Original article 541
Obesity in children with brachial plexus birth palsy Avreeta K. Singha, Janith Millsb, Andrea S. Bauera and Marybeth Ezakib Fetal macrosomia is associated with a 14-fold increased risk of brachial plexus birth palsy (BPBP), and is a predictor of childhood obesity. The purpose of this study was to identify the relationships between BPBP, fetal macrosomia, and childhood obesity. We retrospectively reviewed 214 children with BPBP. The average age was 8 years and 53% had a Narakas 1 grade BPBP. Overall, 49% of children were normal weight, 22% overweight, and 29% obese. Of the children with a history of fetal macrosomia, 41% were obese; a statistically significant difference. Overall quality of life scores, however, were not correlated with obesity. J Pediatr Orthop B 24:541–545 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Introduction Brachial plexus birth palsy (BPBP) occurs at a rate of ∼ 1.5 per 1000 live births within the USA [1]. The condition results from varying degrees of injury to the brachial plexus generally occurring at the time of a difficult delivery. The Narakas grading scale is used to classify babies with BPBP along a clinical continuum into four groups. The groups are determined depending on the severity of injury and number of nerve roots involved [2–4]. Group I, which has C5 and C6 involvement, includes the majority of cases and tends to have the best prognosis, whereas group IV involves total palsy with Horner’s syndrome and connotes the worst prognosis. Known obstetrical risk factors for BPBP include shoulder dystocia, fetal macrosomia, vacuum delivery, breech delivery, and maternal gestational diabetes [1,5–10]. Use of oxytocin and the occurrence of tachysystole during labor have also been identified as risk factors [11]. The risk factor of concern in this study is fetal macrosomia, which is defined by the American College of Obstetricians and Gynecologists as a birth weight equal to or greater than 4.5 kg. Foad et al. [1] demonstrated in an epidemiologic study of BPBP that there is a greater than 14-fold increased risk of having neonatal brachial plexus palsy in an exceptionally large baby (>4.5 kg) compared with that of a baby who weighs less than 4.5 kg. In addition, fetal macrosomia is associated with long-term consequences in children such as the development of metabolic syndrome as well as being an independent predictor of obesity later in childhood [12–18]. Obesity in children is defined as a BMI at or above the 95th percentile for children of the same age and sex. Approximately 17% (or 12.5 million) of US children and adolescents aged 2–19 years of age are obese [19,20]. 1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of Pediatric Orthopaedics B 2015, 24:541–545 Keywords: brachial plexus birth palsy, childhood obesity, fetal macrosomia, Pediatric Outcomes Data Collection Instrument a Department of Orthopaedic Surgery, Shriners Hospital for Children Northern California, Sacramento, California and bDepartment of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
Correspondence to Andrea S. Bauer, MD, Department of Orthopaedic Surgery, Shriners Hospital for Children Northern California, 2425 Stockton Blvd., Sacramento, CA 95817, USA Tel: + 1 916 453 2049; fax: + 1 916 453 2202; e-mail: [email protected]
In 2007, the National Initiative for Children’s Healthcare Quality found that 32.2% of children ages 10–17 in Texas and 30.5% in California were either overweight (BMI between 85th and 95th percentile) or obese. The same study also found significant differences in obesity/overweight rates in children, depending on their family’s income status. Fifty-three percent of Texas children and 44% of California children from families making less than 100% of the Federal Poverty Level were obese as compared with 17% (Texas) and 21% (California) of obese children from families making greater than 400% of the Federal Poverty Level [21,22]. Over the past few decades there has been an increased awareness of the physical and psychosocial effects of childhood obesity. Not only is a higher BMI during childhood associated with an increased risk of cardiovascular events in adulthood [23,24], but obese individuals also face social disadvantages in various aspects of life, including employment, education, healthcare, and interpersonal relationships [25]. The purpose of this study was to identify the relationships between BPBP, fetal macrosomia, and childhood obesity, and to interpret their effects on quality of life. To evaluate quality of life, we used the Pediatric Outcomes Data Collection Instrument (PODCI), a questionnaire that assesses function across several domains, including; upper extremity function, mobility and transfers, ability to participate in sports, comfort/pain, global function (an average of the four previous scores), and happiness with physical condition [26]. This score has previously been validated for use in children with BPBP [27]. Our hypothesis was that children with BPBP would more likely be obese during childhood than the reported prevalence of childhood obesity. Our secondary hypothesis DOI: 10.1097/BPB.0000000000000208
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542 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 6
was that obese children with BPBP would have lower overall PODCI scores.
Methods Our two hospitals are tertiary referral centers for children with BPBP and our patients routinely complete PODCI questionnaires. Data were reviewed retrospectively from 2001 to 2011 at Hospital A and from 2009 to 2012 at Hospital B. We collected information from the medical record including age, race, sex, insurance status, Narakas grade, and birth weight. The child’s height and weight within 3 months of the PODCI assessment were also recorded and a BMI was calculated. The Centers for Disease Control chart was used to calculate BMI-for-age percentile for each child [28]. Pearson correlations were used to determine the relationship between BMI-for-age percentile and PODCI scores. Analysis of variance testing was used to further analyze PODCI scores by the three weight categories of obesity, overweight, and normal weight. Univariate and multivariate regressions of PODCI results were performed using these three weight categories, along with insurance status and Narakas grade. This study was approved by the Institutional Review Boards of both hospitals. No funding was received for this study.
Results Two hundred and seventeen children participated in this study. The average age was 8 years (range 2–19 years). The study was composed of 48% boys with the majority of patients (53%) having a Narakas grade 1 injury (C5 and C6 involvement), mirroring the clinical experience of both centers. PODCI scores were based on the parent form for 74% of children and the child form for the remaining 26% (Table 1). Both parent and child forms of the PODCI data were analyzed together because preliminary statistical analyses revealed no differences between the two forms. The ethnic makeup of the study groups differed between the hospitals. Hospital A included 46% White, 20% Hispanic, and 18% Black, whereas the group from Hospital B included 25% White, 38% Hispanic, and 28% Black. Insurance status was used as a proxy of socioeconomic status. Participants were initially grouped into self-pay, Medicaid, or private insurance; however, statistically the self-pay and private insurance groups behaved very similarly, so the categories were condensed into Medicaid versus all other types of insurance for increased statistical power. Payor mix was similar for both hospitals, with 40% private insurance, 15% self-pay, and 45% Medicaid insurance (Table 1). Obesity rates were different between the two hospitals. Thirty-two percent of patients from Hospital B were obese versus 24% from Hospital A. Overall, 49% were in the normal weight range, 22% were overweight, and 29% were obese (Table 1). Children with a history of being large for gestational age (birth weight > 4000 g)
Table 1
Demographics n (%)
Sex Male Female Missing Race/ethnicity White Hispanic Black Asian Other Missing Birth weight (g) < 4000 4000–4500 > 4500 Missing Age (years) Mean Median Range PODCI form Child Parent Narakas 1 2 3 4 Missing Insurance Private Self-pay Medicaid Missing BMI for age percentile Normal Overweight (85–95) Obese (>95)
Complete sample
California
Texas
105 (48.4) 109 (50.2) 3 (1.4)
37 (50.7) 36 (49.3)
68 (48.2) 73 (51.8)
34 15 13 8 3 1
35 54 40 6 3 5
69 69 53 14 6 6
(31.8) (31.8) (24.4) (6.5) (2.8) (2.8)
(45.9) (20.3) (17.6) (10.8) (4.1) (1.4)
(24.5) (37.8) (28.0) (4.2) (2.1) (3.5)
61 (32.6) 78 (41.7) 48 (25.7) 30
21 (33.3) 26 (41.2) 16 (25.4)
217 (8.6) 217 (8.0) 217 (2–19)
74 (8.2)
57 (26.3) 160 (73.7)
11 (14.9) 63 (85.1)
46 (32.2) 97 (67.8)
116 48 17 21 15
39 18 4 3 10
77 30 13 18 5
(53.5) (22.1) (7.8) (9.7) (6.9)
40 (32.3) 52 (41.9) 32 (25.8)
143 (8.9)
(52.7) (24.3) (5.4) (4.1) (13.5)
(53.8) (21.0) (9.1) (12.6) (3.5)
86 (40.1) 32 (15.0) 96 (44.9) 3
37 (50.7) 6 (8.2) 30 (41.1)
49 (34.8) 26 (18.4) 66 (46.8)
106 (48.8) 48 (22.1) 63 (29)
43 (58.4) 13 (17.6) 18 (24.3)
63 (44.1) 35 (24.5) 45 (31.5)
PODCI, Pediatric Outcomes Data Collection Instrument.
were significantly more likely to be overweight or obese in childhood than infants born at less than 4000 g, a difference that became more pronounced when we compared macrosomic infants (birth weight > 4500 g) to those born at less than 4500 g (Table 2). Previously reported PODCI scores in the literature for BPBP patients were very similar in all domains when compared with scores reported in this study [27,29,30]. The mean upper extremity function PODCI score for our BPBP patients was 79 compared with 77 in the study performed by Huffman and colleagues, and the mean global function PODCI score was 87.5 compared with Table 2
Birth weight versus BMI-for-age percentile
Birth weight (g) < 4000 ≥ 4000 P = 0.03 < 4500 ≥ 4500 P = 0.10
Normal (BMI < 85%) (%)
Overweight (BMI 85–95%) (%)
Obese (BMI > 95%) (%)
51.6 49.2
29.7 16.7
18.8 34.1
52.5 42.9
22.7 16.3
24.8 40.8
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Obesity in BPBP Singh et al. 543
Table 3
PODCI results
Table 4
Multivariate linear regressions of PODCI domains
n (%) Complete sample Upper extremity function Mean 209 (78.9) Median 209 (83) Mobility Mean 210 (96.9) Median 210 (100) Sports and physical function Mean 209 (87.4) Median 209 (91.0) Pain/comfort Mean 209 (87.3) Median 209 (100) Happiness Mean 205 (88.1) Median 205 (95) Global function Mean 203 (87.5) Median 203 (88)
B
California
Texas
74 (77.5)
135 (79.6)
92
74 (96.4)
136 (97.1)
98.4
74 (85.1*)
135 (88.6*)
90.2
74 (86.8)
135 (87.7)
92.4
74 (83.7*)
131 (90.6*)
89.8
74 (86.4)
129 (88.1)
Pediatric norm values
93.3
PODCI, Pediatric Outcomes Data Collection Instrument. *Means for sports and physical function and happiness differ significantly (P ≤ 0.05) between sites.
87.1 (Table 3). As in the study by Huffman et al. [27], when compared with established normative pediatric PODCI data, the reported scores from both hospitals demonstrated lower PODCI values in all domains. There was a mean difference of 13.1 and 5.8 points in upper extremity function and global function domains, respectively. Normative PODCI values are included for reference in Table 3. Using BMI-for-age percentile as a continuous variable, Pearson correlations did not detect a significant effect on any of the PODCI domains. Participants were then grouped into three categories (obese, overweight, and normal weight) based on BMI-for-age percentile. Analysis of variance testing on these three groups also did not reveal any differences in any of the PODCI domains. Univariate regressions revealed significant effects of Narakas grade and insurance status on PODCI domains, and so these variables were included along with weight categories (obese, overweight, and normal weight) in a multivariate regression. This demonstrated significant decreases in upper extremity function, mobility, and global function with increasing Narakas grades. In addition, Medicaid insurance status was associated with significant decreases in upper extremity function, sports and physical function, and global function (Table 4). Weight category did not affect PODCI scores in regression analysis.
Discussion The rate of childhood obesity in the USA has more than tripled in the past 30 years. This population is more likely to have risk factors for developing cardiovascular disease and type II diabetes [23,24]. They are also at an increased risk for bone and joint injuries as a result of alterations in
Upper extremity function (R2 = 0.073) Constant Narakas Medicaid Normal weight Overweight Obese Mobility (R2 = 0.066) Constant Narakas Medicaid Normal weight Overweight Obese Sports and physical function (R2 = 0.070) Constant Narakas Medicaid Normal weight Overweight Obese Pain/comfort (R2 = 0.035) Constant Narakas Medicaid Normal weight Overweight Obese Happiness (R2 = 0.016) Constant Narakas Medicaid Normal weight Overweight Obese Global function (R2 = 0.096) Constant Narakas Medicaid Normal weight Overweight Obese
84.9 − 2.8 − 6.4 – 0.51 4.3 99.0 − 1.0 − 1.2 – − 0.67 0.86 91.9 − 1.3 − 4.4 – 1.2 − 2.2 92.3 − 0.83 − 4.2 – − 0.85 − 4.5 91.1 − 0.53 − 3.5 – − 0.82 − 0.51 92.2 − 1.6 − 4.1 – − 0.12 − 0.83
P
0.038 0.018 0.878 0.165
0.012 0.126 0.494 0.353
0.115 0.011 0.560 0.261
0.515 0.091 0.781 0.117
0.650 0.145 0.777 0.852
0.019 0.002 0.940 0.589
Bold text indicates statistical significance, P ≤ 0.05. PODCI, Pediatric Outcomes Data Collection Instrument.
their bone mineral density, serum leptin levels, and altered balance and gait [31]. Orthopaedic manifestations of obesity include an increased risk of tibia vara, slipped capital femoral epiphysis, genu valgum, and fractures [32]. In addition, the stigma of being an overweight or obese adolescent may result in poor self-esteem and psychological problems. The literature suggests that birth trauma is more likely in macrosomic babies, and can result in BPBP. Moreover, babies that are born large for gestational age also tend to be obese later in childhood [12–18]. Our hypothesis was that children with BPBP would more likely be obese during childhood than the reported prevalence of childhood obesity. Children in our study had an obesity rate of 29%; greater than the national average of 17%. When data from each hospital was analyzed separately, the percentage of children who were either overweight or obese also exceeded the state averages. From Hospital A, 42% of BPBP children were either overweight or obese
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544
Journal of Pediatric Orthopaedics B 2015, Vol 24 No 6
compared with the California state average of 30.5%, and at Hospital B, 56% of BPBP children were overweight or obese compared with the Texas state average of 32% [21,22]. Several studies have demonstrated that children with physical disabilities and chronic medical illnesses are more likely to suffer from emotional and behavior problems [33–35]. The higher prevalence of obesity in children within our cohort compared with age-matched children in the USA, may suggest that children with BPBP are at an even greater risk for psychosocial and physical health consequences. In our study, we used the PODCI to evaluate these consequences. As we expected, pediatric patients with BPBP had overall lower PODCI scores compared with healthy-age matched norms; the greatest difference being most significant in the upper extremity and global function domains. Our findings were similar to those already published by Huffman et al. [27]. Also as expected, PODCI scores were lower for children with more severe injuries, as measured by the Narakas grade. This finding indicates that the PODCI score is a sensitive measure of quality of life differences among children with BPBP. Our study aimed to further identify differences in PODCI scores amongst BPBP patients depending on weight status. We hypothesized that obese children with BPBP would have lower overall PODCI scores compared with normal weight children with BPBP, but this was not the case. Interestingly, having Medicaid insurance was a significant negative predictor of PODCI scores across several domains, including upper extremity function, sports and physical function, and global function. This suggests that children of lower socioeconomic means with BPBP have fewer ameliorating nonmedical interventions available to them, such as proper nutrition, school and community support.
child’s familial environment plays a large role in the development of obesity, both prenatally and postnatally [37,38]. Through early identification of pediatric BPBP patients who are overweight or at risk of becoming obese, health professionals can intervene to help reduce the negative sequelae associated with obesity. Not only can these children be counseled on dietary improvements and lifestyle modifications, but they can be screened earlier for physical and psychological complications associated with obesity. Further research is needed to better understand the complex relationships between BPBP, obesity, and socioeconomic status.
Acknowledgements The authors would like to acknowledge Fred Molitor, PhD, for assistance with statistical analysis. Conflicts of interest
There are no conflicts of interest.
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This study has several limitations. First, in children younger than 10 years, the PODCI questionnaire was filled out by a parent and not the patients themselves. The parent form accounted for 74% of all PODCI forms completed in our study. Concerns regarding reporting bias and accuracy may arise in this situation, as prior research has found that parents tend to underestimate their child’s performance in the upper extremity function domain and overestimate their children’s scores in the pain domain [36]. However, on our initial statistical analysis, these groups did not behave differently, and so we felt the improved statistical power justified analyzing the different form types as one group. Second, we did not control for surgical procedures, which may have influenced the results of this cross-sectional study, as some children may have been studied before a surgical procedure and others after. It is doubtful that this would have introduced a systematic bias, however, as weight category is not a routine part of surgical decision making. Lastly, this study concerns only the obesity rates in children with BPBP, not their families. However, it is likely that the
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Obesity in children with brachial plexus birth palsy Avreeta K. Singha, Janith Millsb, Andrea S. Bauera and Marybeth Ezakib Fetal macrosomia is associated with a 14-fold increased risk of brachial plexus birth palsy (BPBP), and is a predictor of childhood obesity. The purpose of this study was to identify the relationships between BPBP, fetal macrosomia, and childhood obesity. We retrospectively reviewed 214 children with BPBP. The average age was 8 years and 53% had a Narakas 1 grade BPBP. Overall, 49% of children were normal weight, 22% overweight, and 29% obese. Of the children with a history of fetal macrosomia, 41% were obese; a statistically significant difference. Overall quality of life scores, however, were not correlated with obesity. J Pediatr Orthop B 24:541–545 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Introduction Brachial plexus birth palsy (BPBP) occurs at a rate of ∼ 1.5 per 1000 live births within the USA [1]. The condition results from varying degrees of injury to the brachial plexus generally occurring at the time of a difficult delivery. The Narakas grading scale is used to classify babies with BPBP along a clinical continuum into four groups. The groups are determined depending on the severity of injury and number of nerve roots involved [2–4]. Group I, which has C5 and C6 involvement, includes the majority of cases and tends to have the best prognosis, whereas group IV involves total palsy with Horner’s syndrome and connotes the worst prognosis. Known obstetrical risk factors for BPBP include shoulder dystocia, fetal macrosomia, vacuum delivery, breech delivery, and maternal gestational diabetes [1,5–10]. Use of oxytocin and the occurrence of tachysystole during labor have also been identified as risk factors [11]. The risk factor of concern in this study is fetal macrosomia, which is defined by the American College of Obstetricians and Gynecologists as a birth weight equal to or greater than 4.5 kg. Foad et al. [1] demonstrated in an epidemiologic study of BPBP that there is a greater than 14-fold increased risk of having neonatal brachial plexus palsy in an exceptionally large baby (>4.5 kg) compared with that of a baby who weighs less than 4.5 kg. In addition, fetal macrosomia is associated with long-term consequences in children such as the development of metabolic syndrome as well as being an independent predictor of obesity later in childhood [12–18]. Obesity in children is defined as a BMI at or above the 95th percentile for children of the same age and sex. Approximately 17% (or 12.5 million) of US children and adolescents aged 2–19 years of age are obese [19,20]. 1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of Pediatric Orthopaedics B 2015, 24:541–545 Keywords: brachial plexus birth palsy, childhood obesity, fetal macrosomia, Pediatric Outcomes Data Collection Instrument a Department of Orthopaedic Surgery, Shriners Hospital for Children Northern California, Sacramento, California and bDepartment of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
Correspondence to Andrea S. Bauer, MD, Department of Orthopaedic Surgery, Shriners Hospital for Children Northern California, 2425 Stockton Blvd., Sacramento, CA 95817, USA Tel: + 1 916 453 2049; fax: + 1 916 453 2202; e-mail: [email protected]
In 2007, the National Initiative for Children’s Healthcare Quality found that 32.2% of children ages 10–17 in Texas and 30.5% in California were either overweight (BMI between 85th and 95th percentile) or obese. The same study also found significant differences in obesity/overweight rates in children, depending on their family’s income status. Fifty-three percent of Texas children and 44% of California children from families making less than 100% of the Federal Poverty Level were obese as compared with 17% (Texas) and 21% (California) of obese children from families making greater than 400% of the Federal Poverty Level [21,22]. Over the past few decades there has been an increased awareness of the physical and psychosocial effects of childhood obesity. Not only is a higher BMI during childhood associated with an increased risk of cardiovascular events in adulthood [23,24], but obese individuals also face social disadvantages in various aspects of life, including employment, education, healthcare, and interpersonal relationships [25]. The purpose of this study was to identify the relationships between BPBP, fetal macrosomia, and childhood obesity, and to interpret their effects on quality of life. To evaluate quality of life, we used the Pediatric Outcomes Data Collection Instrument (PODCI), a questionnaire that assesses function across several domains, including; upper extremity function, mobility and transfers, ability to participate in sports, comfort/pain, global function (an average of the four previous scores), and happiness with physical condition [26]. This score has previously been validated for use in children with BPBP [27]. Our hypothesis was that children with BPBP would more likely be obese during childhood than the reported prevalence of childhood obesity. Our secondary hypothesis DOI: 10.1097/BPB.0000000000000208
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
542 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 6
was that obese children with BPBP would have lower overall PODCI scores.
Methods Our two hospitals are tertiary referral centers for children with BPBP and our patients routinely complete PODCI questionnaires. Data were reviewed retrospectively from 2001 to 2011 at Hospital A and from 2009 to 2012 at Hospital B. We collected information from the medical record including age, race, sex, insurance status, Narakas grade, and birth weight. The child’s height and weight within 3 months of the PODCI assessment were also recorded and a BMI was calculated. The Centers for Disease Control chart was used to calculate BMI-for-age percentile for each child [28]. Pearson correlations were used to determine the relationship between BMI-for-age percentile and PODCI scores. Analysis of variance testing was used to further analyze PODCI scores by the three weight categories of obesity, overweight, and normal weight. Univariate and multivariate regressions of PODCI results were performed using these three weight categories, along with insurance status and Narakas grade. This study was approved by the Institutional Review Boards of both hospitals. No funding was received for this study.
Results Two hundred and seventeen children participated in this study. The average age was 8 years (range 2–19 years). The study was composed of 48% boys with the majority of patients (53%) having a Narakas grade 1 injury (C5 and C6 involvement), mirroring the clinical experience of both centers. PODCI scores were based on the parent form for 74% of children and the child form for the remaining 26% (Table 1). Both parent and child forms of the PODCI data were analyzed together because preliminary statistical analyses revealed no differences between the two forms. The ethnic makeup of the study groups differed between the hospitals. Hospital A included 46% White, 20% Hispanic, and 18% Black, whereas the group from Hospital B included 25% White, 38% Hispanic, and 28% Black. Insurance status was used as a proxy of socioeconomic status. Participants were initially grouped into self-pay, Medicaid, or private insurance; however, statistically the self-pay and private insurance groups behaved very similarly, so the categories were condensed into Medicaid versus all other types of insurance for increased statistical power. Payor mix was similar for both hospitals, with 40% private insurance, 15% self-pay, and 45% Medicaid insurance (Table 1). Obesity rates were different between the two hospitals. Thirty-two percent of patients from Hospital B were obese versus 24% from Hospital A. Overall, 49% were in the normal weight range, 22% were overweight, and 29% were obese (Table 1). Children with a history of being large for gestational age (birth weight > 4000 g)
Table 1
Demographics n (%)
Sex Male Female Missing Race/ethnicity White Hispanic Black Asian Other Missing Birth weight (g) < 4000 4000–4500 > 4500 Missing Age (years) Mean Median Range PODCI form Child Parent Narakas 1 2 3 4 Missing Insurance Private Self-pay Medicaid Missing BMI for age percentile Normal Overweight (85–95) Obese (>95)
Complete sample
California
Texas
105 (48.4) 109 (50.2) 3 (1.4)
37 (50.7) 36 (49.3)
68 (48.2) 73 (51.8)
34 15 13 8 3 1
35 54 40 6 3 5
69 69 53 14 6 6
(31.8) (31.8) (24.4) (6.5) (2.8) (2.8)
(45.9) (20.3) (17.6) (10.8) (4.1) (1.4)
(24.5) (37.8) (28.0) (4.2) (2.1) (3.5)
61 (32.6) 78 (41.7) 48 (25.7) 30
21 (33.3) 26 (41.2) 16 (25.4)
217 (8.6) 217 (8.0) 217 (2–19)
74 (8.2)
57 (26.3) 160 (73.7)
11 (14.9) 63 (85.1)
46 (32.2) 97 (67.8)
116 48 17 21 15
39 18 4 3 10
77 30 13 18 5
(53.5) (22.1) (7.8) (9.7) (6.9)
40 (32.3) 52 (41.9) 32 (25.8)
143 (8.9)
(52.7) (24.3) (5.4) (4.1) (13.5)
(53.8) (21.0) (9.1) (12.6) (3.5)
86 (40.1) 32 (15.0) 96 (44.9) 3
37 (50.7) 6 (8.2) 30 (41.1)
49 (34.8) 26 (18.4) 66 (46.8)
106 (48.8) 48 (22.1) 63 (29)
43 (58.4) 13 (17.6) 18 (24.3)
63 (44.1) 35 (24.5) 45 (31.5)
PODCI, Pediatric Outcomes Data Collection Instrument.
were significantly more likely to be overweight or obese in childhood than infants born at less than 4000 g, a difference that became more pronounced when we compared macrosomic infants (birth weight > 4500 g) to those born at less than 4500 g (Table 2). Previously reported PODCI scores in the literature for BPBP patients were very similar in all domains when compared with scores reported in this study [27,29,30]. The mean upper extremity function PODCI score for our BPBP patients was 79 compared with 77 in the study performed by Huffman and colleagues, and the mean global function PODCI score was 87.5 compared with Table 2
Birth weight versus BMI-for-age percentile
Birth weight (g) < 4000 ≥ 4000 P = 0.03 < 4500 ≥ 4500 P = 0.10
Normal (BMI < 85%) (%)
Overweight (BMI 85–95%) (%)
Obese (BMI > 95%) (%)
51.6 49.2
29.7 16.7
18.8 34.1
52.5 42.9
22.7 16.3
24.8 40.8
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Obesity in BPBP Singh et al. 543
Table 3
PODCI results
Table 4
Multivariate linear regressions of PODCI domains
n (%) Complete sample Upper extremity function Mean 209 (78.9) Median 209 (83) Mobility Mean 210 (96.9) Median 210 (100) Sports and physical function Mean 209 (87.4) Median 209 (91.0) Pain/comfort Mean 209 (87.3) Median 209 (100) Happiness Mean 205 (88.1) Median 205 (95) Global function Mean 203 (87.5) Median 203 (88)
B
California
Texas
74 (77.5)
135 (79.6)
92
74 (96.4)
136 (97.1)
98.4
74 (85.1*)
135 (88.6*)
90.2
74 (86.8)
135 (87.7)
92.4
74 (83.7*)
131 (90.6*)
89.8
74 (86.4)
129 (88.1)
Pediatric norm values
93.3
PODCI, Pediatric Outcomes Data Collection Instrument. *Means for sports and physical function and happiness differ significantly (P ≤ 0.05) between sites.
87.1 (Table 3). As in the study by Huffman et al. [27], when compared with established normative pediatric PODCI data, the reported scores from both hospitals demonstrated lower PODCI values in all domains. There was a mean difference of 13.1 and 5.8 points in upper extremity function and global function domains, respectively. Normative PODCI values are included for reference in Table 3. Using BMI-for-age percentile as a continuous variable, Pearson correlations did not detect a significant effect on any of the PODCI domains. Participants were then grouped into three categories (obese, overweight, and normal weight) based on BMI-for-age percentile. Analysis of variance testing on these three groups also did not reveal any differences in any of the PODCI domains. Univariate regressions revealed significant effects of Narakas grade and insurance status on PODCI domains, and so these variables were included along with weight categories (obese, overweight, and normal weight) in a multivariate regression. This demonstrated significant decreases in upper extremity function, mobility, and global function with increasing Narakas grades. In addition, Medicaid insurance status was associated with significant decreases in upper extremity function, sports and physical function, and global function (Table 4). Weight category did not affect PODCI scores in regression analysis.
Discussion The rate of childhood obesity in the USA has more than tripled in the past 30 years. This population is more likely to have risk factors for developing cardiovascular disease and type II diabetes [23,24]. They are also at an increased risk for bone and joint injuries as a result of alterations in
Upper extremity function (R2 = 0.073) Constant Narakas Medicaid Normal weight Overweight Obese Mobility (R2 = 0.066) Constant Narakas Medicaid Normal weight Overweight Obese Sports and physical function (R2 = 0.070) Constant Narakas Medicaid Normal weight Overweight Obese Pain/comfort (R2 = 0.035) Constant Narakas Medicaid Normal weight Overweight Obese Happiness (R2 = 0.016) Constant Narakas Medicaid Normal weight Overweight Obese Global function (R2 = 0.096) Constant Narakas Medicaid Normal weight Overweight Obese
84.9 − 2.8 − 6.4 – 0.51 4.3 99.0 − 1.0 − 1.2 – − 0.67 0.86 91.9 − 1.3 − 4.4 – 1.2 − 2.2 92.3 − 0.83 − 4.2 – − 0.85 − 4.5 91.1 − 0.53 − 3.5 – − 0.82 − 0.51 92.2 − 1.6 − 4.1 – − 0.12 − 0.83
P
0.038 0.018 0.878 0.165
0.012 0.126 0.494 0.353
0.115 0.011 0.560 0.261
0.515 0.091 0.781 0.117
0.650 0.145 0.777 0.852
0.019 0.002 0.940 0.589
Bold text indicates statistical significance, P ≤ 0.05. PODCI, Pediatric Outcomes Data Collection Instrument.
their bone mineral density, serum leptin levels, and altered balance and gait [31]. Orthopaedic manifestations of obesity include an increased risk of tibia vara, slipped capital femoral epiphysis, genu valgum, and fractures [32]. In addition, the stigma of being an overweight or obese adolescent may result in poor self-esteem and psychological problems. The literature suggests that birth trauma is more likely in macrosomic babies, and can result in BPBP. Moreover, babies that are born large for gestational age also tend to be obese later in childhood [12–18]. Our hypothesis was that children with BPBP would more likely be obese during childhood than the reported prevalence of childhood obesity. Children in our study had an obesity rate of 29%; greater than the national average of 17%. When data from each hospital was analyzed separately, the percentage of children who were either overweight or obese also exceeded the state averages. From Hospital A, 42% of BPBP children were either overweight or obese
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544
Journal of Pediatric Orthopaedics B 2015, Vol 24 No 6
compared with the California state average of 30.5%, and at Hospital B, 56% of BPBP children were overweight or obese compared with the Texas state average of 32% [21,22]. Several studies have demonstrated that children with physical disabilities and chronic medical illnesses are more likely to suffer from emotional and behavior problems [33–35]. The higher prevalence of obesity in children within our cohort compared with age-matched children in the USA, may suggest that children with BPBP are at an even greater risk for psychosocial and physical health consequences. In our study, we used the PODCI to evaluate these consequences. As we expected, pediatric patients with BPBP had overall lower PODCI scores compared with healthy-age matched norms; the greatest difference being most significant in the upper extremity and global function domains. Our findings were similar to those already published by Huffman et al. [27]. Also as expected, PODCI scores were lower for children with more severe injuries, as measured by the Narakas grade. This finding indicates that the PODCI score is a sensitive measure of quality of life differences among children with BPBP. Our study aimed to further identify differences in PODCI scores amongst BPBP patients depending on weight status. We hypothesized that obese children with BPBP would have lower overall PODCI scores compared with normal weight children with BPBP, but this was not the case. Interestingly, having Medicaid insurance was a significant negative predictor of PODCI scores across several domains, including upper extremity function, sports and physical function, and global function. This suggests that children of lower socioeconomic means with BPBP have fewer ameliorating nonmedical interventions available to them, such as proper nutrition, school and community support.
child’s familial environment plays a large role in the development of obesity, both prenatally and postnatally [37,38]. Through early identification of pediatric BPBP patients who are overweight or at risk of becoming obese, health professionals can intervene to help reduce the negative sequelae associated with obesity. Not only can these children be counseled on dietary improvements and lifestyle modifications, but they can be screened earlier for physical and psychological complications associated with obesity. Further research is needed to better understand the complex relationships between BPBP, obesity, and socioeconomic status.
Acknowledgements The authors would like to acknowledge Fred Molitor, PhD, for assistance with statistical analysis. Conflicts of interest
There are no conflicts of interest.
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