title: Epidemiology of low bone mineral density and fractures in children with severe cerebral palsy: a systematic review.
abstract: OBJECTIVE
  Children with severe cerebral palsy (CP) are at risk for developing low bone mineral density (BMD) and low-impact fractures. The aim of this study was to provide a systematic literature review of the epidemiology of fractures and low BMD in children with severe CP, with an emphasis on risk factors. Gross Motor Function Classification System (GMFCS) levels IV and V were criteria for severe cerebral palsy.
  
  
  METHODS
  The literature (PubMed) was searched and eligible studies were given a level of evidence score using the Scottish Intercollegiate Guidelines Network criteria.
  
  
  RESULTS
  Seven studies were found concerning epidemiology of fractures, 11 studies described epidemiology of low BMD, and 14 studies concerned risk factors. The methodological quality of most of these studies was poor. Five studies were considered well-conducted with low risk of confounding and bias. In these studies, the incidence of fractures in children with moderate to severe CP approached 4% per year, whereas the prevalence of low BMD in the femur was 77%. Limited ambulation, feeding difficulties, previous fractures, anticonvulsant use, and lower body fat mass were associated with low BMD z-scores.
  
  
  CONCLUSIONS
  There is only a limited amount of high-quality evidence on low BMD and fractures in children with severe CP.
authors.affiliation: Medical Department ASVZ, Care and Service Centre for People with Intellectual Disabilities, Sliedrecht, the Netherlands. s.mergler@erasmusmc.nl
authors.forename: Sandra
authors.initials: S
authors.lastname: Mergler
authors.forename: Heleen M
authors.initials: HM
authors.lastname: Evenhuis
authors.forename: Annemieke M
authors.initials: AM
authors.lastname: Boot
authors.forename: Stella A
authors.initials: SA
authors.lastname: De Man
authors.forename: Karen G C B
authors.initials: KG
authors.lastname: Bindels-De Heus
authors.forename: Wim A R
authors.initials: WA
authors.lastname: Huijbers
authors.forename: Corine
authors.initials: C
authors.lastname: Penning
mesh_terms: D000293:Adolescent; D015519:Bone Density; D002547:Cerebral Palsy / Q000150:complications* / Q000453:epidemiology*; D002648:Child; D002675:Child, Preschool; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology*; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015995:Prevalence; D012307:Risk Factors; D012720:Severity of Illness Index