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American Academy of Pediatrics
ELECTRONIC ARTICLE

Bone Density and Metabolism in Children and Adolescents With Moderate to Severe Cerebral Palsy

Richard C. Henderson, Robert K. Lark, Matthew J. Gurka, Gordon Worley, Ellen B. Fung, Mark Conaway, Virginia A. Stallings and Richard D. Stevenson
Pediatrics July 2002, 110 (1) e5; DOI: https://doi.org/10.1542/peds.110.1.e5
Richard C. Henderson
Departments of OrthopaedicsPediatrics
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Robert K. Lark
Departments of Orthopaedics
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Matthew J. Gurka
Biostatistics, University of North Carolina, Chapel Hill, North Carolina
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Gordon Worley
Department of Pediatrics, Duke University, Durham, North Carolina
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Ellen B. Fung
Department of Gastroenterology and Nutrition, Children’s Hospital and Research Center at Oakland, Oakland, California
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Mark Conaway
Departments of Biostatistics
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Virginia A. Stallings
Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
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Richard D. Stevenson
Pediatrics, University of Virginia, Charlottesville, Virginia
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Article Figures & Data

Figures

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  • Fig 1.
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    Fig 1.

    BMD z scores in region 3 of the distal femur as a function of age (years). Best fit linear regression line shown.

  • Fig 2.
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    Fig 2.

    BMD z scores in region 3 of the distal femur as a function of severity of CP as defined by the GMFC scale. Mean ± SE bars shown.

  • Fig 3.
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    Fig 3.

    BMD z scores in the lumbar spine as a function of nutritional status as defined by triceps skinfold z score. Best fit linear regression line shown.

  • Fig 4.
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    Fig 4.

    BMD z scores in the distal femur (region 1) as a function of the caregiver’s reported difficulty feeding the child. Mean ± SE bars shown.

  • Fig 5.
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    Fig 5.

    Serum markers of bone resorption (N-telopeptides in nmoles bone collagen equivalents/L) versus bone formation (osteocalcin in ng/mL). Best fit linear regression line shown.

Tables

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    TABLE 1.

    Comparison of Population-Based and Convenience Cohorts

    Population BasedConvenience SampleP Value*
    Demographic variables
     Age (y)
      Mean ± SE9.7 + 0.69.6 + 0.6≥.2
      Range2.0–19.02.1–18.2
     Gender (male:female)
      n36:2635:20≥.2
      %58%:42%64%:36%
     Race (white:black:other)
      n41:21:035:16:4≥.2
      %66%:34%:0%64%:29%:7%
    Clinical variables
     GMFC level (levels 3:4:5)
      n16:17:292:10:43.0005
      %26%:27%:47%4%:18%:78%
     Anticonvulsants (never:past only:current)
      n20:17:2512:14:29≥.2
      %32%:27%:40%22%:25%:53%
     Fracture (no:yes)
      n55:744:11≥.2
      %89%:11%80%:20%
     Lower limb or scoliosis surgery (no:yes)
      n29:3328:27≥.2
      %47%:53%51%:49%
     CHQ z score (mean ± SE)−0.9 + 0.2−0.8 + 0.2≥.2
    Nutrition variables
     Feeding difficulty (no:mild:mod:severe)
      n33:8:5:1615:9:6:25.04
      %53%:13%:8%:26%27%:16%:11%:45%
     Triceps skinfold z score (mean ± SE)−0.4 + 0.1−0.9 + 0.2.04
     Tube feedings ever (no:yes)
      n29:3325:30≥.2
      %47%:53%45%:55%
     Serum transthyretin level (mean ± SE)22.6 + 0.921.3 + 0.8≥.2
    Growth variables
     Height z score (mean ± SE)−2.5 + 0.2−3.3 + 0.3.01
     Weight z score (mean ± SE)−1.8 + 0.3−3.5 + 0.4.002
    Bone density variables
     Distal femur z scores
      Region 1 (mean ± SE)−2.6 + 0.2−3.6 + 0.2.001
      Region 2 (mean ± SE)−2.8 + 0.2−3.8 + 0.2.003
      Region 3 (mean ± SE)−2.6 + 0.2−3.7 + 0.3.001
      Lumbar spine z score (mean ± SE)−1.8 + 0.1−2.3 + 0.1.006
    • ↵* Statistical comparison between the population-based and convenience cohorts.

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    TABLE 2.

    Bone Density z Scores: Univariate Analyses

    NMean BMD z Score ± SE
    Distal Femur Region 2Lumbar Spine
    Demographic variables
     Age
      2.0–5.9 y31−2.9 ± 0.4−2.5 ± 0.2
      6.0–11.9 y50−3.0 ± 0.2−1.8 ± 0.1
      12.0–19.0 y36−3.7 ± 0.3−2.0 ± 0.2
    P = .01P ≥ .2
     Gender
      Boys71−3.1 ± 0.2−2.1 ± 0.1
      Girls46−3.6 ± 0.3−1.9 ± 0.2
    P = .1P ≥ .2
     Race
      White/other80−3.5 ± 0.2−2.0 ± 0.1
      Black37−2.7 ± 0.2−2.1 ± 0.2
    P = .01P ≥ 0.2
    Clinical variables
     GMFC level
      Level 318−1.8 ± 0.3−1.5 ± 0.2
      Level 427−3.1 ± 0.3−1.9 ± 0.2
      Level 572−3.8 ± 0.2−2.2 ± 0.1
    P < .0001P = .03
     Anticonvulsants
      Never32−2.5 ± 0.3−2.1 ± 0.2
      Past only31−3.0 ± 0.3−1.8 ± 0.1
      Current54−3.8 ± 0.2−2.2 ± 0.2
    P < .003P ≥ .2
     Fracture
      No99−3.1 ± 0.2−2.0 ± 0.1
      Yes18−3.9 ± 0.4−2.2 ± 0.4
    P = .06P ≥ .2
     Temporary immobilization
      Never58−3.1 ± 0.3−2.2 ± 0.1
      Brief17−3.8 ± 0.4−1.7 ± 0.4
      Prolonged42−3.2 ± 0.2−2.0 ± 0.2
    P ≥ .2P ≥ .2
     Children’s Health Status Questionnaire z score
      >−1.054−2.9 ± 0.2−1.9 ± 0.1
      −1.0 to −2.024−3.1 ± 0.4−2.4 ± 0.2
      <−2.031−3.7 ± 0.3−2.1 ± 0.3
    P ≥ .2P = .09
    Nutrition variables
     Triceps skinfold z score
      >031−3.0 ± 0.3−1.6 ± 0.2
      0 to −1.032−3.4 ± 0.3−2.1 ± 0.2
      −1.0 to −2.046−3.3 ± 0.3−2.3 ± 0.2
      <−2.08−3.5 ± 0.5−1.9 ± 0.3
    P ≥ .2P = .003
     Feeding problems
      None48−2.6 ± 0.3−1.7 ± 0.1
      Mild17−2.9 ± 0.3−2.2 ± 0.3
      Moderate11−4.4 ± 0.8−2.3 ± 0.3
      Severe41−3.9 ± 0.2−2.3 ± 0.2
    P = .0003P = .02
     Currently tube fed
      No84−2.9 ± 0.2−2.0 ± 0.1
      Yes33−4.0 ± 0.3−2.3 ± 0.2
    P = .001P ≥ .2
     Calcium intake
      Adequate (>1000)64−3.2 ± 0.2−1.9 ± 0.1
      Marginal (500–1000)46−3.3 ± 0.3−2.1 ± 0.2
      Low (<500 mg/d)7−3.4 ± 0.5−2.7 ± 0.4
    P ≥ .2P ≥ .2
     Serum transthyretin
      Normal (>18 mg/dL)51−3.4 ± 0.3−2.0 ± 0.1
      Marginal (16–18 mg/dL)7−3.6 ± 0.6−2.9 ± 0.3
      Low (<16 mg/dL)5−3.4 ± 0.5−2.9 ± 0.7
    P ≥ .2P = .02
    Growth variables
     Height z score (based on sitting knee height)
      >−1.015−2.5 ± 0.3−1.9 ± 0.4
      −1.0 to −2.025−2.8 ± 0.4−1.8 ± 0.2
      <−2.077−3.6 ± 0.2−2.2 ± 0.1
    P = .0003P ≥ .2
     Weight z score
      >−1.031−2.5 ± 0.3−1.4 ± 0.2
      −1.0 to −2.027−3.0 ± 0.2−2.2 ± 0.2
      <−2.059−3.9 ± 0.2−2.3 ± 0.1
    P < .0001P = .0001
     Arm circumference z score
      >036−2.6 ± 0.3−1.3 ± 0.1
      0 to −1.022−3.0 ± 0.4−2.2 ± 0.3
      −1.0 to −2.028−3.2 ± 0.3−2.2 ± 0.2
      <−2.031−4.4 ± 0.3−2.6 ± 0.1
    P < .0001P < .0001
    Other serum variables
     25 OHD
      Adequate (>20 ng/mL)36−3.5 ± 0.3−2.2 ± 0.2
      Marginal (15–20 ng/mL)27−3.4 ± 0.3−2.2 ± 0.2
      Low (<15 ng/mL)13−3.2 ± 0.4−2.2 ± 0.3
    P ≥ .2P ≥ .2
     N-telopeptides (bone resorption marker)
      Low tertile (<41 nm/L)24−3.5 ± 0.4−1.8 ± 0.2
      Mid tertile (41–57 nm/L)23−3.3 ± 0.4−2.2 ± 0.2
      High tertile (>57 nm/L)24−3.1 ± 0.3−2.2 ± 0.3
    P ≥ .2P ≥ .2
     Osteocalcin (bone formation marker)
      Low tertile (<38 ng/mL)25−3.9 ± 0.5−2.4 ± 0.2
      Mid tertile (38–59 ng/mL)25−3.3 ± 0.3−2.2 ± 0.2
      High tertile (>59 ng/mL)26−3.3 ± 0.3−1.9 ± 0.3
    P ≥ .2P ≥ .2
     Abnormal phosphorous, calcium, or alkaline phosphatase
      No62−3.3 ± 0.2−2.2 ± 0.1
      Yes13−4.0 ± 0.6−2.2 ± 0.3
    P ≥ .2P ≥ .2
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1 Jul 2002
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Bone Density and Metabolism in Children and Adolescents With Moderate to Severe Cerebral Palsy
Richard C. Henderson, Robert K. Lark, Matthew J. Gurka, Gordon Worley, Ellen B. Fung, Mark Conaway, Virginia A. Stallings, Richard D. Stevenson
Pediatrics Jul 2002, 110 (1) e5; DOI: 10.1542/peds.110.1.e5

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Bone Density and Metabolism in Children and Adolescents With Moderate to Severe Cerebral Palsy
Richard C. Henderson, Robert K. Lark, Matthew J. Gurka, Gordon Worley, Ellen B. Fung, Mark Conaway, Virginia A. Stallings, Richard D. Stevenson
Pediatrics Jul 2002, 110 (1) e5; DOI: 10.1542/peds.110.1.e5
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Subjects

  • Rheumatology/Musculoskeletal Disorders
    • Rheumatology/Musculoskeletal Disorders
  • Neurology
    • Neurology
    • Neurologic Disorders

Keywords

  • cerebral palsy
  • bone mineral density
  • osteoporosis
  • pediatrics
  • bone metabolism
  • growth
  • nutrition, osteopenia
  • CP, cerebral palsy
  • 25-OHD, 25-hydroxy vitamin D
  • NAGCePP, North American Growth in Cerebral Palsy Project
  • GMFC, Gross Motor Functional Classification scale
  • UNC, University of North Carolina
  • CHOP, Children’s Hospital of Philadelphia
  • DXA, dual-energy X-ray absorptiometry
  • BMD, bone mineral density
  • SE, standard error
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