portion of one another and require further examination. DISCLOSURES: During the work for this study, Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund and American Academy for Cerebral Palsy and Developmental Medicine. The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The authors have no conflicts of interest to report.

Assessment of Swallowing Disorders, Nutritional and Hydration Status, and Oral Hygiene in Students with Severe Neurological Disabilities Including Cerebral Palsy

BACKGROUND

Special needs schools (SNS) educate children and young people with major neurological disabilities who are at high risk of oropharyngeal dysphagia (OD) and malnutrition (MN). We aimed to assess the prevalence of OD, MN, dehydration (DH), and oral health (OH) in students at an SNS.

METHODS

A cross-sectional observational study was conducted at SNS L'Arboç, Catalonia, Spain. We assessed (a) demographics, health status, comorbidities, and gross motor function classification system (GMFCS), (b) swallowing function, oral-motor evaluation, masticatory capacity, and EDACS classification for eating and drinking abilities, (c) nutritional and DH status (anthropometry, bioimpedance and dietary records), and (d) OH (Oral Hygiene Index Simplified).

RESULTS

A total of 33 students (mean age 13.3 years; 39.4% level V of GMFCS) were included. Main diagnosis was cerebral palsy at 57.6%. All students presented OD, 90.6% had impaired safety, 68.7% were at levels II-III of EDACS, and 31.3% required PEG; furthermore, 89.3% had chronic MN, 21.4% had acute MN, 70% presented intracellular DH, and 83.9% presented impaired OH.

CONCLUSION

MN, DH, OD, and poor OH are highly prevalent conditions in students with cerebral palsy and other neurological disabilities and must be specifically managed through nutritional and educational strategies. The multidisciplinary team at SNS should include healthcare professionals specifically trained in these conditions.

Timecourse of Morbidity Onset Among Adults Living With Cerebral Palsy

INTRODUCTION

Despite the greater risk of an array of morbidities, little is known about when morbidities occur for adults with cerebral palsy. The objective of this study is to determine the timecourse of morbidity risk/development for adults with cerebral palsy and the effect by patient-level factors.

METHODS

Cross-sectional data from 2016 were used from a random 20% sample from the fee-for-service Medicare database. Diagnosis codes identified adults aged ≥18 years with cerebral palsy and 16 clinically relevant morbidities. Qualitative and quantitative approaches identified the age where each morbidity became exceedingly prevalent. The effect of the timecourse by sex, race, and co-occurring intellectual disabilities and epilepsy was examined. Data were sequestered and analyzed in 2020.

RESULTS

Among 16,818 adults with cerebral palsy, the prevalence of most morbidities was already high among those aged 18-30 years, and all morbidities increased with age except liver disease and anxiety. Hypertension and diabetes exhibited a positive linear trend with age. Of the morbidities that did not exhibit a linear trend, the qualitative and quantitative approaches were consistent considering that the cardiorespiratory diseases, osteoarthritis, renal disease, and dementia became exceedingly more prevalent at age >50 years, whereas the threshold was >60 years for depression, cancer, and metastatic cancer. There were interactions with sex, race, and co-occurring intellectual disabilities and epilepsy for some of the morbidities.

CONCLUSIONS

Morbidity prevalence is already elevated early in adulthood among individuals living with cerebral palsy, with an abrupt increase by age 50 years. Preventive efforts should be adopted early in the lifespan and not later than age 50 years for adults with cerebral palsy.

Effect of fat mass index, fat free mass index and body mass index on childhood blood pressure: a cross-sectional study in south China

BACKGROUND

Evidence on how different body composition indexes, such as body mass index (BMI), fat mass index (FMI) and fat free mass index (FFMI), influence blood pressure (BP) in Chinese children and adolescents is sparse. The aim of this study is to assess the effect of different body composition on BP in participants aged 7-18 in south China.

METHODS

A cross-sectional study was conducted in 2013. A total of 1,609 children and adolescents from urban and rural areas in Hainan Province, South China, were selected using multi-stage stratified cluster sampling method. Each participant underwent anthropometric and BP tests. BMI, FMI and FFMI were calculated and analyzed as body composition indexes.

RESULTS

In the population level stratified by sex, FFMI had the highest r-value (Partial Spearman correlations) of correlation with systolic BP in boys (r_s=0.305, P<0.001) and girls (r_s=0.237, P<0.001). FMI was found to have the highest r-value of correlation with DBP in boys (r_s=0.154, P<0.001). The quantile regression model indicated that, within each age group, all body composition indexes was positively associated with systolic BP, and FFMI has the greatest value of regression coefficient (4.38, 95% CI: 3.81-4.95). But for diastolic BP, positive associations with BMI, FMI and FFMI were only observed in the 11-12 years group. Restrict cubic spline models showed that there were both linear and non-linear relations between BMI, FMI and BP, but for FFMI, there was only linear association with BP.

CONCLUSIONS

The relation between BP and FFMI was stronger than with BMI and FMI. Combined measurement of body composition should be considered to help health professionals interpret body mass data from children and adolescents with varied stature and age.

The paradoxical relationship between severity of cerebral palsy and renal function in middle-aged adults: better renal function or inappropriate clinical assessment?

PURPOSE

To determine the association between severity of cerebral palsy with serum creatinine (sCr) and sCr-based equations to estimate glomerular filtration rate (eGFR), a marker of renal function.

METHODS

A clinic-based sample of 30-64 year-olds with cerebral palsy was examined and stratified by motor impairment: gross motor function classification system (GMFCS) I/II (n = 79), GMFCS III (n = 78), and GMFCS IV/V (n = 137). sCr, which is influenced by muscle mass, was obtained and sCr-based eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations.

RESULTS

sCr was lower with increasing GMFCS. The opposite pattern was observed for eGFR: GMFCS IV/V had significantly higher eGFR derived from MDRD compared to other GMFCS groups; GMFCS III had significantly higher eGFR compared to GMFCS I/II. The pattern was similar for CKD-EPI derived eGFR.

CONCLUSIONS

According to widely used clinical assessment methods for renal function, higher severity of cerebral palsy among adults is associated with better renal function, which is incongruent with their other biological systems. This paradoxical relationship is likely driven by lower muscle rather than true renal function, and thus, sCr-based eGFR may overestimate renal function, especially for GMFCS IV/V. Further prospective studies are needed.Implications for rehabilitationCommon methods of clinical assessment may over-estimate renal function for adults with cerebral palsy (CP), potentially giving a false positive for normal renal health due to their reliance on muscle mass.This study of a clinic-based sample of middle-aged adults with CP highlights the paradoxical relationship between severity of CP and renal function, which is likely driven by methodological limitations in the presence of low muscle mass rather than actual better renal function.It is recommended that clinicians have a high suspicion of abnormal renal function and the need for a nephrology consultation, especially with changes in creatinine levels, even within the normal range.Rehabilitation for adults with CP must have a strong focus on muscle and kidney health, especially for patients with more severe forms of CP.

The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy

Children with cerebral palsy (CP) and other medical complexity comprise an outsized proportion of health care use. In this review, we describe the current science of assessment of nutritional status for children with CP, outline a systematic approach to assessing their nutritional status, delineate ramifications of malnutrition on hospitalization-associated outcomes, and identify knowledge gaps and means of addressing those gaps using quality improvement and clinical research tools. Methods to accurately assess body composition and adiposity in this population by using skinfolds, age, sex, and activity level are available but are not widely used. There are limitations in our current method of estimating energy needs in children with CP, who are at higher risk of both obesity and micronutrient deficiencies. There is some evidence of an association between malnutrition, defined as either underweight or obesity, and hospitalization-associated outcomes in children generally, although we lack specific data for CP. The gaps in our current understanding of optimal nutritional status and between current science and practice need to be addressed to improve health outcomes for this vulnerable patient population.

Nontrauma fracture increases risk for respiratory disease among adults with cerebral palsy

Individuals with cerebral palsy (CP) manifest skeletal fragility problems early in life and are vulnerable to nontrauma fracture (NTFx), which may exacerbate the risk of respiratory disease (RD)- the main cause of premature mortality for this population. The purpose of this study was to determine if adults with CP had a greater 12-month risk of RD post-NTFx compared to adults without CP. Data from 2011 to 2017 were leveraged from Optum Clinformatics Data Mart; a claims database from a single private payer in the United States diagnostic codes were used to identify adults (≥18 years) with and without CP, NTFx, incident RD, and pre-NTFx cardiometabolic diseases. Cox proportional hazards regression models were used to compare 12-month RD incidence following NTFx with adjustment for sociodemographics and cardiometabolic diseases. Mean age (SD) at baseline was 57.5 (18.4) for adults with CP (n = 646) and 61.8 (19.7) for adults without CP (n = 321,482). During the follow-up, 172 adults with CP (26.6%) and 73 937 adults without CP (23.0%) developed RD. Adults with CP had higher 12-month post-NTFx RD incidence compared to adults without CP (hazard ratio [HR] = 1.20; 95% confidence interval [CI] = 1.03-1.37). When stratified by the RD subtype, adults with CP had a higher incidence of pneumonia (HR = 2.15; 95% CI = 1.56-2.95), interstitial/pleura disease (HR = 2.13; 95% CI = 1.53-2.96), and other RD (eg, respiratory failure; HR = 2.33; 95% CI = 1.82-2.98), but not acute respiratory infection (HR = 0.93; 95% CI = 0.75-1.15) or chronic obstructive pulmonary disease (HR = 1.15; 95% CI = 0.86-1.53). Among privately insured adults with CP, NTFx is associated with greater risk of RD among adults with vs without CP.

Advanced CKD Among Adults With Cerebral Palsy: Incidence and Risk Factors

Rationale & Objective

Recent evidence suggests that adults with cerebral palsy have an elevated risk for developing advanced chronic kidney disease (CKD). To develop effective interventions, the objective was to identify whether demographics and preexisting medical conditions are risk factors for advanced CKD among adults with cerebral palsy.

Study Design

Retrospective cohort study.

Setting & Participants

Data were from the Optum Clinformatics Data Mart. Adults 18 years or older with cerebral palsy and without advanced CKD (CKD stage 4 or later) were identified from 2013 and subsequently followed up from January 1, 2014, to the development of advanced CKD, death, loss to follow-up, or end of the study period (December 31, 2017), whichever came first. Diagnostic, procedure, and diagnosis-related group codes were used to identify cerebral palsy, incident cases of advanced CKD, comorbid intellectual disability, and 10 preexisting medical conditions.

Exposures

Demographic variables and 10 preexisting medical conditions: CKD stages 1-3, hypertension, diabetes, heart and cerebrovascular disease, non-CKD urologic conditions, bowel conditions, respiratory disease, skeletal fragility, arthritis, and dysphagia.

Outcome

Incidence of advanced CKD.

Analytic Approach

Crude incidence rate (IR) of advanced CKD and IR ratios with 95% CIs were estimated. Cox proportional hazards regression models that were adjusted for demographics, intellectual disability, and preexisting medical conditions were used to evaluate the adjusted independent effect of predictor variables.

Results

237 of the 8,011 adults with cerebral palsy developed advanced CKD during follow-up (IR, 10.16/1,000 person years; 95% CI, 8.87-11.46). In the crude analysis, all preexisting medical conditions were associated with an elevated IR and IR ratio of advanced CKD. In the fully adjusted Cox proportional hazards regression model, the HR was elevated for older age, CKD stages 1-3 (HR, 3.32; 95% CI, 2.39-4.61), diabetes (HR, 2.69; 95% CI, 2.03-3.57), hypertension (HR, 1.54; 95% CI, .10-2.16), heart and cerebrovascular disease (HR, 1.53; 95% CI, 1.12-2.07), and non-CKD urologic conditions (HR, 1.39; 95% CI, 1.05-1.84).

Limitations

Private insurance database, short follow-up period, and lack of laboratory values, such as albuminuria/proteinuria.

Conclusions

Advanced CKD was common among adults with cerebral palsy and its development was associated with both traditional and nontraditional urologic risk factors.

Polypharmacy Among Privately Insured Adults with Cerebral Palsy: A Retrospective Cohort Study

BACKGROUND

Adults with cerebral palsy (CP) have increased risk for developing various secondary chronic diseases, especially when they have other neurodevelopmental disabilities (NDDs). Multiple medications are likely prescribed to manage the greater morbidity-related burden for adults with CP; however, because health care delivery and care coordination is suboptimal for this population, adults with CP may have an increased risk for polypharmacy. To date, very little is known about the prescribing practices and extent of polypharmacy for adults with CP.

OBJECTIVE

To determine the prevalence and adjusted odds of polypharmacy among adults with CP only and those with CP+NDDs, compared with adults without CP.

METHODS

Data from 2017 Optum Clinformatics Data Mart, a U.S. private administrative database, was used for this retrospective cohort study. Diagnosis codes were used to identify adults (aged ≥ 18 years) with CP, NDDs (e.g., intellectual disabilities, epilepsy, and autism spectrum disorders), and 24 relevant morbidities. Polypharmacy was examined as 0-4 versus ≥ 5, 0-9 versus ≥ 10, and 0-14 versus ≥ 15 medications. Logistic regression estimated the OR and 95% CI of polypharmacy before and after adjusting for age, sex, region of residence, and multimorbidity (as 0, 1, 2, 3, 4-5, and ≥ 6 morbidities). Exploratory analyses were conducted to compare polypharmacy among young (18-40 years) and middle-aged (41-64 years) adults with CP only and CP + NDDs with elderly (≥ 65 years) adults without CP.

RESULTS

Adults with CP only (n = 5,603) and CP + NDDs (n = 2,474) had higher unadjusted prevalence and adjusted OR for each polypharmacy definition compared with adults without CP (n = 9.0 million; e.g., ≥ 5 medications: adjusted OR for CP only = 1.38, 95% CI = 1.30-1.47; CP + NDDs: OR = 2.42, 95% CI = 2.20-2.67). Adults with CP+NDDs had higher unadjusted prevalence and adjusted OR of each polypharmacy definition compared with CP only. Compared with elderly without CP, the unadjusted prevalence of polypharmacy was lower for young adults with CP only (e.g., ≥ 5 medications: 60.2%, 43.8%), similar for young adults with CP+NDDs (e.g., ≥ 15 medications: 10.9%, 12.5%), and elevated for middle-aged CP only and CP + NDDs (e.g., ≥ 10 medications: 28.7%, 34.3%, 41.7%).

CONCLUSIONS

Privately insured adults with CP only and CP + NDDs have an elevated prevalence of polypharmacy compared with adults without CP, even after accounting for multimorbidity. Importantly, adults aged 18-40 years with CP have a similar (CP + NDDs) prevalence of polypharmacy compared with the general geriatric population, with the prevalence increasing further for CP by middle age.

DISCLOSURES

Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund and the American Academy of Cerebral Palsy and Developmental Medicine. These funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The other authors have no conflicts of interest to disclose.

Effect of pain on mood affective disorders in adults with cerebral palsy

AIM

To determine if pain is associated with 12-month incidence of mood affective disorders (MAD) in adults with cerebral palsy (CP).

METHOD

Data from Optum Clinformatics^® Data Mart (2013-2016) were used for this retrospective cohort study. Diagnostic codes were used to identify adults (≥18y) with CP, incident cases of MAD, and covariates (other neurodevelopmental conditions, sleep disorders, arthritis). Pain (any type, location) was identified between 1st October 2014 and 30th September 2015. The pain group was divided into new or consistent pain if they had a history of pain (i.e. consistent) in the 12 months before their first pain claim date. Crude incidence rates of MAD (expressed per 100 person-years) were estimated. Cox regression was used to estimate hazard ratio (95% confidence interval [CI]) of MAD after adjusting for covariates.

RESULTS

Adults that had new pain (n=859; incidence rate=15.5) or consistent pain (n=1303; incidence rate=17.9) had greater crude incidence rate of MAD compared to adults without pain (n=3726; incidence rate=5.9). The elevated rate of MAD remained after adjusting for covariates, for new pain (hazard ratio=2.4; 95% CI=1.9-3.0) and consistent pain (hazard ratio=2.1; 95% CI=1.7-2.7).

INTERPRETATION

Pain is associated with greater incidence of MAD in adults with CP. This association remained after accounting for potential confounding factors.

WHAT THIS PAPER ADDS

What this paper adds Pain was associated with higher 12-month incidence of mood affective disorders (MAD). The 12-month MAD incidence was similar between new and consistent pain groups. The MAD incidence remained higher adjusting for neurodevelopmental comorbidities, sleep disorders, and arthritis.

The Formula for Health and Well-Being in Individuals With Cerebral Palsy: Cross-Sectional Data on Physical Activity, Sleep, and Nutrition

Objective

To determine physical activity, sleep, and nutrition patterns in individuals with cerebral palsy (CP) and investigate the association of Gross Motor Function Classification System (GMFCS) and age with these health behaviors.

Methods

A cross-sectional study was conducted in an outpatient setting. Participants included adolescents and adults with CP (n=28; GMFCS level I–V; mean age 35.1±14.4 years). An Exercise Questionnaire or Leisure Time Physical Activity Questionnaire was used to measure physical activity in adolescents and adults, respectively. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). An adapted version of the PrimeScreen questionnaire was used to assess nutrition. Linear regression analyses were performed to investigate the association between GMFCS and age with physical activity, sleep, and nutrition.

Results

The average total physical activity was 29.2±30.0 min/day. Seventy-five percent of the participants had poor sleep quality (PSQI score >5). Seventy-one percent reported “fair” eating behaviors; none reported “excellent” eating behaviors. Neither GMFCS nor age were significantly associated with PSQI score, PrimeScreen score, or total physical activity. A negative correlation existed between sleep quantity (hr/night) and PSQI score (r=-0.66, p=0.01).

Conclusion

The triad of health components, consisting of physical activity, sleep, and nutrition, was not associated with GMFCS or age in our sample of 28 individuals with CP, suggesting that these three health behaviors should be assessed during clinical encounters of CP in adolescents and adults at all levels of the GMFCS.

Greater Visceral Fat but No Difference in Measures of Total Body Fat in Ambulatory Children With Spastic Cerebral Palsy Compared to Typically Developing Children

BACKGROUND

Individuals with cerebral palsy (CP) are at increased risk for obesity and obesity-related complications. Studies of total body fat in those with CP are inconsistent and studies of abdominal fat are lacking in children with CP. The objective of this study was to determine if ambulatory children with spastic CP have greater central adiposity compared to typically developing children.

METHODOLOGY

Eighteen ambulatory children with spastic CP (n = 5 girls; 8.6 ± 2.9 yr) and 18 age-, sex-, and race-matched typically developing children (controls; 8.9 ± 2.1 yr) participated in this cross-sectional study. Children with CP were classified as I or II using the Gross Motor Function Classification System. Dual-energy X-ray absorptiometry assessed body composition, including total body, trunk and abdominal fat mass, fat-free mass, fat mass index (FMI), and fat-free mass index (FFMI).

RESULTS

There were no group differences in fat mass, fat-free mass, FMI, and FFMI in the total body, fat mass, fat-free mass, and FFMI in the trunk, or fat mass, visceral fat mass, and subcutaneous fat mass in the abdomen (p > 0.05). Compared to controls, children with CP had higher trunk FMI, abdominal FMI, and visceral FMI (p < 0.05). Although marginally insignificant (p = 0.088), children with CP had higher subcutaneous FMI.

CONCLUSIONS

Ambulatory children with spastic CP have elevated central adiposity, especially in the visceral region, despite no differences in measures of total body fat. How this relates to cardiometabolic disease progression in those with CP requires further investigation.

The Relationship Between Body Composition and Muscle Tone in Children with Cerebral Palsy: A Case-Control Study

The monitoring of children with cerebral palsy (CP) should include a precise assessment of the nutritional status to identify children and adolescents at risk of nutrition disorders. Available studies assessing the nutritional status of children with CP mainly focus on the relationship between body composition and the coexistence of motor dysfunctions, frequently overlooking the role of muscle tone. Therefore, the aim of this study was to assess the relationship between body composition and muscle tone in children with CP. In a case-control study (n = 118; mean age 11 y; SD = 3.8), the children with CP presented various stages of functional capacities, corresponding to all the levels in gross motor function classification system (GMFSC), and muscle tone described by all the grades in Ashworth scale. The control group consisted of healthy children and adolescents, strictly matched for gender and age in a 1:1 case-control manner. The children with CP were found with significantly lower mean values of fat-free mass (FFM kg = 29.2 vs. 34.5, p < 0.001), muscle mass (MM kg = 18.6 vs. 22.6, p < 0.001), body cell mass (BCM kg = 15.1 vs. 18.3, p < 0.001), and total body water (TBW L = 23.0 vs. 26.7, p < 0.001). The same differences in body composition were identified with respect to gender (p < 0.01 respectively). Moreover, children with higher muscle tone (higher score in Ashworth scale) were found with significantly lower values of fat mass (FM), FFM, MM, BCM, and TBW (p < 0.05). The findings showed lower parameters of body composition in the children with CP compared to the healthy children, and a decrease in the parameters coinciding with higher muscle tone in the study group. This observation suggests that it is necessary to measure muscle tone while assessing nutritional status of children with CP.

Incidence Rate of Advanced Chronic Kidney Disease Among Privately Insured Adults with Neurodevelopmental Disabilities

Purpose

Due to complex medical profiles, adults with neurodevelopmental disabilities (NDDs) may have a heightened risk for early development of chronic kidney disease (CKD) and accelerated CKD progression to advanced stages and kidney failure. The purpose of this study was to estimate the incidence rate of advanced CKD for adults with NDDs and compare the incidence rate to adults without NDDs.

Patients and Methods

Data were used from the Optum Clinformatics^® Data Mart to conduct this retrospective cohort study. The calendar year 2013 was used to identify eligible participants: individuals ≥18 years of age and without advanced CKD. Participants were followed from 01/01/2014 to advanced CKD, loss to follow-up, death, or end of the study period (12/31/2017), whichever came first. Diagnostic, procedure, and diagnosis-related group codes identified NDDs (intellectual disabilities, cerebral palsy, autism spectrum disorders), incident cases of advanced CKD (CKD stages 4+), diabetes, cardiovascular diseases, and hypertension present in the year 2013. Crude incidence rates (IR) of advanced CKD and IR ratios (IRR), comparing adults with vs without NDDs (with 95% CI) were estimated. Then, Cox regression estimated the hazard ratio (HR and 95% CI) for advanced CKD, comparing adults with NDDs to adults without NDDs while adjusting for covariates.

Results

Adults with NDDs (n=33,561) had greater crude IR of advanced CKD (IRR=1.32; 95% CI=1.24–1.42) compared to adults without NDDs (n=6.5M). The elevated rate of advanced CKD among adults with NDDs increased after adjusting for demographics (HR=2.19; 95% CI=2.04–2.34) and remained elevated with further adjustment for hypertension and diabetes (HR=2.01; 95% CI=1.87–2.15) plus cardiovascular disease (HR=1.84; 95% CI=1.72–1.97). Stratified analyses showed that the risk of advanced CKD was greater for all NDD subgroups.

Conclusion

Study findings suggest that adults with NDDs have a greater risk of advanced CKD than do adults without NDDs, and that difference is not explained by covariates used in our analysis.

Elevated fracture risk for adults with neurodevelopmental disabilities

BACKGROUND

Fracture is a high-burden condition that accelerates unhealthful aging and represents a considerable economic burden. Adults with neurodevelopmental disabilities (NDDs) may be susceptible for fracture at younger ages compared to adults without NDDs; and yet, very little is known about the burden of fracture for these underserved populations. The purpose of this study was to determine the sex-stratified prevalence of all-cause fracture among adults with NDDs, as compared to adults without NDDs, and if comorbidity of NDDs is associated with greater risk of fracture.

METHODS

Data from 2016 were extracted from Optum Clinformatics® Data Mart (private insurance) and a random 20% sample from Medicare fee-for-service (public insurance). ICD-10-CM diagnosis codes were used to identify adults with NDDs, including intellectual disabilities, autism spectrum disorders, and cerebral palsy. Age-standardized prevalence of any fracture and fracture by anatomical location was compared between adults with and without NDDs, and then for adults with 1 NDD vs. 2 and 3 NDDs.

RESULTS

Adults with intellectual disabilities (n=69,456), autism spectrum disorders (n=21,844), and cerebral palsy (n=29,255) had a higher prevalence of any fracture compared to adults without NDDs (n=8.7 million). For women, it was 8.3%, 8.1%, and 8.5% vs. 3.5%, respectively. For men, it was 6.6%, 5.9%, and 6.7% vs. 3.0%, respectively. Women with NDDs had a higher prevalence of fracture of the head/neck, thoracic, lumbar/pelvis, upper extremities, and lower extremities compared to women without NDDs. A similar pattern was observed for men, except for no difference for lumbar/pelvis for all NDDs and thoracic for autism spectrum disorders. For women and men, increasing comorbidity of NDDs was associated with a higher prevalence of any fracture: 1 NDD (women, 7.7%; men, 5.7%); 2 NDDs (women, 9.4%; men, 7.2%); all 3 NDDs (women, 11.3%; men, 13.7%).

CONCLUSIONS

Study findings suggest that adults with NDDs have an elevated prevalence of fracture compared to adults without NDDs, with the fracture risk being higher with greater numbers of comorbid NDD conditions for most anatomical locations. Our study findings indicate a need for earlier screening and preventive services for musculoskeletal frailty for adults with NDDs.

The effect of low-trauma fracture on one-year mortality rate among privately insured adults with and without neurodevelopmental disabilities

BACKGROUND

Individuals with neurodevelopmental disabilities (NDDs) have poor development and preservation of skeletal health throughout the lifespan, and are especially vulnerable to low-trauma fracture and post-fracture health complications. However, no studies have examined if adults with NDDs have greater post-fracture mortality risk compared to adults without NDDs. The purpose of this study was to determine whether adults with NDDs have greater 12-month mortality rates following a low-trauma fracture compared to adults without NDDs.

METHODS

Data from 2011 to 2017 was leveraged from Optum Clinformatics® Data Mart; a nationwide claims database from a single private payer in the U.S. Data were extracted from adults (18+ years) with and without NDDs that sustained a low-trauma fracture between 01/01/2012-12/31/2016, as well as pre-fracture chronic diseases (i.e., cardiovascular diseases, cerebrovascular diseases, diabetes, chronic obstructive pulmonary diseases, cancer). Mortality rate was estimated for adults with and without NDDs, and the mortality rate ratio (RR) and 95% confidence interval (CI) was calculated. Cox regression was used to estimate hazard ratio (HR) and 95% CI for 1-, 3-, 6-, and 12-month post-fracture mortality rates between adults with and without NDDs after adjusting for age, sex, race, U.S. region, and pre-fracture chronic diseases.

RESULTS

Mean age (SD) at baseline was 56.7 (20.6) for adults with NDDs (n = 3749; 45.2% men) and 63.9 (19.2) for adults without NDDs (n = 585,910; 34.4% men). During the 12-month follow-up period, 182 adults with NDDs (mean age [SD] = 69.8 [14.7]; 46.2% men) and 25,456 adults without NDDs (mean age [SD] = 78.9 [9.8]; 38.3% men) died. Crude mortality rate was not different between adults with and without NDDs for any time points (e.g., 12-months: 5.40 vs. 4.96 per 100 person years; RR = 1.09; 95% CI = 0.94-1.26); however, it was greater for adults with intellectual disabilities compared to adults without NDDs (RR = 1.46; 95% CI = 1.23-1.79). After adjustments, adults with NDDs had greater post-fracture mortality rates for 3-, 6-, and 12-month time points (e.g., 12-months: HR = 1.46; 95% CI = 1.27-1.69). When stratified by the type of NDD, adults with intellectual disabilities and adults with autism spectrum disorders, but not adults with cerebral palsy, had greater 12-month post-fracture mortality risk. When stratified by fracture location, lower extremities were associated with greater crude mortality rate (RR = 1.69; 95% CI = 1.22-2.35) and adjusted mortality risk (HR = 2.41; 95% CI = 1.73-3.35), while upper extremities were associated with greater adjusted mortality risk (HR = 1.76; 95% CI = 1.23-2.50) for adults with vs. without NDDs.

CONCLUSIONS

Among privately insured adults with NDDs, low-trauma fracture is associated with greater mortality risk within 1 year of the fracture event, even after adjusting for pre-fracture chronic diseases. Study findings suggest the need for earlier fracture prevention strategies and improved post-fracture healthcare management.

Total and regional body fat status among children and young people with cerebral palsy: A scoping review

The purpose of our scoping review was to determine if children and young people with cerebral palsy (CP) have elevated total or regional body fat compared to children and young people without CP. Databases (Ovid MEDLINE, Embase Ovid, CINHAL and Scopus) were systematically searched from 1 January 1993 to 7 December 2018 in order to identify articles that compared weight status, total body fat or regional body fat (eg, abdominal) between children and young people (0-21 years) with and without CP. Extracted data included country, subject characteristics, group sample sizes and matching strategies, methods/measures for weight status/fat depot, fat depot(s) assessed and key findings. Twenty-two studies were included. Of these, 19 studies examined total body fat; the most common method was use of anthropometrics and the more common measures were body mass index and skin-fold thickness. Twelve studies examined at least one regional fat depot; the most common method was use of anthropometrics and the most common measure was skin-fold thickness. Findings were inconsistent across studies. Further, among 10 studies that examined total and regional body fat depots, 8 found differences across fat depots within the same children and young people (eg, no difference in total body fat but higher abdominal fat). This review provides a summary of inconsistent findings from published studies on body fat comparisons between children and young people with vs without CP, highlights limitations for evaluating body fat for children with CP and discusses future research directions.

Prevalence of Mental Health Disorders Among Adults With Cerebral Palsy: A Cross-sectional Analysis

BACKGROUND

Persons with cerebral palsy (CP) have an increased risk for secondary chronic conditions during childhood, including mental health disorders. However, little is known about how these disorders affect adults with CP.

OBJECTIVE

To determine the prevalence of mental health disorders among adults with CP compared with those without CP.

DESIGN

Cross-sectional.

SETTING

2016 Optum Clinformatics Data Mart.

PATIENTS

8.7 million adults (including 7348 adults with CP).

MEASUREMENTS

Other neurodevelopmental comorbid conditions (intellectual disabilities, autism spectrum disorders, epilepsy) and 37 mental health disorders (as 6 categories) were identified on the basis of diagnosis codes. Direct age-standardized prevalence of the mental health disorder categories was estimated by sex for adults with CP alone, adults with CP and neurodevelopmental disorders, and adults without CP.

RESULTS

Men with CP alone had higher age-standardized prevalence than men without CP for schizophrenic disorders (2.8% [95% CI, 2.2% to 3.4%] vs. 0.7%), mood affective disorders (19.5% [CI, 18.0% to 21.0%] vs. 8.1%), anxiety disorders (19.5% [CI, 18.0% to 21.0%] vs. 11.1%), disorders of adult personality and behavior (1.2% [CI, 0.8% to 1.6%] vs. 0.3%), and alcohol- and opioid-related disorders (4.7% [CI, 3.9% to 5.5%] vs. 3.0%). The same pattern was observed for women. Compared with adults with CP alone, those with CP and neurodevelopmental disorders had similar or higher age-standardized prevalence of the 6 mental health disorder categories, except for the lower prevalence of alcohol- and opioid-related disorders in men.

LIMITATIONS

Single claims code was used to define the cohort of interest. Information on the severity of CP was not available.

CONCLUSION

Compared with adults without CP, those with CP have an elevated prevalence of mental health disorders, some of which may be more pronounced in patients with comorbid neurodevelopmental disorders.

PRIMARY FUNDING SOURCE

National Institute on Disability, Independent Living, and Rehabilitation Research.

Incidence of osteoarthritis, osteoporosis and inflammatory musculoskeletal diseases in adults with cerebral palsy: A population-based cohort study

BACKGROUND

People with cerebral palsy (CP) may be at increased risk of musculoskeletal conditions due to various factors including malnutrition and abnormal levels of skeletal loading. This study aimed to compare the incidence of osteoporosis, osteoarthritis and inflammatory musculoskeletal diseases between adults with and without CP.

METHODS

A population based cohort study was conducted using data from the Clinical Practice Research Datalink collected between 1987 and 2015. Adults with CP were matched to adults without CP for age, sex and general practice. Cox models, stratified by matched set and adjusted for potential confounders, were fitted to compare the risk of osteoporosis, osteoarthritis and inflammatory musculoskeletal diseases.

RESULTS

1705 adults with CP were matched to 5115 adults without CP. Adults with CP had an increased risk of osteoporosis in unadjusted (Hazard Ratio (HR) 3.67, 95% Confidence Interval (CI) 2.32 to 5.80, p < 0.001) and adjusted (HR 6.19, 95% CI 3.37 to 11.39, p < 0.001) analyses. No evidence of increased risk of inflammatory musculoskeletal diseases was observed in unadjusted or adjusted analyses. For osteoarthritis no evidence of increased risk was seen in the unadjusted analysis, but evidence of an increased risk was seen when the analysis was adjusted for alcohol consumption, smoking status, and mean yearly general practice (GP) visits (HR 1.54, 95% CI 1.17 to 2.02, p < 0.001).

CONCLUSIONS

After accounting for potential confounding variables, we found that CP is associated with increased risk of osteoporosis and osteoarthritis. These findings provide the strongest epidemiological evidence to date for increased risk of osteoporosis and osteoarthritis in people with CP, and highlight need for clinical awareness of such conditions in this population.

Racial differences in skeletal fragility but not osteoarthritis among women and men with cerebral palsy

Background

Adults with cerebral palsy (CP) have increased risk for skeletal fragility and osteoarthritis. However, racial differences in these outcomes have not been examined. Such knowledge could improve patient-specific clinical care for the prevention and management of these conditions. The purpose of this study was to determine if there were racial differences in the prevalence of osteoporosis, all-cause fracture, and osteoarthritis among young and middle-aged adults with CP.

Methods

Data from 2016 were extracted from a random 20% sample of the Medicare fee-for-service database. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify 18-64 year olds with CP, as well as osteoporosis, all-cause fracture, osteoarthritis, and neurodevelopmental and noncommunicable disease comorbidities.

Results

Of the 16,488 adults with CP, 13,334 were White, 2477 were Black, and 677 were Hispanic. The age-standardized prevalence of osteoporosis (women: 12.9%, 9.0%, 8.3%, respectively; men: 9.2%, 4.8%, 7.9%, respectively) and fracture (women: 7.4%, 4.2%, 9.9%; men: 6.0%, 2.3%, 6.0%) was lower for Black adults with CP compared to White adults with CP (all p < 0.005). No racial differences were observed for age-standardized prevalence of osteoarthritis (women: 13.6%, 14.4%, 9.6%; men: 10.7%, 10.4%, 12.7%). The racial differences between Black and White adults with CP remained even after adjusting for age, U.S. region, neurodevelopmental comorbidities, and several noncommunicable diseases for osteoporosis (women: OR = 0.66, 99.5% CI = 0.48-0.91; men: OR = 0.51, 99.5% CI = 0.35-0.75) and fracture (women: OR = 0.57, 99.5% CI = 0.37-0.89; men: OR = 0.39, 99.5% CI = 0.23-0.68).

Conclusions

Study findings suggest racial differences in skeletal fragility among young and middle-aged adults with CP, with White women and men with CP having greater risk compared to Black women and men with CP. This study found no evidence of racial differences in the prevalence of osteoarthritis.

Adults with Cerebral Palsy have Higher Prevalence of Fracture Compared with Adults Without Cerebral Palsy Independent of Osteoporosis and Cardiometabolic Diseases

Individuals with cerebral palsy (CP) have an increased risk of fracture throughout their lifespan based on an underdeveloped musculoskeletal system, excess body fat, diminished mechanical loading, and early development of noncommunicable diseases. However, the epidemiology of fracture among adults with CP is unknown. The purpose of this cross-sectional study was to determine the prevalence of fracture among a large sample of privately insured adults with CP, as compared with adults without CP. Data were from the Optum Clinformatics Data Mart (Eden Prairie, MN, USA), a deidentified nationwide claims database of beneficiaries from a single private payer. Diagnostic codes were used to identify 18- to 64-year-old beneficiaries with and without CP and any fracture that consisted of osteoporotic pathological fracture as well as any type of fracture of the head/neck, thoracic, lumbar/pelvic, upper extremity, and lower extremity regions. The prevalence of any fracture was compared between adults with (n = 5,555) and without (n = 5.5 million) CP. Multivariable logistic regression was performed with all-cause fracture as the outcome and CP group as the primary exposure. Adults with CP had a higher prevalence of all-cause fracture (6.3% and 2.7%, respectively) and fracture of the head/neck, thoracic, lumbar/pelvic, upper extremity, and lower extremity regions compared with adults without CP (all p < 0.01). After adjusting for sociodemographic and socioeconomic variables, adults with CP had higher odds of all-cause fracture compared with adults without CP (OR 2.5; 95% CI, 2.2 to 2.7). After further adjusting for cardiometabolic diseases, adults with CP had higher odds of all-cause fracture compared with adults without CP (OR 2.2; 95% CI, 2.0 to 2.5). After further adjusting for osteoporosis, adults with CP still had higher odds of all-cause fracture compared with adults without CP (OR 2.0; 95% CI, 1.8 to 2.2). These findings suggest that young and middle-aged adults with CP have an elevated prevalence of all-cause fracture compared with adults without CP, which was present even after accounting for cardiometabolic diseases and osteoporosis. © 2019 American Society for Bone and Mineral Research.

Prevalence of high-burden medical conditions and health care resource utilization and costs among adults with cerebral palsy

Purpose: Individuals with cerebral palsy (CP) are susceptible to early development of high-burden medical conditions, which may place a considerable strain on health care resources. However, little is known about the prevalence of high-burden medical conditions or health care resource utilization among adults with CP. The purpose of this study was to determine the prevalence of high-burden medical conditions and health care resource utilization and costs among adults with CP, as compared to adults without CP.

Patients and methods: Cross-sectional data from the 2016 Optum Clinformatics^® Data Mart, a de-identified nationwide claims database of beneficiaries from a single private payer in the US. ICD-10-CM diagnosis codes were used to identify all medical conditions among beneficiaries with and without CP who were between 18 and 64 years of age. Medical and outpatient pharmacy claims were used to identify annual all-cause health care resource utilization and health care costs as standardized reimbursement and patient out-of-pocket costs.

Results: Adults with CP (n=5,555) had higher prevalence and odds of all medical conditions compared to adults without CP (OR=1.3–5.8; all P<0.05), except cancer (OR=1.1; 95% CI=0.9–1.3). Adults with CP had greater annual mean counts of all health care service types (eg, inpatient, emergency department) compared to adults without CP (all P<0.01). Adults with CP had higher unadjusted standardized reimbursement (mean difference=$16,288; cost ratio [CR]=3.0; 95% CI=2.9–3.1) and patient out-of-pocket (mean difference=$778; CR=1.7; 95% CI=1.6–1.7) costs compared to adults without CP. After adjusting for all prevalent medical conditions, adults with CP still had higher standardized reimbursement (CR=2.5; 95% CI=2.5–2.6) and patient out-of-pocket (CR=1.8; 95% CI=1.7–1.8) costs.

Conclusion: Adults with CP have a higher prevalence of high-burden medical conditions, health care resource utilization, and health care costs compared to adults without CP. Study findings suggest the need for earlier screening strategies and preventive medical services to quell the disease and economic burden attributable to adults with CP.

Criterion validity of assessment methods to estimate body composition in children with cerebral palsy: A systematic review

BACKGROUND

Poor nutritional status is a problem in a high number of children with cerebral palsy (CP) and impairs their well-being. Therefore, periodic assessment of nutritional status and especially body composition is essential. However, we lack consensus on the best method to assess body composition in clinical practice.

OBJECTIVE

We aimed to systematically review the available evidence on the criterion validity of equation-based skinfold measurement and bioelectrical impedance analysis (BIA) to estimate body composition in children with CP.

METHODS

In a systematic review (MEDLINE, Cochrane Library and EMBASE), we identified studies that reported on the agreement between the estimation of body composition by equations of skinfold thickness or impedance values of BIA with a gold standard (isotope techniques or dual-energy-X-ray-absorptiometry [DXA]) in children with CP. We included only studies that provided correlations or agreement between estimations of body compartments (e.g., percentage body fat [%BF] or fat mass). Limits of agreement of 2.5%BF points were considered acceptable. Study quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies 2.

RESULTS

We included reports of 9 studies describing 3 skinfold equations and 4 equations to estimate body composition with BIA. Neither skinfold equations nor BIA could be reliably used to assess body composition in an individual child with CP at one point in time. On a population level, the Gurka skinfold equation was valid in ambulant children with CP, and the Kushner and Fjeld BIA equations were valid in a heterogeneous group of children with CP. Conclusions The future role of skinfold equations and BIA to assess and monitor body composition in an individual child with CP needs to be further investigated.

Nutritional Status and Cardiometabolic Risk Factors in Institutionalized Adults with Cerebral Palsy

Background and Objectives: Cerebral palsy (CP) is a set of permanent disorders that limit physical activity and increase the risk of developing other diseases, such as metabolic syndrome (MS). Adequate nutrition can contribute to the prevention of associated symptoms. The main objective of this study is to evaluate the nutritional status and the prevalence of cardiometabolic risk factors in adults with CP and Gross Motor Function Classification System (GMFCS) levels between IV and V. Materials and Methods: A sample of 41 adults with CP and GMFCS levels from IV to V were studied. The variables used in the study were age, sex, weight, height, mean age, and GMFCS level range. To evaluate nutritional status, body mass index and the Mini Nutritional Assessment (MNA), a nutritional screening tool, were used. To assess cardiometabolic risk, data on obesity, central obesity, blood pressure, fasting plasma glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides were collected. Results: More than 80% of the population studied was malnourished or at risk of malnutrition, according to the MNA tool classification ranges, and around 35% of the studied population was within the underweight range. Regarding cardiometabolic risk factors, only one adult with CP was diagnosed with MS. Conclusions: The studied population of adults with CP and GMFCS levels between IV and V is not a population at risk of MS; however, the high prevalence of malnutrition, as well as some of the most prevalent cardiovascular risk factors, should be taken into consideration.