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.

Bone measurements by peripheral quantitative computed tomography (pQCT) in children with cerebral palsy.

OBJECTIVE: To use peripheral quantitative computed tomography (pQCT) to determine bone measurements in patients with cerebral palsy (CP) age 3 to 20 years and compare them with control subjects. STUDY DESIGN: A total of 13 (5 male) patients with CP, along with 2 sex- and age-matched controls for each, were included in a mixed-model analysis with matched pairs as random effects for pQCT bone measurements of the 20% distal tibia. RESULTS: Tibia length was similar in the CP and control groups (P = .57). Weight was marginally higher in the control group (P = .06). Cortical bone mineral content (BMC), area, thickness, polar strength-strain index (pSSI), and periosteal and endosteal circumferences were greater in the control group (P < .05 for all). Relationships between bone measurements and weight showed that cortical BMC, area, periosteal circumference, and pSSI were greater at higher weights in the control group (group-by-weight interaction, P < .05 for all). Cortical thickness was greater in the control group and was correlated with weight. Cortical volumetric bone mineral density (vBMD) was greater with higher weights in the CP group (group-by-weight interaction, P = .03). CONCLUSIONS: Bone strength, as indicated by pSSI, is compromised in children with CP due to smaller and thinner bones, not due to lower cortical bone density.

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.

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.

Relationship of nutritional status to health and societal participation in children with cerebral palsy.

OBJECTIVES: To describe nutritional status in a population-based sample of children with moderate or severe cerebral palsy (CP) and to explore the relationships between nutritional status and health and functional outcomes. STUDY DESIGN: A population-based strategy was used to enroll children with CP at 6 geographic sites. Research assistants performed anthropometric assessment, determined severity of motor impairment, and interviewed caregivers with the Child Health Questionnaire and a questionnaire designed specifically for this study. Anthropometric measures were converted to Z scores and the relationship between health and nutritional status was assessed using regression models. RESULTS: Among the 235 participants, indicators of malnutrition were common. Poor nutritional status correlated with increased health care utilization (hospitalizations, doctor visits) and decreased participation in usual activities by the child and parent. CONCLUSIONS: Malnutrition is common in children with moderate or severe CP and associated with poorer health status and limitations in societal participation. Further studies are needed to determine the nature of these associations and how to manage nutrition in children with CP to optimize growth and health outcomes.

Bisphosphonates to treat osteopenia in children with quadriplegic cerebral palsy: a randomized, placebo-controlled clinical trial.

OBJECTIVE: To evaluate in a double-blind, placebo-controlled clinical trial the safety and efficacy of intravenous pamidronate to treat osteopenia in nonambulatory children with cerebral palsy. STUDY DESIGN: Six pairs of subjects generally matched within each pair for age, sex, and race completed the protocol. One member of each pair randomly received plain saline placebo, the other pamidronate. Drug/placebo was administered intravenously daily for 3 consecutive days, and this 3-day dosing session was repeated at 3-month intervals for one year. Evaluations were continued for 6 months after the year of treatment. Bone mineral density (BMD) was measured in the distal femur, a site specifically developed for use in this contracted population, and the lumbar spine. RESULTS: In the metaphyseal region of the distal femur, BMD increased 89% +/- 21% (mean +/- SEM) over the 18-month study period in the pamidronate group compared with 9% +/- 6% in the control group. Age-normalized z scores increased from -4.0 +/- 0.6 to -1.8 +/- 1.0 in the pamidronate group and did not significantly change in the control group (-4.2 +/- 0.3 to -4.0 +/- 0.3). The first dosing with pamidronate caused a transient drop in serum calcium that was asymptomatic and not treated. No other potentially adverse effects were noted. CONCLUSIONS: In this small controlled clinical trial, pamidronate was found to be a safe and very effective agent to increase BMD in nonambulatory children with cerebral palsy.