Impaired Bone Growth and Mineral Density in Children with Cerebral Palsy: Can It Be Corrected?



Children with cerebral palsy have an increased risk of osteoporosis and osteopenia due to multiple factors, including limited weight bearing, decreased muscle strength, immobilization, malnutrition, rickets of prematurity, use of anti-convulsant medications, and deficiencies of growth hormone and sex hormones. Children with CP have an increased risk of fractures, especially of the distal femur. The relationship between osteopenia and fracture risk is not as well defined as it is in adults but fracture risk does increase with decreasing bone mineral density. Preventive measures include maximal weight bearing, vibration therapy, adequate nutrition (especially calcium and vitamin D intake), and treatment of growth hormone and sex hormone deficiency. DXA scanning is the most commonly used method for evaluation of BMD, but other methods are also available. Thresholds for treatment are not well defined but treatment is indicated in patients with osteoporosis and a history of significant fractures. Proposed interventions include adequate nutrition, increased weight bearing, exercise, calcium, vitamin D, vitamin K, growth hormone, and bisphosphonates. Bisphosphonates are the most effective treatments, but there is no consensus regarding treatment thresholds, dose, frequency, and choice of agent. Pamidronate and alendronate are the most commonly used agents, but it is likely that all bisphosphonates are similar in efficacy. Adverse effects are uncommon but need to be kept in mind. Further research is needed to clarify optimal screening and treatment protocols.


Bone Mineral Density Growth Hormone Fracture Risk Cerebral Palsy Growth Hormone Deficiency 



Bone mineral density


Cerebral palsy


Dual-energy X-ray absorptiometry


Insulin-like growth factor


Insulin-like growth factor binding protein


Magnetic resonance imaging


Quantitative computerized tomography


  1. Adams JE. Eur J Radiol. Quantitative computed tomography. 2009;71:415–24.PubMedCrossRefGoogle Scholar
  2. Ali O, Shim M, Fowler E, Greenberg M, Perkins D, Oppenheim W, Cohen P. Growth hormone therapy improves bone mineral density in children with cerebral palsy: a preliminary pilot study. J Clin Endocrinol Metab. 2007;92:932–7.PubMedCrossRefGoogle Scholar
  3. Bachrach LK, Ward LM. J Clin Endocrinol Metab. 2009;94:400–9.PubMedCrossRefGoogle Scholar
  4. Bachrach SJ, Kecskemethy HH, Harcke HT, Lark RK, Miller F, Henderson RC. Clinical review 1: bisphosphonate use in childhood osteoporosis. J Clin Densitometry 2006;9:167–74.CrossRefGoogle Scholar
  5. Bischof F, Basu D, Pettifor JM. Pathological long-bone fractures in residents with cerebral palsy in a long-term care facility in South Africa. Dev Med Child Neurol. 2002;44:119–22.PubMedCrossRefGoogle Scholar
  6. Caulton JM, Ward KA, Alsop CW, Dunn G, Adams JE, Mughal MZ. A randomised controlled trial of standing programme on bone mineral density in non-ambulant children with cerebral palsy. Arch Dis Child. 2004;89:131–5.PubMedCrossRefGoogle Scholar
  7. Coniglio SJ, Stevenson RD, Rogol AD. Apparent growth hormone deficiency in children with cerebral palsy. Dev Med Child Neurol. 1996;38:797–804.PubMedCrossRefGoogle Scholar
  8. Dimeglio LA, Peacock M. Two-year clinical trial of oral alendronate versus intravenous pamidronate in children with osteogenesis imperfecta. J Bone Mineral Res. 2006;21:132–40.CrossRefGoogle Scholar
  9. Gatti D, Antoniazzi F, Prizzi R, Braga V, Rossini M, Tatò L, Viapiana O, Adami S. Intravenous neridronate in children with osteogenesis imperfecta: a randomized controlled study. J Bone Mineral Res 2005;20:758–63.CrossRefGoogle Scholar
  10. Grissom LE, Kecskemethy HH, Bachrach SJ, Mckay C, Harcke HT. Bone densitometry in pediatric patients treated with pamidronate. Pediatric Radiol. 2005;35:511–7.CrossRefGoogle Scholar
  11. Guglielmi G, de Terlizzi F. Quantitative ultrasound in the assessment of osteoporosis. Eur J Radiol. 2009;71:425–31.PubMedCrossRefGoogle Scholar
  12. Henderson RC. Bone density and other possible predictors of fracture risk in children and adolescents with spastic quadriplegia. Dev Med Child Neurol. 1997;39:224–7.PubMedCrossRefGoogle Scholar
  13. Henderson RC, Lin PP, Greene WB. Bone-mineral density in children and adolescents who have spastic cerebral palsy. J Bone Joint Surg Am. 1995;77:1671–81.PubMedGoogle Scholar
  14. Henderson RC, Berglund LM, May R, Zemel BS, Grossberg RI, Johnson J, Plotkin H, Stevenson RD, Szalay E, Wong B, Kecskemethy HH, Harcke HT. The relationship between fractures and DXA measures of BMD in the distal femur of children and adolescents with cerebral palsy or muscular dystrophy. J Bone Mineral Res. 1997;0:1–30.Google Scholar
  15. Henderson RC, Lark RK, Gurka MJ, Worley G, Fung EB, Conaway M, Stallings VA, Stevenson RD. Bone density and metabolism in children and adolescents with moderate to severe cerebral palsy. Pediatrics. 2002a;110:e5.PubMedCrossRefGoogle Scholar
  16. Henderson RC, Lark RK, Kecskemethy HH, Miller F, Harcke HT, Bachrach SJ. Bisphosphonates to treat osteopenia in children with quadriplegic cerebral palsy: a randomized, placebo-controlled clinical trial. J Pediatr. 2002b;141:644–51.PubMedCrossRefGoogle Scholar
  17. Henderson RC, Kairalla JA, Barrington JW, Abbas A, Stevenson RD. Longitudinal changes in bone density in children and adolescents with moderate to severe cerebral palsy. J Pediatr. 2005;146:769–75.PubMedCrossRefGoogle Scholar
  18. Jekovec-Vrhovsek M, Kocijancic A, Prezelj J. Effect of vitamin D and calcium on bone mineral density in children with CP and epilepsy in full-time care. Dev Med Child Neurol. 2000;42:403–5.PubMedCrossRefGoogle Scholar
  19. King W, Levin R, Schmidt R, Oestreich A, Heubi JE. Prevalence of reduced bone mass in children and adults with spastic quadriplegia. Dev Med Child Neurol. 2003;45:12–6.PubMedCrossRefGoogle Scholar
  20. Kok D, Sakkers R, Janse A, Pruijs H, Verbout A, Castelein R, Engelbert R. Quality of life in children with osteogenesis imperfecta treated with oral bisphosphonates (Olpadronate): a 2-year randomized placebo-controlled trial. Eur J Pediatr. 2007;166:1155–61.PubMedCrossRefGoogle Scholar
  21. Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet. 2004;363:1619–31.CrossRefGoogle Scholar
  22. Landsmeer-Beker EA, Massa GG, Maaswinkel-Mooy PD, Van De Kamp JJP, Papapoulos SE. Treatment of osteogenesis imperfecta with the bisphosphonate olpadronate (dimethylaminohydroxypropylidene bisphosphonate). Eur J Pediatr. 1997;156:792–4.PubMedCrossRefGoogle Scholar
  23. Leet AI, Mesfin A, Pichard C, Launay F, Brintzenhofeszoc K. Fractures in children with cerebral palsy. J Pediatr Orthop. 2006;26:624–7.PubMedCrossRefGoogle Scholar
  24. Mergler S, Evenhuis HM, Boot AM, De Man SA, Bindels-De Heus KG, Huijbers WA, Penning C. Epidemiology of low bone mineral density and fractures in children with severe cerebral palsy: a systematic review. Dev Med Child Neurol. 2009;51:773–8.PubMedCrossRefGoogle Scholar
  25. Modlesky C, Kanoff S, Johnson D, Subramanian P, Miller F. Evaluation of the femoral midshaft in children with cerebral palsy using magnetic resonance imaging. Osteoporosis Int. 2009;20:609–15.CrossRefGoogle Scholar
  26. O’Donnell S, Cranney A, Wells GA, Adachi JD, Reginster JY. Strontium ranelate for preventing and treating postmenopausal osteoporosis. Cochrane Database Syst Rev. 2006;CD005326.Google Scholar
  27. Panigrahi I, Das RR, Sharda S, Marwaha RK, Khandelwal NJ. Response to zolendronic acid in children with type III osteogenesis imperfecta. Bone Miner Metab. 2010 Jul;28(4):451–5. Epub 2010 Feb 4.Google Scholar
  28. Plotkin H, Coughlin S, Kreikemeier R, Heldt K, Bruzoni M, Lerner G. Response to zolendronic acid in children with type III osteogenesis imperfecta 2010. Dev Med Child Neurol. 2006;48:709–12.PubMedCrossRefGoogle Scholar
  29. Presedo A, Dabney KW, Miller F. Fractures in patients with cerebral palsy. J Pediatr Orthop. 2007;27:147–53.PubMedCrossRefGoogle Scholar
  30. Rauch F, Travers R, Glorieux FH Pamidronate in children with osteogenesis imperfecta: histomorphometric effects of long-term therapy. J Clin Endocrinol Metab. 2006 Feb;91(2):511–6. Epub 2005 Nov 15.Google Scholar
  31. Rauch F, Cornibert S, Cheung M, Glorieux FH. Long-bone changes after pamidronate discontinuation in children and adolescents with osteogenesis imperfecta. Bone. 2007;40:821–7.PubMedCrossRefGoogle Scholar
  32. Rauch F, Munns CF, Land C, Cheung M, Glorieux FH. Risedronate in the treatment of mild pediatric osteogenesis imperfecta: a randomized placebo-controlled study. J Bone Mineral Res. 2009;24:1282–9.CrossRefGoogle Scholar
  33. Shah I, Johari A. Oral bisphosphonate treatment for osteogenesis imperfecta–an Indian perspective. Ann Trop Paediatr Int Child Health. 2007;27:39–43.CrossRefGoogle Scholar
  34. Shaw NJ. Management of osteoporosis in children. Eur J Endocrinol. 2008;159:S33–9.PubMedCrossRefGoogle Scholar
  35. Shim ML, Moshang T, Jr., Oppenheim WL, Cohen P. Is treatment with growth hormone effective in children with cerebral palsy? Dev Med Child Neurol. 2004;46:569–71.PubMedCrossRefGoogle Scholar
  36. Stevenson RD, Conaway M, Barrington JW, Cuthill SL, Worley G, Henderson RC. Fracture rate in children with cerebral palsy. Pediatr Rehabil. 2006;9:396–403.PubMedGoogle Scholar
  37. Ward K, Alsop C, Caulton J, Rubin C, Adams J, Mughal Z. A randomised controlled trial of standing programme on bone mineral density in non-ambulant children with cerebral palsy. J Bone Miner Res. 2004;19:360–9.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Medical College of WisconsinMilwaukeeUSA

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