Changes in diffusion MRI and clinical motor function after physical/occupational therapies in toddler-aged children with spastic unilateral cerebral palsy.

Diffusion-weighted magnetic resonance imaging (DMRI) is a potential tool to assess changes in brain connectivity and microstructure resulting from physical and occupational therapy in young children with cerebral palsy. This works was carried out to assess whether DMRI can detect changes after 36 weeks of physical and occupational therapy in the microstructure and connectivity of the brains of children with cerebral palsy and determine whether imaging findings correlate with changes in clinical measures of motor function. Five children underwent anatomical MRI and DMRI and evaluations of motor function skills at baseline and after 36 weeks of intensive or once-weekly physical and occupational Perception-Action Approach therapies. Diffusion tensor imaging and constrained spherical deconvolution methods were used to calculate fractional anisotropy (FA) and fiber orientation distribution functions (fODFs), respectively. The fODFs were used to generate tractograms of the cerebrospinal tract (CST). After 36 weeks of physical and occupational therapy, all children showed increases in motor function. No changes were observed in anatomical MRI before and after therapy but CST tractography did show small differences indicating possible altered microstructure and connectivity in the brain. FA values along the CSTs, however, showed no significant changes. Reliable longitudinal DMRI can be employed in toddler-aged children with CP and DMRI has the potential to monitor neuroplastic changes in white matter microstructure. However, there is a high variability between subjects and clinical improvements were not always correlated with measures of FA along the CST.

How does the intensity of physical therapy affect the Gross Motor Function Measure (GMFM-66) total score in children with cerebral palsy? A systematic review protocol.

INTRODUCTION: Intensive physical therapy (PT) interventions administered to children with cerebral palsy (CP) have received a significant amount of attention in published literature. However, there is considerable variability in therapy intensity among studies and notable lack of information on optimal intervention dosing. This makes it difficult for clinicians to use evidence to inform practice. Many studies use the Gross Motor Function Measure (GMFM-66) to assess functional progress in children with CP. The purpose of this systematic review will be to identify the GMFM-66 change score reported in published studies, with outcomes based on intervention intensity. Whether the type of PT intervention, child's age, and Gross Motor Function Classification System level influence the GMFM-66 scores will be also assessed. METHODS AND ANALYSIS: This systematic review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 checklist. In March 2018, nine databases (PubMed, Ovid MEDLINE, Cochrane Library, Embase, Scopus, Web of Science, CINAHL, ClinicalTrials.gov, and REHABDATA) were searched for controlled clinical trials and single-subject design studies of PT interventions of any kind and intensity that used the GMFM-66 as an outcome measure for children with CP, age up to 18 years. Two authors independently reviewed the titles and abstracts and arrived at consensus on paper selection for a full-text review. The same process was used for a full-text article screening based on further detailed inclusion criteria, with a final selection made for those suitable for data extraction. Prior to commencement of data extraction, all searches will be updated, and new results re-screened. ETHICS AND DISSEMINATION: This study will involve a systematic review of published articles and no primary data collection. Therefore, no ethical approval will be necessary. Results will be disseminated in a peer-reviewed publication and presented at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42020147669.

Feasibility of an intensive outpatient Perception-Action Approach intervention for children with cerebral palsy: a pilot study.

PURPOSE: The purpose of this pilot study was (1) to evaluate feasibility of attendance and parent satisfaction with an intensive outpatient physical and occupational therapy program for young children with spastic cerebral palsy (CP) and (2) to examine changes in motor function. Methods: Sixteen children with CP, age range 18-36 months (mean 24.3 ± 6.3 months), received physical and occupational therapy sessions (30 minutes each) 5 days per week for 12 weeks. Attendance rates and parent satisfaction were assessed. Change in motor function using a one-group pre-post design was evaluated using the Gross Motor Function Measure-66 (GMFM-66), Quality of Upper Extremity Skills Test, and Pediatric Evaluation of Disability Inventory. GMFM-66 outcomes were also compared with expected outcomes using previously published normative developmental trajectories of children receiving standard therapies. Results: An average of 82% of scheduled outpatient physical and occupational therapies for 16 children were completed and the 11 parents who completed the Hills and Kitchen's Physiotherapy Outpatient Satisfaction Questionnaire were satisfied with the therapies and with their child's progress. Participants showed notable, statistically significant improvement across all activity-related measures. Conclusion: An intensive protocol of outpatient therapies utilizing Perception-Action Approach was feasible for most families of young children with spastic CP to attend at the outpatient clinic location. As this was not an experimental study, no reliable conclusions related to efficacy can be made, but the promising results suggest that further research into the effectiveness of intensive protocols is worthwhile.

Evaluating Latino WIC Mothers' Perceptions of Infant's Healthy Growth: A Formative Assessment.

OBJECTIVES: This article reports on a formative assessment with Latino mothers in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) evaluating knowledge, attitudes and behaviors regarding healthy growth for infants and their understanding of infant growth monitoring. Further, we explored the acceptability and feasibility of mothers' monitoring their infants' growth. This assessment includes healthy growth perceptions from mothers, caregivers and from WIC staff. METHODS: Utilizing a mixed method approach, this assessment included qualitative focus groups with WIC mothers that included a growth chart plotting exercise and a quantitative survey. In-depth interviews with clinic staff discussing protocols used in assessing children's growth were also conducted in one WIC clinic. RESULTS: Focus group participants included 34 mothers and 19 caregivers with a mean age of 32 years; 90 % identified as Latino. Themes included concern for underweight status, and reports of limited conversations between mothers and healthcare providers regarding overweight status, and infant feeding practices/beliefs that may contribute to feeding behaviors associated with risk for excess weight gain during infancy. Growth charts were well received, mothers were able to plot with modest accuracy; but effectiveness of growth plotting might be limited without refinement for health literacy and the provision of culturally-sensitive education in relation to feeding behaviors to support healthy infant growth. CONCLUSIONS: This represents a first effort in evaluating Latino mothers' perceptions of infants' healthy growth and use growth charts as a potential tool that can help prevent excess weight gain in early infancy.

Why parents use the emergency department during evening hours for nonemergent pediatric care.

BACKGROUND: Emergency departments (EDs) are commonly used by pediatric patients for nonemergent reasons. There is little information regarding how parents perceive their use of the ED and primary care availability during evening hours. METHODS: We conducted a survey of parental perspectives of ED use during evening hours. Participants were parents of pediatric patients (age 0-18 years) at a large quaternary medical center's ED presenting between 17:00 and 22:00 hours from January 15, 2013 to March 12, 2013. RESULTS: Most patients had a primary care pediatrician (98/102, 96.1%); 80% of their pediatricians (78/98) did not have evening hour availability. Overall, 46.7% of parents would have preferred to go to their primary care pediatrician. CONCLUSIONS: Many parents who expect outpatient treatment prefer to take their child to a primary care pediatrician during evening hours, but present to the ED because of lack of primary care access.

Risk factors associated with anemia, iron deficiency and iron deficiency anemia in rural Nepali pregnant women.

We conducted a cross sectional study to investigate risk factors associated with severe anemia [hemoglobin (Hb) < 8.0 g dl(-1)] and poor iron status among Nepali pregnant women. Socio-demographic, anthropometric, health and dietary data were collected from 3,531 women living in the southeastern plains of Nepal. Stool samples were analyzed for intestinal helminthes. Dark adaptation was assessed using the Night Vision Threshold Test (NVTT). Hb levels were measured in all subjects to detect anemia and the soluble transferrin receptor (sTfR) was measured among a subsample of 479 women. The iron status categories were: 1) normal (Hb> or = 11.0 g/dl and sTfR < or = 8.5 mg/l); 2) anemia without iron deficiency (Hb<11.0 g/dl and sTfR < or = 8.5 mg/l); 3) iron deficiency without anemia (Hb > or = 11.0 g/dl and sTfR>8.5 mg/l); and 4) iron deficiency anemia (IDA): (Hb<11.0 g/dl and sTfR>8.5 mg/l). Factors associated with severe anemia and poor iron status were determined using logistic regression. Hookworm infection increased the risk for developing severe anemia [adjusted odds ratio (AOR): 4.26; 95% CI 1.67-10.89; p<0.01] and IDA [relative risk ratio (RRR): 2.18; 95% CI 1.14-4.16; p<0.05]. Impaired dark adaptation was a common risk factor for iron deficiency with and without anemia. Intake of iron supplements as tablets and/or tonic was protective against severe anemia, anemia without iron deficiency and IDA. Dietary heme iron was significantly associated with iron deficiency without anemia (RRR: 0.1; 95% CI 0.02-0.47; p<0.01). These results indicate the risk factors varied by classification and multiple approaches are needed to reduce anemia and associated nutrient deficiencies.

Evaluating intense rehabilitative therapies with and without acupuncture for children with cerebral palsy: a randomized controlled trial.

OBJECTIVE: To compare the outcomes of conventional therapies (physical, occupational, and hydrotherapies) plus acupuncture with those without acupuncture when administered intensely in the management of children with spastic cerebral palsy (CP). DESIGN: Evaluation-blind, prospective randomized controlled trial. SETTING: Therapies and video-recorded assessments at a children's hospital in Beijing, China, and blind scoring and data analyses at a university in the United States. PARTICIPANTS: Children (N=75), 12 to 72 months of age, with spastic CP. INTERVENTIONS: Intensely administered (5 times per week for 12wk) physical therapy, occupational therapy, and hydrotherapy either with acupuncture (group 1) or without acupuncture (group 2). To satisfy standard of care, group 2 subsequently received acupuncture (weeks 16-28). MAIN OUTCOME MEASURES: The Gross Motor Function Measure (GMFM)-66 and the Pediatric Evaluation of Disability Inventory (PEDI) assessments at 0, 4, 8, 12, 16, and 28 weeks. RESULTS: At the end of 12 weeks, there was no statistically significant difference between the 2 groups, but when group 2 received acupuncture (16-28wk) there was a shift toward improvement in the GMFM-66 and the PEDI-Functional Skills Self-Care and Mobility domain. When groups were combined, statistically significant improvements after intense therapies occurred from baseline to 12 weeks for each outcome measure at each Gross Motor Function Classification System (GMFCS) level. After adjusting for expected normative maturational gains based on age, the GMFM gains for children with GMFCS II level was statistically significant (P<.05) with a mean gain of 6.5 versus a predicted gain of 3.4. CONCLUSIONS: Intense early administered rehabilitation improves function in children with spastic CP. The contribution from acupuncture was unclear. Children's response varied widely, suggesting the importance of defining clinical profiles that identify which children might benefit most. Further research should explore how this approach might apply in the U.S.

Child healthcare workers in resource-limited areas improve health with innovative low-cost projects.

Most child health workers in resource-limited communities are dedicated, imaginative, innovative practitioners with ideas that would improve the care of children and families. However, they often lack experience in seeking funds and implementing their ideas. In 2006, the Section on International Child Health in the American Academy of Pediatrics launched a program, I-CATCH to fill this gap. The program provides mentors to assist in writing a proposal for the community-conceived and community-driven idea to improve child health, makes a small amount of funds available to the selected proposals, and offers mentors to help with the project's implementation. To date, 29 projects in 20 different non-industrialized countries have been funded. The impressive results achieved by the four completed and three ongoing projects are presented.

An evaluation of a nutrition intervention in Kapinga Village on Pohnpei, Federated States of Micronesia.

The people of Kapinga Village are suffering from chronic diseases as a result of their lifestyles and eating habits, similar to many Pohnpeians. Kapinga Village is an urban area on the island of Pohnpei, Federated States of Micronesia, settled by people from Kapingamarangi, a remote atoll. The villagers have limited access to traditional staple foods, including breadfruit, banana, and taro, fruits, vegetables, and other healthy foods. The Island Food Community of Pohnpei (IFCP) carried out several nutrition interventions in Kapinga Village to prevent disease, including promotion of physical activity through growing local food, a nutritious diet of local foods, cooking classes, container gardening, and charcoal oven workshops. This study evaluated the effect of those interventions on dietary intake. A 7-day Food Frequency Questionnaire (FFQ) was administered in June-July, 2010 to participants from 68 households and data were compared to 2009 baseline data. Qualitative data were collected and analyzed to identify salient themes that were associated with changes in dietary intake. The FFQ data indicated that there was an increase in consumption of local fruits and vegetables compared with the baseline. Qualitative data revealed that participants viewed the interventions positively. The data also revealed that some of the new foods and drinks consumed were those already available in the village, but for which their uses had not previously been known (such as banana flower and hibiscus tea). Such improvements are likely to be sustainable. Recommendations are for more education, in the Kapingan language if possible, and future research to determine what culturally appropriate interventions are still needed to improve nutrition in Kapinga Village.

Immediate and long-term effects of hippotherapy on symmetry of adductor muscle activity and functional ability in children with spastic cerebral palsy.

OBJECTIVES: To investigate the immediate effects of 10 minutes of hippotherapy, compared with 10 minutes of barrel-sitting, on symmetry of adductor muscle activity during walking in children with cerebral palsy (CP) (phase I). To investigate the long-term effects of 12 weeks of hippotherapy on adductor activity, gross motor function, and self-concept (phase II). DESIGN: Pretest/posttest randomized controlled trial plus clinical follow-up. SETTING: Outpatient therapy center. PARTICIPANTS: Children with spastic CP (phase I: n=47; phase II: n=6). INTERVENTIONS: Phase I: 10 minutes of hippotherapy or 10 minutes of barrel-sitting; phase II: 12 weekly hippotherapy sessions. MAIN OUTCOME MEASURES: Phases I and II: adductor muscle activity measured by surface electromyography. Phase II: gross motor function and self-perception profiles. RESULTS: Phase I: hippotherapy significantly improved adductor muscle asymmetry (P<.001; d=1.32). Effects of barrel-sitting were not significant (P>.05; d=.10). Phase II: after 12 weeks of hippotherapy, testing in several functional domains showed improvements over baseline that were sustained for 12 weeks posttreatment. CONCLUSIONS: Hippotherapy can improve adductor muscle symmetry during walking and can also improve other functional motor skills.

Effectiveness of osteopathy in the cranial field and myofascial release versus acupuncture as complementary treatment for children with spastic cerebral palsy: a pilot study.

CONTEXT: Case reports and clinical trials have indicated that osteopathic manipulative treatment (OMT) may improve motor function and quality of life for children with cerebral palsy. OBJECTIVE: To assess the effectiveness of osteopathy in the cranial field, myofascial release, or both versus acupuncture in children with moderate to severe spastic cerebral palsy, as measured by several outcomes instruments in a randomized controlled trial. METHODS: Children between the ages of 20 months and 12 years with moderate to severe spastic cerebral palsy were enrolled in a single-blind, randomized wait-list control pilot study. There were three arms in the study: OMT (ie, osteopathy in the cranial field, myofascial release, or both, using direct or indirect methods), acupuncture, and control (ie, nontherapeutic attention). Children who were initially randomly assigned to the control arm were subsequently randomly reassigned to the intervention arms, increasing the sample size. Outcome measures included standard instruments used in the evaluation of children with cerebral palsy. Less traditional measures were also used, including serial evaluations by an independent blind osteopathic physician and visual analog scale assessments by an independent osteopathic physician and the parents or guardians. A total of 11 outcome variables were analyzed. RESULTS: Fifty-five patients were included in the study. Individual analyses of the 11 outcome variables revealed statistically significant improvement in two mobility measures for patients who received OMT--the total score of Gross Motor Function Measurement and the mobility domain of Functional Independence Measure for Children (P<.05). No statistically significant improvements were seen among patients in the acupuncture treatment arm. CONCLUSIONS: A series of treatments using osteopathy in the cranial field, myofascial release, or both improved motor function in children with moderate to severe spastic cerebral palsy. These results can be used to guide future research into the effectiveness of OMT or acupuncture in treating children with spastic cerebral palsy.

Common/Unity: an innovative program to address 3 root causes of many of the social ills seen in adolescents.

Multiple community agencies coordinated their individual expertise to develop a comprehensive program for a planned community in a 24-apartment complex for single, young (age range, 18-21 years), homeless mothers and their infants and children. Although objective evaluation of the program proved difficult, "community" was established and lives were changed. The program was designed to address multiple issues faced by teenaged mothers but did not directly address critical factors of youths' internal motivation and decision-making processes. Attempting to reverse major impediments in the lives of young mothers with histories of violence, abuse, unstable early home environments, and lack of education while assuming the sole responsibility of raising a child, advancing their education, and maintaining employment is a daunting task, but a task that deserves our urgent attention.

Confirmatory factor analysis in osteopathic medicine: fascial and spinal motion restrictions as correlates of muscle spasticity in children with cerebral palsy.

CONTEXT: While numerous measures are available to assist physicians in assessing patients with cerebral palsy, there is a paucity of instruments that capture data relevant to osteopathic assessment. The lack of such tools limits the reach of research in key osteopathic indicators. METHODS: A structured objective form designed to assist osteopathic physicians in the evaluation of fascial restriction, restriction of spinal motion, and muscle spasticity was developed for use during osteopathic musculoskeletal structural examinations. Data were collected as part of a larger study investigating the effects of osteopathic manipulative treatment versus acupuncture in children with cerebral palsy. In the present study, confirmatory factor analysis was used to examine the relationships between fascial and spinal motion restrictions in addition to spasticity. RESULTS: In 57 children with spastic cerebral palsy, latent factors for fascial restrictions and spinal motion restriction fit the data well and both factors were correlated with a visual analog scale rating of the child's muscle spasticity. CONCLUSIONS: These findings provide preliminary evidence for the factorial and concurrent validity of fascial and spinal motion restrictions, demonstrating the benefits of an instrument for assessing the results of osteopathic musculoskeletal structural examinations.

Resident continuity clinic: a modest proposal.

Resident continuity clinics are an integral and mandated component of the pediatric core curriculum. Hospital-based and community-based settings have been traditionally used, with varied success. This article proposes the use and testing of an additional site, the primary care clinic housed at the Children's Clinic for Rehabilitative Services. This site provides concomitant continuity, and community and advocacy experiences for children with complex chronic conditions. Further study of the educational efficiency of this site is warranted.

The concentration of free holo-retinol binding protein is higher in vitamin A-sufficient than in deficient Nepalese women in late pregnancy.

Free holo-retinol binding protein (RBP) [i.e., unbound to transthyretin (TTR)] plays a role in transporting vitamin A across the placenta during pregnancy. In a cross-sectional study of clinically healthy urban women, we assessed the association among clinical and biochemical factors on estimated concentrations of free holo-RBP during the last trimester of pregnancy. Serum samples obtained from a subsample of women (n = 259), who had participated in the Night Vision Threshold Test study in Nepal, were analyzed for determinations of retinol by HPLC, and RBP, TTR, and alpha-1 acid glycoprotein by radial immunodiffusion. Free holo-RBP concentrations were calculated using dissociation constants for free holo- and apo-RBP. Among these women, 30% were vitamin A deficient based on either the RBP:TTR index < or = 0.36 or serum retinol < 1.05 micromol/L. Using stepwise regression analyses, the RBP:TTR index explained 75% of the variance in free holo-RBP concentrations, whereas retinol explained only 14%. Women were classified as vitamin A sufficient (n = 185) or deficient (n = 74) using the RBP:TTR index and were stratified into 3 gestational groups (I: 24-28 wk, II: 29-33 wk, III: >33 wk). Concentrations of free holo-RBP were higher in vitamin A-sufficient women than in vitamin A-deficient women (mean +/- SEM, 48.1 +/- 1.2 vs. 27.6 +/- 0.8 nmol/L; P < 0.001), and in a 3 x 2 factorial analysis, the interaction between gestational group and vitamin A status was significant. These results demonstrate that the RBP:TTR index is a useful proxy for free holo-RBP concentration and that vitamin A status affects its distribution.

Bacteriuria management and urological evaluation of patients with spina bifida and neurogenic bladder: a multicenter survey.

PURPOSE: We assessed how groups at spina bifida clinics evaluate and manage the urinary tract in patients with spina bifida, neurogenic bladder and bacteriuria. MATERIALS AND METHODS: A survey was mailed to all 169 clinics listed by the Spina Bifida Association of America. Survey items addressed baseline and surveillance evaluation, criteria used to assess urinary tract health and approaches to treatment in patients with spina bifida and neurogenic bladder. RESULTS: Of the 169 clinics personnel at 59 (35%) responded to the survey. Almost half of the respondents had an established protocol or standard of care. At most clinics the use of ultrasound (93%), voiding cystourethrograms (85%) and urodynamic testing (76%) was supported but not renal isotopic studies (14%) or excretory urograms (2%) for baseline evaluation. At all clinics ultrasound was supported for routine surveillance but there was no consensus for other imaging modalities. Assessment of clinic approaches to the evaluation and management of bacteriuria demonstrated variable results, although at most clinics fever, flank pain, dysuria, and changes in urinary pattern were identified as being consistent with true infection. Groups at clinics following their protocol or standard of care showed no significant differences in their approach compared to those at clinics lacking a protocol or standard of care. CONCLUSIONS: No consensus exists for the evaluation and management of bacteriuria in patients with spina bifida and neurogenic bladder at clinics specializing in the care of such patients, even at those with established standards of care. A clear need exists for an established, national set of evidence based guidelines to assist medical decision making in this high risk population and, thus, improve care.

The night vision threshold test is a better predictor of low serum vitamin A concentration than self-reported night blindness in pregnant urban Nepalese women.

This study was conducted to validate the night vision threshold test (NVTT) as an indicator of night blindness. A total of 1401 pregnant women from the National Maternity Hospital participated in this study. Women were queried about night blindness and took the NVTT using standardized procedures after 10 min of dark adaptation. Sixteen percent failed the NVTT, but only 6.4% reported having night blindness. Blood samples from women who failed the NVTT (cases) and matched controls indicated the serum vitamin A (SVA) concentration was lower (P < 0.05) in cases (1.19 +/- 0.03 micromol/L) than in controls (1.29 +/- 0.03 micromol/L). The SVA concentrations did not differ between women who reported and did not report night blindness. The SVA concentration was correlated (r = 0.22, P < 0.001) with the NVTT scores. Twenty-five percent of women with an SVA < 0.35 micromol/L reported night blindness while 100% failed the NVTT. Nineteen percent of women with an SVA < 0.70 micromol/L reported night blindness while 73% failed the NVTT. A receiver operating characteristics analysis indicated that the NVTT had greater sensitivity (0.73 vs. 0.19) and less specificity (0.51 vs. 0.87) compared with reported night blindness for women with SVA < 0.70 micromol/L and greater sensitivity (100.0 vs. 0.73) and similar specificity (0.51 vs. 0.50) for women with SVA < 0.35 micromol/L. The NVTT identified women with low SVA and self-reported night blindness was misleading. We provide a preliminary algorithm to predict the population of women with low SVA concentrations.