Multiple Nutritional Deficiencies in Cerebral Palsy Compounding Physical and Functional Impairments

Status and factors related to hemoglobin concentration of people with vs. without disability-using nationwide claims check-up database

Background

Blood hemoglobin level is a key indicator of organ function and health status throughout the life course. As hemoglobin-related health problems are gaining attention, many studies on factors related to hemoglobin concentration are being conducted, yet few researches have been conducted targeting persons with disabilities. Furthermore, researches that consider the association between blood hemoglobin and the regional level health welfare resources are rare. This study aimed to explore the factors related to blood hemoglobin concentration among people with and without disability, and to contribute to the development of future nutritional policies and projects for persons with disabilities.

Methods

A health insurance claims database with check-ups provided by the National Health Insurance Services (NHIS) was used. One-to-three propensity score matching was conducted between participants with and without disabilities. In addition to the individual clinical and health behavioral aspects based on the claims data, regional-level data of healthcare and social welfare resources was also collected, and multi-level analysis was conducted to identify factors associated with low blood hemoglobin level.

Results

A total of 1,697 participants with disability and 5,091 without disabilities were yielded. Disability was significantly associated with lower hemoglobin level, even after propensity score matching. Sex, BMI, health behaviors, and clinical indicators were significantly associated with the blood hemoglobin level. Furthermore, region-level welfare budget was a significant factor among persons with disability.

Conclusion

Our findings confirmed the significant association between disability and lower hemoglobin level. Regional health and welfare resources, as well as individual characteristics should be considered in implementation of further nutrition and health policies for persons with disabilities. Further studies are needed to understand of health outcomes of low hemoglobin level.

Prevalence of Vitamin D Deficiency in Children With Cerebral Palsy: A Meta-Analysis

BACKGROUND

Vitamin D deficiency stands out as a significant contributor to reduced bone mineral density in children diagnosed with cerebral palsy (CP). The objective of the meta-analysis was to estimate the prevalence of vitamin D deficiency in children with CP.

METHODS

This meta-analysis adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guide. For children with CP aged between zero and 18 years with vitamin D deficiency, relevant articles were retrieved from PubMed, Scopus, ScienceDirect, and Cochrane. Following keywords were used: "cerebral palsy," "children," "childhood," "vitamin D," "vitamin D deficiency," "prevalence," and "frequency." Newcastle-Ottawa Scale was used to assess methodologic quality. Meta-analysis was performed using Stata 13.0.

RESULTS

In total, seven articles were considered suitable for inclusion in the meta-analysis of 411 articles initially identified. These studies involved a total of 430 children diagnosed with CP, ranging in age from zero to 18 years. Among the seven studies, two followed a cross-sectional approach, whereas the remaining five utilized a case-control design. Six of these studies were determined to have a low risk of bias, whereas one exhibited a moderate risk of bias. The combined prevalence of vitamin D deficiency in children with CP was determined to be 42.18% (95% confidence interval = 32.90% to 51.73%, I2 = 74.41%, and P < 0.001).

CONCLUSIONS

In conclusion, this meta-analysis reveals evidence of high prevalence of vitamin D deficiency in children with CP. This finding underscores the importance of addressing nutritional factors in the management of CP among pediatric populations.

Evaluation of serum vitamin B12 and D, iron, ferritin, folate, calcium, phosphorus and magnesium levels in children in palliative care clinic: a single-center cross-sectional study

BACKGROUND

Pediatric palliative care (PPC) patients are at an elevated risk of malnutrition. Nutritional inadequacy can also cause micronutrient deficiencies. These factors can lead to weight loss, stunted growth, and poor quality of life. Despite the prevalence of these issues, limited research exists in the micronutrient status of PPC patients. The purpose of this study was to determine the vitamin B12 and D, iron, ferritin, folate, calcium, phosphorus, and magnesium levels of PPC patients to contribute to a better understanding of their micronutrient needs as well as the appropriate management of diet and treatment approaches.

METHODS

This was a single-center observational cross-sectional retrospective study. This study evaluated the levels of vitamin B12, 25-hydroxyvitamin D, iron, ferritin, folate, calcium, phosphorus, and magnesium in PPC patients. The patients were classified according to the Chronic Complex Conditions (CCC) v2 and then compared.

RESULTS

A total of 3,144 micronutrient data points were collected from 822 hospitalizations of 364 patients. At least one micronutrient deficiency was identified in 96.9% of the patients. The most prevalent deficiencies were observed for iron, calcium, and phosphate. In addition, 25-hydroxyvitamin D deficiency was observed in one-third of patients. Calcium, magnesium, phosphorus, folate, and 25-hydroxyvitamin D were negatively correlated with age.

CONCLUSION

The results of this study indicate that micronutrient deficiencies are highly prevalent in PPC patients. These findings have the potential to contribute to improvements in the nutritional and therapeutic management of patients.

Hematological and biochemical profiles in children with cerebral palsy: A cross-sectional study

PURPOSE

Cerebral palsy is a common pediatric neurological problem that has multiple comorbidities, including nutritional issues. Hematological and biochemical parameters significantly affect the health status of patients with cerebral palsy, and till now very few studies have analyzed these parameters. This study aimed to describe the hematological and biochemical parameters of children diagnosed with cerebral palsy.

METHODS

This four-year observational study included children with cerebral palsy who were admitted to the Department of Pediatrics of a medical college teaching hospital.Hemoglobin, platelet count, white blood count (WBC), red blood cells (RBCs), packed cell volume, RBC indices, and biochemical parameters (urea, creatinine, total bilirubin, total protein, albumin, globulin, aspartate transaminase, alanine transaminase, electrolytes, calcium and alkaline phosphatase) were noted and values (mean, standard deviation, and interquartile range) presented. Age and gender-based analyses were performed.

RESULTS

The average hemoglobin level was 11.48 mg/dl, platelet count was 301.24×109/L, and WBC count was 11.13 109/L. Anemia was observed more commonly in males younger than nine years of age. Of 282 patients, 14 (4.96%) had a platelet count of less than 150×109/L. Abnormal alkaline phosphatase levels were observed more commonly in patients who were younger than nine years of age and in females more than males, and the difference was statistically significant. Protein levels and calcium levels were similar between both age groups.

CONCLUSION

Anemia was more common in younger patients and males with cerebral palsy. Abnormal bone turnover markers (alkaline phosphatase) were more common in young patients and females with cerebral palsy. Understanding the differential effect of age and gender on various investigational parameters will help improve care of children with cerebral palsy by initiating appropriate and timely clinical interventions, thereby providing a better quality of life.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

STUDY DESIGN

This is a systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dysregulation of multiple signaling pathways: A possible cause of cerebral palsy

Cerebral palsy (CP) is a lifelong disability characterized by the impairment of brain functions that result in improper posture and abnormal motor patterns. Understanding this brain abnormality and the role of genetic, epigenetic, and non-genetic factors such as signaling pathway dysregulation and cytokine dysregulation in the pathogenesis of CP is a complex process. Hypoxic-ischemic injury and prematurity are two well-known contributors of CP. Like in the case of other neurodevelopmental disorders such as intellectual disability and autism, the genomic constituents in CP are highly complex. The neuroinflammation that is triggered by maternal cytokine response plays a critical role in the pathogenesis of fetal inflammation response, which is one of the contributing factors of CP, and it continues even after the birth of children suffering from CP. Canonical Wnt signaling pathway is important for the development of mammalian fetal brain and it regulates distinct processes including neurogenesis. The glycogen synthase kinase-3 (GSK-3) antagonistic activity in the Wnt signaling pathway plays a crucial role in neurogenesis and neural development. In this review, we investigated several genetic and non-genetic pathways that are involved in the pathogenesis of CP and their regulation, impairment, and implications for causing CP during embryonic growth and developmental period. Investigating the role of these pathways help to develop novel therapeutic interventions and biomarkers for early diagnosis and treatment. This review also helps us to comprehend the mechanical approach of various signaling pathways, as well as their consequences and relevance in the understanding of CP.

Effect of Moringa Oleifera fortified porridge consumption on protein and vitamin A status of children with cerebral palsy in Nairobi, Kenya: A randomized controlled trial

BACKGROUND

Malnutrition due to inadequate dietary intake is commonly reported in children with Cerebral palsy (CP). Poor dietary intakes are majorly caused by feeding dysfunctions secondary to oro-motor impairment characteristic of the condition. Strategies that improve nutrient densities in foods can help enhance nutrient intakes by these children.

OBJECTIVE

This study investigated the effect of consumption of fermented finger millet porridge fortified with Moringa oleifera leaf powder (MoLP) on the protein and vitamin A status of children with CP.

DESIGN

A randomized controlled trial was conducted among 113 children aged 5-11 years with CP. The study had two arms (intervention [N = 57] and control [N = 56]). The intervention group received a daily serving of fortified finger millet porridge for 3 months while the control group received non-fortified finger millet porridge servings. All children received the same amounts of porridge servings. The levels of serum albumin and retinol between the groups were compared at both baseline and end line. The BMI-for-age Z-scores (BMIAZ) and morbidity prevalence of the children were also assessed.

RESULTS

At baseline, the two study groups were similar in all demographic and socio-economic characteristics, nutrient intakes, serum levels of albumin and retinol, weight status and morbidity. At end line, the children from the intervention group had significantly higher intakes of vitamin A at 717.12±432.7 μg/d (p = 0.038) and protein at 44.367±17.2 g/d (p = 0.031) respectively. The serum nutrients levels increased significantly from baseline by 0.456±0.12 g/dL (p<0.001) for albumin and by 0.243±0.10 μmol/L (p<0.001) for retinol among children in the intervention group. Among the children in the control group, the changes in the levels of both serum albumin 0.012±0.07 g/dL (p = 0.868) and serum retinol [0.0021±0.02 μmol/L (p = 0.890)] were not significant. At endline, the BMI-for-age Z-scores results showed that 10.52% and 34.0% of children from intervention and control group respectively were undernourished [χ2 = 30.985; p = 0.037]. Among the children in the intervention, group there was a significant change in the weight status between baseline and endline (p = 0.036). The weight status among children in the control group was not significantly different between baseline and endline (p = 0.109). Significant difference in morbidity prevalence between the two groups was also observed at endline (p = 0.003) with the prevalence being 24.6% and 51.8% among children in the intervention and control group respectively.

CONCLUSION

Consumption of M. oleifera fortified porridge significantly improved the children's serum albumin and retinol levels, as well as BMIAZ.

REGISTRATION NUMBER AND NAME OF TRIAL REGISTRY

The trial is registered at Pan African Clinical Trials Registry, number PACTR202107669905145 URL link: https://pactr.samrc.ac.za/.

Lactoferrin versus iron hydroxide polymaltose complex for the treatment of iron deficiency anemia in children with cerebral palsy: a randomized controlled trial

Iron deficiency anemia (IDA) is common among children with cerebral palsy (CP), and studies on the efficacy of lactoferrin (Lf) in the treatment of IDA are limited. This study aimed to compare the efficacy of Lf with that of iron hydroxide polymaltose complex (IPC) in the treatment of IDA in children with CP. This randomized controlled study, conducted at Alexandria University Children's Hospital, enrolled 70 children aged 1-10 years with CP and IDA; 35 children randomly received IPC, whereas the other 35 received Lf. Four children withdrew from the study; thus, only 66 children were analyzed (32 in the IPC group and 34 in the Lf group). At baseline, the hemoglobin level and other blood parameters were similar between the two intervention groups. After four weeks of treatment, both the IPC and Lf groups showed significant improvements in hemoglobin (Hb), serum ferritin (SF), serum iron, total iron-binding capacity, mean corpuscular volume, and mean corpuscular hemoglobin from baseline. Upon comparing the two treatment groups, adjusted mean Hb and SF changes in the Lf group were significantly higher than that of the IPC group (p =0.001and p= 0.033, respectively), and constipation was less likely to occur in the Lf group than the IPC group (p = 0.049 ).Conclusion: Lactoferrin is effective and superior to IPC as an oral iron replacement therapy in children with CP and IDA, as it has fewer side effects. What is Known: • Lactoferrin (LF) is a natural glycoprotein capable of treating iron deficiency anemia (IDA). • Studies on the efficacy of Lf in the treatment of IDA in children with cerebral palsy (CP) are limited. What is New? • This trial compared the efficacy of Lf and iron hydroxide polymaltose complex (IPC) as treatments of IDA in children with CP. • Lf is effective and even better than IPC as a treatment of IDA in children with CP, as it has fewer side effects.

Serum trace element and amino acid profile in children with cerebral palsy

BACKGROUND

The existing data demonstrate that both trace elements and amino acids play a significant role in neurodevelopment and brain functioning. Certain studies have demonstrated alteration of micronutrient status in children with cerebral palsy, although multiple inconsistencies exist.

THE OBJECTIVE

of the present study was to assess serum trace element and mineral, as well as amino acid levels in children with cerebral palsy.

METHODS

71 children with cerebral palsy (39 boys and 32 girls, 5.7 ± 2.3 y.o.) and 84 healthy children (51 boys and 33 girls, 5.4 ± 2.3 y.o.) were enrolled in the present study. Serum trace element and mineral levels were assessed using inductively-coupled plasma mass-spectrometry (ICP-MS). Amino acid profile was evaluated by means of high-pressure liquid chromatography (HPLC).

RESULTS

Children with cerebral palsy are characterized by significantly lower Cu and Zn levels by 6% and 8%, whereas serum I concentration exceeded the control values by 7%. A tendency to increased serum Mn and Se levels was also observed in patients with cerebral palsy. Serum citrulline, leucine, tyrosine, and valine levels were 15 %, 23 %, 15 %, and 11 % lower than those in healthy controls. Nearly twofold lower levels of serum proline were accompanied by a 44 % elevation of hydroxyproline concentrations when compared to the control values. In multiple regression model serum I, Zn, and hydroxyproline levels were found to be independently associated with the presence of cerebral palsy. Correlation analysis demonstrated a significant correlation between Cu, Mn, Se, I, and Zn levels with hydroxyproline and citrulline concentrations.

CONCLUSION

The observed alterations in trace element and amino acid metabolism may contribute to neurological deterioration in cerebral palsy. However, the cross-sectional design of the study does not allow to estimate the causal trilateral relationships between cerebral palsy, altered trace element, and amino acid metabolism.

Total Joint Arthroplasty in Patients With Cerebral Palsy

INTRODUCTION

Cerebral palsy (CP) is a neurodevelopmental condition with a wide range of presentations that usually lead to muscle imbalance culminating with precocious knee and hip arthrosis, often leading to total hip (THA) and knee arthroplasty (TKA). This study sought to determine the following: (1) the inherent differences of in-hospital characteristics and comorbidities between CP and non-CP patients undergoing total joint arthroplasty (TJA) and (2) do patients with CP have an increased risk of perioperative complications after TJA?

METHODS

The Nationwide Inpatient Sample database from 2005 to 2014 was queried in this retrospective cohort study to compare patient demographics and comorbidities, hospital characteristics, perioperative complications, and length of stay in patients with CP undergoing TJA compared with their non-CP counterparts. Statistical analyses were performed using the Rao-Scott chi-square test and analysis of variance. All analyses took into account the sampling procedure and weighting.

RESULTS

A total of 2,062 and 2,193 patients with CP underwent THA and TKA, respectively, during the study period. Both CP groups were younger (P < 0.0001), were more likely to have Medicaid insurance (P < 0.0001), and had longer lengths of hospital stay (P < 0.0001) compared with their non-CP counterparts. Non-CP patients had significantly higher rates of obesity, coronary artery disease, diabetes, and peripheral vascular disease (P < 0.05). However, patients with CP undergoing THA had a lower Charlson Comorbidity Index (P = 0.0002), whereas those undergoing TKA had similar comorbidity profile as the non-CP group (P = 0.097). Both THA and TKA CP patients had a higher risk of overall postoperative complications (P < 0.05) and surgical complications (P < 0.05), in particular acute postoperative anemia (P < 0.05).

CONCLUSION

Despite being younger with fewer comorbidities, patients with CP are at an increased risk of immediate perioperative complications after TJA compared with the general osteoarthritis population. Given that these patients have satisfactory long-term outcomes after TJA, these procedures can be performed successfully for patients with CP with careful medical management and surgical planning.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Vitamin B1 and B12 mitigates neuron apoptosis in cerebral palsy by augmenting BDNF expression through MALAT1/miR-1 axis

Through the roles of vitamin B1 and B12 in neuroprotection and in improving cerebral palsy symptoms have been previously noticed, the action mechanism is still unclear. This study aims to investigate the protective effect of vitamin B1 and B12 on neuron injury in cerebral palsy and to clarify the mechanism of vitamin B1 and B12 inhibiting neurons apoptosis, and to focus on the role of lncRNA MALAT1 in this process. In order to investigate the effect of vitamin B1 and B12 on neurons injury in vivo and on neuron apoptosis in vitro, we, respectively, introduced vitamin B1 and B12 into cerebral palsy rat and in apoptosis-induced N2A neurons by Oxygen Glucose Deprivation/reoxygenation (OGD/R). Our results demonstrated that vitamin B1 and B12 treatment improved the motor and memory functions and ameliorated the neurons injury in cerebral palsy rats. OGD/R treatment repressed the expression of MALAT1 and BDNF and the phosphorylation of PI3K and Akt, and enhanced the miR-1 expression, which were all reversed by vitamin B1 and B12 treatment in N2A neurons. Vitamin B1 and B12 inhibited miR-1 expression through MALAT1, promoted BDNF expression and activated PI3K/Akt signaling through the MALAT1/miR-1 axis. Vitamin B1 and B12 suppressed neuron apoptosis by up-regulating BDNF via MALAT1/miR-1 pathway. MALAT1 interference abolished the neuroprotective effect of vitamin B1 and B12 in cerebral palsy rats. Collectively, vitamin B1 and B12 up-regulates BDNF and its downstream PI3K/Akt signaling through MALAT1/miR-1 axis, thus suppressing neuron apoptosis and mitigating nerve injury in cerebral palsy rats.