Mortality in children with cerebral palsy in rural Bangladesh: a population-based surveillance study

Estimating the Prevalence of Cerebral Palsy in a Semi-Urban City in Benin: A Door-to-Door Community-Based Study

INTRODUCTION

Cerebral palsy (CP) is the most common cause of pediatric motor disability. While epidemiological data are widespread in high-income countries, corresponding data in low-income countries in sub-Saharan Africa are still rare. This study aimed to estimate the prevalence of CP in Northern Benin, a French-speaking low-income country in sub-Saharan Africa.

METHODS

This study was a community-based door-to-door study involving children younger than 18 years old, in Parakou, a semi-urban city in Benin. We used a two-stage procedure. The first one consisted on children screening to identify potential cases of CP. During the second stage, suspected children were examined by neurologists with high experience with CP.

RESULTS

In total, 2,630 children were screened with 10 confirmed cases of CP, resulting in a crude prevalence (95% confidence interval) of 3.8 (1.4, 6.15) per 1,000 children. Of the 10 confirmed cases, six were younger than 5 years old, and five were male. Eight children over ten were spastic with six bilateral spastic subtype according to the Surveillance of Cerebral Palsy in Europe classification system. Seven children had a Gross Motor Function Classification System level III-V, and six were classified level III to V of the manual ability classification system.

CONCLUSION

CP is highly prevalent in semi-urban area in Northern Benin. Large studies on potential risk factors are needed for the development of effective preventive strategies.

Dietary Intake, Feeding Pattern, and Nutritional Status of Children with Cerebral Palsy in Rural Bangladesh

(1) Background: Data on immediate causes of malnutrition among children with Cerebral Palsy (CP) are limited in low- and middle-income countries (LMICs). We aimed to assess the dietary intake pattern, feeding characteristics, and nutritional status of children with CP in Bangladesh; (2) Methods: We conducted a descriptive observational study in Shahjadpur, Bangladesh. Children with CP registered into the Bangladesh CP Register were included. Socio-demographic, clinical, dietary intake, feeding, gastro-intestinal conditions, and anthropometric data were collected. Descriptive and inferential statistics were reported; (3) Results: 75 children (mean (SD) age 3.6 (2.7) years, 42.7% female) and their caregivers participated. Overall, 53.6% and 46.4% of children were underweight and stunted, respectively. Two-thirds children consumed ≤4 out of 8 food groups. Meat, poultry, and fish; dairy products; and sugar consumption was lower among underweight children (43.4%, 48.8%, 25.0%) than others (56.7%, 51.2% 75.0%). Inappropriate feeding position was observed in 39.2% of children. Meal duration was >30 min/meal for 21.7‒28.0% children. Among all, 12.0% had feeding difficulties, 88.0% had ≥1 gastro-intestinal conditions; (4) Conclusions: The study reports preliminary data on the feeding characteristics, dietary intake, and nutritional status of children with CP in rural Bangladesh. The findings are crucial for cost-effective interventions, prevention, and management of malnutrition among children with CP in Bangladesh and other LMICs.

Nutritional status and growth of children and adolescents with and without cerebral palsy in eastern Uganda: A longitudinal comparative analysis

There is a need to understand the growth and burden of malnutrition in children with cerebral palsy (CP) in order to design appropriate inclusive nutrition strategies. We compared the nutritional status and four-year longitudinal growth of a population-based cohort of children and adolescents (C&A) with CP (n = 97; 2-17 years; 55/42 M/F), and an age and sex matched group without CP (n = 91; 2-17y; 50/41 M/F) in rural Uganda. The cohorts were assessed in 2015 and 2019 for weight, height, social demographic characteristics, and feeding related factors. Nutritional status was determined using the World Health Organization (WHO) Z-scores. Wilcoxon sign rank and Mann-Whitney tests were used to test within and between group differences. Multivariable linear regression was used to determine predictors of the change in growth. Approximately two thirds (62/97 (64%)) of C&A with CP were malnourished (with <-2SD in any of the WHO Z-scores), especially those with feeding difficulties (OR = 2.65; P = 0.032), and those who needed to be fed (OR = 3.8; P = 0.019). Both the CP and non-CP groups deviated negatively from the WHO reference growth curve for height, with a significantly slower growth in the CP group (median change score of height-for-age Z score (HAZ) between assessments = -0.80(-1.56, 0.31), p<0.01), than the non-CP group (median HAZ change score = -0.27(-0.92,0.34, p = 0.034). There was a statistically significant group difference in the median HAZ change score between the CP and non-CP groups (z = -2.21, p = 0.026). Severity of motor impairment measured by the Gross Motor Function Classification System (GMFCS-level) correlated negatively (r = -1.37,95%CI -2.67, -0.08) with the change in HAZ scores among the CP group. Children and adolescents with severe motor impairments exhibit an increased risk of malnutrition and growth retardation compared to their age matched peers without CP, which underscores the need to develop inclusive community-based nutrition strategies for children with cerebral palsy.

Risk Factors for Mortality in Patients With Cerebral Palsy: A Systematic Review and Meta-Analysis

Cerebral palsy (CP) is a developmental and physical disorder with different degrees of severity. Since CP manifests itself in early childhood, numerous research studies have concentrated on children with CP. Patients with CP encounter different severity of motor impairments attributed to the damage or disturbance to the fetal or infant developing brain, which begins in early childhood and persists through adulthood. Patients with CP are more prone to mortality compared to the general population. This systematic review and meta-analysis aimed to assess the risk factors that predict and influence mortality in patients with CP. Systematic search for studies assessing the risk factors for mortality in CP patients that were conducted from 2000 to 2023 in Google Scholar, PubMed, and Cochrane Library was performed. R-One Group Proportion was used for statistical analysis and Newcastle-Ottawa Quality Assessment Scale (NOS) for quality appraisal. Of the 1791 total database searches, nine studies were included. Based on the NOS tool for quality appraisal, seven studies were of moderate quality, and two studies were rated as of high quality. The risk factors included pneumonia and other respiratory infections, neurological disorders, circulatory diseases, gastrointestinal infections, and accidents. Pneumonia (OR = 0.40, 95% CI = 0.31 - 0.51), neurological disorders (OR = 0.11, 95% CI = 0.08 - 0.16), respiratory infections (OR = 0.36, 95% CI = 0.31 - 0.51), cardiovascular and circulatory diseases (OR = 0.11, 95% CI = 0.04 - 0.27), gastrointestinal and metabolic causes (OR = 0.12, 95% CI = 0.06 - 0.22), and accidents (OR = 0.05, 95% CI = 0.04 - 0.07) were the risk factors assessed. It was concluded that multiple factors predict the risk of mortality in patients with CP. Pneumonia and other respiratory infections are associated with a high risk of mortality. Cardiovascular and circulatory diseases, gastrointestinal and metabolic disorders, and accidents are strongly linked to mortality in CP patients.

Novel weight estimation equation for children with cerebral palsy in low-resource settings: Validation in a population-based cohort

AIM

To validate a novel equation to estimate weight from mid-upper arm circumference (MUAC) among children with cerebral palsy (CP) in rural Bangladesh.

METHOD

Children with CP aged 2 to 18 years registered in the Bangladesh CP Register were randomly selected. Data on sociodemographics, Gross Motor Function Classification System level, and anthropometric measurements were extracted. Bland-Altman plots with a 95% agreement limit and Lin's concordance correlation coefficient with 95% confidence intervals (CI) were reported to measure agreement between observed and estimated weight. Percentage error was used to determinate the method's accuracy.

RESULTS

There were 497 participants with a mean age at assessment of 9 years (SD 4 years 11 months) (47.7% female). Lin's concordance correlation coefficient between the observed and estimated weights was 0.90 (95% CI 0.89-0.92). Bland-Altman plots showed a reasonable accuracy of the equation in the study cohort. The mean percentage error of the equation was 5.04%. The average difference between observed and estimated weights was -1.02 kg (SD 5.1). The differences between observed and estimated weights were significantly greater among children with weight-for-age, height-for-age, or BMI-for-age z-scores less than or equal to -4.

INTERPRETATION

It is possible to predict the weight of children with CP from MUAC with sufficient accuracy. The equation can be used for populations in low-resources and low- and middle-income countries.

WHAT THIS PAPER ADDS

The equations predict the weight of children with cerebral palsy from their mid-upper arm circumference reasonably accurately. The difference between observed and estimated weights ranged between 0 kg and ± 5 kg in 81.5% of children. Sex and Gross Motor Function Classification System level did not affect the accuracy of the equations. The equations were less accurate for estimating the weight of severely undernourished children.

Serious health-related suffering experienced by children with disability and their families living in Bangladesh: A scoping review

BACKGROUND

In 2020, the International Association for Hospice and Palliative Care redefined palliative care to incorporate the concept of serious health-related suffering. An estimated 21 million children globally live with conditions which would benefit from a palliative approach to relieve suffering. Bangladesh is a lower-middle income country with isolated provision of palliative care.

AIM

To synthesise existing evidence describing serious health-related suffering of children with disability and their families living in Bangladesh and the intersection between this suffering, palliative care and rehabilitation.

DESIGN

Scoping review methodology.

DATA SOURCES

A search strategy related to serious health-related suffering and childhood disability was applied to online databases and grey literature. English language studies (1990-2021) were included. Papers pertaining to serious health-related suffering of typically developing children and those over eighteen years were excluded. Data which addressed the three domains of serious health-related suffering (physical, social and emotional/spiritual) were extracted. Palliative care interventions were assessed with a pre-existing checklist.

RESULTS

Forty-six studies were included, representing ten different methodologies. Sample sizes ranged from 11 to 2582 participants, with 87% of studies including children with cerebral palsy. Serious health-related suffering was described in 100% of the studies, only 14 of the studies described specific interventions to mitigate suffering. Convergence between palliative care and rehabilitation approaches was evident.

CONCLUSION

Findings document the extensive nature and burden of serious childhood health-related suffering that may be remediated by a palliative approach. They highlight the urgent need to prioritise service development and research in this area.

SUpporting People in extreme POverty with Rehabilitation and Therapy (SUPPORT CP): a trial among families of children with cerebral palsy in Bangladesh

AIM

To test the efficacy of an integrated microfinance/livelihood and community-based rehabilitation (IMCBR) programme in improving health-related quality of life (HRQoL) and motor function of children with cerebral palsy (CP) and gain in social capital to their ultra-poor families in rural Bangladesh.

METHOD

This was an open-label cluster randomized control trial. Children with CP aged 5 years or under were randomly allocated to three arms; Arm A: IMCBR; Arm B: community-based rehabilitation (CBR); and Arm C: care-as-usual. The CBR was modified with phone follow-up followed by home-based CBR at 2.5 months post-enrolment because of the COVID-19 pandemic. Intention-to-treat analysis was performed.

RESULTS

Twenty-four clusters constituting 251 children-primary caregivers' dyads were assigned to three arms (Arm A = 80; Arm B = 82; Arm C = 89). Between baseline and endline, the percentage mean change in the physical functioning domain of HRQoL was highest in Arm A (30.0%) with a significant mean difference between Arm A and Arm B (p = 0.015). Improvement in the mean social capital score was significantly higher in Arm A compared to Arm C (p < 0.001).

INTERPRETATION

The findings suggest that IMCBR could improve the HRQoL of children with CP and the social capital of their ultra-poor families. Long-term follow-up of the trial participants and future exploration of such interventions are essential. The integrated livelihood and CBR programme holds potential to improve health and well-being of children with CP and their ultra-poor families.

Epidemiology of cerebral palsy among children in the remote Gorkha district of Nepal: findings from the Nepal cerebral palsy register

PURPOSE

To describe the epidemiology of cerebral palsy (CP) among children in Gorkha, Nepal.

METHODS

We established the first population-based register of children with CP aged <18 y in Gorkha, Nepal (i.e., Nepal CP Register). Children with suspected CP underwent detailed neurodevelopmental assessment by a multidisciplinary assessment team. Socio-demographic, etiology, motor severity, rehabilitation, and educational status were documented.

RESULTS

Between January and October 2018, 182 children with confirmed CP were registered (mean (standard deviation (SD)) age: 10 years 1 months (4 years 10 months), 37.4% females). The majority (88.3%) had CP acquired pre- or perinatally. Mean (SD) age of CP diagnosis was four years five months. Mothers who did not receive any formal schooling had 4.5, 3.1, and 6.3 times higher odds of having inadequate antenatal care, homebirth, and unskilled birth attendants, respectively, when adjusted for other factors. Most children had spastic CP (77.5%) and Gross Motor Function Classification System level III-V (54.9%). Overall, 45.8% had never received rehabilitation services, 58.0% of school-aged children were not attending schools. The median age of receiving rehabilitation services was three years zero months.

CONCLUSIONS

The delayed diagnosis and clinical severity indicate the overall poor health status of children with CP in Nepal which could be improved by ensuring early diagnosis and intervention. Implications for rehabilitationThe first population-based cerebral palsy register in Nepal suggests diagnosis of CP is considerably delayed among children.The high burden of severe motor impairment and poor communication skill with limited access to timely rehabilitation among children with CP in Nepal is concerning.Capacity development of community-based health workers and mothers of children with CP could help implementing community-based programs for prevention and early diagnosis of CP, and to promote early intervention for children with CP in remote Gorkha, Nepal.

Improving epilepsy control among children with cerebral palsy in rural Bangladesh: a prospective cohort-based study

OBJECTIVE

To define the prevalence and seizure subtypes among children with cerebral palsy (CP) in rural Bangladesh and explore barriers to optimum epilepsy control.

DESIGN

Prospective cohort study.

SETTING

The study was conducted in Shahjadpur, a rural subdistrict of Bangladesh.

PARTICIPANTS

Children (<18 years) with CP and epilepsy identified using the Bangladesh CP Register (BCPR) in the study site.

METHODS

Assessments were conducted in three focused epilepsy clinics overseen by a paediatric neurologist between December 2016 and January 2018, with intervening phone and video-conference follow-ups. Details of event type, frequency and medication compliance were collected. Antiepileptic drugs (AEDs) were prescribed based on seizure type, family income, comorbidity and medication availability.

RESULTS

23.4% (170/726) of the BCPR cohort had a clinical diagnosis of epilepsy of whom 166 were assessed. Following the focused epilepsy clinics, 62.0% (103/166) children were clinically determined to have ongoing epileptic seizures. 62.1% (64/103) had generalised onset tonic clonic seizures, 27.2% (28/103) had focal onset seizures with impaired awareness and 10.7% (11/103) had other seizure types. None of the children with prolonged seizures (31/103) had an emergency seizure management plan. Non-epileptic events were being pharmacologically treated as seizures in 18.1% (30/166) children. Financial constraints were the main reason for non-compliance on follow-up.

CONCLUSIONS

Gaps in optimum epilepsy management in rural Bangladesh are amenable to improvement anchored with local healthcare workers. Training and clinical care focused on recognition of common seizure types, seizure mimics and rationalising use of available AEDs can be facilitated by better referral pathways and telehealth support.

Nutrition Interventions for Children with Cerebral Palsy in Low- and Middle-Income Countries: A Scoping Review

Background: Malnutrition is substantially higher among children with cerebral palsy (CP) in low- and middle-income countries (LMICs) when compared with the general population. Access to appropriate interventions is crucial for better management of malnutrition and nutritional outcomes of those children. We aimed to review the existing evidence on nutrition interventions for children with CP in LMICs. Methods: Online databases, i.e., PubMed and Scopus, and Google Scholar were searched up to 10 January 2022, to identify peer-reviewed publications/evidence on LMIC focused nutritional management guidelines/interventions. Following title screening and abstract review, full articles that met the inclusion/exclusion criteria were retained for data charting. Information about the study characteristics, nutrition interventions, and their effectiveness were extracted. Descriptive data were reported. Results: Eight articles published between 2008 and 2019 were included with data from a total of n = 252 children with CP (age range: 1 y 0 m–18 y 7 m, 42% female). Five studies followed experimental design; n = 6 were conducted in hospital/clinic/center-based settings. Four studies focused on parental/caregiver training; n = 2 studies had surgical interventions (i.e., gastrostomy) and n = 1 provided neurodevelopmental therapy feeding intervention. Dietary modification as an intervention (or component) was reported in n = 5 studies and had better effect on the nutritional outcomes of children with CP compared to interventions focused on feeding skills or other behavioral modifications. Surgical interventions improved nutritional outcomes in both studies; however, none documented any adverse consequences of the surgical interventions. Conclusion: There is a substantial knowledge gap on nutrition interventions for children with CP in LMICs. This hinders the development of best practice guidelines for the nutritional management of children with CP in those settings. Findings suggest interventions directly related to growth/feeding of children had a better outcome than behavioral interventions. This should be considered in planning of nutrition-focused intervention or comprehensive services for children with CP in LMICs.

Supporting Ultra Poor People with Rehabilitation and Therapy among families of children with Cerebral Palsy in rural Bangladesh (SUPPORT CP): Protocol of a randomised controlled trial

INTRODUCTION

Poverty is a key contributor to delayed diagnosis and limited access to early intervention and rehabilitation for children with cerebral palsy (CP) in rural Bangladesh. 97% of families of children with CP live below the poverty line in Bangladesh. Therefore, in low-and middle-income countries (LMICs), efforts to improve outcomes for children with CP (including health-related quality of life, motor function, communication, and nutritional attainments) should also include measures to improve family economic and social capital. We propose a randomised controlled trial (RCT) to evaluate the effectiveness of an integrated microfinance/livelihood and community-based rehabilitation (IMCBR) program for ultra-poor families of children with CP in rural Bangladesh.

MATERIAL AND METHODS

This will be a cluster RCT comparing three arms: (a) integrated microfinance/livelihood and community-based rehabilitation (IMCBR); (b) community-based rehabilitation (CBR) alone; and (c) care-as-usual (i.e. no intervention). Seven clusters will be recruited within each arm. Each cluster will consist of 10 child-caregiver dyads totalling 21 clusters with 210 dyads. Parents recruited in the IMCBR arm will take part in a microfinance/livelihood program and Parent Training Module (PTM), their children with CP will take part in a Goal Directed Training (GDT) program. The programs will be facilitated by specially trained Community Rehabilitation Officers. The CBR arm includes the same PTM and GDT interventions excluding the microfinance/livelihood program. The care-as-usual arm will be provided with information about early intervention and rehabilitation. The assessors will be blinded to group allocation. The duration of the intervention will be 12 months; outcomes will be measured at baseline, 6 months, 12 months, and 18 months.

CONCLUSION

This will be the first RCT of an integrated microfinance/livelihood and CBR program for children with CP in LMIC settings. Evidence from the study could transform approaches to improving wellbeing of children with CP and their ultra-poor families.

Epidemiology of cerebral palsy in low- and middle-income countries: preliminary findings from an international multi-centre cerebral palsy register

AIM

To describe the epidemiology of cerebral palsy (CP) in children from low- and middle-income countries (LMICs) using data from the Global Low- and Middle-Income Country CP register (GLM-CPR).

METHOD

The GLM-CPR is a multi-country initiative that combines and compares data from children with CP (<18y) in LMICs. Children with CP are registered after detailed neurodevelopmental assessment by a multidisciplinary medical team using a harmonized protocol. Data are collected on agreed core variables. Descriptive analyses are completed to report findings from participating countries.

RESULTS

Between January 2015 and May 2019, 2664 children were recruited from Bangladesh, Nepal, Indonesia, and Ghana (mean age [SD] at assessment: 7y 8mo [4y 8mo], 95% confidence interval 7y 6mo-7y 11mo; male [n=1615] 60.6%, female [n=1049] 39.4%). Overall, 86.6% children acquired CP prenatally and perinatally (e.g. preterm birth, birth asphyxia, neonatal encephalopathy). Median age at CP diagnosis was 3 years. Moreover, 79.2% children had spastic CP and 73.3% were classified in Gross Motor Function Classification System levels III to V. Notably, 47.3% of children never received rehabilitation services (median age at receiving rehabilitation services was 3y; 12.7% received assistive devices) and 75.6% of school-age children had no access to education.

INTERPRETATION

Population-based data show that the proportion of severe cases of CP is very high in LMICs. Children with CP in LMICs lack access to rehabilitation and educational services and a large proportion of children have potentially preventable risk factors, for example, birth asphyxia and neonatal infections. Delayed diagnosis, severe motor impairments, and lack of rehabilitation in most children call for urgent action to identify preventive opportunities and promote early diagnosis and intervention for children with CP in LMICs. What this paper adds The proportion of severe cases of cerebral palsy (CP) is very high in rural low- and middle-income countries (LMICs). Children with CP in LMICs lack access to rehabilitation and educational services. A large proportion of children with CP in LMICs have potentially preventable risk factors.

Epidemiology of Malnutrition among Children with Cerebral Palsy in Low- and Middle-Income Countries: Findings from the Global LMIC CP Register

Background: This study aimed to describe the epidemiology of malnutrition among children with cerebral palsy (CP) in low- and middle-income countries (LMICs). Methods: Data from children with confirmed CP aged <18 years registered into the Global LMIC CP Register (GLM CPR) from Bangladesh, Indonesia, Nepal, and Ghana were included. Anthropometric measurements were collected, and nutritional status was determined following the WHO guidelines. Descriptive statistics and adjusted logistic regression were used to describe the nutritional status and identify predictors of malnutrition. Results: Between January 2015 and December 2020, 3619 children with CP were registered into the GLM CPR (median age at assessment: 7.0 years, 39% female). Overall, 72–98% of children from Bangladesh, Indonesia, Nepal, and Ghana had at least one form of undernutrition. The adjusted analysis showed, older age, low maternal education, spastic tri/quadriplegia, and Gross Motor Functional Classification System (GMFCS) levels III–V were significant predictors of underweight and stunting among children with CP in Bangladesh. In Nepal, female children, GMFCS III–V had higher odds of underweight and stunting. In Ghana, low maternal education was significantly associated with underweight, whereas older age and the presence of associated impairments were the significant predictors of stunting among children with CP. Having a GMFCS of III–V increased the odds of being underweight among children in Indonesia; however, no predictors were identified for stunting, as nearly all children with CP registered from Indonesia were stunted. Conclusion: Most children with CP in GLM CPR had undernutrition. Maternal education and moderate-to-severe motor impairment (GMFCS III–V) were significant predictors. Practical nutrition education to mothers/caregivers and management guidelines according to the motor severity using local resources could improve the nutritional outcome of children with CP in LMICs.

Outcome of Community-Based Early Intervention and Rehabilitation for Children with Cerebral Palsy in Rural Bangladesh: A Quasi-Experimental Study

We evaluated the outcome of a community-based early intervention and habilitation for children with cerebral palsy (CP) in Bangladesh. Children registered on the Bangladesh CP Register (BCPR) were recruited in two groups for this study: Group A received a comprehensive six-month long community-based caregiver-led intervention program at the “Shishu Shorgo” (Bengali title, which translates to ‘Children’s Heaven’) Early Intervention and Rehabilitation Centres developed to support participants from the BCPR. Group B received standard care. A quasi-experimental study was conducted. Data were obtained at baseline, at the end of the program (i.e., 6 months), and at a 12-month follow-up. Outcome measures for children included gross motor functional measure (GMFM-66), Communication Function Classification System (CFCS), and Viking Speech Scale (VSS) and, for adult caregivers, the depression, anxiety, and stress scale (DASS 21). Between October 2016 and March 2017, 156 children with CP were recruited (77 in Group A and 79 in Group B). The total score of GMFM-66, CFCS level, and VSS level significantly improved statistically in Group A (p < 0.05 for all) and deteriorated in Group B (p < 0.001, p = 0.095, p = 0.232). The intervention showed promising outcomes particularly for children with CP under five years of age. There is a need for caregiver-led community-based programs for children with CP in LMICs.

Nutritional Status of Children with Cerebral Palsy in Gorkha, Nepal: Findings from the Nepal Cerebral Palsy Register

Background: The study aimed to define the burden and underlying risk factors of malnutrition among children with cerebral palsy (CP) in Gorkha district, Nepal. Methods: The first population-based register of children with CP in Gorkha, Nepal (i.e., Nepal CP Register—NCPR) was established in 2018. Children aged <18 years with confirmed CP were registered following standard protocol. Nutritional status was determined based on anthropometric measurements (height/length, weight, mid-upper-arm-circumference) following WHO guidelines. Descriptive analyses and adjusted logistic regression were completed. Results: Between June–October 2018, 182 children with CP were registered into the NCPR (mean (SD) age at assessment: 10.3 (5.0) years, 37.4% female). Overall, 51.7%, 64.1%, and 29.3% children were underweight, stunted, and thin, respectively. Furthermore, 14.3% of children with CP aged <5 years had severe wasting. Underweight and stunting were significantly higher among children with spastic CP (p = 0.02, p < 0.001) and/or Gross Motor Function Classification System (GMFCS) level (III–V) (p = 0.01, p < 0.001) and/or who were not enrolled in school (p = 0.01, p < 0.001). In adjusted analysis, GMFCS level III–V and non-attendance to school significantly increased the odds of stunting by 8.2 (95% CI 1.6, 40.8) and 4.0 (95% CI 1.2, 13.2) times, respectively. Conclusions: the high rate of different forms of undernutrition among children with CP in Gorkha, Nepal is concerning. Need-based intervention should be taken as priority to improve their nutritional outcome.

Situation analysis of rehabilitation services for persons with disabilities in Bangladesh: identifying service gaps and scopes for improvement

PURPOSE

Rehabilitation needs are rising globally; however, the rate is strikingly higher in low- and middle-income countries (LMICs). Like many LMICs, the situation of rehabilitation services for persons with disabilities (PwDs) in Bangladesh is mostly unknown. We assessed the current situation of rehabilitation services for PwDs in Bangladesh.

MATERIALS AND METHODS

This mixed-method study incorporated an online survey of rehabilitation service providers and a scoping review of documents published on rehabilitation services for PwDs in Bangladesh. Descriptive and thematic analyses were completed.

RESULTS

A total of 1102 rehabilitation service providers were interviewed, and 36 documents were reviewed. Rehabilitation services for PwDs were found not integrated into the mainstream health services, financing mechanisms, information systems, and health policies in Bangladesh. There are 6.8 rehabilitation units for 1 million people, and 6.2% of them are located in rural areas. In terms of the rehabilitation workforce, there are 9.4 physiotherapists, 1.3 occupational therapists, 0.9 speech and language therapists, and 0.2 prosthetist and orthotists for 1 million people in Bangladesh. Majority (66.3%) of rehabilitation services require an out-of-pocket payment.

CONCLUSIONS

A critical shortage and uneven distribution of the rehabilitation workforce are evident, indicating a likelihood of very high unmet rehabilitation needs in Bangladesh. To strengthen the rehabilitation capacity of Bangladesh, rehabilitation services should be integrated into mainstream health policies and programs with a special focus on the rehabilitation workforce training, recruitment and distribution, and allocation of resources.Implications for rehabilitationRehabilitation services in Bangladesh are mostly provided by the private sector, although the government of Bangladesh operates a small number of rehabilitation services outside of the mainstream public health service delivery system.Rehabilitation services are lacking in the primary and secondary health facilities, while services at tertiary level public hospitals are mainly provided by medical technologists in the absence of a qualified rehabilitation workforce.A severe shortage of rehabilitation workforce coupled with an uneven distribution of the existing limited number of rehabilitation services and out-of-pocket expenditures might result in inadequate access and poor rehabilitation service uptake amongst persons with disabilities (PwDs) in Bangladesh.Robust governance and leadership are needed to monitor the implementation of existing legislations and policies and develop strategies to improve the situation of rehabilitation services for PwDs in Bangladesh.

Predictors of Rehabilitation Service Utilisation among Children with Cerebral Palsy (CP) in Low- and Middle-Income Countries (LMIC): Findings from the Global LMIC CP Register

BACKGROUND

We assessed the rehabilitation status and predictors of rehabilitation service utilisation among children with cerebral palsy (CP) in selected low- and middle-income countries (LMICs).

METHODS

Data from the Global LMIC CP Register (GLM-CPR), a multi-country register of children with CP aged <18 years in selected countries, were used. Descriptive and inferential statistics (e.g., adjusted odds ratios) were reported.

RESULTS

Between January 2015 and December 2019, 3441 children were registered from Bangladesh (n = 2852), Indonesia (n = 130), Nepal (n = 182), and Ghana (n = 277). The proportion of children who never received rehabilitation was 49.8% (n = 1411) in Bangladesh, 45.8% (n = 82) in Nepal, 66.2% (n = 86) in Indonesia, and 26.7% (n = 74) in Ghana. The mean (Standard Deviation) age of commencing rehabilitation services was relatively delayed in Nepal (3.9 (3.1) year). Lack of awareness was the most frequently reported reason for not receiving rehabilitation in all four countries. Common predictors of not receiving rehabilitation were older age at assessment (i.e., age of children at the time of the data collection), low parental education and family income, mild functional limitation, and associated impairments (i.e., hearing and/or intellectual impairments). Additionally, gender of the children significantly influenced rehabilitation service utilisation in Bangladesh.

CONCLUSIONS

Child's age, functional limitation and associated impairments, and parental education and economic status influenced the rehabilitation utilisation among children with CP in LMICs. Policymakers and service providers could use these findings to increase access to rehabilitation and improve equity in rehabilitation service utilisation for better functional outcome of children with CP.

Premature Mortality, Risk Factors, and Causes of Death Following Childhood-Onset Neurological Impairments: A Systematic Review

Background: Neurological impairment (NI) and disability are associated with reduced life expectancy, but the risk and magnitude of premature mortality in children vary considerably across study settings. We conducted a systematic review to estimate the magnitude of premature mortality following childhood-onset NI worldwide and to summarize known risk factors and causes of death. Methods: We searched various databases for published studies from their inception up to 31st October 2020. We included all cohort studies that assessed the overall risk of mortality in individuals with childhood-onset epilepsy, intellectual disability (ID), and deficits in hearing, vision and motor functions. Comparative measures of mortality such as the standardized mortality ratio (SMR), risk factors and causes were synthesized quantitatively under each domain of impairment. This review is registered on the PROSPERO database (registration number CRD42019119239). Results: The search identified 2,159 studies, of which 24 studies were included in the final synthesis. Twenty-two (91.7%) studies originated from high-income countries (HICs). The median SMR was higher for epilepsy compared with ID (7.1 [range 3.1-22.4] vs. 2.9 [range 2.0-11.6]). In epilepsy, mortality was highest among younger age groups, comorbid neurological disorders, generalized seizures (at univariable levels), untreatable epilepsy, soon after diagnosis and among cases with structural/metabolic types, but there were no differences by sex. Most deaths (87.5%) were caused by non-epilepsy-related causes. For ID, mortality was highest in younger age groups and girls had a higher risk compared to the general population. Important risk factors for premature mortality were severe-to-profound severity, congenital disorders e.g., Down Syndrome, comorbid neurological disorders and adverse pregnancy and perinatal events. Respiratory infections and comorbid neurological disorders were the leading causes of death in ID. Mortality is infrequently examined in impairments of vision, hearing and motor functions. Summary: The risk of premature mortality is elevated in individuals with childhood-onset NI, particularly in epilepsy and lower in ID, with a need for more studies for vision, hearing, and motor impairments. Survival in NI could be improved through interventions targeting modifiable risk factors and underlying causes.

Data on cerebral palsy in Vietnam will inform clinical practice and policy in low and middle-income countries

PURPOSE

To document known risk factors, clinical severity, associated impairments and rehabilitation status of children presenting with cerebral palsy (CP) to the National Children's Hospital (NCH) in Hanoi, Vietnam.

MATERIALS AND METHODS

Active prospective ascertainment of cases of CP presenting between June and November 2017 to the NCH using surveillance modelled on the Paediatric Active Enhanced Disease Surveillance system in Australia.

RESULTS

Data were collected on 765 children with CP (mean age: 2 years 7 months (SD 2 y 6 mo). Mean age at diagnosis was 1 year 8 months (SD 1 y 9 mo). Children predominantly had spastic CP (95.2%, n = 729), most were quadriplegic (69.6%, n = 532) and 60.3% (n = 454) were Gross Motor Functional Classification System level III-V. Of the children 76.2% (n = 583) had one/more associated impairments. 36.3% (n = 276) had presumed perinatal asphyxia, 26.5% (n = 202) were preterm. Physiotherapy (94.3%, n = 663) was the most common form of intervention used. Only 2.6% (n = 12) of the children who would have benefitted from assistive devices had wheelchairs.

CONCLUSION

We established hospital-based surveillance of CP in Hanoi and confirmed a high burden and severity of CP with potentially preventable risk factors. These data will inform clinician training and health policy and identify need for evidence-based care and assistive devices.IMPLICATIONS FOR REHABILITATIONWe identified a high number of children with severe forms of cerebral palsy (CP) in Hanoi, Vietnam through hospital-based surveillance.There is an urgent need for clinician training and access to and use of evidence-based interventions including assistive technology.This study will inform local capacity building and health policy for improved diagnosis and care of children with CP in Vietnam and other low and middle-income countries.

Excessive premature mortality among children with cerebral palsy in rural Uganda: A longitudinal, population-based study

Background

Studies from high-income countries reported reduced life expectancy in children with cerebral palsy (CP), while no population-based study has evaluated mortality of children with CP in sub-Saharan Africa. This study aimed to estimate the mortality rate (MR) of children with CP in a rural region of Uganda and identify risk factors and causes of death (CODs).

Methods and findings

This population-based, longitudinal cohort study was based on data from Iganga-Mayuge Health and Demographic Surveillance System in eastern Uganda. We identified 97 children (aged 2–17 years) with CP in 2015, whom we followed to 2019. They were compared with an age-matched cohort from the general population (n = 41 319). MRs, MR ratios (MRRs), hazard ratios (HRs), and immediate CODs were determined.

MR was 3952 per 100 000 person years (95% CI 2212–6519) in children with CP and 137 per 100 000 person years (95% CI 117–159) in the general population. Standardized MRR was 25·3 in the CP cohort, compared with the general population. In children with CP, risk of death was higher in those with severe gross motor impairments than in those with milder impairments (HR 6·8; p = 0·007) and in those with severe malnutrition than in those less malnourished (HR = 3·7; p = 0·052). MR was higher in females in the CP cohort, with a higher MRR in females (53·0; 95% CI 26·4–106·3) than in males (16·3; 95% CI 7·2–37·2). Age had no significant effect on MR in the CP cohort, but MRR was higher at 10–18 years (39·6; 95% CI 14·2–110·0) than at 2–6 years (21·0; 95% CI 10·2–43·2). Anaemia, malaria, and other infections were the most common CODs in the CP cohort.

Conclusions

Risk of premature death was excessively high in children with CP in rural sub-Saharan Africa, especially in those with severe motor impairments or malnutrition. While global childhood mortality has significantly decreased during recent decades, this observed excessive mortality is a hidden humanitarian crisis that needs to be addressed.

Epidemiology of cerebral palsy in Sumba Island, Indonesia

AIM

To define the epidemiology, clinical characteristics, and rehabilitation status of children with cerebral palsy (CP) in Sumba Island, Indonesia.

METHOD

A community-based key informant method survey among children (aged <18y) with CP was conducted between March and August 2017. Children with suspected CP underwent detailed neurodevelopmental assessment by a multidisciplinary medical team. Socio-demographic characteristics, aetiology, motor type, motor severity, associated impairments, educational, and rehabilitation status were documented.

RESULTS

There were 130 children with clinically confirmed CP. The mean age at assessment was 8 years 11 months and 43.8% (n=57) of the children were female. The mean age at CP diagnosis was 6 years 5 months. Of these children, 46.9% (n=61) had post-neonatally acquired CP, most frequently because of vaccine-preventable infectious encephalopathy (73.8%, n=45). In total, 80.8% (n=105) had a predominantly spastic motor type of CP and 83.8% (n=109) were classified in Gross Motor Functional Classification System levels III to V. A total of 77.7% (n=101) had at least one associated impairment (speech 77.5%, intellectual 29.2%, visual 13.8%, hearing 20.0%, and epilepsy 13.5%). And 66.2% (n=86) had never received rehabilitation services.

INTERPRETATION

Post-neonatally acquired CP was common in this setting. Addressing preventable post-neonatally acquired risk factors for CP should be a public health priority. Earlier identification and diagnosis of CP would also provide new opportunities for early intervention and targeted rehabilitation services.

'Flower of the body': menstrual experiences and needs of young adolescent women with cerebral palsy in Bangladesh, and their mothers providing menstrual support

Background

This study offers voice to young adolescent women with cerebral palsy (CP) in Bangladesh as they describe their menstrual experiences and needs, and their mothers providing menstrual support.

Method

Semi-structured focus groups with adolescents with CP, and separately their mother. Data was analysed using a material discursive framework and drawing on feminist disability theory. Participants were recruited from the Bangladesh CP Register (BCPR); a population-based surveillance of children and adolescents with CP in rural Bangladesh.

Results

Participants were 45 women including 12 female adolescents with CP and 33 female caregivers. Participants reported a wide range of experiences and needs; menarche acted as a gateway to menstrual information although for some a discourse of silence prevailed due to exclusion from peer and familial networks. Menstruation was discursively constructed as a sign of ‘female maturation’ marked by an expectation of ‘independence’, required for acceptance into socially valued adult roles, and was positioned alongside increased vulnerability to sexual abuse. Young adolescent women with CP were expected to ‘quietly endure’ the material aspects of menstruation although unmanaged pain and distress were described. Mothers reported an imperative for meeting their adolescent’s menstrual needs however this role was discursively positioned as ‘painful’, ‘irritating’ and ‘shameful’, in part due to an absence of affordable, functional menstrual resources.

Conclusion

The findings of the present study provide motivation for disability services in Bangladesh to account for the menstrual needs of young adolescent women with CP within service delivery through strategies such as providing menstrual education and by embedding value in constructs such as ‘interdependence’. Moreover, interventions focused on alleviating menstrual pain among young adolescent women with CP as well as those targeted to alleviate distress among mothers providing menstrual care are required. Finally, policy responses are required to ensure that ‘inclusive development’ considers the needs of menstruating women with disability.

Nomogram for pneumonia prediction among children and young people with cerebral palsy: A population-based cohort study

BACKGROUND

Pneumonia is the leading cause of death among children and young people (CYP) with severe cerebral palsy (CP). Only a few studies used nomogram for assessing risk factors and the probability of pneumonia. Therefore, we aimed to identify risk factors and devise a nomogram for identifying the probability of severe pneumonia in CYP with severe CP.

METHODS

This retrospective nationwide population-based cohort study examined CYP with newly diagnosed severe CP before 18 years old between January 1st, 1997 and December 31st, 2013 and followed them up through December 31st, 2013. The primary endpoint was defined as the occurrence of severe pneumonia with ≥ 5 days of hospitalization. Logistic regression analysis was used for determining demographic factors and comorbidities associated with severe pneumonia. These factors were assigned integer points to create a scoring system to identify children at high risk for severe pneumonia.

RESULTS

Among 6,356 CYP with newly diagnosed severe CP, 2,135 (33.59%) had severe pneumonia. Multivariable logistic regression analysis revealed that seven independent predictive factors, namely age <3 years, male sex, and comorbidities of pressure ulcer, gastroesophageal reflux, asthma, seizures, and perinatal complications. A nomogram was devised by employing these seven significant predictive factors. The prediction model presented favorable discrimination performance.

CONCLUSIONS

The nomogram revealed that age, male sex, history of pressure ulcer, gastroesophageal reflux, asthma, seizures, and perinatal complications were potential risk factors for severe pneumonia among CYP with severe CP.

Nutritional Status of Children with Cerebral Palsy-Findings from Prospective Hospital-Based Surveillance in Vietnam Indicate a Need for Action

Background: Lack of evidence on the burden and risk factors for malnutrition among children with cerebral palsy (CP) in Vietnam limits evidence-based interventions. We aimed to define the nutritional status of children with CP in Vietnam. Materials and Methods: The study utilized data from active prospective hospital-based surveillance modelled on the Pediatric Active Enhanced Disease Surveillance system. Children (0–18 years) with CP attending the National Children’s Hospital Hanoi, Vietnam between June–November 2017 were included. Data on demographic, clinical and rehabilitation status were collected following detailed neurodevelopmental assessment. Anthropometric measurements were taken. Nutritional status was determined using the World Health Organization guideline. Results: Of 765 children (the mean (SD) age was 2.6 (2.5) years; 35.8% were female), 28.9% (n = 213) were underweight and 29.0% (n = 214) stunted. The odds of underweight were significantly higher among children aged >5 years and/or having a monthly family income of <50 USD. Underweight and/or stunting was high among children with quadriplegia (81%, n = 60 and 84.5%, n = 87) and/or Gross Motor Functional Classification System (GMFCS) level IV–V (62.5%, n = 45 and 67.0%, n = 67). Nearly one-third of intellectually impaired and more than half of hearing-impaired children were underweight and/or stunted. Conclusions: Poor economic status and increased motor severity increased vulnerability to malnutrition. Our findings will inform nutritional rehabilitation programs among these vulnerable children.