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

Measuring Physical Activity in Children Who Do Not Walk and With Cerebral Palsy: An Exploratory Case Series

AIM

The purpose of this case series was to describe physical activity (PA) amount and intensity in the home and school environment. Accelerometers and heart rate (HR) monitors are reliable and valid measures of PA in children with cerebral palsy (CP) who can walk. There is limited research on PA measures in children with CP who cannot walk.

METHODS

Three 9-year-old boys with CP, Gross Motor Function Classification System levels IV and V, participated in a 1-week measurement period wearing waist- and wrist-worn triaxial accelerometers to measure PA counts and a wrist-worn HR monitor to measure PA intensity. PA intensity was calculated using an estimated HR max. Accelerometer counts were reported. Parents and school staff completed activity and eating journals.

RESULTS

Six days of PA and HR data were analyzed. Two participants spent more time in moderate/vigorous PA intensity during school compared to at home. Activities with greatest PA intensity included oral eating, communication, and social engagement. Higher activity counts were recorded from the wrist compared with the waist accelerometers. PA and eating journal adherence were high in both settings.

CONCLUSION

The findings provide preliminary data to evaluate PA amount and intensity in children with CP who have little walking ability. It is important to consider PA levels in daily activity for youth with CP when designing plans of care.

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.

Latin American Cerebral Palsy Register (LATAM-CPR): study protocol to develop a collaborative register with surveillance of children with cerebral palsy in Latin American countries

INTRODUCTION

Cerebral palsy (CP) is one of the leading causes of childhood disability globally with a high burden in low-income and middle-income countries (LMICs). Preliminary findings from the global LMIC CP Register (GLM CPR) suggest that the majority of CP in LMICs are due to potentially preventable causes. Such data are lacking in the Latin American region. Generating comparable epidemiological data on CP from this region could enable translational research and services towards early diagnosis and early intervention. We aim to establish a Latin American multicountry network and online data repository of CP called Latin American Cerebral Palsy Register (LATAM-CPR).

METHODS AND ANALYSIS

The LATAM-CPR will be modelled after the GLM CPR and will support new and emerging Latin American CP registers following a harmonised protocol adapted from the GLM CPR and piloted in Argentina (ie, Argentine Register of Cerebral Palsy). Both population-based and institution-based surveillance mechanisms will be adopted for registration of children with CP aged less than 18 years to the participating CP registers. The data collection form of the LATAM-CPR will include risk factors, clinical profile, rehabilitation, socioeconomical status of children with CP. Descriptive data on the epidemiology of CP from each participating country will be reported, country-specific and regional data will be compared.

ETHICS AND DISSEMINATION

Individual CP registers have applied ethics approval from respective national human research ethics committees (HREC) and/or institutional review boards prior to the establishment and inclusion into the LATAM-CPR. Ethical approval for LATAM-CPR has already been obtained from the HREC in the two countries that started (Argentina and Mexico). Findings will be disseminated and will be made publicly available through peer-reviewed publications, conference presentations and social media communications.

Physical activity is associated with walking and balance ability but not fatigue, knee extension strength, or body composition in adults with cerebral palsy: a pilot cross-sectional study

Common secondary impairments associated with aging in adults with cerebral palsy (CP) decrease physical functions, including walking and balance ability, and increase the sense of fatigue. This motor dysfunction results in decreased physical activity (PA) and could be associated with obesity and sarcopenia. This study examined the association of daily PA levels with fatigue, physical function, and body composition in 22 adults with CP (age, 37.4 ± 14.7 years; Gross Motor Function Classification System level, I: 6, II: 16). The level of daily PA was divided into percent of sedentary behavior, light PA, and moderate-to-vigorous PA (%MVPA) per day. These outcomes were examined for correlation with the Fatigue Severity Scale, knee extension strength, comfortable and maximum walking speed, Timed-Up-and-Go-Test (TUG), and body fat percentage and skeletal muscle mass using Spearman's rank correlation coefficient. An additional partial correlation analysis with sex and age adjustment was performed. The %MVPA correlated positively with comfortable walking speed (rs = 0.424, P  = 0.049) and negatively with TUG (rs = -0.493, P  = 0.020). The partial correlation revealed associations of %MVPA with maximum walking speed (r = 0.604, P  = 0.022) and TUG (r = -0.604, P  = 0.022). The results show that among adults with CP, increased PA is associated with improvements in mobility but not in perceived fatigue or body composition, regardless of sex and age. Maintaining and improving %MVPA and walking and balance ability in adults with CP have a positive impact on each other, and potentially on overall health management.

Body Mass Index, Physical Activity, Cardiorespiratory Endurance and Quality of Life among Children with Physical Disabilities

BACKGROUND

Children with physical disabilities (PD) have reduced levels of physical activity (PA) compared to typically developing children, which increases their risk of becoming overweight and obese, which leads to numerous adverse health consequences. This study aimed to determine the differences between groups classified by body mass index (BMI) percentile in terms of PA levels, cardiorespiratory endurance and quality of life (QoL), and also to evaluate the relationship between BMI percentile and PA levels, cardiorespiratory endurance and QoL in children and adolescents with physical disabilities.

METHODS

A total of 172 children and adolescents with PD aged between 5 and 17 years from Hospital Tunku Azizah were included in this cross-sectional study. The BMI percentile was calculated to determine the weight status. PA levels were assessed with the Physical Activity Questionnaire for Older Children (PAQ-C), cardiorespiratory endurance was measured by the Six-Minute Walk Test (6MWT) and QoL was measured by the Paediatric Quality of Life Inventory version 2.0 (PedsQL 2.0).

RESULTS

According to the BMI percentile, 70.3% had a healthy BMI percentile (50th to 84th percentile), 11.6% were overweight (50th to 84th percentile), 11% were underweight (0-49th percentile) and 7.0% were obese (95th percentile and above). Most children reported a healthy weight, and the rates of being overweight and obese were higher in children who could ambulate without aids (6.4% and 3.5%, respectively) compared to those who used walking aids (5.2% and 3.5%, respectively). Significant differences were found in the PAQ-C, 6MWT and PedsQL 2.0 scores between different BMI percentile groups (p < 0.05). There were also significant correlations between the BMI percentile and the PAQ-C (r = 0.209, p < 0.001), 6MWT (r = 0.217, p < 0.001) and PedsQL 2.0 (r = 0.189, p < 0.001).

CONCLUSION

The rate of being overweight and obese is greater among children who ambulate without aids than among those with aids. An increase in the BMI percentile can reduce the QoL in different ways. This study suggests that children with PD who can walk without aids are at a greater risk of being overweight and obese. Hence, the engagement of this population in PA is crucial for their weight management.

Growth patterns in children and adolescents with cerebral palsy from Argentina and Germany

To analyze growth patterns of children with CP between countries; to examine differences in growth; and to assess the fit of growth charts. Cross-sectional study in children with CP from 2 to 19 years old, 399 from Argentina and 400 from Germany. Growth measures were converted into z-scores and compared to WHO reference and US CP growth charts. Generalized Linear Model was used to analyze the growth expressed as mean z-scores. 799 children. Mean age 9 years (± 4). Compared to the WHO reference, the decrease in Height z-scores (HAZ) with age in Argentina (- 0.144/year) was double that in Germany (- 0.073/year). For children in GMFCS IV-V, BMI z-scores (BMIZ) decreased with age (- 0.102/year). Using the US CP charts, both countries showed decreasing HAZ with age, in Argentina (- 0.066/year) and in Germany (- 0.032/year). BMIZ increased more among children with feeding tubes (0.062/year), similar in both countries. Argentinian children with oral feeding decrease their Weight z-score (WAZ) by - 0.553 compared to their peers. With WHO charts BMIZ presented an excellent fit for GMFCS I-III. HAZ presents a poor fit to growth references. BMIZ and WAZ presented a good fit to US CP Charts. Growth differences due to ethnicity also act in children with CP, and are related to motor impairment, age and feeding modality, possibly reflecting differences in environment or health care.

Dietary Patterns of Competitive Swimmers with Moderate-to-Severe Cerebral Palsy: A 3-Year Longitudinal Evaluation

AIM

To evaluate the longitudinal dietary patterns of three adolescents with moderate-to-severe cerebral palsy (CP) participating in a performance-focused swimming training intervention.

METHOD

Participants were three previously inactive adolescents with CP (15-16 years, GMFCS IV) who had recently (<6 months) enrolled in a swimming training program. Diet quality from diet histories was calculated at 10-time points over 3.25 years using the Dietary Guidelines Index for Children and Adolescents (DGI-CA) and the Healthy Eating Index for Australian Adults (HEIFA-2013). A food group analysis was compared to the Australian Guide to Healthy Eating recommendations. Trends were considered in the context of dietary advice given and the training load.

RESULTS

Longitudinal diet quality scores were consistent and ranged from 40 to 76 (DGI-CA) and 33 to 79 (HEIFA-2013). Food group intake remained stable; participants rarely met the recommendations for fruit, vegetables, dairy, grain, and meat but frequently achieved discretionary serves.

CONCLUSIONS

Participants with moderate-to-severe CP who were enrolled in a performance-focused swimming training intervention and were monitored frequently maintained diet quality throughout a period where it conventionally declined. Scores were higher than the general population and were maintained irrespective of the training load. Participants frequently met food group recommendations for discretionary foods and were comparable to the general population for other food groups.

andomised to early neuroprotection and neurorehabilitation: protocol for a follow-up study of participants from four randomised clinical trials

INTRODUCTION

School readiness includes cognitive, socio-emotional, language and physical growth and development domains which share strong associations with life-course opportunities. Children with cerebral palsy (CP) are at increased risk of poor school readiness compared with their typically developing peers. Recently, earlier diagnosis of CP has allowed interventions to commence sooner, harnessing neuroplasticity. First, we hypothesise that early referral to intervention for children at-risk of CP will lead to improved school readiness at 4-6 years relative to placebo or care as usual. Second, we hypothesise that receipt of early diagnosis and early intervention will lead to cost-savings in the form of reduced healthcare utilisation.

METHODS AND ANALYSIS

Infants identified as at-risk of CP ≤6 months corrected age (n=425) recruited to four randomised trials of neuroprotectants (n=1), early neurorehabilitation (n=2) or early parenting support (n=1) will be re-recruited to one overarching follow-up study at age 4-6 years 3 months. A comprehensive battery of standardised assessments and questionnaires will be administered to assess all domains of school readiness and associated risk factors. Participants will be compared with a historical control group of children (n=245) who were diagnosed with CP in their second year of life. Mixed-effects regression models will be used to compare school readiness outcomes between those referred for early intervention versus placebo/care-as-usual. We will also compare health-resource use associated with early diagnosis and intervention versus later diagnosis and intervention.

ETHICS AND DISSEMINATION

The Children's Health Queensland Hospital and Health Service, The University of Queensland, University of Sydney, Monash University and Curtin University Human Research Ethics Committees have approved this study. Informed consent will be sought from the parent or legal guardian of every child invited to participate. Results will be disseminated in peer-reviewed journals, scientific conferences and professional organisations, and to people with lived experience of CP and their families.

TRIAL REGISTRATION NUMBER

ACTRN12621001253897.

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.

Desenvolvimento de crianças, adolescentes e jovens adultos com Paralisia Cerebral de acordo com a CIF? Uma revisão do escopo

Estudos sobre o desenvolvimento de indivíduos com PC ajudam terapeutas e pais a planejarem abordagens de tratamento e prognóstico futuro. Os principais desfechos investigados em indivíduos com PC foram atividade e estruturas e funções corporais. Pouco tem sido explorado em desfechos de participação e de fatores contextuais ao longo do tempo.

Development of children, adolescents, and young adults with cerebral palsy according to the ICF: A scoping review

AIM

To identify and provide a descriptive overview of the development of children, adolescents, and young adults with cerebral palsy (CP) in longitudinal studies; and map areas of focus according to the components of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF).

METHOD

Longitudinal studies of the development of children, adolescents, and/or young adults with CP were included in this scoping review. A search for eligible studies was conducted in the databases MEDLINE, PubMed, LILACS, EMBASE, Cochrane, CINAHL, and Scopus, and was restricted to the years 2002 to 2022. All outcome measures of the studies were classified into ICF components.

RESULTS

In the 56 studies included, there were 19 438 participants, involving mainly children, followed by adolescents, and lastly young adults. All components of the ICF were investigated and many studies reported outcomes in more than one component. Activity was the most investigated (67.9%; n = 38 studies), followed by body functions and structures (42.9%; n = 24 studies). Participation (14.2%; n = 8 studies) and environmental factors (3.6%; n = 2 studies) were the least studied. None of the studies investigated personal factors as an outcome.

INTERPRETATION

This scoping review provides an overview of studies on the development of children, adolescents, and young adults with CP, using the ICF framework, identifying current areas of focus and gaps in the research. Future studies should target participation, contextual factors, and the transition into adulthood.

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).

Physical activity, sedentary time and nutritional status in Brazilian children with cerebral palsy

OBJECTIVE

This study had the purpose investigate the physical activity (PA) and sedentary time profile of children with cerebral palsy and its association with body composition.

METHODS

A cross-sectional study evaluated 53 children, between 2 and 10 years old, enrolled in three health services Recife-city, northeast of Brazil. Sedentary and PA were measured for a week using the ActiGraph GTX3 accelerometer. Body composition was assessed by anthropometry and an electrical bioimpedance device.

RESULTS

Time on PA was one hour longer among the mild/moderate CP compared to severe ones, but, sedentary time is similar. Dyskinetic children spent more time in PA, but also in sedentary activities (15.5 hours a day) than spastic ones (12.8). Stunting occurred in 15 (30%) of the sample, all children with stunting had severe impairment. Underweight occurred in 25% of the severe group and 11.8% in the mild/moderate group. Overweight affected 3% of the sample; no overweight children were in the severe group. Body fat% was inversely related to time spent in moderate to vigorous PA.

CONCLUSIONS

Children with CP spend more than a half of their daily time in sedentary activity. In contrast, children with mild to moderate CP spent twice as much time in moderate to vigorous PA and had a tendency (p = 0.07) to spend 50% more time in light PA. Moreover, time spent on moderate to vigorous activity was inversely related to fat mass.

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.

Operationalization, measurement, and health indicators of sedentary behavior in individuals with cerebral palsy: a scoping review

PURPOSE

To explore the operationalization and measurement of sedentary behavior (SB) in individuals with cerebral palsy (CP).

MATERIALS AND METHODS

We searched five databases from 2011 to 2020 for primary studies of experimental, qualitative, longitudinal, or observational designs measuring SB or postures typically characterized as sedentary (sitting, reclining, lying).

RESULTS

We screened 1112 citations and selected 47 studies. SB was operationalized through muscle activation, energy expenditure or oxygen consumption in typically sedentary postures (n = 9), and through thresholds and postures used by accelerometers, activity monitors, and a questionnaire to measure time spent in SB (n = 25). Seven out of the eight studies that measured energy expenditure found ≤1.5 metabolic equivalents of task (METs) for sitting and lying. While different accelerometer thresholds were used to measure SB, the behavior (SB) was consistently operationalized as sitting and lying. Little consistency existed in the subpopulation, instruments and cut-points for studies on validity or reliability of tools for measuring SB (n = 19).

CONCLUSIONS

Sitting and lying are considered sedentary postures, which is defined as ≤1.5 METs in individuals with CP. There is variability in the tools used to measure SB in individuals with CP. Therefore, consensus on the definition and reporting of SB is needed.Implications for rehabilitationAlthough sedentary behavior (SB) is increased in individuals with cerebral palsy (CP) compared to the typically developing population, there is no standard definition for SB for these individuals; this makes it difficult to synthesize data across studies.Sitting and lying are ≤1.5 METs in individuals with CP, suggesting we only need to measure posture to show change in SB.The commonly used accelerometer cut-point in the typically developing population of ≤100 counts per minute generally has excellent reliability across multiple devices in ambulatory children with CP.

Feasibility of Using Mobile Technology to Improve Physical Activity Among People Living with Diabetes in Asia

Background: Chronic conditions such as diabetes (DM) and cardiovascular disease are associated with disability and poor quality of life. Asians are 30% more likely than non-Hispanic Whites to develop type 2 DM. The important roles of wearable technological applications or devices in maintaining individuals' motivation to attain their physical activity (PA) goal have been reported. However, evidence of the feasibility and impact of the mobile technology on the PA in Thailand is limited. This study aims to examine the feasibility and the impact of the immediate performance feedback feature of the wearable device on PA. Methods: This pilot study recruited persons aged 18 or older with diabetes from two diabetes clinics in Chiang Mai, Thailand. Participants were randomly assigned into three groups: the aware group (AW: can see the step count on the device screen), the unaware group (UW: the device screen was completely covered), and the control group (usual care). Participants in the AW and UW groups were asked to wear the device for 2 full days while the usual care group did not wear the device. All participants completed a questionnaire package at their first study visit. Data analysis of univariate and multivariate general linear models were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC). All significance levels were set at 5%. Results: One hundred and fourteen participants age ranged from 39 to 75 years old were included in this analysis. The majority were female (n = 86, 69%) and married (n = 103, 82%). No adverse events were reported among device users. Within 2 days, there were less than 10% missing data and more than 70% of participants liked the devices mainly because they could see the step count. More than 63% of participants who wore the device had an average of steps greater than 10,000 per day. Although the number of steps and sleep hours were not significantly different between the AW and UW groups, 68% of the AW participants found that the device help them with their exercise. Discussion: The results demonstrate the feasibility of the use of the wearable device among people living with chronic conditions. Participants found that the step count screen provided immediate physical performance feedback that was helpful with their exercise. The behavioral changes, however, could not be examined due to the short duration of the usage. Future studies that require longer device usage in larger sample sizes are needed.

Anthropometrical Features of Para-Footballers According to Their Cerebral Palsy Profiles and Compared to Controls

Cerebral palsy (CP) football is a team para-sport practiced by para-athletes with eligible impairments of hypertonia, athetosis, and ataxia. This study aimed: (1) to describe the anthropometrical and body composition profiles of international CP para-footballers with different CP profiles (i.e., spastic diplegia, athetosis/ataxia, spastic hemiplegia, and minimum impairment); (2) to analyze the differences between both affected/nondominant and nonaffected/dominant sides; and (3) to compare the sample of international-level CP para-footballers (n = 141) with a sample of highly trained able-bodied footballers (n = 39). Anthropometric measures included four breadths, nine girths, and six skinfolds, while body composition was measured through fat mass (including Carter's, Faulkner's, and Withers' equations), muscle mass (Lee's equation), and bone mass (Rocha's and Martin's equations). This study found differences between the able-bodied footballers and the following impairment profiles: spastic diplegia (skinfolds); ataxia/athetosis (corrected calf of the nondominant side, and calf skinfolds for both sides); and spastic hemiplegia (all measurements excepting femur breadth, and thigh and ankle girths). No differences were found between para-athletes with minimum impairment and the able-bodied footballers. This study demonstrates that football players with or without physical impairments of hypertonia athetosis or ataxia may be considered homogeneous in shape when dominant size is compared. Besides, the study provides reference scores on anthropometric measures and body composition of international-level CP para-footballers that can help sports coaches and physical trainers to monitor physical fitness of their para-athletes.

Delayed motor skills associated with pediatric obesity

OBJECTIVE

To review the literature regarding associations between developmental motor delay (DMD) and pediatric obesity. We hope to identify potential interventions that can improve motor coordination at an early age, thereby minimizing the deterring factors of physical activity down the road.

DESIGN

An integrative review was undertaken using search combinations to best identify potential publications. Manuscripts were reviewed, summarized, and discussed in detail. An experienced clinician in pediatric obesity reviewed the final searches for substantive content.

CRITERIA

Inclusion criteria include English language studies or publications, children ≤18 years old, publication/study relates to DMD and pediatric obesity. Excluded publications regarded topics of pediatric obesity that have been extensively studied such as maternal and family histories of obesity, isolated nutritional or physical interventions to improve obesity without discussion of DMD.

RESULTS

21 publications were included for review. Papers fell into three main categories regarding the association between pediatric obesity and DMD: 1) Motor function - negative association with motor function and obesity 2) Motor Development - lower levels of motor function are associated with decreased levels of exercise, and 3) Role of Intervention - specific physical activity intervention showed improvements in motor function.

CONCLUSIONS

Motor function deficits appear to be associated with obesity. However, it is not well understood if children with obesity have delayed motor skills as a consequence of their weight or if the DMD is a risk factor for the development of obesity; existing studies do not provide an answer.

Sedentary Behavior in Children With Cerebral Palsy Between 1.5 and 12 Years: A Longitudinal Study

PURPOSE

To determine longitudinal change in sedentary behavior in children with cerebral palsy (CP) from 1.5 to 12 years.

METHODS

Ninety-one children, Gross Motor Function Classification System (GMFCS) levels I to III, who participated in a large longitudinal cohort study were participants. Longitudinal change was analyzed in objectively measured sedentary behavior and associations with sex, body mass index Z score, and socioeconomic status. Moderate-vigorous intensity physical activity (MVPA) was estimated at 8 to 12 years.

RESULTS

Average sedentary minutes/day peaked at 4 years in children at GMFCS I and 5 years in children at GMFCS II to III, then plateaued. Male sex was associated with increased sedentary behavior. At 8 to 12 years, children at GMFCS I, II, and III accumulated on average 54, 47, and 14 minutes/day, respectively, of MVPA.

CONCLUSIONS

When measured to 12 years, sedentary behavior peaks by 5 years for children with CP who are walking with differences in trajectory according to GMFCS.

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

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

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

Does exclusion of extreme reporters of energy intake (the "Goldberg cutoffs") reliably reduce or eliminate bias in nutrition studies? Analysis with illustrative associations of energy intake with health outcomes

BACKGROUND

The Goldberg cutoffs are used to decrease bias in self-reported estimates of energy intake (EISR). Whether the cutoffs reduce and eliminate bias when used in regressions of health outcomes has not been assessed.

OBJECTIVE

We examined whether applying the Goldberg cutoffs to data used in nutrition studies could reliably reduce or eliminate bias.

METHODS

We used data from the Comprehensive Assessment of Long-Term Effects of Reducing Intake of Energy (CALERIE), the Interactive Diet and Activity Tracking in American Association of Retired Persons (IDATA) study, and the National Diet and Nutrition Survey (NDNS). Each data set included EISR, energy intake estimated from doubly labeled water (EIDLW) as a reference method, and health outcomes including baseline anthropometric, biomarker, and behavioral measures and fitness test results. We conducted 3 linear regression analyses using EISR, a plausible EISR based on the Goldberg cutoffs (EIG), and EIDLW as an explanatory variable for each analysis. Regression coefficients were denoted ${\hat{\beta }_{\rm SR}}$, ${\hat{\beta }_{\rm G}}$, and ${\hat{\beta }_{\rm DLW}}$, respectively. Using the jackknife method, bias from ${\hat{\beta }_{\rm SR}}$ compared with ${\hat{\beta }_{\rm DLW}}$ and remaining bias from ${\hat{\beta }_{\rm G}}$ compared with ${\hat{\beta }_{\rm DLW}}$ were estimated. Analyses were repeated using Pearson correlation coefficients.

RESULTS

The analyses from CALERIE, IDATA, and NDNS included 218, 349, and 317 individuals, respectively. Using EIG significantly decreased the bias only for a subset of those variables with significant bias: weight (56.1%; 95% CI: 28.5%, 83.7%) and waist circumference (WC) (59.8%; 95% CI: 33.2%, 86.5%) with CALERIE, weight (20.8%; 95% CI: -6.4%, 48.1%) and WC (17.3%; 95% CI: -20.8%, 55.4%) with IDATA, and WC (-9.5%; 95% CI: -72.2%, 53.1%) with NDNS. Furthermore, bias significantly remained even after excluding implausible data for various outcomes. Results obtained with Pearson correlation coefficient analyses were qualitatively consistent.

CONCLUSIONS

Some associations between EIG and outcomes remained biased compared with associations between EIDLW and outcomes. Use of the Goldberg cutoffs was not a reliable method for eliminating bias.

Nutritional status of children with cerebral palsy in remote Sumba Island of Indonesia: a community-based key informants study

AIM

To assess the burden and underlying factors of malnutrition among children with cerebral palsy (CP) in the remote Sumba Island, Indonesia.

METHODS

This is a community-based key informant (KI) method survey of children with CP in the southwest regency of Sumba Island, Indonesia (child population∼152 471). Children with suspected CP identified by trained community volunteers (KIs) underwent a detailed neurodevelopmental assessment by a multidisciplinary medical assessment team to confirm diagnosis of CP. Anthropometric measurements were taken, z scores were calculated, and nutritional status was determined following the World Health Organization guideline. Descriptive analyses were performed, multivariable linear regression model was fitted to identify potential predictors of malnutrition.

RESULTS

One hundred and thirty children with CP aged <18 years were included in the study. The majority were severely underweight (78.8%) and severely stunted (85.9%). Severe malnutrition was overrepresented among young children, children who had spastic tri/quadriplegia, Gross Motor Function Classification System levels III-V, had at least one associated impairment, speech impairment and/or swallowing difficulties. Age and presence of visual impairment were found to be significantly associated with weight-for-age z score (i.e., underweight) whereas, epilepsy was significantly associated with the height-for-age z score (i.e., stunting) when adjusted for other covariates.

CONCLUSIONS

The substantial-high burden of malnutrition among children with CP in remote Sumba Island highlights their vulnerability to poor health-related outcomes. There is an urgent need for nutritional rehabilitation services to avert such consequences among children with CP in low and middle-income countries like Indonesia.Implications for rehabilitationMalnutrition among children with cerebral palsy (CP) is alarmingly high in the remote Sumba island of Indonesia.Children with severe gross motor function limitations or spastic tri/quadriplegia had the most severe malnutrition.There is an urgent need for rehabilitation services including nutrition and feeding interventions for children with CP in low and middle-income countries like Indonesia.

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

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

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.

Usefulness of Cerebral Palsy Curves in Mexican Patients: A Cross-Sectional Study

Cerebral palsy describes a group of movement and posture disorders that cause activity limitation, and are attributable to nonprogressive disorders that occur in the fetal or infant brain. The growth of these children should not be compared with those of the healthy population. We studied 452 children, 186 female and 266 male. We compared the results in 2 growth charts, Centers for Disease Control and Prevention (CDC) and cerebral palsy, and the results were statistically significant ( P = .00001). With the CDC charts, 40.71% of the patients were below the 5th percentile and only 5.5% of them when we used the charts for cerebral palsy patients. The Mexican cerebral palsy patients were similar to US cerebral palsy patients when we compared height ( P = .4075) and body mass index (BMI) ( P = .4075). Only the weight was found to be different ( P = .00001). All the correlation indexes were negative: Eating and Drinking Ability Classification System (EDACS)-BMI (rho = -0.4798) ( P = .00001), Communication Function Classification System (CFCS)-BMI (rho = -0.4353) ( P = .00001), and Gross Motor Function Classification System (GMFCS)-BMI (rho = -0.3584) ( P = .00001). The growth charts of the healthy pediatric population tend to overestimate the underweight. We propose to use cerebral palsy charts as a reference in our patients. It is possible to determine a functional profile (communication, gross motor function and safety, and feed efficiency) for the cerebral palsy population based on their BMI.

Bioimpedance Spectroscopy Imprecisely Assesses Lean Body Mass in Pediatric Dialysis Patients

OBJECTIVES

Alterations in body compositions are strongly associated with poor outcomes in end-stage renal disease patients. Hence, assessment of lean body mass is crucial for clinically monitoring these patients. The use of multifrequency bioimpedance spectroscopy measurements has also been advocated, but their usefulness in children is questioned. We investigated whether their application is appropriate for lean body mass measurement in pediatric patients receiving chronic dialysis.

METHODS

Lean body mass estimates as assessed by multifrequency bioimpedance spectroscopy and by deuterium dilution were obtained for 15 patients (mean age 10.9 ± 3.6 years).

RESULTS

Lean body mass (mean ± standard deviation) determined by bioimpedance was 24.2 ± 10.7 and 24.4 ± 10.3 kg by deuterium technique. Bland-Altman analysis showed a mean (±standard deviation) difference between the 2 methods of -0.25 ± 2.30 kg with 95% limits of agreement of -4.80 to 4.25 kg. In a multiple linear regression model, the hydration status was associated with measurement bias after adjusting for age, sex, weight, and body surface area.

CONCLUSIONS

Our results show a high level of agreement between measurements by bioimpedance and deuterium technique, but the limits of agreement were wide. These findings do not support the use of bioimpedance to individually assess lean body mass in pediatric dialysis patients with and without overhydration.

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.

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.

Noncommunicable disease and multimorbidity in young adults with cerebral palsy

Purpose

Individuals with cerebral palsy (CP) are at increased risk for frailty and chronic disease due to factors experienced throughout the lifespan, such as excessive sedentary behaviors and malnutrition. However, little is known about noncommunicable diseases (NCDs) and multimorbidity profiles in young adults with CP. The study objective was to compare NCD and multimorbidity profiles between young adults with and without CP.

Methods

A clinic-based sample of adults (18-30 years) with (n=452) and without (n=448) CP was examined at the University of Michigan Medical Center. The prevalence and predictors of 13 NCDs were evaluated, including existing diagnoses or historical record of musculoskeletal, cardiometabolic, and pulmonary morbidities. The level of motor impairment was determined by the Gross Motor Function Classification System (GMFCS) and stratified by less vs more severe motor impairment (GMFCS I-III vs IV-V). Logistic regression was used to determine the odds of NCD morbidity and multimorbidity in adults with CP compared to adults without CP, and for GMFCS IV-V compared to GMFCS I-III in those with CP, after adjusting for age, sex, body mass index, and smoking.

Results

Adults with CP had a higher prevalence of osteopenia, osteoporosis, hypertension, myocardial infarction, hyperlipidemia, asthma, and multimorbidity compared to adults without CP, and higher odds of musculoskeletal (odds ratio [OR]: 6.97) and cardiometabolic morbidity (OR: 1.98), and multimorbidity (OR: 2.67). Adults with CP with GMFCS levels IV-V had a higher prevalence of osteopenia/osteoporosis, osteoarthritis, hypertension, other cardiovascular conditions, pulmonary embolism, and multimorbidity, and higher odds of musculoskeletal (OR: 3.41), cardiometabolic (OR: 2.05), pulmonary morbidity (OR: 1.42), and multimorbidity (OR: 3.45) compared to GMFCS I-III.

Conclusion

Young adults with CP have a higher prevalence of chronic NCDs and multimorbidity compared to young adults without CP, which is pronounced in those with more severe motor impairment. These findings reiterate the importance of early screening for prevention of NCDs in CP.