The development of urinary continence is typically delayed in children with CP. A study of 601 children with CP found that by the age of 6,54% of children with spastic quadriparesis and 80% with spastic hemiparesis or diparesis had gained urinary continence spontaneously (77). The most important factors associated with urinary incontinence were quadriparesis and impaired cognition. Incontinence was the most common complaint, but frequency, urgency, hesitancy, and urinary retention may also be present (77). Frequency and urgency are often associated with spasticity of the detrusor muscle, causing small, frequent voids. Detrusor over activity and a small bladder capacity were the most common findings on urodynamic studies in children referred for voiding dysfunction, but a minority of children were also found to have detrusor sphincter dyssynergia (78,79).

The association between lower urinary tract dysfunction and upper urinary tract dysfunction in CP is unclear. In general, it is reported to be uncommon (80). Symptoms of detrusor sphincter dyssynergia (interrupted voiding, urinary retention, and hesitancy) and culture proven febrile urinary tract infections were shown to correlate with upper tract dysfunction in one study (81). Urodynamic studies should be considered to evaluate the physiology of the bladder in patients with lower tract symptoms. The results can aid in promoting continence, but it is also important to assess basic communication, mobility, equipment and environmental supports, which have also been shown to be important components to obtaining continence (82).


Children with CP are at increased risk for respiratory illnesses. Impaired control of respiratory muscles, ineffective cough, aspiration due to impaired swallowing, gastroesophageal reflux, and seizures all increase the risk for chronically increased airway secretions. Increased airway secretions may lead to wheezing, atelectasis, recurrent aspiration pneumonia, restrictive lung disease, or bronchiectasis. Bronchopulmonary dysplasia, in an infant born prematurely, will also increase the risk for respiratory disorders.


Decreased bone mineral density (BMD) and increased risk of fracture are present in patients with moderate to severe CP, especially those who are nonambulatory (83). A population-based study revealed that children in GMFCS levels I to III had a similar incidence and pattern for fractures as normally developing children (83). By the age of 10 years, most nonambulatory children have osteopenia, as defined by a BMD z score of less than -2.0 in their femurs (84). Data from the NAGCPP revealed that increasing severity of neurologic impairment, increasing difficulty feeding the child, use of anticonvulsants, and lower triceps skin fold z scores all independently contribute to lower BMD z scores in the femur (84). A published systematic review of available research, used to inform evidence-based clinical practice, concluded that there was probable evidence for bisphosphonates, possible evidence for vitamin D and calcium, and insufficient evidence for weight-bearing activities as effective interventions to improve low BMD. The evidence addressing fragility fractures was sparse. There was possible evidence that bisphosphonates prevent fragility fractures and inadequate evidence to support the use of weight-bearing or vitamin D or calcium to decrease fragility fractures (85). The current evidence for weight-bearing activities is conflicting and consists of studies with small sample sizes, which may result in inadequate power, and studies of relatively short duration and significant variability in how much weight-bearing actually occurred (85). An observational, population study showed a fourfold reduction of nontraumarelated fractures in children who used standers versus those who did not, but this outcome may be attributed to reasons the children were not using standers, such as severe contractures (83). A recent small study demonstrated greater increases in BMD in dynamic loading interventions versus passive, suggesting this method of weight-bearing deserves further study (86). Given the possible effectiveness of vitamin D and calcium supplementation, and the relative safety of this intervention, vitamin D monitoring and supplementation, as well as ensuring adequate calcium intake is recommended for children with CP at risk for osteoporosis (85).

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