Assessment of body composition in children with cerebral palsy: a cross-sectional study in Norway

Muscle Mass as a Biomarker for Health Status and Function in Pediatric Individuals with Neuromuscular Disabilities: A Systematic Review

This systematic review aims to investigate the relationship between muscle mass and specific health outcomes in pediatric populations with neuromuscular disorders. A search was performed for any relevant studies published in English from 1996 to 2023 in five databases. To be included in this analysis, articles must have had participants with an average age ≤21, focus on children with neuromuscular disabilities, and primarily examine relationships between muscle mass and any functional or health outcomes measure. Studies including typically developing children were used to contrast and enhance findings. Thirty-two studies were included, with 10,129 unique individuals represented: seventeen studies focused on healthy/typically developing children; seven on children with cerebral palsy; three on children with Duchenne muscular dystrophy; two on children with sarcopenia; and one study each on children with osteoporosis, congenital muscular dystrophy, and other various neurologic disorders. Thirteen studies assessed functional outcomes, ten assessed bone outcomes, and nine assessed other cardiovascular/metabolic outcomes. All of the included studies demonstrated relationships between muscle mass and respective outcomes in varying measures. The results of this review demonstrate that there is a consistently recognized relationship between muscle mass and important health outcomes in children, supporting clinically targeting muscle mass as a means to optimize desired outcomes.

Telehealth Movement-to-Music With Arm-Based Sprint-Intensity Interval Training to Improve Cardiometabolic Health and Cardiorespiratory Fitness in Children With Cerebral Palsy: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Children with mobility disabilities, including those with cerebral palsy, have limited options and limited time to exercise to manage their cardiometabolic health and cardiorespiratory fitness. Regular cardiovascular exercise during childhood is a critical health behavior for preventing health decline in adulthood. Thus, there is an urgent need for accessible, age-appropriate, convenient exercise modalities in this group. Sprint-intensity interval training (SIT), combined with telehealth procedures, may be ideal for children with disabilities. SIT includes repetitive bouts of maximal exercise effort combined with rest periods, which can be effective in eliciting comparable results to moderate-exercise training with very short training durations.

OBJECTIVE

This phase 1 pilot feasibility randomized controlled trial aims to investigate the potential effects of a 12-week SIT program on indicators of cardiorespiratory fitness and cardiometabolic health among children with cerebral palsy. An ancillary aim is to evaluate the feasibility of the program through several process feasibility metrics.

METHODS

This study uses a 2-armed parallel group design. A total of 50 physically inactive children with cerebral palsy (aged 6-17 years) will be randomly allocated into 1 of 2 groups: a 12-week SIT or a waitlist control group that continues habitual activity for 12 weeks. The SIT prescription includes 3 tele-supervised sessions per week with 30 repeated sequences of 4 seconds of maximal arm exercise, with active recovery, warm-up, and cooldown periods (for an approximately 20-minute total session). SIT includes guided videos with child-themed arm routines and music. The exercise sessions will be remotely supervised through a web-based videoconference application and include safety monitoring equipment. Outcomes are measured at pre- and postintervention (weeks 0 and 13, respectively). Health outcome measures include peak oxygen consumption (VO2 peak), measured by a graded exercise test; high-sensitivity C-reactive protein and blood insulin, hemoglobin A1c, triglycerides, and cholesterol using a finger stick dried blood spot test; blood pressure, using a sphygmomanometer; and body composition (total mass, total lean mass, tissue % lean, and tissue % fat) using dual x-ray absorptiometry. Feasibility will be evaluated by the following metrics: adverse events or problems experienced throughout the intervention related to participant safety; perceived enjoyment; and recruitment, enrollment, and attrition rates.

RESULTS

Recruitment procedures started in November 2023. All data are anticipated to be collected by February 2025. Full trial results are anticipated to be analyzed and submitted for publication by March 2025. Secondary analyses of data will be subsequently published.

CONCLUSIONS

This trial tests an accessible and low-cost exercise program that leverages principles of high-intensity exercise to provide a convenient program for children with physical disabilities. Knowledge obtained from this study will inform the development of a larger trial for improving the cardiometabolic health, cardiorespiratory fitness, and well-being of children with physical disabilities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05619211; https://clinicaltrials.gov/study/NCT05619211.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56499.

A Cross-Sectional Study Examining the Relationship Between Malnutrition and Gross Motor Function in Cerebral Palsy

Introduction Cerebral palsy (CP) characterizes a range of permanent, nonprogressive symptoms of postural and motor dysfunction caused by an insult to the developing central nervous system in a fetus or an infant. CP manifests early in life, often within the first two to three years of age. CP is associated with poor growth, that is the deviation from the normal growth parameters. The prevalence of CP ranges from 2.0 to 3.5 per 1000 live births in high-income countries which is comparable to the estimates from low-income countries. Antenatal and perinatal insults are among the most commonly reported causes of CP; however, a large number of cases do not have an identifiable etiology of CP. The current study aims to examine the relationship between malnutrition and gross motor function in children with CP. Materials and Methods This study was conducted at the Department of Pediatrics and Neonatology, Nehru Hospital, Baba Raghav Das (BRD) Medical College, Gorakhpur (UP) over a period of one year (August 2020 to July 2021) after obtaining ethical clearance from the College Research Council. Children of age 1-15 years with CP attending the pediatric outpatient and inpatient departments were enrolled as the study participants after obtaining informed consent from a legal guardian. Assessment of motor function was done using the gross motor function classification system (GMFCS). Associations of malnutrition across levels of gross motor function were tested using Chi-square or Fisher's exact test whichever was applicable. Statistical significance was set at p < 0.05 as significant. Data was analyzed using IBM SPSS Statistics for Windows, Version 21 (Released 2012; IBM Corp., Armonk, New York, United States). Result We analyzed 110 children with a diagnosis of CP (median age 6.5 years, interquartile range (IQR) 4.4-9.0 years). The majority (65/110; 59%) of the patients were male, and 68 (61.8%) delivered at term gestation. The most common presenting symptom among children with CP was seizures (79/110; 72.3%), the second most common being delayed milestones among 73 (66.8%), followed by difficulty in breathing among 63 (57.5%). The association between the anthropometric index of participants and GMFCS was found to be highly significant. Conclusion Most CP patients were facing gross motor disturbances. Spastic type of CP was most frequent, and more than half of the patients experienced feeding difficulty. A statistically significant association was found between gross motor functioning and the prevalence of malnutrition and stunting.

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.

Low skeletal muscle mass and liver fibrosis in children with cerebral palsy

The purpose of the study was to conduct a nutritional and metabolic assessment of children with cerebral palsy, including an investigation of liver status, body composition, and bone mineral density. In this cross-sectional study we included 22 children with cerebral palsy. By using ultrasound, transient elastography, dual x-ray absorptiometry (DXA) scan, blood samples, anthropometric measurements, and a three-day diet registration, the nutritional and metabolic status was evaluated. Liver fibrosis and steatosis were found in four patients (18.2%), all with severe motor impairments, low skeletal muscle mass, and epilepsy. All patients with liver involvement had normal liver-related blood samples. Decreased bone mineral density was found in 26.3%, and 91.0% had low skeletal muscle mass. Fat mass and muscle mass were significantly lower in the patients with severe motor impairments compared to the patients with less severe motor impairments. Within the children classified as 'underweight' or 'normal' according to body mass index, body fat determined by DXA scan was normal or high in 50% of these patients.

CONCLUSIONS

This study is the first to report liver fibrosis and steatosis in children with cerebral palsy. Possible causes of liver fibrosis and/or steatosis are altered body composition with low skeletal muscle mass, decreased mobility and medical drug intake. Further investigations of liver involvement and risk factors are needed.

WHAT IS KNOWN

• Children and adolescents with cerebral palsy are at risk of malnutrition and altered body composition, both of which can lead to fatty liver disease. • It is unknown whether children with cerebral palsy are at increased risk of metabolic disturbances such as fatty liver disease.

WHAT IS NEW

• Altered body composition and low skeletal muscle mass, regardless of ambulation is present in 91% of the children with cerebral palsy. • Liver fibrosis and/or steatosis were found in 18.2% of the patients. Possible causes are altered body composition, decreased mobility and medical drug intake.

Physical Activity Levels and Adiposity in Ambulant Children and Adolescents With Cerebral Palsy Compared With Their Typically Developing Peers

PURPOSE

This study assessed physical activity (PA) and body composition of ambulatory children and adolescents with cerebral palsy (CP) and their typically developing peers.

METHODS

Participants included youth with CP (ages 8-18 y and Gross Motor Function Classification System [GMFCS] levels I-III) and their typically developing peers. Outcomes included PA (actigraphy) and fat/lean mass index (FMI/LMI; dual-energy X-ray absorptiometry). Statistical analyses included linear mixed effects models with Bonferroni adjustment. Fixed effects were study group (CP and typically developing); random effects were participant clusters (sex and age). Exploratory analyses included association of body composition and PA, GMFCS level, and CP involvement (unilateral and bilateral).

RESULTS

Seventy-eight participants (CP: n = 40, girls: n = 29; GMFCS I: n = 20; GMFCS II: n = 14; GMFCS III: n = 6) met inclusion criteria. Individuals with CP had lower moderate to vigorous PA (MVPA; β = -12.5; 98.3% confidence interval, -22.6 to -2.5 min; P = .004) and lower LMI (β = -1.1; 97.5% confidence interval, -2.1 to -0.0 kg/m2; P = .020). Exploratory analyses indicated increased LMI with greater MVPA (P = .001), reduced MVPA for GMFCS II (P = .005) and III (P = .001), increased sedentary time for GMFCS III (P = .006), and greater fat mass index with unilateral motor impairment (P = .026).

CONCLUSIONS

The findings contribute to the knowledge base of increasing MVPA and LMI deficits with the greater functional impact of CP. Associations of increasing LMI with greater MVPA support efforts targeting enhanced PA participation to promote independent mobility.

Measurement of body composition by deuterium oxide dilution technique and development of a predictive equation for body fat mass among severe neurologically impaired children

Introduction

Neurologically impaired (NI) children are at risk of malnutrition, which consequently impacts their health and quality of life. Accurate nutrition assessment is an important step in guiding appropriate nutrition support. Conventional anthropometric measurements among NI children have some limitations. Determining body composition requires more complex equipment, which is not routinely performed. This study was conducted to evaluate the association between anthropometric parameters and body composition assessed using the deuterium dilution technique (DDT) in NI children.

Methods

A cross-sectional study enrolled severe NI children aged 1-20 years who received home enteral nutrition for at least 3 months. Weight, length, and 4-site skinfold thickness were measured. Body composition was determined using DDT following the International Atomic Energy Agency (IAEA) protocol.

Results

A total of 37 NI children (56.76% male, median age 7.2 years) were enrolled. The prevalence of underweight, stunting, and overweight were 22, 38, and 35%, respectively. Body composition analysis showed the mean (SD) of total body water (TBW) and fat mass (FM) were 10.52 (4.51) kg and 9.51 (6.04) kg, respectively. Multivariate GLM analysis showed that the factors associated with FM were age (β = 0.07 [0.05,0.08]; p < 0.001), body mass index (BMI) (β = 0.82 [0.52, 1.12]; p < 0.001), biceps skinfold thickness (BSF) (β = 0.49 [0.23,0.75]; p = 0.001), and subscapular skinfold thickness (SSF) (β = -0.24 [-0.46,0.03]; p = 0.030). A predictive equation for FM was constructed.

Conclusion

A high prevalence of malnutrition was found among severe NI children despite enteral nutrition support. Our findings showed that age, BMI, BSF, and SSF were associated with FM. The predictive equation of FM was proposed and needed to be further validated and applied to clinical practice.

Gurka vs Slaughter equations to estimate the fat percentage in children with cerebral palsy from all subtypes and levels of the Gross Motor Function Classification System

BACKGROUND

Body composition assessment in children with cerebral palsy (CP) is a challenge, specially the fat percentage. There are different methods that can be used to estimate the fat percentage in this population, such as anthropometric equations, but there is still a need to determine which is the best and most accurate. The purpose of the study was to determine the method that best estimates the fat percentage in children from all CP subtypes and levels of the Gross Motor Function Classification System (GMFCS).

METHODS

Analytical cross-sectional study in which 108 children with CP diagnosed by a pediatric neurologist were included with any type of dysfunction and from all levels of the GFMCS. Slaughter equation, Gurka equation and Bioelectrical impedance analysis (BIA) as reference method, were used. Groups were stratified by sex, CP subtypes, GMFCS level and Tanner stage. Median differences, Kruskal-Wallis, Mann-Whitney U test, Spearman's correlation coefficients and simple regressions were used, also multivariate models were performed.

RESULTS

The Slaughter equation differed from the other methods in the total population and when it was compared by sex, CP subtypes, gross motor function and Tanner stage. The Gurka equation showed significant differences by sex and gross motor function. Gurka equation correlated positively and significantly with BIA to estimate the fat percentage in all the CP subtypes and levels of the GMFCS. Tricipital skinfold (TSF), arm fat area (AFA) and weight for age index (W/A) showed the highest variability with respect to fat percentage.

CONCLUSION

Gurka equation is more appropriate and accurate than Slaughter equation to estimate the fat percentage in children with CP from all subtypes and levels of the GMFCS.

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.

Influence of malnutrition and body composition on the gross motor function of children with cerebral palsy in Kano, Nigeria: a cross-sectional study

Background

Malnutrition is common among children with cerebral palsy (CWCP); however, its impact on gross motor function (GMF) is not adequately reported. The study evaluated the influence of malnutrition and body composition on GMF.

Methods

In the cross-sectional survey, CWCP were recruited using purposive sampling from three selected secondary and tertiary hospitals in Kano, Nigeria. Sociodemographic variables were recorded on a data capture form. Anthropometric variables were measured using standard procedures. Percent (%) body fat, malnutrition, and GMF were assessed using skinfold thickness, screening tool for the assessment of malnutrition in pediatrics, and GMF classification system (GMFCS), respectively. The data was analyzed with one-way ANOVA, chi-square, and logistic regression using SPSS version 20 at p < 0.05.

Results

The 146 CWCP have mean age of 4.70 ± 2.46 years. About 95 (65.1%) are malnourished. Those with GMFCS V had lower %body fat and higher malnutrition than children with GMFCS II and I, respectively (p < 0.05). Malnutrition has no significant influence on GMF (B = 0.984, OR = 2.676; 95% CI = 0.965–7.423, p > 0.05). %body fat (B = −0.192, OR = 0.826; 95% CI = 0.687–0.992, p < 0.05), type of CP (OR = 12.106; 95% CI = 3.771–38.866, p < 0.005), child’s position in the family (OR = 1.639; 95% CI = 1.162–2.312, p < 0.05), and mothers’ education (B = −2.815, OR = 0.060; 95% CI = 0.012–0.309, p < 0.005) all predicted GMF.

Conclusions

Majority of the CWCP in this study are malnourished. But malnutrition did not however significantly predict GMF, meaning that though malnutrition could impair children’s physical growth and motor development, it however did not have significant influence on their motor function. Hence, CWCP undergoing rehabilitation may not likely experience significant decrease in their motor function due to inadequate nutrition. Decrease in body fat, type of CP, low level of mothers’ education, and child occupying 4th or more position in the family have negative influence on GMF. It was recommended that physiotherapists should routinely assess for malnutrition in CWCP. Prompt nutritional intervention may prevent considerable lose of body fat and augment the gains of physical rehabilitation by providing appropriate nutrition to support muscle growth and the supply of adequate energy for participation in physical exercise. Adequate caregiver education is important for ensuring satisfactory nutrition for CWCP.

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.

The PURPLE N study: objective and perceived nutritional status in children and adolescents with cerebral palsy

PURPOSE

To obtain information on characteristics, management, current objective nutritional status and perception of nutritional status of children with cerebral palsy (CP) from healthcare professionals (HCPs) and caregivers.

MATERIALS AND METHODS

A detailed survey of several items on eight main topics (general characteristics, motor function, comorbidities, therapies, anthropometry, feeding mode and problems and perceived nutritional status) was developed and tested for the study. Correlation between nutritional status and Gross Motor Function Classification System (GMFCS) levels was assessed using continuous variables (Z-scores for weight-for-age, height-for-age, weight-for-height, and body mass index-for-age), and categorical variables (being malnourished, stunted, or wasted). HCP and caregiver perceptions of the child's nutritional status as well as agreement between perceived and objective nutritional status and agreement between perceived nutritional status and concerns about the nutritional status were analyzed.

RESULTS

Data were available for 497 participants from eight European countries. Poorer nutritional status was associated with higher (more severe) GMFCS levels. There was minimal agreement between perceived and objective nutritional status, both for HCPs and caregivers. Agreement between HCP and caregiver perceptions of the child's nutritional status was weak (weighted kappa 0.56). However, the concerns about the nutritional status of the child were in line with the perceived nutritional status.

CONCLUSIONS

The risk of poor nutritional status is associated with more severe disability in children and adolescents with CP. There is a mismatch between HCP and caregiver perceptions of participants' nutritional status as well as between subjective and objective nutritional status. Our data warrant the use of a simple and objective screening tool in daily practice to determine nutritional status in children and adolescents with CP. Clinical trial registration: ClinicalTrials.gov Identifier: NCT03499288 (https://clinicaltrials.gov/ct2/show/NCT03499288). IMPLICATIONS FOR REHABILITATIONUse of the ESPGHAN recommendations and simple screening tools in daily practice is needed to improve nutritional care for individuals with CP.Attention should be paid to the differences in the perception of nutritional status of individuals with CP between professionals and caregivers to improve appropriate referral for nutritional support.Objective measures rather than the professional's perception need to be used to define the nutritional status of individuals with CP.

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).

Diagnostic Evaluation of the Functional Muscle-Bone Unit in Children With Cerebral Palsy With and Without Low Trauma Fractures

Children and adolescents with cerebral palsy (CP) are at increased risk of low trauma fractures (LTF) due to low bone mineral content (BMC). The risk of LTFs might be overestimated by only age - and sex adjusted Z-scores for BMC because Z-score based DXA techniques do not take into account other relevant parameters like height, muscle and fat mass. This study aimed to present an update of the functional muscle-bone unit-algorithm (uFMBU-A) to evaluate bone health in children with CP in order to predict the risk of LTF taking into account the parameters sex, age, height, muscle and fat mass. We performed a monocentric retrospective analysis of 177 DXA-scans of children and adolescents with CP aged 8-19. Six of these 177 patients had sustained at least 1 LTF. Age-, sex- and size adjusted Z-scores of total body less head (TBLH)-BMC, lean body mass and fat mass were calculated. The uFMBU-A was applied to the study group and results were compared with established Z-score based DXA-measurements and algorithm based diagnostic techniques concerning the prediction of LTF risk. The uFMBU-A had the greatest diagnostic odds ratio (13.3 [95% CI 2.41; 72.9]) of the evaluated predictors with a sensitivity of 50.0% (95% CI 11.8; 88.2), specifity of 93% (95% CI 88.1; 96.3). The uFMBU-A was the most accurate method of the evaluated parameters to predict LTF in children with CP and is recommended when evaluating bone health.

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.

Malnutrition and nutritional deficiencies in children with cerebral palsy: a systematic review and meta-analysis

OBJECTIVES

This systematic review study and meta-analysis sought to estimate the prevalence of malnutrition and nutritional deficiencies in children with cerebral palsy (CP).

STUDY DESIGN

This is a systematic review and meta-analysis.

METHODS

The systematic review was conducted according to the PRISMA guidelines. The articles were chosen using the PubMed, Embase, Scopus, Web of Science, Cochrane Library, SciELO, and Lilacs databases and the bibliographical reference lists of the articles. No limitations were placed on the time of publication, but the articles had to include children from 0 to 18 years old with CP who presented the prevalence of malnutrition and nutritional deficiencies. The methodological quality of the articles was assessed using the verification list for analytical cross-sectional studies, the Newcastle-Ottawa scale, and the Cochrane Collaboration tool for randomized studies. The meta-analysis of proportions was conducted based on the prevalence data for malnutrition or nutritional deficiencies. The study is registered in PROSPERO under CRD number 42020175068.

RESULTS

Sixty-seven articles (N = 453,804) published between 1986 and 2019 were included. Most of the articles presented a low risk of bias and no publication was excluded for quality reasons. The most widely used anthropometric index for diagnosing nutritional status was weight-to-age and the estimated prevalence of malnutrition was 40% (95% CI = 28.0-53.0). Nutrient deficiency was investigated by nine publications, with hypocalcemia and reduced serum concentrations of zinc, copper, and vitamin D being reported the most.

CONCLUSIONS

We found a high rate of malnutrition in the population in this review, moreover, we suggest that some nutritional deficiencies are associated with food deficit and that the socio-economic and age factors of these children may relate with the poor nutritional outcome. This makes monitoring and personalized nutritional management necessary, in accordance with the characteristics and particularities of children with CP.

Body Fat Distribution and Associated Risk of Cardiovascular Disease in Adults With Cerebral Palsy

Objective: Fat distribution has increasingly been acknowledged as a more significant health parameter than general obesity, in terms of the risk of cardiovascular disease (CVD). We aimed to investigate the regional fat distribution pattern and general body fat characteristics of adults with cerebral palsy (CP), and we explored the risk of CVD in this population. Methods: People aged ≥20 years who were diagnosed with CP were recruited between February 2014 and November 2014. The subjects underwent a structured interview, laboratory studies, and physical examination. The amount and distribution of fat were determined directly by dual-energy X-ray absorptiometry. Laboratory analysis was performed to measure total cholesterol and triglyceride, high-density lipoprotein (HDL), low-density lipoprotein, and fasting plasma glucose levels. The Framingham risk score (FRS) was used to present the 10-year risk for having CVD, and predictors such as sex, age, total cholesterol, HDL, systolic blood pressure, treatment for hypertension, and smoking status were used to calculate the FRS. Results: Ninety-nine adults (58 men, mean age 41.77 ± 8.95 years) with CP were included. The participants consisted of all five levels of the Gross Motor Function Classification System. The mean body mass index (BMI) was 22.52 ± 4.58 kg/m². According to BMI criteria, 54.9% were overweight and 27.3% were obese. The fat mass index criteria revealed 10.1% excess fat and 7.6% obesity. In univariable regression analysis, age, the timing of physical function deterioration, and android fat percentage were associated with the FRS (p <0.001, p <0.001, and p = 0.007, respectively). In multiple regression analysis, the FRS was associated with age and android fat percentage, based on the following formula: " FRS= - 18 . 549 + 0 . 410  ∗  Age + 0 . 577  ∗  Android percent fat  ( % )   ( R 2 =0 . 528 ) ' '                                                                                                                                          ( p < 0.001 ) . Conclusions: Body fat distribution in the android area is significantly associated with future CVD risk in adults with CP.

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.

Effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic cerebral palsy: a randomized controlled trial

BACKGROUND

Children with cerebral palsy show various degrees of dysphagia causing late development of oral motor skills.

AIM

To investigate effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic quadriplegia.

DESIGN

This was a double-masked, randomized controlled clinical trial.

SETTING

Out-patient Clinics of Faculty of Physical Therapy, Cairo University and Modern University of Technology and information.

POPULATION

A convenient sample of 71 children age ranged from 12 to 48 months diagnosed with spastic quadriplegia, were randomly assigned into two groups.

METHODS

Children in the control group received 90 minutes conventional physical therapy training five times/week for 4 successive months while those in the experimental group received 20 minutes of oral sensorimotor stimulation before the same program as in control group for 60 minutes. Oral motor function, body weight, segmental trunk control and gross motor function were assessed at base-line and after completing treatment.

RESULTS

In total, 64 (experimental n=32, control n=32) children completed treatment and data collection. The baseline assessment showed non-significant difference regarding all measured variables while with-in group comparison showed significant improvement in the two groups. The post-treatment comparisons revealed significant difference the oral motor function and physical growth in favor of the experimental group (p < 0.05). Finally, there was non-significant difference regarding segmental trunk control and gross motor function (p > 0.05).

CONCLUSIONS

Oral sensorimotor stimulation has the capability to improve feeding in children with spastic cerebral palsy diagnosed with oropharyngeal dysphagia.

CLINICAL REHABILITAYION IMPACT

OSMS has effect on some of the essential oral motor skills that contribute toward the improvement of feeding performance in children with spastic CP. The results of our study offer remarkable clinical importance for the children and their families.

Parent-delivered interventions used at home to improve eating, drinking and swallowing in children with neurodisability: the FEEDS mixed-methods study

BACKGROUND

Eating, drinking and swallowing difficulties are common in young children with neurodisability. These difficulties may lead to inadequate calorie intake, which affects a child's nutrition, growth and general physical health.

OBJECTIVE

To examine which interventions are available that can be delivered at home by parents to improve eating, drinking and swallowing in young children with neurodisability and are suitable for investigation in pragmatic trials.

DESIGN

This was a mixed-methods study that included focus groups, surveys, an update of published systematic reviews of interventions, a systematic review of measurement properties of existing tools, evidence mapping, evidence synthesis, a Delphi survey and stakeholder workshops.

SETTING

The study was carried out in NHS hospitals, community services, family homes and schools.

PARTICIPANTS

Parents of children who had neurodisability and eating, drinking and swallowing difficulties. Professionals from health and education. Young people with eating, drinking and swallowing difficulties or young people who had previously experienced eating, drinking and swallowing difficulties.

DATA SOURCES

Literature reviews; national surveys of parents and professionals; focus groups with parents, young people and professionals; and stakeholder consultation workshops.

REVIEW METHODS

An update of published systematic reviews of interventions (searched July-August 2017), a mapping review (searched October 2017) and a systematic review of measurement properties using COnsensus-based Standards for the Selection of health status Measurement INstruments (COSMIN) methodology (searched May 2018).

RESULTS

Significant limitations of the available research evidence regarding interventions and tools to measure outcomes were identified. A total of 947 people participated: 400 parents, 475 health professionals, 62 education professionals and 10 young people. The survey showed the wide range of interventions recommended by NHS health professionals, with parents and professionals reporting variability in the provision of these interventions. Parents and professionals considered 19 interventions as relevant because they modified eating, drinking and swallowing difficulties. Parents and professionals considered 10 outcomes as important to measure (including Nutrition, Growth and Health/safety); young people agreed that these were important outcomes. Stakeholder consultation workshops identified that project conclusions and recommendations made sense, were meaningful and were valued by parents and professionals. Parents and health professionals were positive about a proposed Focus on Early Eating, Drinking and Swallowing (FEEDS) toolkit of interventions that, through shared decision-making, could be recommended by health professionals and delivered by families.

LIMITATIONS

The national surveys included large numbers of parents and professionals but, as expected, these were not representative of the UK population of parents of children with eating, drinking and swallowing difficulties. Owing to the limitations of research evidence, pragmatic decisions were made about interventions that might be included in future research and outcomes that might be measured. For instance, the reviews of research found only weak or poor evidence to support the effectiveness of interventions. The review of outcome measures found only limited low-level evidence about their psychometric properties.

CONCLUSIONS

Opportunities and challenges for conducting clinical trials of the effectiveness of the FEEDS toolkit of interventions are described. Parents and professionals thought that implementation of the toolkit as part of usual NHS practice was appropriate. However, this would first require the toolkit to be operationalised through development as a complex intervention, taking account of constituent interventions, delivery strategies, implementation and manualisation. Subsequently, an evaluation of its clinical effectiveness and cost-effectiveness could be undertaken using appropriate research methods.

FUTURE WORK

Initial steps include FEEDS toolkit development and evaluation of its use in clinical practice, and identification of the most robust methods to measure valued outcomes, such as Nutrition and Growth.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10454425.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 22. See the NIHR Journals Library website for further project information.

Bone Microarchitecture Assessed by Trabecular Bone Score Is Independent of Mobility Level or Height in Pediatric Patients with Cerebral Palsy

Bone strength and fracture risk do not only depend on bone density, but also on bone structure. The trabecular bone score (TBS) evaluates homogeneity of bone microarchitecture indirectly by measuring gray-level variations of two-dimensional (2D) DXA images. Although TBS is well-established for adults, there have been only few publications in pediatrics. In this monocentric retrospective analysis, we investigated TBS in children and adolescents with cerebral palsy (CP), a patient group vulnerable to low bone mineral mass due to impaired mobility. The influence of different parameters on TBS and areal BMD (aBMD) were evaluated, as well as the relationship between TBS and aBMD. We compared TBS values of our study population to a reference population. A total of 472 lumbar spine-dual-energy X-ray absorptiometry (LS-DXA) scans of children and adolescents with CP (205 female), aged between 4 and 18 years, were analyzed. The DXA-scans were part of the routine examination. The children had no records of fractures or specific bone diseases. Our study population with CP had similar TBS as the reference population. TBS did not increase with age until an inflection point at 10 years in females, and 12 years in males. Girls had significantly higher TBS than boys (p = .049) and pubertal girls aged 8 to 13 years had significantly higher TBS than prepubertal girls (p = .009). TBS standard deviation score for age (SDS-TBS) and aBMD Z-scores correlated weakly (p < .001; R = 0.276 [males], R = 0.284 [females]). Other than for aBMD Z-scores, SDS-TBS was not influenced by age-adjusted height Z-scores and there was no significant difference in SDS-TBS when grouped by mobility levels, using the Gross Motor Function Classification System (GMFCS). Our results indicate that children with CP have a similar homogeneous distribution of trabecular microarchitecture as controls. Puberty initiation appears to be essential for increase of TBS with age and for sex differences. TBS seems less influenced by body composition, height, and mobility than aBMD. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Obesity and cardio-metabolic risk factors among children and adolescents with cerebral palsy

Introduction

Background: obesity and associated cardiometabolic complications are increasing among adults with cerebral palsy (CP). Information in children is scarce, and there is no consensus definition of obesity. Objectives: to describe the frequency of obesity and metabolic complications in children and adolescents with CP. Methods: a descriptive, cross-sectional study performed in two outpatient pediatric special needs centers. Demographic, anthropometric (Brooks 2011), and motor function (GMFCS) data, as well as antiepileptic use, were recorded. Fasting triglycerides (TG), total cholesterol (TC), vitamin D (25OHD), glycemia (GLY), and insulinemia levels were measured. The HOMA index was calculated. Results: sixty-five patients were enrolled. Aage was 10.8 ± 4.9 years; 63.1 % were male; 81.6 % had GMFCS IV-V; 43.5 % had a gastrostomy; and 83.1 % were on antiepileptics. According to their BMI, 15.4 % were underweight (< 10th percentile) and 10.8 % overweight (> 75th percentile). Overall, 6.1 % had TC ≥ 200 mg/dL, 21.4 % had TG ≥ 110 or 130 mg/dL, 4.6 % had GLY ≥ 100 mg/dL, 16.9 % had HOMA ≥ 3, and 76.9 % had 25OHD < 30 ng/mL. Children with BMI ≥ 75th percentile had higher HOMA and insulin resistance rates than those with BMI < 75th percentile. Elevated TGs were associated with high motor impairment and low vitamin D. HOMA was associated to feminine gender and BMI ≥ 75th percentile. Conclusions: the frequency of cardiometabolic risk factors was high in this sample of pediatric patients with CP, associated with overweight, low mobility, and vitamin D deficiency. We propose a BMI > 75th percentile as cutoff point for metabolic risk factors.

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.

Prevalence and factors associated with overweight and obesity among Spanish students attending special education schools

BACKGROUND

Some studies suggest that children and adolescents with intellectual disability (ID) are at elevated risk of obesity. The objective was to determine the prevalence of and factors associated with overweight and obesity among students attending special education schools in Cantabria, Spain.

METHODS

Cross-sectional design. A sample of n = 220 students with intellectual disability attending seven special education schools was selected using convenience sampling. Body mass index was classified into four categories according to the International Obesity Task Force (IOTF) criteria: underweight; normal weight; overweight; obesity.

RESULTS

The prevalence of overweight/obesity was 40.9% (95% CI: 34.6-47.5). Obesity was more frequent among females (26.0%) than males (9.8%), with an OR = 3.23 (95% CI: 1.53-6.85). Participants with Down syndrome showed an increased risk of obesity compared to other conditions (p = .005).

CONCLUSIONS

The prevalence of overweight/obesity among children, adolescents and young adults with intellectual disability was remarkably high, with females in general and students of both sexes with Down syndrome at particularly high risk.

Anthropometric measurements to identify undernutrition in children with cerebral palsy

AIM

To evaluate the diagnostic performance of anthropometric indicators to identify undernutrition in children with cerebral palsy (CP).

METHOD

The present study was a monocentric retrospective analysis of prospectively collected data among children and adolescents with CP participating in a rehabilitation program. Undernutrition was defined as a z-score for dual-energy X-ray absorptiometry (DXA) determined body fat percentage less or equal to -2.0. The cut-off values for body mass index (BMI) of the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC), and the cut-off values for BMI and height for age of the Robert Koch Institut (RKI) were evaluated.

RESULTS

In total, 329 children with CP (181 males, 148 females, Gross Motor Function Classification System levels I-V) were eligible for analysis. The mean age was 12 years 4 months (SD 2y 9mo). The BMI cut-off values showed the following sensitivities and specificities: WHO, sensitivity of 0.474 (95% confidence interval [CI] 0.244-0.711), specificity of 0.897 (95% CI: 0.857-0.928); CDC, sensitivity of 0.632 (95% CI: 0.384-0.837), specificity of 0.819 (95% CI: 0.772-0.861); RKI, sensitivity of 0.789 (95% CI: 0.544-0.939), specificity of 0.732 (95% CI: 0.679-0.781); and for height for age, sensitivity of 0.263 (95% CI: 0.091-0.512), specificity of 0.668 (95% CI: 0.612-0.720).

INTERPRETATION

BMI had a high specificity but very low sensitivity in identifying undernutrition in children with CP. Z-scores for height for age had even lower specificity and sensitivity and seemed not to be appropriate for predicting undernutrition in children with CP.

WHAT THIS PAPER ADDS

Body mass index (BMI) z-scores had a high specificity but very low sensitivity in identifying undernutrition in children with cerebral palsy (CP). Height z-scores were not appropriate for predicting undernutrition in children with CP. Undernutrition assessed by BMI was overestimated in children with CP versus when assessed by dual-energy X-ray absorptiometry (DXA).

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 care: The 'poor child' of clinical care in children with cerebral palsy

There is a considerable risk of malnutrition for children with Cerebral Palsy (CP) due to insufficient nutritional intake. The most important causes of insufficient intake are feeding problems which are highly prevalent in children with CP (depending on definition, age and heterogeneity of the researched population). Considering these facts, nutritional status should have the full attention of healthcare professionals but this is not yet the case. Evidence from research in clinical practice suggests that: 1) there is no consensus regarding who should perform the measurement and how often, 2) no standardised nutritional assessment is implemented, and 3) there is suboptimal communication and management about feeding and nutritional status in most healthcare networks. To overcome these problems, validated and practical tools for the screening and assessment of nutritional status should be a topic of research and subsequently made available and implemented in clinical practice. Because body composition is an objective indicator of available energy stores, research should focus on optimising measurement methods to determine body composition using anthropometric measures or bioelectrical impedance analysis (BIA). Furthermore, there is a definite need among health care providers for explicit and clear agreements on organisation and communication about nutritional care for children with CP.

Individualized evaluation of lumbar bone mineral density in children with cerebral palsy

Lumbar spine bone mineral density (LS-BMD) assessed by dual-energy X-ray absorptiometry (DXA) is used in children with cerebral palsy (CP) to evaluate bone health. LS-BMD results in children with CP are influenced significantly by their height, BMI, and mobility level. An adjustment for these parameters might improve the clinical significance of the method.

PURPOSE/INTRODUCTION

DXA evaluation is considered useful in children with CP to assess bone health. For this purpose, LS-BMD is often used. The aim of the study was to estimate the effect of height, BMI, and reduced mobility level of children with CP on LS-BMD and to develop a method to adjust individual results of LS-BMD for these factors.

METHODS

We conducted a monocentric retrospective analysis of data collected in children and adolescents with CP, who participated in a rehabilitation program and had no history of recurrent fractures. The DXA scan was part of the routine examination for participants older than 4 years of age. The relationship between height and BMI for age Z-scores and age-adjusted LS-BMD Z-scores was analyzed.

RESULTS

LS-DXA scans of 500 children and adolescents with CP (Gross Motor Function Classification System levels I-V) were included in the statistical analysis (217 female). The mean age was 9.4 years (± 3.7 years). Children with moderate to severe CP had significantly (p < 0.001) lower LS-BMD Z-scores than children with mild CP. We provided nomograms to adjust individual LS-BMD results to their height, BMI, and mobility level.

CONCLUSIONS

LS-BMD results in children with CP were influenced significantly by their height, BMI, and mobility level. An adjustment of the LS-BMD results to height, BMI, and mobility level might improve the clinical significance of an individual result.

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

Background/Objectives:

Children with cerebral palsy (CP) are at risk for having a misclassified overweight/obesity status based on BMI thresholds due to their lower fat-free mass and similar fat mass compared to typically developing children. The primary objective was to determine if BMI could predict fat mass index (FMI) and fat-free mass index (FFMI) in children with CP.

Subjects/Methods:

Forty-two children with CP and 42 typically developing children matched to children with CP for age and sex participated in the study. Dual-energy x-ray absorptiometry was used to assess body composition. Childrenwith CP who could ambulate without assistance were considered ambulatory (ACP) and the rest were considered nonambulatory (NACP).

Results:

Children with CP had higher percent body fat (%Fat) and FMI and lower fat-free mass and FFMI than controls (p < 0.05) but no difference in fat mass (p = 0.10). When BMI wasstatistically controlled, NACP had higher %Fat, fat mass and FMI and lower FFMI than ACP and controls (p < 0.05). NACP also had lower fat-free mass than controls (p < 0.05). ACP had higher %Fat and FMI and lower fat-free mass and FFMI than controls (p < 0.05). BMIwas a strong predictor of FMI (r² = 0.83) and a moderately-strongpredictor of FFMI (r² = 0.49) in children with CP (both p < 0.01). Prediction of FMI (R² = 0.86) and FFMI (R² = 0.66) from BMI increased (p < 0.05) whenage, sex and ambulatory status were included.

Conclusion:

Compared to typically developing children, children with CP have a higher FMI and lower FFMI for a given BMI which is more pronounced in NACP than ACP. The finding suggests that the prevalence of overweight/obesity status may be underestimated in children with CP.

Gastrointestinal and nutritional issues in children with neurological disability

Neurological disability is often associated with feeding and gastrointestinal disorders leading to malnutrition and growth failure. Assessment of nutritional status represents the first step in the clinical evaluation of children with neurological disability. The European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recently issued a consensus statement on gastrointestinal and nutritional management in children with neurological disability. Here we critically review and address implications of this consensus for clinical practice, including assessment and monitoring of nutritional status, definition of nutritional requirements, diagnosis and treatment of gastro-oesophageal reflux disease, and indications for and modalities of nutritional support. There is a strong evidence base supporting the ESPGHAN guidelines; their application is expected to lead to better management of this group of children.

WHAT THIS PAPER ADDS

Assessment of nutritional status in children with neurological disability should include the evaluation of body composition. Standard polymeric formula via gastrostomy tube is an effective, long-term nutritional intervention. Tube feeding should be started early, before the development of malnutrition.

The risk, burden, and management of non-communicable diseases in cerebral palsy: a scoping review

AIM

To examine the risk, burden, and management of non-communicable diseases (NCDs) among people with cerebral palsy (CP).

METHOD

Databases (Ovid MEDLINE, Embase Ovid, CINAHL Plus) were systematically searched up to August 2017. Data on the prevalence of risk factors for, and the burden and management of, cardiovascular diseases, diabetes, cancers, and respiratory diseases were extracted.

RESULTS

Thirty-six studies that examined the prevalence of risk factors among people with CP were identified. There was inconsistent evidence that people with CP had higher prevalence of metabolic risk factors such as hypertension, hyperlipidaemia, and obesity, but strong evidence that they participated in low levels of physical activity, compared with people without CP. Seven studies reported on the burden of NCDs. Adults with CP had a higher risk of NCDs, including stroke, chronic obstructive pulmonary disease, and other heart conditions, and death due to NCDs, including cancers, chronic obstructive pulmonary disease, stroke, and ischaemic heart disease, compared with the general population. Only one study reported on the management of NCD, specifically the uptake of breast cancer screening among females.

INTERPRETATION

The burden of NCDs is higher among adults with CP compared with the general population. Further research is required to determine the prevalence of metabolic risk factors and management of NCDs among people with CP.

WHAT THIS PAPER ADDS

Adults with cerebral palsy (CP) have an increased risk of non-communicable diseases (NCDs) and increased risk of death because of NCDs. Evidence is inconsistent about the elevated prevalence of metabolic risk factors for NCDs. Evidence is consistent that people with CP participate in reduced physical activity. Only one study reported on management of NCD among people with CP. Available evidence suggests people with CP are less likely to receive preventive medicine.

Diagnostic performance of body mass index to identify excess body fat in children with cerebral palsy

AIM

To assess the diagnostic performance of body mass index (BMI) cut-off values according to recommendations of the World Health Organization (WHO), the World Obesity Federation (WOF), and the German Society for Adiposity (DAG) to identify excess body fat in children with cerebral palsy (CP).

METHOD

The present study was a monocentric retrospective analysis of prospectively collected data among children and adolescents with CP participating in a rehabilitation programme. Excess body fat was defined as a body fat percentage above the 85th centile assessed by dual-energy X-ray absorptiometry.

RESULTS

In total, 329 children (181 males, 148 females) with CP were eligible for analysis. The mean age was 12 years 4 months (standard deviation 2y 9mo). The BMI cut-off values for 'overweight' according to the WHO, WOF, and DAG showed the following sensitivities and specificities for the prediction of excess body fat in our population: WHO: sensitivity 0.768 (95% confidence interval [CI] 0.636-0.870), specificity 0.894 (95% CI 0.851-0.928); WOF: sensitivity 0.696 (95% CI 0.559-0.812), specificity 0.934 (95% CI 0.898-0.960); DAG: sensitivity 0.411 (95% CI 0.281-0.550), specificity 0.993 (95% CI 0.974-0.999).

INTERPRETATION

Body mass index showed high specificity, but low sensitivity in children with CP. Thus, 'normal-weight obese' children with CP were overlooked, when assessing excess body fat only using BMI.

WHAT THIS PAPER ADDS

Excess body fat in children with cerebral palsy (CP) is less common than previously reported. Body mass index (BMI) had high specificity but low sensitivity in detecting excess body fat in children with CP. BMI evaluation criteria of the German Society for Adiposity could be improved in children with CP.

European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment

OBJECTIVES

Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment.

METHODS

Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.

The functional muscle-bone unit in children with cerebral palsy

Our results suggest that the prevalence of bone health deficits in children with CP was overestimated, when using only age- and height-adjusted bone mineral content (BMC) and areal bone mineral density (aBMD). When applying the functional muscle-bone unit diagnostic algorithm (FMBU-A), the prevalence of positive results decreased significantly. We recommend applying the FMBU-A when assessing bone health in children with CP.

INTRODUCTION

The prevalence of bone health deficits in children with cerebral palsy (CP) might be overestimated because age- and height-adjusted reference percentiles for bone mineral content (BMC) and areal bone mineral density (aBMD) assessed by dual-energy X-ray absorptiometry (DXA) do not consider reduced muscle activity. The aim of this study was to compare the prevalence of positive DXA-based indicators for bone health deficits in children with CP to the prevalence of positive findings after applying a functional muscle-bone unit diagnostic algorithm (FMBU-A) considering reduced muscle activity.

METHODS

The present study was a monocentric retrospective analysis of 297 whole body DXA scans of children with CP. The prevalence of positive results of age- and height-adjusted BMC and aBMD defined as BMC and aBMD below the P3 percentile and of the FMBU-A was calculated.

RESULTS

In children with CP, the prevalence of positive results of age-adjusted BMC were 33.3% and of aBMD 50.8%. Height-adjusted results for BMC and aBMD were positive in 16.8 and 36.0% of cases. The prevalence of positive results applying the FMBU-A regarding BMC and aBMD were significantly (p < 0.001) lower than using age- and height-adjusted BMC and aBMD (8.8 and 14.8%).

CONCLUSIONS

Our results suggest that the prevalence of bone health deficits in children with CP was overestimated, when using age- and height-adjusted BMC and aBMD. When applying the FMBU-A, the prevalence decreased significantly. We recommend applying the FMBU-A when assessing bone health in children with CP.

Differences in Body Composition According to Gross Motor Function in Children With Cerebral Palsy

OBJECTIVE

To assess differences in body composition according to gross motor function in children with cerebral palsy (CP) compared with healthy controls.

DESIGN

Retrospective case-control study.

SETTING

Tertiary referral center for CP.

PARTICIPANTS

Participants (N=146) comprised consecutive patients with CP (n=100; mean age, 11.5±4.2y) who were admitted for orthopedic surgery between May 2014 and March 2016 and typically developing children (TDC, n=46; control group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Bioelectrical impedance analysis (BIA) was used to assess body composition, including body fat, soft lean mass (SLM), fat-free mass (FFM), skeletal muscle mass (SMM), body cell mass (BCM), bone mineral content (BMC), and basal metabolic rate. Body composition measures were compared according to Gross Motor Function Classification System (GMFCS) level, as well as between children with CP and TDC.

RESULTS

Children with CP with GMFCS levels IV and V had a lower height, weight, and body mass index than those with GMFCS levels I to III. Children with CP with GMFCS levels IV and V had a significantly lower SLM, SLM index, FFM, FFM index, SMM, SMM index, BCM, BCM index, BMC, and BMC index than those with GMFCS levels I to III and TDC. GMFCS level significantly affected SLM and BMC.

CONCLUSIONS

Body composition analysis using BIA showed that nonambulatory children with CP had significantly lower FFM, SLM, SMM, BCM, and BMC than ambulatory children with CP and TDC. However, further study is required to allow the use of BIA as a valid nutritional assessment tool in patients with CP.

Pressure Injuries in Medically Complex Children: A Review

Pressure injuries are a challenging problem in the care of medically complex children. Available evidence is limited, and there are theoretical reasons to use caution before extrapolating adult data, including key differences in body composition, common locations of pressure injury, and association with medical devices. The focus of this article will be to review the definition of a pressure injury and what is known about pathophysiology, prevention, recognition, staging, and treatment of pressure injuries in children with medical complexity.

Body composition, diet, and physical activity: a longitudinal cohort study in preschoolers with cerebral palsy

BACKGROUND

Altered body composition in children with cerebral palsy (CP) could be due to differences in energy intake, habitual physical activity (HPA), and sedentary time.

OBJECTIVE

We investigated the longitudinal relation between the weight-for-age z score (WZ), fat-free mass (FFM), percentage of body fat (%BF), and modifiable lifestyle factors for all Gross Motor Function Classification System (GMFCS) levels (I-V).

DESIGN

The study was a longitudinal population-based cohort study of children with CP who were aged 18-60 mo (364 assessments in 161 children; boys: 61%; mean ± SD recruitment age: 2.8 ± 0.9 y; GMFCS: I, 48%; II, 11%; III, 15%; IV, 11%; and V, 15%). A deuterium dilution technique or bioelectrical impedance analysis was used to estimate FFM, and the %BF was calculated. Energy intake, HPA, and sedentary time were measured with the use of a 3-d weighed food diary and accelerometer wear. Data were analyzed with the use of a mixed-model analysis.

RESULTS

Children in GMFCS group I did not differ from age- and sex-specific reference children with typical development for weight. Children in GMFCS group IV were lighter-for-age, and children in GMFCS group V had a lower FFM-for-height than those in GMFCS group I. Children in GMFCS groups II-V had a higher %BF than that of children in GMFCS group I, with the exception of orally fed children in GMFCS group V. The mean %BF of children with CP classified them as overfat or obese. There was a positive association between energy intake and FFM and also between HPA level and FFM for children in GMFCS group I.

CONCLUSIONS

Altered body composition was evident in preschool-age children with CP across functional capacities. Gross motor function, feeding method, energy intake, and HPA level in GMFCS I individuals are the strongest predictors of body composition in children with CP between the ages of 18 and 60 mo.

Growth during infancy and early childhood in children with cerebral palsy: a population-based study

AIM

To describe growth in infancy and early childhood in children with cerebral palsy (CP).

METHOD

One hundred and four children with CP born at minimum 36 weeks' gestation in 2002 to 2010 were included. Prospectively collected growth data were requested from public health clinics. We calculated standard deviation (SD) scores (z-scores) for weight and height for 12 set age points for each child from birth to 5 years, and for head circumference from birth to 12 months.

RESULTS

Children with CP had normal growth in weight and height if they were born non-small for gestational age (non-SGA) or had mild motor impairments (i.e. Gross Motor Function Classification System [GMFCS] I-II), whereas children born SGA or with severe motor impairments (GMFCS III-V) had reduced growth (p<0.001). Children with feeding difficulties in infancy had reduced growth in weight and height throughout early childhood, while children without feeding difficulties had normal growth. Head circumference growth decreased most severely among children born SGA, who had mean z-scores of -3.0 (95% confidence interval [CI] -3.7 to -2.2) at 1 year.

INTERPRETATION

Children with mild CP had normal growth in weight and height until 5 years, and in head circumference during infancy. Feeding difficulties in infancy and being born SGA were strongly associated with reduced growth.

Association between gross motor function and nutritional status in children with cerebral palsy: a cross-sectional study from Colombia

AIM

To determine the association between gross motor function and nutritional status in children with cerebral palsy (CP) residing in an urban area in a developing country.

METHOD

We conducted a cross-sectional study in 177 children (ages 2-12y, 59.3% male) with a diagnosis of CP who were attending rehabilitation centres in Bucaramanga, Colombia (2012-2013). A physiotherapist evaluated patients using the Gross Motor Function Classification System (GMFCS, levels I to V). Nutritional status was evaluated by nutritionists and classified according to the World Health Organization growth charts. We used linear and multinomial logistic regression methods to determine the associations.

RESULTS

There were 39.5%, 6.8%, 5.6%, 16.4%, and 31.6% patients classified in levels I to V respectively. The mean adjusted differences for weight-for-age, height-for-age, BMI-for-age, and height-for-weight z-scores were significantly larger for children classified in levels II to V compared with those in level I. The children classified in levels IV and V were more likely to have malnutrition (adjusted odds ratio [OR] 5.64; 95% confidence interval [CI] 2.27-14.0) and stunting (OR 8.42; 95% CI 2.90-24.4) than those classified in GMFCS levels I to III.

INTERPRETATION

Stunting and malnutrition are prevalent conditions among paediatric patients with CP, and both are directly associated with higher levels of gross motor dysfunction.

Accuracy of Body Mass Index Cutoffs for Classifying Obesity in Chilean Children and Adolescents

OBJECTIVE

To determine the accuracy of two international Body Mass Index (BMI) cut-offs for classifying obesity compared to the percentage of fat mass (%FM) assessed by Dual-Energy X-ray Absorptiometry (DXA) in a Chilean sample of children and adolescents;

MATERIAL AND METHODS

The subjects studied included 280 children and adolescents (125 girls and 155 boys) aged 8 to 17 years. Weight and height were measured. The BMI was calculated. Two international references (IOFT and WHO) were used as cut-off points. The %FM was assessed by DXA. The receiver operating characteristic (ROC) curve was used to assess the performance of BMI in detecting obesity on the basis of %FM;

RESULTS

A high correlation was observed between the %FM measured by the DXA and the Z-scores of IOTF and WHO scores in the Chilean adolescents separated by sex (r = 0.78-0.80). Differences occurred in both references (IOFT and WHO) in relation to the criteria (p < 0.001). Both references demonstrated a good ability to predict sensitivity (between 84% and 93%) and specificity (between 83% and 88%) in both sexes of children and adolescents;

CONCLUSIONS

A high correlation was observed between the Z-score of the BMI with the percentage of fat determined by the DXA. Despite this, the classifications using the different BMI cut-off points showed discrepancies. This suggests that the cut-off points selected to predict obesity in this sample should be viewed with caution.

Accurate body composition measures from whole-body silhouettes

PURPOSE

Obesity and its consequences, such as diabetes, are global health issues that burden about 171 × 10(6) adult individuals worldwide. Fat mass index (FMI, kg/m(2)), fat-free mass index (FFMI, kg/m(2)), and percent fat mass may be useful to evaluate under- and overnutrition and muscle development in a clinical or research environment. This proof-of-concept study tested whether frontal whole-body silhouettes could be used to accurately measure body composition parameters using active shape modeling (ASM) techniques.

METHODS

Binary shape images (silhouettes) were generated from the skin outline of dual-energy x-ray absorptiometry (DXA) whole-body scans of 200 healthy children of ages from 6 to 16 yr. The silhouette shape variation from the average was described using an ASM, which computed principal components for unique modes of shape. Predictive models were derived from the modes for FMI, FFMI, and percent fat using stepwise linear regression. The models were compared to simple models using demographics alone [age, sex, height, weight, and body mass index z-scores (BMIZ)].

RESULTS

The authors found that 95% of the shape variation of the sampled population could be explained using 26 modes. In most cases, the body composition variables could be predicted similarly between demographics-only and shape-only models. However, the combination of shape with demographics improved all estimates of boys and girls compared to the demographics-only model. The best prediction models for FMI, FFMI, and percent fat agreed with the actual measures with R(2) adj. (the coefficient of determination adjusted for the number of parameters used in the model equation) values of 0.86, 0.95, and 0.75 for boys and 0.90, 0.89, and 0.69 for girls, respectively.

CONCLUSIONS

Whole-body silhouettes in children may be useful to derive estimates of body composition including FMI, FFMI, and percent fat. These results support the feasibility of measuring body composition variables from simple cameras such as those found in cell phones.

Greater Adipose Tissue Distribution and Diminished Spinal Musculoskeletal Density in Adults With Cerebral Palsy

OBJECTIVES

To examine differences in adipose tissue distribution, lumbar vertebral bone mineral density (BMD), and muscle attenuation in adults with and without cerebral palsy (CP), and to determine the associations between morphologic characteristics.

DESIGN

Cross-sectional, retrospective analyses of archived computed tomography scans.

SETTING

Clinical treatment and rehabilitation center.

PARTICIPANTS

Adults (N=352) with CP (age, 38.8±14.4y; body mass, 61.3±17.1kg; Gross Motor Function Classification System levels, I-V) and a matched cohort of neurotypical adults. Of the 41 adults with CP included in the study, 10 were not matchable because of low body masses.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Computed tomography scans were assessed for visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) areas, psoas major area and attenuation in Hounsfield units (Hu), and cortical and trabecular BMDs.

RESULTS

Adults with CP had lower cortical (β=-63.41 Hu, P<.001) and trabecular (β=-42.24 Hu, P<.001) BMDs and psoas major areas (β=-374.51mm(2), P<.001) and attenuation (β=-9.21 Hu, P<.001) after controlling for age, sex, and body mass. Adults with CP had greater VAT (β=3914.81mm(2), P<.001) and SAT (β=4615.68mm(2), P<.001). Muscle attenuation was significantly correlated with trabecular (r=.51, P=.002) and cortical (r=.46, P<.01) BMD, whereas VAT was negatively associated with cortical BMD (β=-.037 Hu/cm(2), r(2)=.13, P=.03).

CONCLUSIONS

Adults with CP had lower BMDs, smaller psoas major area, greater intermuscular adipose tissue, and greater trunk adiposity than neurotypical adults. VAT and cortical BMD were inversely associated.