Cerebral palsy pain instruments: Recommended tools for clinical research studies by the National Institute of Neurological Disorders and Stroke Cerebral Palsy Common Data Elements project

AIM

This study describes the process of updating the cerebral palsy (CP) common data elements (CDEs), specifically identifying tools that capture the impact of chronic pain on children's functioning.

METHOD

Through a partnership between the American Academy for Cerebral Palsy and Developmental Medicine and the National Institute of Neurological Disorders and Stroke (NINDS), the CP CDEs were developed as data standards for clinical research in neuroscience. Chronic pain was underrepresented in the NINDS CP CDEs version 1.0. A multi-step methodology was applied by an interdisciplinary professional team. Following an adapted CP chronic pain tools' rating system, and a review of psychometric properties, clinical utility, and compliance with inclusion/exclusion criteria, a set of recommended pain tools was posted online for external public comment in May 2022.

RESULTS

Fifteen chronic pain tools met inclusion criteria, representing constructs across all components of the International Classification of Functioning, Disability and Health.

INTERPRETATION

This paper describes the first condition-specific pain CDEs for a pediatric population. The proposed set of chronic pain tools complement and enhance the applicability of the existing pediatric CP CDEs. The novel CP CDE pain tools harmonize the assessment of chronic pain, addressing not only intensity of chronic pain, but also the functional impact of experiencing it in everyday activities.

Septopreoptic holoprosencephaly: a mild subtype associated with midline craniofacial anomalies

SUMMARY

HPE is a congenital brain malformation characterized by failure of the prosencephalon to divide into 2 hemispheres. We have identified 7 patients who have a mild subtype of HPE in which the midline fusion was restricted to the septal region or preoptic region of the telencephalon. This subtype, which we call septopreoptic HPE, falls in the spectrum of lobar HPE, but lacks significant frontal neocortical fusion seen in lobar HPE. Other imaging characteristics include thickened or dysplastic fornix, absent or hypoplastic anterior CC, and single unpaired ACA. The SP was fully formed in 4, partially formed in 2, and absent in 1. Mild midline craniofacial malformation, such as SMMCI and CNPAS were found in 86% and 71%, respectively. Patients outside of infancy often manifested language delay, learning disabilities, or behavioral disturbances, while motor function was relatively spared.

Parental perspectives on living with a child with HoPE

This article describes the experiences and perceived needs of a small cohort of parents of children with holoprosencephaly (HPE). The factors that are important to the lives of children vary across families and stages of development. As children living with HPE grow and change, parents adapt their goals and expectations to reflect their child's now and future state. Relevant literature is integrated within the discussion to support recommendations for care.

Can spasticity and dystonia be independently measured in cerebral palsy?

Selecting and evaluating appropriate treatments for children with cerebral palsy has been challenging. One difficulty is in the ability to quantify the presence and importance of coexisting motor signs. This study presents quantitative measures developed to assess spasticity and dystonia. Children diagnosed with extrapyramidal or spastic cerebral palsy and matched control children were studied. Spasticity was measured as the slope of the force-velocity relationship from a test where we measured the forces required to passively extend the elbow at different velocities. Dystonia was assessed by measuring "overflow" movements of arm during active movement of the other arm. Measures of dystonia and spasticity did not correlate with one another, but did correlate with their respective clinical measurement tools, the Modified Ashworth scale and the Barry-Albright Dystonia scale. Most children had a combination of both spasticity and dystonia, despite diagnosis. Our measures also related to different aspects of reaching: children with increased dystonia made more curved paths, and children with increased spasticity hit higher peak velocities. These measurements allow us to distinguish between different motor disorders and the degree to which each contributes to reaching performance. Use of quantitative measures should improve selection and evaluation of treatments for childhood motor disorders.

Links between abnormal brain structure and cognition in holoprosencephaly

Converging information on medical issues, motor ability, and cognitive outcomes is essential when addressing long-term clinical management in children with holoprosencephaly. This study considered whether adding more informative structural indices to classic holoprosencephaly categories would increase prediction of cognitive outcomes. Forty-two children with holoprosencephaly were examined to determine the association of deep gray nuclei abnormalities with cognitive abilities and the effect of motor skill deficits on cognitive performance. Additionally, a cognitive profile was described using the Carter Neurocognitive Assessment, an experimental diagnostic instrument designed specifically for young children with severe neurodevelopmental dysfunction. Findings indicated that nonseparation of the deep gray nuclei was significantly associated with the cognitive construct of vocal communication, but not with the cognitive constructs of social awareness, visual attention, or auditory comprehension. Importantly, motor skill deficits did not significantly affect performance on the Carter Neurocognitive Assessment. This study is the first investigation to provide a descriptive overview of specific cognitive skills in this group of children. The results also strongly suggest that this feature of the brain's structure does not predict all aspects of neurodevelopmental function. These findings contribute a critical component to the growing body of knowledge regarding the medical and clinical outcomes of children with holoprosencephaly.

Factor analysis of neuroanatomical and clinical characteristics of holoprosencephaly

The objective of this study is to better understand the relationship between neuroradiologic and clinical characteristics in holoprosencephaly (HPE) using the multivariate analysis called factor analysis. HPE is a brain malformation characterized by incomplete cleavage of the cerebral hemispheres and deep gray structures. We performed evaluations on 89 children with HPE that included their history, developmental assessment, and physical examination. Ten clinical variables included in factor analysis were the grade of spasticity, dystonia, choreoathetosis, hypotonia, mobility, upper extremity/hand function, expressive language, feeding/swallowing difficulty, endocrinopathies, and temperature dysregulation. Five neuroimaging variables graded by pediatric neuroradiologists were the grade of HPE (from least to most severe: lobar, semilobar, and alobar) and the degree of non-separation of caudate, lentiform, thalamic, and hypothalamic nuclei. Factor analysis using principle component extraction and varimax rotation was utilized. Four significant factors were identified: (1) neuroimaging/developmental factor, (2) motor factor, (3) hypothalamic/oromotor factor, and (4) hypotonia factor. These four factors accounted for 65.2% of the variance. In this factor analysis of HPE patients, we were able to reduce the large number of clinical and radiological variables into four factors. These factors and the constructs underlying them provide structure to the data and provide key parameters for future studies involving neurodevelopmental outcomes in HPE.

A retrospective survey of perinatal risk factors of 104 living children with holoprosencephaly

Holoprosencephaly (HPE) is a brain malformation resulting from a primary defect in development of the basal forebrain during early gestation. Prenatal genetic and environmental factors and birth outcomes were described in a population of 104 children with holoprosencephaly referred to three clinical centers from 1998 through 2002. The mean child age was 4 years. Of cases karyotyped, 9% presented with a chromosomal abnormality. This study of living children with holoprosencephaly, the majority of whom are cytogenetically normal, provides new information on the subsample of children with a less severe phenotype. Most children were born at term; about 51% were microcephalic at birth. Consistent with previous research, the association between HPE and maternal history of diabetes merits further investigation. Several findings have important implications for future research. Only 22% of the children in this study sample were diagnosed with holoprosencephaly prenatally. The vast majority of children (72%) were diagnosed with HPE between birth and 1 year of age. Also, 19% of the cases referred to the Carter Centers with HPE were not confirmed on scan review. When possible, future population-based epidemiological studies should emphasize mechanisms that identify children with HPE outside of the newborn period and confirm the diagnosis by review of MRI or high quality CT brain scan.

Neuroanatomy of holoprosencephaly as predictor of function: beyond the face predicting the brain

BACKGROUND

Despite advances in neuroimaging and molecular genetics of holoprosencephaly (HPE), the clinical spectrum of HPE has remained inadequately described.

OBJECTIVE

To better characterize the clinical features of HPE and identify specific neuroanatomic abnormalities that may be useful predictors of neurodevelopmental function.

METHODS

The authors evaluated 68 children with HPE in a multicenter, prospective study. Neuroimaging studies were assessed for the grade of HPE (lobar, semilobar, and alobar), the degree of nonseparation of the deep gray nuclei, and presence of dorsal cyst or cortical malformation.

RESULTS

In general, the severity of clinical problems and neurologic dysfunctions correlated with the degree of hemispheric nonseparation (grade of HPE). Nearly three-quarters of the patients had endocrinopathies, with all having at least diabetes insipidus. The severity of endocrine abnormalities correlated with the degree of hypothalamic nonseparation (p = 0.029). Seizures occurred in approximately half of the children with HPE. The presence of cortical malformations was associated with difficult-to-control seizures. The presence and degree of dystonia correlated with the degree of nonseparation of the caudate and lentiform nuclei and the grade of HPE (p < 0.05). Hypotonia correlated with the grade of HPE (p < 0.05). Mobility, upper extremity function, and language correlated with the degree of nonseparation of the caudate, lentiform and thalamic nuclei, and grade of HPE (p < 0.01).

CONCLUSIONS

Patients with HPE manifest a wide spectrum of clinical problems and neurologic dysfunction. The nature and severity of many of these problems can be predicted by specific neuroanatomic abnormalities found in HPE.

Test or trauma? The voiding cystourethrogram experience of young children

Many diagnostic procedures, while necessary and appropriate, may be experienced by a child as a trauma. Health care professionals often perceive invasive procedures such as surgery and needle biopsies as more painful and threatening to the child than "test" such as voiding cystourethrograms (VCUGs). However, clinical experience indicates that the VCUG is often perceived by children as more highly distressing than other procedures. Success and a sense of competence (or shame and doubt) in mastering challenging life experiences, such as medical procedures, contribute to a child's evolving self-concept (Harter, 1983). These memories and successful behaviors can be applied to future similar situations. Health care professionals are challenged to help the child and the parents through the procedure with minimal distress in an effective and efficient manner. A series of vignettes illustrating parents' and children's experiences with a VCUG procedure highlight the impact of the VCUG on children's coping ability and adjustment. Recommendations for developmentally appropriate clinical practice standards of care related to the VCUG procedure in young children also are presented. Preparation as an ongoing partnership process among children, parents, and health care professionals.

Effects of physical activity on preterm birth

The authors conducted a cohort study of low income women to determine the effect of physical activity on the risk of preterm birth. Women were sampled prenatally from four clinic sites and were scheduled for delivery at the University of Maryland Medical Systems (UMMS). Women who delivered infants at UMMS but who had received no prenatal care were also eligible. Preterm delivery was defined as a delivery prior to 37 completed weeks gestation. After adjusting for confounders, the odds of preterm delivery were increased for women who climbed stairs > or = 10 times per day (odds ratio (OR) = 1.60, 95% confidence interval 1.05-2.46) and for women who engaged in purposive walking > or = 4 days per week (OR = 2.10, 95% CI 1.38-3.20). Leisure-time exercise (> or = 60 days in the first and second trimesters combined) had a protective effect on preterm delivery (OR = 0.51, 95% CI 0.27-0.95). Television viewing had a U-shaped relation with preterm delivery (ORs (95% CI): < 15 hours, 2.09 (1.21-3.61); 29-42 hours, 1.50 (0.84-2.67); > 42 hours, 3.05 (1.75-5.40)). While the results support current recommendations regarding leisure-time activities, activities of daily living appear to increase risk of preterm delivery among low income women. These findings and those for television watching warrant further investigation.

Central line associated bacteremia in the pediatric patient

PURPOSE

To define the per-day risk of central line associated bacteremia in an infant-toddler population and to describe risk factors associated with the development of central line bacteremia.

METHOD

The Central Line Data Tool collected information on 102 central venous catheters from 73 patients ranging in age from 1 day to 29 months. Each line was in place for 3 days or longer.

FINDINGS

There were 17 documented catheter-related infections during the 1-year study period (7.7 infections per 1,000 catheter days). Factors significantly associated with central line bactermia included: PAS infusion, catheter type and site, medication administration, blood withdrawal, and accidental line disruption.

CONCLUSIONS

Use of central lines for multiple purposes should be minimized.

Type A behavior in children: psychometric properties of the Matthews Youth Test for Health

The purpose of this study was to investigate the psychometric properties of the Matthews Youth Test for Health (MYTH) as a measure of components of Type A behavior in school-age children. The sample consisted of 216 middle-class, white, 6 to 11 year old, same-sex twin children. Pairs were randomly split into two subgroups for cross-validation. The MYTH was completed by 88% of the children's teachers. The Perceived Competence Scale was completed by 118 of the 124 children 8 to 11 years old; a parallel form of this instrument was completed by teachers of 108 of these children. The 17 items of the MYTH instrument were factor analyzed. Two factors, Impatience-Aggression and Competitive Achievement-Striving, were derived and cross-validated. These MYTH factors were internally consistent and replicated previous studies of school-age children. The construct validity of the MYTH subscales was partially supported by evidence of relationships between these components of Type A behavior and teacher-ratings of the child's competence in specific domains. Children's ratings of their competence and perceptions of global self-worth were not related to total MYTH scores or subscale scores.

Type A behavior and physiological cardiovascular risk factors in school-age twin children

The relationship of Type A behavior pattern (TABP) and its components to physiological cardiovascular disease (CVD) risk factors of blood pressure, obesity, and lipids and lipoproteins was examined in 112 pairs of twin children. Blood pressure, triceps skinfold thickness, and fasting venous specimens for lipid profiles were collected during a home visit. Teachers rated children's Type A-B behaviors using the Matthews Youth Test for Health (MYTH) (Matthews & Angulo, 1980). For statistical analyses, one member of each twin pair was assigned to Group I and the co-twin to Group II. In Groups I and II, significant, p less than or equal to .01, negative correlations between the impatience-aggression component of TABP and atherogenic lipids were observed before and after covariate adjustments. Children were classified as MYTH Type A or B on the basis of a median-split. Marginally significant differences (B greater than A) were found between the mean lipid levels of Type A and Type B children. No significant A-B differences in blood pressure or measures of obesity were observed in either group. Multivariate analysis of variance results suggested that lipid profiles in Group I differed significantly, p less than or equal to .02, by Type A-B classification. The results of this study suggest that TABP and its components are not positively associated with physiological risk factors for CVD; and the impatience-aggression component of TABP is associated with lower levels of atherogenic lipids.