Assessment of growth, nutritional status, and bone health in children with cerebral palsy
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Cerebral palsy (CP) is the most common cause of chronic motor disability in childhood. Children with CP experience motor difficulties as well as a number of associated impairments, such as feeding problems, malnutrition, and poor growth. Children with physical disabilities that limit ambulation usually have low bone mineral density (BMD), and many will sustain fractures. Impaired growth and feeding problems are common among children with CP. It is important to monitor nutritional status and growth in children with CP, but doing so accurately is challenging. The main aim of this thesis was to study some aspects of growth and nutrition in children with CP, with emphasis on bone health as well as clinical applicable and reliable methods of assessment of growth and nutritional status. The first study confirmed that feeding problems in children with cerebral palsy are common and more prevalent in children with speech difficulties and severe gross and fine motor function. Furthermore, we reported that feeding problems are associated with poor nutritional status assessed by body mass index (BMI). In standard clinical care, BMI is used to determine obesity in children. Doing so works well when BMI is high, but did not work well with the children in the study on assessment methods, who had low or normal BMI and excess fat. In our study on assessment of growth and nutritional status, all children with CP who were thin based on BMI calculation had adequate or excess fat percentage as assessed by DXA. A low BMI in children with CP may also be due to altered body composition, such as low muscle and bone mass. Thus, the results regarding poor nutritional status reported initially should be interpreted with caution. The only way to adequately assess fat percentage in this population of children with CP was by using Slaughter equations based on skinfold thickness measurements modified for use in children with CP as noted by Gurka et al. The assessment of body composition is a certainly a challenge in children with CP. However, by using multiple clinical tools, including fat percentage estimated from skinfold thickness, nutritional care can improve. The rates of overweight and obesity are increasing in the CP population, which are worrying because of the long-term consequences associated with obesity. This adds to the importance of assessing body composition in children with CP routinely with methods that are reliable. We examined vitamin D status and bone mineral density (BMD) in children with CP using dual X-ray absorptiometry. We found that the main predictor of BMD was the grade of severity and subsequent immobility. Among ambulatory children with CP, those with GMFCS level II had significantly lower BMD z-scores than children with GMFCS level I. The majority of the children had insufficient vitamin D status. However, we found no correlation between vitamin D status and BMD. Thus, the main conclusion of this thesis is that feeding problems, poor growth, and poor nutritional status, including vitamin D-deficiency and poor bone health, are common in children with CP. Because bone growth and bone density are relevant to overall linear growth, optimizing bone growth in CP is an important aspect of improving health in this population. The best way to assess nutritional status may be by measuring body composition, using CP specific equations based on skinfold thickness measurements.