Adaptation of the lateral distal femur DXA scan technique to adults with disabilities.

The technique that best addresses the challenges of assessing bone mineral density in children with neuromuscular impairments is a dual-energy X-ray absorptiometry (DXA) scan of the lateral distal femur. The purpose of this study was to adapt this technique to adults with neuromuscular impairments and to assess the reproducibility of these measurements. Thirty-one adults with cerebral palsy had both distal femurs scanned twice, with the subject removed and then repositioned between each scan (62 distal femurs, 124 scans). Each scan was independently analyzed twice by 3 different technologists of varying experience with DXA (744 analyses). Precision of duplicate analyses of the same scan was good (range: 0.4%-2.3%) and depended on both the specific region of interest and the experience of the technologist. Precision was reduced when comparing duplicate scans, ranging from 7% in the metaphyseal (cancellous) region to 2.5% in the diaphyseal (cortical) region. The least significant change was determined as recommended by the International Society for Clinical Densitometry for each technologist and each region of interest. Obtaining reliable, reproducible, and clinically relevant assessments of bone mineral density in adults with neuromuscular impairments can be challenging. The technique of obtaining DXA scans of the lateral distal femur can be successfully applied to this population but requires a commitment to developing the necessary expertise.

Characterization of Patients in a Lifestyle Medicine Practice.

Objective. Lifestyle medicine is a relatively new specialty within medicine. The aim of this report is to characterize patients who present to a lifestyle medicine clinical practice. Methods. LifeStyle Medical Centers is an independent, community-based practice; this report is based on over 3200 patients within this practice. Most of the data presented were obtained from an intake questionnaire developed by the practice to provide background and screening particularly relevant to lifestyle medicine, including areas such as stress, sleep, physical activity, health knowledge, motivation, weight loss history and goals, and smoking. Results. Patients who present for lifestyle care come with varied goals, past histories, and current lifestyle issues. Many express a very high level of motivation to lose an unrealistically large amount of weight. The prevalence of physical inactivity, inadequate sleep, high stress, and risk of depression are high, yet the importance of these to health and well-being are often not recognized by the patient. Over 90% of the cost of care was covered by insurance. Conclusions. Having a better understanding of the patients who come to a lifestyle medicine clinic will help practices better design their lifestyle programs and guide lifestyle medicine providers to better engagement and care of their patients.

Anthropometric measures: poor predictors of body fat in children with moderate to severe cerebral palsy.

AIM: This purpose of our study was to assess and compare anthropometric measures of adiposity and direct measurement of percentage body fat by dual emission X-ray absorptiometry (DXA) in children with cerebral palsy (CP). We also compared our results in children with CP with results from a national sample of typically developing children from the National Health and Nutrition Examination Survey. METHOD: Anthropometry and DXA were obtained from 58 participants with CP (25 females, 33 males; Gross Motor Function Classification System levels III-V; mean age 13 y 1 mo [SD 3 y], range 8-18 y). Height was estimated from knee height, which was measured with knee height calipers; weight was measured on a sitting scale. The relation between percentage body fat measured by DXA and z-scores of each of the anthropometric measures (body mass index, mid-upper arm circumference, triceps skinfold, and mid-upper arm fat area) was assessed by linear models. Agreement analysis was performed to assess the ability of each anthropometric measure to predict percentage body fat by DXA. RESULTS: None of the anthropometric measures were adequately associated with percentage body fat by DXA. All anthropometric methods tended to underestimate percentage body fat in children with CP. INTERPRETATION: Single anthropometric measures do not perform well in predicting percentage body fat in children with or without CP. Further work is needed to develop clinically useful and simple assessments that will predict percentage body fat and to determine the relation between percentage body fat and health to guide clinical practice.

Assessment and correction of skinfold thickness equations in estimating body fat in children with cerebral palsy.

AIM: To assess the accuracy of skinfold equations in estimating percentage body fat in children with cerebral palsy (CP), compared with assessment of body fat from dual energy X-ray absorptiometry (DXA). METHOD: Data were collected from 71 participants (30 females, 41 males) with CP (Gross Motor Function Classification System [GMFCS] levels I-V) between the ages of 8 and 18 years. Estimated percentage body fat was computed using established (Slaughter) equations based on the triceps and subscapular skinfolds. A linear model was fitted to assess the use of a simple correction to these equations for children with CP. RESULTS: Slaughter's equations consistently underestimated percentage body fat (mean difference compared with DXA percentage body fat -9.6/100 [SD 6.2]; 95% confidence interval [CI] -11.0 to -8.1). New equations were developed in which a correction factor was added to the existing equations based on sex, race, GMFCS level, size, and pubertal status. These corrected equations for children with CP agree better with DXA (mean difference 0.2/100 [SD=4.8]; 95% CI -1.0 to 1.3) than existing equations. INTERPRETATION: A simple correction factor to commonly used equations substantially improves the ability to estimate percentage body fat from two skinfold measures in children with CP.

Revised pediatric reference data for the lateral distal femur measured by Hologic Discovery/Delphi dual-energy X-ray absorptiometry.

Lateral distal femur (LDF) scans by dual-energy X-ray absorptiometry (DXA) are often feasible in children for whom other sites are not measurable. Pediatric reference data for LDF are not available for more recent DXA technology. The objective of this study was to assess older pediatric LDF reference data, construct new reference curves for LDF bone mineral density (BMD), and demonstrate the comparability of LDF BMD to other measures of BMD and strength assessed by DXA and by peripheral quantitative computed tomography (pQCT). LDF, spine and whole body scans of 821 healthy children, 5-18 yr of age, recruited at a single center were obtained using a Hologic Discovery/Delphi system (Hologic, Inc., Bedford, MA). Tibia trabecular and total BMD (3% site), cortical geometry (38% site) (cortical thickness, section modulus, and strain-strength index) were assessed by pQCT. Sex- and race-specific reference curves were generated using LMS Chartmaker (LMS Chartmaker Pro, version 2.3. Tim Cole and Huiqi Pan. Copyright 1997-2006, Medical Research Council, UK) and Z-scores calculated and compared by correlation analysis. Z-scores for LDF BMD based on published findings demonstrated overestimation or underestimation of the prevalence of low BMD-for-age depending on the region of interest considered. Revised LDF reference curves were generated. The new LDF Z-scores were strongly and significantly associated with weight, body mass index, spine and whole body BMD Z-scores, and all pQCT Z-scores. These findings demonstrate the comparability of LDF measurements to other clinical and research bone density assessment modes, and enable assessment of BMD in children with disabilities, who are particularly prone to low trauma fractures of long bones, and for whom traditional DXA measurement sites are not feasible.

Hemiepiphyseodesis for late-onset tibia vara.

BACKGROUND: The amount of correction obtained with tibial and/or femoral hemiepiphyseodesis in late-onset tibia vara is quite variable. The purpose of this study is to identify preoperative factors which might help to predict the amount of correction that is obtainable. METHODS: Fifty-three patients (67 knees) have been treated with hemiepiphyseodesis and followed until skeletal maturity or a secondary realignment procedure before maturity. The amount of correction obtained was correlated with multiple preoperative factors including age, body weight, and degree of deformity. RESULTS: In 65 limbs treated with tibial hemiepiphyseodesis, the average correction in the tibia was 9 degrees, ranging widely from 33 degrees of correction to 6 degrees worsening of the deformity. In 22 limbs treated with femoral hemiepiphyseodesis, the average correction in the femur was 8 degrees (range, 0-19 degrees). Ultimately, 19 of the 67 limbs have been treated with an osteotomy and 10 more were left with greater than 10 degrees of varus deformity at maturity. In addition, 14 of the 67 limbs overcorrected into excessive valgus and/or required medial hemiepiphyseodesis procedures to prevent overcorrection. Using multiple regression analysis it was found that younger age and lesser deformity were weakly predictive of greater correction with tibial hemiepiphyseodesis. No factors were statistically significant predictors of femoral correction. CONCLUSIONS: Variable amounts of correction are obtained with hemiepiphyseodesis in patients with late-onset tibia vara. Even very large amounts of correction may be obtainable in some cases, but unfortunately preoperative factors such as age, weight, and degree of deformity cannot be relied upon in clinical practice to predict outcome. Surgical decision making must weigh the safety and simplicity of this procedure against the much more extensive but much more predicable realignment obtained with osteotomy procedures. LEVEL OF EVIDENCE: Level IV; retrospective and prospective longitudinal evaluation of a case series.

Fracture prediction and the definition of osteoporosis in children and adolescents: the ISCD 2007 Pediatric Official Positions.

Osteoporosis in adults has been defined on the basis of densitometric criteria, but at present the term osteoporosis does not have a widely recognized definition in pediatrics. Consequently, the International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference reviewed the literature describing the relationship between bone densitometric studies and fractures in apparently healthy children and adolescents, and prepared Official Positions regarding the definition of osteoporosis in children and adolescents. The ISCD Official Positions with respect to the above issues, as well as the rationale and evidence used to derive these positions, are presented here.

Growth and nutritional status in residential center versus home-living children and adolescents with quadriplegic cerebral palsy.

OBJECTIVE: To describe growth and nutrition in nonambulatory youth (<19 years of age) with cerebral palsy (CP) living in residential centers compared with similar youth living at home. STUDY DESIGN: A multicenter, cross-sectional, single observational assessment of 75 subjects living in a residential care facility compared with 205 subjects living at home. Primary outcome measures included anthropometric measures of height, weight, triceps, and subscapular skinfolds, and mid-upper-arm muscle area. Z scores were calculated from reference values for healthy children. Age, use of a feeding tube, and Gross Motor Functional Classification System (GMFCS) level were included as important confounders. RESULTS: Use of a feeding tube was associated with higher skinfold Z scores, and a significantly higher percentage of the residential subjects had a feeding tube. Height, weight, and arm-muscle area Z scores all diverged (negatively) from reference values with age, and the residential subjects were on average older than the home-living subjects. After controlling for age, GMFCS level and use of a feeding tube, residential living was associated with significantly greater weight, height, skinfold thicknesses, and mid-arm muscle area Z scores. CONCLUSION: Poor growth and nutrition in children with CP is a prevalent, important, and complex problem. Although factors intrinsic to the condition of CP likely play a significant role, it is also clear that environmental factors, including the living situation of the child, can have an impact.

Promotion of physical fitness and prevention of secondary conditions for children with cerebral palsy: section on pediatrics research summit proceedings.

Inadequate physical fitness is a major problem affecting the function and health of children with cerebral palsy (CP). Lack of optimal physical activity may contribute to the development of secondary conditions associated with CP such as chronic pain, fatigue, and osteoporosis. The purpose of this article is to highlight the content and recommendations of a Pediatrics Research Summit developed to foster collaborative research in this area. Two components of physical fitness-muscle strength and cardiorespiratory fitness-were emphasized. Although there is evidence to support the use of physical fitness interventions, there are many gaps in our current knowledge. Additional research of higher quality and rigor is needed in order to make definitive recommendations regarding the mode, intensity, frequency, and duration of exercise. Outcome measurements have focused on the body functions and structures level of the International Classification of Functioning, Disability and Health (ICF), and much less is known about effects at the activities and participation levels. Additionally, the influence of nutritional and growth factors on physical fitness has not been studied in this population, in which poor growth and skeletal fragility have been identified as serious health issues. Current intervention protocols and outcome measurements were critically evaluated, and recommendations were made for future research.

Pamidronate treatment and posttreatment bone density in children with spastic quadriplegic cerebral palsy.

Little is known about the long-term effects of a course of pamidronate treatment on bone mineral density (BMD) of children with spastic quadriplegic cerebral palsy (SQCP). Nine patients with SQCP who had low bone density and/or history of previous fracture(s) were studied during treatment and more than 1 yr after cyclic pamidronate treatment ended. Over the 12 mo of treatment, spine BMD increases raised average Z-score from -4.0 to -2.8. In the distal femoral metaphysis, BMD increase raised average Z-score from -3.6 to -1.7. Observations posttreatment ranged from 12 to 49 mo. Changes in BMD were variable among individuals. Group spine Z-score an average of 34 mo posttreatment approached pretreatment value. Six of eight patients had final distal femur posttreatment Z-scores the same or better than pretreatment baseline an average of 27.1 mo later. While most but not all gains in BMD were lost over the first 2 yr after treatment, no patient sustained fracture during or after treatment for a cumulative follow-up of more than 27 patient-yr.

Feeding dysfunction is associated with poor growth and health status in children with cerebral palsy.

OBJECTIVE: To describe parent-reported feeding dysfunction and its association with health and nutritional status in children with cerebral palsy. DESIGN: Anthropometry was measured and z scores calculated. The Child Health Questionnaire was used to assess health status, and a categorical scale (none to severe) was used to classify subjects according to severity of feeding dysfunction. SUBJECTS: 230 children (9.7+/-4.6 years; 59% boys) with moderate to severe cerebral palsy were recruited from 6 centers in the United States and Canada. STATISTICAL ANALYSES: Descriptive statistics, the Kruskal-Wallis and Pearson chi2 tests. RESULTS: Severity of feeding dysfunction was strongly associated with indicators of poor health and nutritional status. The mean weight z scores were -1.7, -2.5, -3.3, and -1.8 among children with none, mild, moderate, or severe (largely tube-fed) feeding dysfunction, respectively (P= .003). Similar results were observed for height z score (P=.008), triceps z score (P=.03), and poor Global Health score (part of the Child Health Questionnaire) (P<.001). Subjects who were tube fed were taller (P=.014) and had greater body fat stores (triceps z score, P=.001) than orally fed subjects with similar motor impairment. For subjects exclusively fed by mouth, a dose-response relationship was observed between feeding dysfunction severity and poor nutritional status. Subjects with only mild feeding dysfunction had reduced triceps z score (-0.9) compared with those with no feeding problems (-0.3). CONCLUSION: For children with moderate to severe cerebral palsy, feeding dysfunction is a common problem associated with poor health and nutritional status. Even children with only mild feeding dysfunction, requiring chopped or mashed foods, may be at risk for poor nutritional status. Parental report of feeding dysfunction with a structured questionnaire may be useful in screening children for nutritional risk.

The relationship between fractures and DXA measures of BMD in the distal femur of children and adolescents with cerebral palsy or muscular dystrophy.

Children with limited or no ability to ambulate frequently sustain fragility fractures. Joint contractures, scoliosis, hip dysplasia, and metallic implants often prevent reliable measures of bone mineral density (BMD) in the proximal femur and lumbar spine, where BMD is commonly measured. Further, the relevance of lumbar spine BMD to fracture risk in this population is questionable. In an effort to obtain bone density measures that are both technically feasible and clinically relevant, a technique was developed involving dual-energy X-ray absorptiometry (DXA) measures of the distal femur projected in the lateral plane. The purpose of this study is to test the hypothesis that these new measures of BMD correlate with fractures in children with limited or no ability to ambulate. The relationship between distal femur BMD Z-scores and fracture history was assessed in a cross-sectional study of 619 children aged 6 to 18 years with muscular dystrophy or moderate to severe cerebral palsy compiled from eight centers. There was a strong correlation between fracture history and BMD Z-scores in the distal femur; 35% to 42% of those with BMD Z-scores less than -5 had fractured compared with 13% to 15% of those with BMD Z-scores greater than -1. Risk ratios were 1.06 to 1.15 (95% confidence interval 1.04-1.22), meaning a 6% to 15% increased risk of fracture with each 1.0 decrease in BMD Z-score. In clinical practice, DXA measure of BMD in the distal femur is the technique of choice for the assessment of children with impaired mobility.

Puberty, statural growth, and growth hormone release in children with cerebral palsy.

OBJECTIVE: Children with cerebral palsy (CP) are smaller than normally growing children.. The association between the growth hormone (GH) axis and growth in children with CP during puberty is unknown. We compared growth and markers of the GH axis in pre-pubertal and pubertal children with moderate to severe CP and without CP over a three-year period. STUDY DESIGN: Twenty children with CP, ages 6-18, Gross Motor Function Classification System levels III-V, were compared to a group of sixty-three normally growing children of similar age. Anthropometry, Tanner stage, bone age, and laboratory analyses were performed every six months for three years. Laboratory values included spontaneous overnight GH release, fasting IGF-1 and IGFBP-3. Repeated measures models were used to evaluate interactions among Tanner stage and group (children with CP vs. reference children), taking into account gender, age, and nutritional status. RESULTS: Children with CP grew more slowly than those without CP at all Tanner stages (p<0.01). Patterns of IGF-1 and GH secretion in children with CP were similar to those of the reference group; however, the concentrations of IGF-1 (p<0.01) and GH (p<0.01) were lower in girls with CP, with a similar trend for boys (p=0.10 and 0.14, respectively). CONCLUSIONS: Diminished circulating IGF-1 and GH concentrations may explain the differences in growth between the two groups.

Quantifying weight bearing while in passive standers and a comparison of standers.

Mechanical loading plays an important role in skeletal health, and this is a major reason standing devices are widely used with non-ambulatory persons. However, little is known about the true axial loading that occurs while in a stander, or the factors which may impact loading. The purpose of this study was to quantify weight borne while in a stander, and to directly compare different standers. Load measuring footplate adaptors were designed and fabricated specifically for this study. Weight bearing loads in 20 non-ambulatory persons with quadriplegic cerebral palsy aged 6 to 21 years (median 14 y) were continuously monitored during routine 30-minute standing sessions. Fourteen participants were female, six were male; one was Gross Motor Function Classification System (GMFCS) Level IV, and 19 were GMFCS Level V. Each participant was monitored on four to six occasions over an 8-week period, two to three times in each of two different standers (total 108 standing sessions). Weight bearing loads ranged widely from 37 to 101% of body weight. The difference between standers was as much as 29% body weight. There is wide variance in the actual weight borne while in passive standers. The type of stander utilized is one factor which can significantly affect the amount of weight borne.

Quantifying weight-bearing by children with cerebral palsy while in passive standers.

PURPOSE: Children who are nonambulatory are placed into standers with the goal of providing benefits from weight-bearing. The purpose of this study was to quantify weight-bearing loads by children with cerebral palsy while in standers. METHODS: Electronic load-measuring footplates were fabricated specifically for this study. Weight-bearing loads were continuously measured in 19 children who were nonambulatory during routine 30-minute standing sessions (3-6 sessions/child, total 110 sessions). RESULTS: Weight-bearing ranged widely (23%-102%) with a mean of 68% of body weight. There was some variation over the course of a session and between different sessions, but more variance was noted between subjects. CONCLUSIONS: Actual weight borne in a stander is quite variable, and in some instances only a fraction of actual body weight. Further studies are required to delineate relevant factors and identify ways to maximize weight-bearing loads while in a stander.

Fracture rate in children with cerebral palsy.

OBJECTIVES: To determine the prevalence of previous fracture, the rate of fracture over time and associated risk factors for fracture in children with moderate or severe cerebral palsy (CP). STUDY DESIGN: Three hundred and sixty-four children with moderate-to-severe motor impairment (Gross Motor Function Classification System III, IV and V) enrolled in a multi-centre, region-based longitudinal study of growth, nutrition and health. Of these, 297 had baseline fracture information and 261 children had at least one follow-up assessment. Median duration of follow-up was 1.6 years, for over 600 person-years of follow-up. RESULTS: Forty-six (15.5%) children reported 62 previous fractures at baseline assessment. Children with a history of fractures at baseline were older (mean age 11.9 vs. 8.9 years, p<0.0001) and had greater body fat (triceps z-score -0.01 vs. -0.68, p=0.0003) than children with no previous fracture. Twenty children (6.7%) reported 24 fractures during the follow-up period. Factors associated with risk of fracture during the follow-up period were higher body fat (p=0.03), gastrostomy use (p=0.05) and previous fracture (p=0.10). Based on 24 fractures in 604.5 person-years of follow-up, the rate of fracture was 4.0 per hundred children (4.0%) per year. For children with a history of fracture at baseline, the fracture rate was 7.0% per year; for children with gastrostomy, 6.8% per year; and for children with high triceps skinfold, 9.7% per year. CONCLUSIONS: Children with moderate or severe CP are at high risk for fracture. Children with greater body fat, feeding gastrostomy and prior history of fracture are at highest risk and may benefit most from intervention. Further longitudinal study and clinical trials in children with CP are needed to better understand the factors contributing to fracture risk in this population and the best methods of prevention and treatment.

Growth and health in children with moderate-to-severe cerebral palsy.

BACKGROUND: Children with cerebral palsy frequently grow poorly. The purpose of this study was to describe observed growth patterns and their relationship to health and social participation in a representative sample of children with moderate-severe cerebral palsy. METHODS: In a 6-site, multicentered, region-based cross-sectional study, multiple sources were used to identify children with moderate or severe cerebral palsy. There were 273 children enrolled, 58% male, 71% white, with Gross Motor Function Classification System levels III (22%), IV (25%), or V (53%). Anthropometric measures included: weight, knee height, upper arm length, midupper arm muscle area, triceps skinfold, and subscapular skinfold. Intraobserver and interobserver reliability was established. Health care use (days in bed, days in hospital, and visits to doctor or emergency department) and social participation (days missed of school or of usual activities for child and family) over the preceding 4 weeks were measured by questionnaire. Growth curves were developed and z scores calculated for each of the 6 measures. Cluster analysis methodology was then used to create 3 distinct groups of subjects based on average z scores across the 6 measures chosen to provide an overview of growth. RESULTS: Gender-specific growth curves with 10th, 25th, 50th, 75th, and 90th percentiles for each of the 6 measurements were created. Cluster analyses identified 3 clusters of subjects based on their average z scores for these measures. The subjects with the best growth had fewest days of health care use and fewest days of social participation missed, and the subjects with the worst growth had the most days of health care use and most days of participation missed. CONCLUSIONS: Growth patterns in children with cerebral palsy were associated with their overall health and social participation. The role of these cerebral palsy-specific growth curves in clinical decision-making will require further study.

Longitudinal changes in bone density in children and adolescents with moderate to severe cerebral palsy.

OBJECTIVE: To assess the natural history of "growth" in bone mineral density (BMD) in children and adolescents with moderate to severe cerebral palsy (CP). STUDY DESIGN: A prospective, longitudinal, observational study of BMD in 69 subjects with moderate to severe spastic CP ages 2.0 to 17.7 years. Fifty-five subjects were observed for more than 2 years and 40 subjects for more than 3 years. Each evaluation also included assessments of growth, nutritional status, Tanner stage, general health, and various clinical features of CP. RESULTS: Lower BMD z-scores at the initial evaluation were associated with greater severity of CP as judged by gross motor function and feeding difficulty, and with poorer growth and nutrition as judged by weight z-scores. BMD increased an average of 2% to 5%/y in the distal femur and lumbar spine, but ranged widely from +42%/y to -31%. In spite of increases in BMD, distal femur BMD z-scores decrease with age in this population. CONCLUSIONS: Children with severe CP develop over the course of their lives clinically significant osteopenia. Unlike elderly adults, this is not primarily from true losses in bone mineral, but from a rate of growth in bone mineral that is diminished relative to healthy children. The efficacy of interventions to increase BMD can truly be assessed only with a clear understanding of the expected changes in BMD without intervention.

Altered skeletal maturation in moderate to severe cerebral palsy.

Abnormalities of growth and development are prevalent in children with cerebral palsy (CP). The purpose of this study was to assess skeletal maturation ('bone age') in this population and to identify those factors related to alterations in this aspect of development. The study group was a convenience sample of 80 participants (47 males, 33 females; age range 2 y 6 mo to 21 y 1 mo; mean age 10 y 10 mo, SD 4 y 2 mo). All had moderate to severe spastic or mixed spastic CP at Gross Motor Function Classification System level III (n=8, 10%); level IV (n=21, 26%); or level V (n=51, 64%). Skeletal maturation was assessed by the detailed Fels method of scoring hand-wrist radiographs. Each evaluation included clinical and anthropometric assessments, Tanner staging, bone density measurements, and the Children's Health Status Questionnaire. Follow-up evaluations were obtained for 41 participants, providing a total of 143 evaluations. Median interval between first and last evaluations was 24.7 months (range 11.9 to 45mo). For the study group as a whole there was no significant difference between a child's skeletal age and chronological age. However, there was a high prevalence of individual participants in whom skeletal age was advanced (7%) or delayed (10%), relative to chronological age, by more than 2 years. In multivariant analyses it was found that diminished linear growth (height), low lumbar-spine bone density, and low body fat as measured by triceps skinfolds were all independently associated with delays in skeletal maturation. Multiple aspects of skeletal growth and development, including skeletal maturation, are frequently altered in children with moderate to severe CP.

Serum prealbumin and albumin concentrations do not reflect nutritional state in children with cerebral palsy.

Serum prealbumin concentration (PALB) and albumin concentration (ALB) were evaluated as markers of undernutrition in 107 children with cerebral palsy (CP) age 2 to 18 years. PALB and ALB were rarely below the normal reference ranges and showed little to no correlation with anthropometric measures (eg, skinfolds, midarm fat area), growth (height), severity of CP (eg, feeding dysfunction, motor impairment), or general health.