Prenatal and perinatal factors in the etiology of cerebral palsy

Adults with Cerebral Palsy: Navigating the Complexities of Aging

The goal of this narrative review is to highlight the healthcare challenges faced by adults with cerebral palsy, including the management of long-term motor deficits, difficulty finding clinicians with expertise in these long-term impairments, and scarcity of rehabilitation options. Additionally, this narrative review seeks to examine potential methods for maintaining functional independence, promoting social integration, and community participation. Although the brain lesion that causes the movement disorder is non-progressive, the neurodevelopmental disorder worsens from secondary complications of existing sensory, motor, and cognitive impairments. Therefore, maintaining the continuum of care across one's lifespan is of utmost importance. Advancements in healthcare services over the past decade have resulted in lower mortality rates and increased the average life expectancy of people with cerebral palsy. However, once they transition from adolescence to adulthood, limited federal and community resources, and health care professionals' lack of expertise present significant obstacles to achieving quality healthcare and long-term benefits. This paper highlights the common impairments seen in adults with cerebral palsy. Additionally, it underscores the critical role of long-term healthcare and management to prevent functional decline and enhance quality of life across physical, cognitive, and social domains.

Safety and adherence of pressure garment therapy in children with upper limb unilateral cerebral palsy. Results from a randomized clinical trial ancillary analysis

Background

This study was conducted to assess the safety and adherence of the use of a PGT (Pressure Garment Therapy) Lycra® sleeve to treat upper limb unilateral cerebral palsy (UCP) in children.

Methods

This study was conducted as a prospective, placebo-controlled, double-blinded, randomized monocenter study. Included in the study were 58 UCP children, 49 of whom were analyzed. 25 children (mean age 6.6 ± 1.6 years; 12 girls) were allocated to the active group vs. 24 (mean age 6.7 ± 1.6 years; 10 girls) in the placebo group. The intervention consisted of an active PGT Lycra® arm sleeve manufactured to generate a homogeneous pressure ranging from 15 to 25 mmHg. The placebo PGT Lycra® sleeve was manufactured to generate a homogeneous pressure under 7 mmHg. The time of wearing period was set at 3 h/day at minimum and 6 h/day at maximum, over the course of 6 months. The main outcome measures were safety outcomes including the number and intensity of Adverse Events of Special Interest (AESIs). AESIs were defined as adverse events imputable to compressive therapy and Lycra® wearing. Level of adherence was expressed in percentage of number of days when the sleeve was worn for at least 3 h per day compared to length of duration in days (start and end date of wearing period).

Results

Frequency of AESIs were very low and no different between groups (4.12 ± 11.32% vs. 1.83 ± 3.38%; p = 0.504). There were no differences in adherence (91.86 ± 13.86% vs. 94.30 ± 9.95%; p = 0.425).

Conclusion

The use of PGT Lycra® arm sleeve in children with UCP is safe and well-tolerated with a very good adherence. The low rate of AESIs is promising for further randomized clinical trials on efficacy.

Role of integrating cannabinoids and the endocannabinoid system in neonatal hypoxic-ischaemic encephalopathy

Neonatal hypoxic-ischaemic events, which can result in long-term neurological impairments or even cell death, are among the most significant causes of brain injury during neurodevelopment. The complexity of neonatal hypoxic-ischaemic pathophysiology and cellular pathways make it difficult to treat brain damage; hence, the development of new neuroprotective medicines is of great interest. Recently, numerous neuroprotective medicines have been developed to treat brain injuries and improve long-term outcomes based on comprehensive knowledge of the mechanisms that underlie neuronal plasticity following hypoxic-ischaemic brain injury. In this context, understanding of the medicinal potential of cannabinoids and the endocannabinoid system has recently increased. The endocannabinoid system plays a vital neuromodulatory role in numerous brain regions, ensuring appropriate control of neuronal activity. Its natural neuroprotection against adult brain injury or acute brain injury also clearly demonstrate the role of endocannabinoid signalling in modulating neuronal activity in the adult brain. The goal of this review is to examine how cannabinoid-derived compounds can be used to treat neonatal hypoxic-ischaemic brain injury and to assess the critical function of the endocannabinoid system and its potential for use as a new neuroprotective treatment for neonatal hypoxic-ischaemic brain injury.

Epilepsy and drug-resistant epilepsy in children with cerebral palsy: A retrospective observational study

PURPOSE

The objective of this study was to determine risk factors for epilepsy and drug-resistant epilepsy (DRE) development in children with cerebral palsy.

METHOD

Two hundred twenty-nine patients presenting to the pediatric neurology clinic and diagnosed as having cerebral palsy between November 2016 and November 2019 were included in the study. Medical histories and clinical, laboratory, and radiological findings were examined retrospectively from patient records in the hospital data system.

RESULTS

Girls represented 103 patients (45%) and boys 126 (55%). The patients' mean age was 8.39 ± 4.54 years. Epileptic seizures were present in 120 (52.4%) patients and drug-resistant seizures in 64 (27.9%). The risk of epilepsy was significantly higher in patients with motor or speech impairment, with hearing impairment, or undergoing first seizure in the neonatal period. We also observed a higher risk of epilepsy in patients with psychiatric comorbidity, particularly autism spectrum disorder. The risk of epilepsy was also higher in patients with microcephaly or quadriplegic cerebral palsy and in patients with focal and generalized epileptiform abnormality on electroencephalograms (EEGs). However, no significant difference was identified when all these factors were evaluated in terms of the risk of developing DRE.

CONCLUSION

Patients with cerebral palsy have high comorbid epilepsy rates. We think that the risk of epilepsy may be higher in patients undergoing first seizure in the neonatal period, with microcephaly, with quadriplegic type cerebral palsy, and with additional psychiatric comorbidity. The rate of DRE development was very low in patients with normal EEG findings or with only background rhythm abnormalities on first EEGs during neonatal seizures. This may be regarded as a good prognostic factor for nondevelopment of DRE.

Inter-pregnancy interval and long-term neurological morbidity of the offspring

PURPOSE

The purpose of our study was to evaluate the effect of IPI on long-term neurological morbidity of the offspring.

METHODS

In this retrospective cohort study, 144,397 singleton infants born to multiparous mothers, between the years 1991 and 2014 in a tertiary medical center, were evaluated for different perinatal outcomes and were followed until 18 years of age for long-term neurological morbidity according to three IPI groups: Short IPI (< 6 months), long IPI (> 60 months) and intermediate IPI (6-60 months). We used a Kaplan-Meier survival curve to compare cumulative incidence of long-term neurological morbidity, and a Cox regression analysis to control for confounders such as gestational age, birth weight and maternal age.

RESULTS

Offspring born to mothers with long IPI had higher rates of neurological morbidity (3.62% among offspring born after long IPI vs. 3.18% and 3.19% among offspring born after short and intermediate IPI, respectively, p = 0.041). The cumulative incidence of long-term neurological morbidity was significantly higher in the long IPI group (Kaplan-Meier log-rank test p < 0.001). Being born after a long IPI was found to be an independent risk factor for long-term neurological morbidity of the offspring (adjusted hazard ratio 1.2; 95% confidence interval 1.1-1.4; p < 0.001).

CONCLUSION

Long IPI is independently associated with an increased risk of long-term neurological morbidity of the offspring.

Nonpresenting Dichorionic Twins and Placental Vascular Malperfusion

OBJECTIVE

To explore the hypothesis that selective placental pathology affecting the nonpresenting twin is a significant contributory factor mediating the smaller size at birth of nonpresenting dichorionic twins.

METHODS

We conducted a retrospective cohort study of all dichorionic twin deliveries in a single tertiary center between 2002 and 2015 where by departmental policy, all placentas from multifetal gestations are routinely sent for pathologic examination. Maternal charts, neonatal charts, and pathology reports were reviewed. Placental abnormalities were classified into lesions associated with maternal vascular malperfusion, fetal vascular malperfusion, placental hemorrhage, and chronic villitis. Comparison of neonatal outcomes and placental abnormalities was made between all nonpresenting and all presenting twins as well as within twin pairs.

RESULTS

A total of 1,322 women with dichorionic twins were studied. Nonpresenting twins were smaller at birth compared with the presenting cotwin starting at 32 weeks of gestation (birth weight [±standard deviation] 2,224±666 g compared with 2,278±675 g, P=.036). Nonpresenting twins had smaller placentas (361±108 g compared with 492±129 g, P<.001) as early as 24 weeks of gestation. Nonpresenting twins had higher odds for any placental abnormality (adjusted odds ratio [OR] 1.91, 95% confidence interval [95% CI] 1.63-2.23), small placenta (adjusted OR 4.69, 95% CI 3.75-5.88), and maternal vascular malperfusion (OR 2.75, 95% CI 2.32-3.27) compared with their presenting cotwins. In nonpresenting twins, the presence of maternal vascular malperfusion pathology was associated with lower birth weight compared with their presenting cotwin during the third trimester.

CONCLUSION

The lower birth weight of nonpresenting fetuses in dichorionic twin pregnancies is correlated with a higher rate of placental maternal vascular malperfusion pathology.

Chorioamnionitis in the Development of Cerebral Palsy: A Meta-analysis and Systematic Review

CONTEXT

Chorioamnionitis (CA) has often been linked etiologically to cerebral palsy (CP).

OBJECTIVES

To differentiate association from risk of CA in the development of CP.

DATA SOURCES

PubMed, Cochrane Library, Embase, and bibliographies of original studies were searched by using the keywords (chorioamnionitis) AND ((cerebral palsy) OR brain).

STUDY SELECTION

Included studies had to have: (1) controls, (2) criteria for diagnoses, and (3) neurologic follow-up. Studies were categorized based on: (1) finding incidence of CP in a CA population, or risk of CP; and (2) incidence of CA in CP or association with CP.

DATA EXTRACTION

Two reviewers independently verified study inclusion and extracted data.

RESULTS

Seventeen studies (125 256 CA patients and 5 994 722 controls) reported CP in CA. There was significantly increased CP inpreterm histologic chorioamnionitis (HCA; risk ratio [RR] = 1.34, P < .01), but not in clinical CA (CCA). Twenty-two studies (2513 CP patients and 8135 controls) reported CA in CP. There was increased CCA (RR = 1.43, P < .01), but no increase in HCA in preterm CP. Increased HCA was found (RR = 4.26, P < .05), as well as CCA in term/near-term CP (RR = 3.06, P < .01).

CONCLUSIONS

The evidence for a causal or associative role of CA in CP is weak. Preterm HCA may be a risk factor for CP, whereas CCA is not. An association with term and preterm CP was found for CCA, but only with term CP for HCA.

Pediatric Cerebral Palsy in Botswana: Etiology, Outcomes, and Comorbidities

BACKGROUND

Cerebral palsy is the most common cause of motor dysfunction in children worldwide and is often accompanied by multiple comorbidities. Although cerebral palsy has been studied extensively in high-resource settings, there are few published studies on cerebral palsy etiology, outcomes and comorbidities in low-resource settings.

METHODS

Children with cerebral palsy were prospectively enrolled from inpatient and outpatient settings at a referral center in Gaborone, Botswana, in a cross-sectional study conducted from 2013 to 2014. Cerebral palsy etiology, outcomes, and comorbidities were determined through caregiver interviews, review of medical records, and direct physical examination.

RESULTS

Sixty-eight children with cerebral palsy were enrolled. Subjects were 41% male, with a median age of 4 years (interquartile range = 2 to 7). The most common etiologies for cerebral palsy in our cohort were intrapartum hypoxic events (18%), postnatal infections (15%), prematurity (15%), focal ischemic strokes (10%), and prenatal infections (10%). Severe motor impairment was common, with the most severe category present in 41%. The predominant comorbidities were cognitive impairment (84%), epilepsy (77%), and visual impairment (46%).

CONCLUSIONS

Cerebral palsy in Botswana has different etiologies and is associated with poorer outcomes and higher prevalence of comorbidities than what has been reported in high-resource settings. Further studies are necessary to determine optimal preventative and treatment strategies in this population.

Birth Spacing and Risk of Autism and Other Neurodevelopmental Disabilities: A Systematic Review

CONTEXT

Both short and long interpregnancy intervals (IPIs) have recently been associated with increased risk of autism spectrum disorder (ASD). However, this association has not been systematically evaluated.

OBJECTIVE

To examine the relationship between birth spacing and the risk of ASD and other neurodevelopmental disabilities.

DATA SOURCES

Electronic databases from their inception to December 2015, bibliographies, and conference proceedings.

STUDY SELECTION

Observational studies with results adjusted for potential confounding factors that reported on the association between IPIs or birth intervals and neurodevelopmental disabilities.

DATA EXTRACTION

Two reviewers independently extracted data on study characteristics, IPIs/birth intervals, and outcome measures.

RESULTS

Seven studies (1 140 210 children) reported an association between short IPIs and increased risk of ASD, mainly the former subtype autistic disorder. Compared with children born to women with IPIs of ≥36 months, children born to women with IPIs of <12 months had a significantly increased risk of any ASD (pooled adjusted odds ratio [OR] 1.90, 95% confidence interval [CI] 1.16-3.09). This association was stronger for autistic disorder (pooled adjusted OR 2.62, 95% CI 1.53-4.50). Three of these studies also reported a significant association between long IPIs and increased risk of ASD. Short intervals were associated with a significantly increased risk of developmental delay (3 studies; 174 940 children) and cerebral palsy (2 studies; 19 419 children).

LIMITATIONS

Substantial heterogeneity, and few studies assessing neurodevelopmental disabilities other than ASD.

CONCLUSIONS

Short IPIs are associated with a significantly increased risk of ASD. Long IPIs also appear to increase the risk of ASD.

Changes in the clinical spectrum of cerebral palsy over two decades in North India--an analysis of 1212 cases

BACKGROUND

Clinical spectrum of cerebral palsy (CP) is different in developing and developed countries. We evaluated the clinical profile, etiological factors and co-morbidities of children with CP in North India, and compared with our previous study.

METHODS

1212 children with CP registered in last 10 years in our rehabilitation center were compared with our previous study of 1000 children from same center.

RESULTS

Spastic quadriplegia is the commonest type of CP (51.5%) although lesser than previous decade (61%). Birth asphyxia remains the main (51.98%) etiological factor as earlier (45.3%). CP due to CNS infections decreased from 63.5% to 57.4%, due to bilirubin-encephalopathy remained same (∼30%). Speech problems (83.7%), microcephaly (64.27%), seizures (44.5%) and intellectual disability (38.61%) are common co-morbidities. Common neuroimaging findings include hypoxic-ischemic changes and periventricular leucomalacia.

CONCLUSION

The spectrum of CP is evolving in the developing countries with an increase in diplegic and a decrease in quadriplegic CP.

A systematic review of risk factors for cerebral palsy in children born at term in developed countries

AIM

The aim of this study was to conduct a systematic review in order to identify the risk factors for cerebral palsy (CP) in children born at term. The secondary aim was to ascertain if the potential for prevention of these risk factors has been adequately explored.

METHOD

A MEDLINE search up to 31 July 2011 was completed, following the Meta-Analysis of Observational Studies in Epidemiology guidelines. Publications were reviewed to identify those with both a primary aim of identifying risk factors for all children or term-born children with CP and a cohort or case-control study design. Studies were examined for potential chance or systematic bias. The range of point estimates of relative risk is reported.

RESULTS

From 21 articles meeting inclusion/exclusion criteria and at low risk of bias, data from 6297 children with CP and 3 804 791 children without CP were extracted. Ten risk factors for term-born infants were statistically significant in each study: placental abnormalities, major and minor birth defects, low birthweight, meconium aspiration, instrumental/emergency Caesarean delivery, birth asphyxia, neonatal seizures, respiratory distress syndrome, hypoglycaemia, and neonatal infections. Strategies for possible prevention currently exist for three of these.

INTERPRETATION

Ten consistent risk factors have been identified, some with potential for prevention. Efforts to prevent these risk factors to interrupt the pathway to CP should be extended.

Using the endocannabinoid system as a neuroprotective strategy in perinatal hypoxic-ischemic brain injury

One of the most important causes of brain injury in the neonatal period is a perinatal hypoxic-ischemic event. This devastating condition can lead to long-term neurological deficits or even death. After hypoxic-ischemic brain injury, a variety of specific cellular mechanisms are set in motion, triggering cell damage and finally producing cell death. Effective therapeutic treatments against this phenomenon are still unavailable because of complex molecular mechanisms underlying hypoxic-ischemic brain injury. After a thorough understanding of the mechanism underlying neural plasticity following hypoxic-ischemic brain injury, various neuroprotective therapies have been developed for alleviating brain injury and improving long-term outcomes. Among them, the endocannabinoid system emerges as a natural system of neuroprotection. The endocannabinoid system modulates a wide range of physiological processes in mammals and has demonstrated neuroprotective effects in different paradigms of acute brain injury, acting as a natural neuroprotectant. The aim of this review is to study the use of different therapies to induce long-term therapeutic effects after hypoxic-ischemic brain injury, and analyze the important role of the endocannabinoid system as a new neuroprotective strategy against perinatal hypoxic-ischemic brain injury.

The association of cerebral palsy with birth asphyxia: a definitional quagmire

AIM

The aim of this study was to investigate whether current literature provides a useful body of evidence reflecting the proportion of cerebral palsy (CP) that is attributable to birth asphyxia.

METHOD

We identified 23 studies conducted between 1986 and 2010 that provided data on intrapartum risks of CP.

RESULTS

The proportion of CP with birth asphyxia as a precursor (case exposure rate) varied from less than 3% to over 50% in the 23 studies reviewed. The studies were heterogeneous in many regards, including the definitions for birth asphyxia and the outcome of CP.

INTERPRETATIONS

Current data do not support the belief, widely held in the medical and legal communities, that birth asphyxia can be recognized reliably and specifically, or that much of CP is due to birth asphyxia. The very high case exposure rates linking birth asphyxia to CP can probably be attributed to several factors: the fact that the clinical picture at birth cannot specifically identify birth asphyxia; the definition of CP employed; and confusion of proximal effects - results - with causes. Further research is needed.

Genetic [corrected] insights into the causes and classification of [corrected] cerebral palsies

Cerebral palsy-the most common physical disability of childhood-is a clinical diagnosis encompassing a heterogeneous group of neurodevelopmental disorders that cause impairments of movement and posture that persist throughout life. Despite being commonly attributed to a range of environmental factors, particularly birth asphyxia, the specific cause of cerebral palsy remains unknown in most individuals. A growing body of evidence suggests that cerebral palsy is probably caused by multiple genetic factors, similar to other neurodevelopmental disorders such as autism and intellectual disability. Recent advances in next-generation sequencing technologies have made possible rapid and cost-effective sequencing of the entire human genome. Novel cerebral palsy genes will probably be identified as more researchers and clinicians use this approach to study individuals with undiagnosed neurological disorders. As our knowledge of the underlying pathophysiological mechanisms of cerebral palsy increases, so will the possibility of developing genomically guided therapeutic interventions.

The effects of multiple pre- and perinatal risk factors on the occurrence of cerebral palsy. A Norwegian register based study

AIMS

To examine the effects of multiple risk factors on cerebral palsy (CP).

MATERIALS/METHODS

For 176,591 Norwegian infants born 1996-98 and surviving the early neonatal period, data on a number of potential pre- and perinatal risk factors (RFs) for CP were available in the Medical Birth Registry of Norway. For 241 children with CP detailed clinical data were available in the Norwegian CP registry.

RESULTS

In children born at term, 31% had no RF, and none had five or more, while in children born preterm, 9% had no RF in addition to prematurity (p < 0.001 vs. term), and 5% had five or more (p < 0.02 vs. term). In both groups, few children shared the same combination of RFs. Interdependent sequences were more often observed among children born preterm than at term (p < 0.001 vs. term). The most detrimental effect was observed for the combination of maternal disease and low 5-min Apgar score, registered in 11.2% of children with CP. The combination of maternal disease and premature birth had an interaction contrast ratio of 9.25 (CI: 3.56; 14.94), which may be consistent with biological interaction.

CONCLUSIONS

The majority of children with CP born at term most likely had an antenatal or single cause, suggesting individual susceptibility to an injury. The majority of children born preterm, had combinations or sequences of antenatal and perinatal risk factors as the most likely cause of CP.

Cannabinoid as a neuroprotective strategy in perinatal hypoxic-ischemic injury

Perinatal hypoxia-ischemia remains the single most important cause of brain injury in the newborn, leading to death or lifelong sequelae. Because of the fact that there is still no specific treatment for perinatal brain lesions due to the complexity of neonatal hypoxic-ischemic pathophysiology, the search of new neuroprotective therapies is of great interest. In this regard, therapeutic possibilities of the endocannabinoid system have grown lately. The endocannabinoid system modulates a wide range of physiological processes in mammals and has demonstrated neuroprotective effects in different paradigms of acute brain injury, acting as a natural neuroprotectant. Concerning perinatal asphyxia, the neuroprotective role of this endogenous system is emerging these years. The present review mainly focused on the current knowledge of the cannabinoids as a new neuroprotective strategy against perinatal hypoxic-ischemic brain injury.

Perinatal risk indicators for long-term neurological morbidity among preterm neonates

OBJECTIVE

Many obstetric interventions are performed to improve long-term neonatal outcome. However, long-term neonatal outcome is usually not a primary outcome because it is time-consuming and expensive. The aim of this project was to identify different perinatal risk indicators and to develop prediction models for neurologic morbidity at 2 and 5 years of age.

STUDY DESIGN

Data from a Dutch cohort study of preterm and small-for-gestational-age infants was used. Neonates who were born in The Netherlands in 1983 with a gestational age of <34 weeks and without congenital abnormalities were included (n = 753). Infants were divided in 3 groups: no handicap, minor handicap, and major handicap.

RESULTS

Common risk indicators for major handicaps at 2 and 5 years of age were male sex (odds ratio, 2.7 and 3.0, respectively), seizures after ≥2 days of life (odds ratio, 5.8 and 5.8, respectively), and intracranial hemorrhage (odds ratio, 3.8 and 2.6, respectively).

CONCLUSION

In this cohort, male sex, intracranial hemorrhage, and seizures seem to be important risk indicators for long-term neurologic morbidity.

Cerebral palsy among term and postterm births

CONTEXT

Although preterm delivery is a well-established risk factor for cerebral palsy (CP), preterm deliveries contribute only a minority of affected infants. There is little information on the relation of CP risk to gestational age in the term range, where most CP occurs.

OBJECTIVE

To determine whether timing of birth in the term and postterm period is associated with risk of CP.

DESIGN, SETTING, AND PARTICIPANTS

Population-based follow-up study using the Medical Birth Registry of Norway to identify 1,682,441 singleton children born in the years 1967-2001 with a gestational age of 37 through 44 weeks and no congenital anomalies. The cohort was followed up through 2005 by linkage to other national registries.

MAIN OUTCOME MEASURES

Absolute and relative risk of CP for children surviving to at least 4 years of age.

RESULTS

Of the cohort of term and postterm children, 1938 were registered with CP in the National Insurance Scheme. Infants born at 40 weeks had the lowest risk of CP, with a prevalence of 0.99/1000 (95% confidence interval [CI], 0.90-1.08). Risk for CP was higher with earlier or later delivery, with a prevalence at 37 weeks of 1.91/1000 (95% CI, 1.58-2.25) and a relative risk (RR) of 1.9 (95% CI, 1.6-2.4), a prevalence at 38 weeks of 1.25/1000 (95% CI, 1.07-1.42) and an RR of 1.3 (95% CI, 1.1-1.6), a prevalence at 42 weeks of 1.36/1000 (95% CI, 1.19-1.53) and an RR of 1.4 (95% CI, 1.2-1.6), and a prevalence after 42 weeks of 1.44 (95% CI, 1.15-1.72) and an RR of 1.4 (95% CI, 1.1-1.8). These associations were even stronger in a subset with gestational age based on ultrasound measurements: at 37 weeks the prevalence was 1.17/1000 (95% CI, 0.30-2.04) and the relative risk was 3.7 (95% CI, 1.5-9.1). At 42 weeks the prevalence was 0.85/1000 (95% CI, 0.33-1.38) and the relative risk was 2.4 (95% CI, 1.1-5.3). Adjustment for infant sex, maternal age, and various socioeconomic measures had little effect.

CONCLUSION

Compared with delivery at 40 weeks' gestation, delivery at 37 or 38 weeks or at 42 weeks or later was associated with an increased risk of CP.

Determinants of ambulation in children with spastic quadriplegic cerebral palsy: a population-based study

The objective of this study was to identify factors that predict ambulation in spastic quadriplegic cerebral palsy. A 4-year registry-based birth cohort was searched for patients with a diagnosis of spastic quadriplegic cerebral palsy. All patients were then divided in 2 groups: (a) Gross Motor Function Classification System level < or = III (ambulant group) and (b) Gross Motor Function Classification System level > or = IV (nonambulant group). Clinical features were then compared between the 2 groups. A total of 85 children with a diagnosis of spastic quadriplegic cerebral palsy were identified. Of these, 65 and 20 were classified in the ''nonambulant'' and ''ambulant'' groups, respectively. The presence of seizures in the first 24 or 72 hours of life and the administration of antibiotics during pregnancy/delivery were all associated with an eventual inability to achieve ambulation. A gestational age < or = 27 weeks, birth weight <1000 g, Caucasian mother, and the presence of hyperbilirubinemia were significantly linked with independent ambulation.

[Cerebral palsy and perinatal asphyxia (I--diagnosis)]

Cerebral palsy (CP) is a group of disorders of the development of movement and posture, causing activity limitations, that are attributed to nonprogressing disturbances that occurred in the developing fetal or infant brain. The motor abnormalies are often accompanied by disturbances of sensation, perception, cognition, behavior and/or by a seizure disorder. The prevalence of CP has not decreased in developed countries over the past 30 years, despite the widespread use of electronic fetal heart rate monitoring and a 5- to 6-fold increase in the cesarean delivery rate. In the term newborn, CP may be attributed to perinatal asphyxia in case of metabolic acidosis in the cord blood (pH<7,00 and base deficit>12 mmol/L), followed by a moderate or severe neonatal encephalopathy within 24 hours and a further neurological impairement characterized by spastic quadriplegia and dyskinesia/dystonia. Dating the time of fetal asphyxia during delivery is possible when there are acute catastrophic complications during labor and unexpected acute or progressive fetal heart rate anomalies after a normal admission test, when there is a need for intensive neonatal resuscitation, a multi-organ failure within 72 hours of birth and visualization of acute non focal cerebral abnormalities, mainly by early magnetic resonance imaging (MRI). MRI sequences show either a brain-damaged pattern of the central basal ganglia, thalami and posterior limbs of internal capsules with relative cortical sparing, in acute, near-total asphyxial insults manifested by a continuous bradycardia or a pattern of cortical injury in the watershed zones and relative sparing of the central grey matter, in prolonged partial asphyxia, manifested by late or atypical variable decelerations with progressive fetal tachycardia, loss of reactivity and absent fluctuation. Prolongation of either type of asphyxial insult results in more global brain damage. In order to differentiate a CP occurring after perinatal asphyxia from other neurological sequelae in relation with infection, hemorrhage, stroke, malformations, genetic or metabolic diseases, it is essential that a definitive information from the brain by MRI and an extensive histological examination of the placenta are at disposal.

Congenital anomalies in children with cerebral palsy: a population-based record linkage study

AIM

Our aim was to determine the proportion of children with cerebral palsy (CP) who have a congenital anomaly (CA) in three regions (Isère Region, French Alps; Funen County, Denmark; Northern Region, England) where population-based CP and CA registries exist, and to classify the children according to CA subtype.

METHOD

Data for children born between 1991 and 1999 were linked using electronic matching of cases. All potential matches were checked manually by each centre and verified as true matches.

RESULTS

A total of 1104 children with CP were born during the study period (663 males, 441 females). Of these, 166 (15%; 95% Confidence Interval [CI] 13.0-17.3) children with CP had a CA: 8.8% had a cerebral anomaly, 4.8% had a non-cerebral anomaly, and 1.4% had a non-cerebral-related syndrome or a chromosomal/genetic anomaly.

INTERPRETATION

The prevalence of cerebral anomaly was highest in children with ataxic CP (41.7%) and lowest in those with dyskinetic CP (2.1%). Cerebral anomalies were found in 8.4% and 7% of children with bilateral and unilateral spastic CP respectively. The most frequent cerebral anomalies were primary microcephaly (26.5%) and congenital hydrocephalus (17.3%). The most common non-cerebral anomalies recorded were cardiac (12.6% of children with CP and CA), urinary (5.4%), and musculoskeletal (5.4%). The prevalence of cerebral anomalies was higher among children born at term (13%) than among those born preterm (3.8%). Associated sensorineural or intellectual impairments occurred more often in children with CP and cerebral anomalies. We concluded that cerebral and non-cerebral CA prevalence was higher among the CP population than in the general population of live births.

Quantitative EEG in babies at risk for hypoxic ischemic encephalopathy after perinatal asphyxia

OBJECTIVE

To evaluate an electroencephalography (EEG)-based index, the Cerebral Health Index in babies (CHI/b), for identification of neonates with high Sarnat scores and abnormal EEG as markers of hypoxic ischemic encephalopathy (HIE) after perinatal asphyxia.

STUDY DESIGN

This is a retrospective study using 30 min of EEG data collected from 20 term neonates with HIE and 20 neurologically normal neonates. The HIE diagnosis was made on clinical grounds based on history and examination findings. The maximum-modified clinical Sarnat score was used to grade HIE severity within 72 h of life. All neonates underwent 2-channel bedside EEG monitoring. A trained electroencephalographer blinded to clinical data visually classified each EEG as normal, mild or severely abnormal. The CHI/b was trained using data from Channel 1 and tested on Channel 2.

RESULT

The CHI/b distinguished among HIE and controls (P<0.02) and among the three visually interpreted EEG categories (P<0.0002). It showed a sensitivity of 82.4% and specificity of 100% in detecting high grades of neonatal encephalopathy (Sarnat 2 and 3), with an area under the receiver operator characteristic (ROC) curve of 0.912. CHI/b also identified differences between normal vs mildly abnormal (P<0.005), mild vs severely abnormal (P<0.01) and normal vs severe (P<0.002) EEG groups. An ROC curve analysis showed that the optimal ability of CHI/b to discriminate poor outcome was 89.7% (sensitivity: 87.5%; specificity: 82.4%).

CONCLUSION

The CHI/b identified neonates with high Sarnat scores and abnormal EEG. These results support its potential as an objective indicator of neurological injury in infants with HIE.

The role of perinatal and intrapartum risk factors in the etiologyof cerebral palsy in term deliveries in a Turkish population

OBJECTIVE

To investigate the relationship between cerebral palsy (CP) and perinatal and intrapartum risk factors and markers of birth asphyxia.

METHODS

This was a retrospective case-control study of 101 children with CP and 308 controls who were born at the Zeynep Kamil Hospital between 1990 and 2000. The roles of possible perinatal and intrapartum risk factors were investigated in CP development. Chi-square tests, Fisher's exact tests, Student t-tests, and regression analysis were used for statistical analysis (p < 0.05).

RESULTS

The only significant perinatal risk factor was neonatal weight of <2500 grams. The CP rate in the presence of solely intrapartum risk factors was estimated as 24.7% (n = 25). In 39.6% of cases, no risk factor could be identified. When regression analysis was performed, the following factors were significant: decreased beat-to-beat variability on electronic fetal monitoring (EFM) (p = 0.02), an Apgar score of <7 at 1 and 5 minutes (p = 0.02), and the necessity for neonatal intensive care unit admission (p < 0.0001).

CONCLUSION

Intrapartum risk factors were significantly more frequent in the CP group (p < 0.01). An increased cesarean section rate could not prevent CP, suggesting that the hypoxic insult that causes CP might be of chronic onset. The development of diagnostic tests to detect non-reassuring fetal status in its intrauterine life and interventions at appropriate times may decrease the CP rate.

Association of preterm birth with brain malformations

This study investigates the rate of preterm birth in babies with congenital brain defects. Autopsy case reports of congenital brain anomalies were obtained from the literature. The control cases were from a large registry, a published report from the Metropolitan Atlanta Congenital Defects Program. From 428 publications, 1168 cases were abstracted that had autopsy studies of congenital brain defects and information on the gestational age (GA) at birth. The control data from Atlanta included 7738 infants with significant birth defects of any kind and 264,392 infants without birth defects. In the autopsy cases with brain defects, the mean GA was 36.6 wk, whereas the Atlanta data showed a mean GA of 39.3 wk for infants with no defects and a significantly shorter gestation of 38.1 wk (p < 0.0001) for infants with defects. In the Atlanta data, the rate of preterm birth was 9.3% for those with no defects compared with 21.5% (p < 0.0001) for those with defects. In the autopsy cases with brain defects, the rate of preterm birth was even greater (33.1%, p < 0.0001). In conclusion, these data show an association of brain defects with preterm births.

Treatment of the term newborn with brain injury: simplicity as the mother of invention

Neonatal brain injury remains a common cause of developmental disability, despite tremendously enhanced obstetrical and neonatal care. The timing of brain injury occurs throughout gestation, labor, and delivery, providing an evolving form of brain injury and a moving target for therapeutic intervention. Nonetheless, markedly improved methods are available to identify those infants injured at birth, via clinical presentation with neonatal encephalopathy and neuroimaging techniques. Postischemic hypothermia has been shown to be of tremendous clinical promise in several completed and ongoing trials. As part of this approach to the treatment of the newborn, other parameters of physiologic homeostasis can and should be attended to, with strong animal and clinical evidence that their correction will have dramatic influence on the outcome of the newborn infant. This review addresses aspects of newborn care to which we can direct our attention currently, and which should result in a safe and efficacious improvement in the prognosis of the newborn with neonatal encephalopathy.

Causation--fetal brain injury and uterine rupture

The purpose of this article is to familiarize the reader with the concept of causation and the role of the concept of foreseeability of harm in obstetric malpractice lawsuits. These concepts are incorporated into several hypothetical fetal brain injury and uterine rupture cases. The discussion involves an overview of available scientific evidence used to substantiate or refute whether a child's brain damage or a maternal uterine rupture was in fact related to the obstetric care in question. In the event of the delivery of a depressed newborn, a checklist of scientific evidence to be gathered at the time of delivery is also provided.

Dual Role of Intrauterine Immune Challenge on Neonatal and Adult Brain Vulnerability to Hypoxia-Ischemia

Epidemiologic evidence has underlined the impact of prenatal inflammation on the development of postnatal hypoxia-ischemia (HI) brain injury. To study to what extent prenatal inflammation affects CNS vulnerability later during development, C57BL/6 mice were subjected to intrauterine injection of lipopolysaccharide (LPS) at gestational day 15. At postnatal day (PND) 5, 9, and 70, the offspring were subjected to HI. It was found that, in neonatal mice, LPS-exposed brains showed markedly enhanced brain injury after HI, whereas in adult mice, LPS exposure resulted in a significant reduction in tissue loss after HI. Reduced myelin in subcortical white matter was noticed after HI in the LPS-exposed brains at PND14 and PND75. Increased activities of nuclear factor-kappaB and caspase-3 were obtained in fetal/neonatal brain after LPS administration. Conclusions were that 1) a prenatal low dose of LPS sensitized to HI-induced brain injury in neonates but confers protection in adulthood, 2) reduced myelination is seen after prenatal LPS exposure and HI in both neonatal and adult mice despite the fact that LPS reduced total tissue loss in adult mice; and 3) nuclear factor-kappaB and caspase-3 activation early after LPS exposure may play a role in the sensitization/protection (preconditioning) effects.

Anesthetic-mediated protection/preconditioning during cerebral ischemia

Cerebral ischemia is a multi-faceted neurodegenerative pathology that causes cellular injury to neurons within the central nervous system. In light of the underlying mechanisms being elucidated, clinical trials to find possible neuroprotectants to date have failed, thus highlighting the need for new putative targets to offer protection. Recent evidence has clearly shown that anesthetics can confer significant protection and or induce a preconditioning effect against cerebral ischemia-induced injury. This review will focus on the putative protection/preconditioning that is afforded by anesthetics, their possible interaction with GABA(A) and glutamate receptors and two-pore potassium channels. In addition, the interaction with inflammatory, apoptotic and underlying molecular (particularly immediately early genes and inducible nitric oxide synthase etc) pathways, the activation of K(ATP) channels and the ability to provide lasting protection will also be addressed.

Antenatal and delivery risk factors and prevalence of cerebral palsy in Duzce (Turkey)

This cross-sectional study aimed at investigating the prevalence and the etiological factors of cerebral palsy (CP) and comparing them with normal population within the rural and urban areas of Duzce province. Of the 102 children with cerebral palsy, 98 were associated with antenatal and delivery risk factors. The mean crude prevalence of cerebral palsy was 1.1 per 1000 live births. The children with CP were compared with 530 control subjects. The mothers of the children with cerebral palsy were significantly younger than the mothers of children in control group, and they had less parity and abortion. Preeclampsia, premature rupture of membranes, home births, prolonged labor, and twin pregnancies were significantly more common in the mothers of children with cerebral palsy, where no significant differences were found between the groups in terms of breech delivery, rate of cesarean births, gestational diabetes, and hemorrhage in late pregnancy. Birth asphyxia, liqueur with meconium stained, prolonged jaundice and neonatal seizure were also significantly more common in the group with cerebral palsy. Of the children with cerebral palsy, 78% were born at term, 20% were born with gestational ages of 32-36 weeks, 2% were born with gestational ages of 30-31 weeks. Nine percent of those children had a birth weight of >or= 3000 g, 12.2% had a birth weight of 2500-2999 g, 33.7% had a birth weight of 1500-2499 g, and 5.1% had a birth weight of <or= 1500 g. The causes of low prevalence of cerebral palsy were due to insufficient neonatal care, resulting in low survival in preterm and low birth weight children, and poor postnatal care of children with cerebral palsy.

Twenty-four-hour CTG monitoring: comparison of normal pregnancies of 25-30 weeks of gestation versus 36-42 weeks of gestation

OBJECTIVE

Routinely antepartal cardiotocogram (CTG) is recorded for 30 min in order to obtain normal resting phases (<30 min) or a decrease of irregulatory due to hypoxia (>30 min) or to differentiate these from each other. In case of early onset of hypoxia first pathological findings might only be seen by chance in incidentally recorded CTG. The goal of this study was, if a continuous 24-h CTG allows an earlier detection of beginning hypoxia in case of normal pregnancies of 36-42 weeks compared to pregnancies of 25-30 weeks of gestation, and if there are any differences between both groups concerning the qualitative and quantitative description or the detection of a circadian rhythm.

METHODS

21 patients in each group had 24-h CTGs by means of telemetry (Hewlett-Packard type 78101A, 80110A). In both study groups, fetal heart-rate tracing included a full qualitative and quantitative description. Comparison of the results of both groups was done to look for early signs of pathological findings concerning reduced fetal well-being and a potential day and night rhythm.

RESULTS

In comparison to 36-42 weeks of pregnancies 25-30 weeks had significantly more physiological undulatory oscillation and less narrowed undulatory oscillation (P < 0.001), as well as less resting phases (P < 0.001). Baseline tachycardia and bradycardia showed significantly increasing quantity (P < 0.001).

CONCLUSION

Twenty-four-hour CTG is a good screening method to detect early onset of hypoxia in case of second and third trimester pregnancies and a big help to detect a fetus at risk earlier. In future computerized CTG-systems should be proved in this connection and should be compared with our study.

Predictors of respiratory depression at birth in the term infant

OBJECTIVE

To evaluate predictive factors for respiratory depression at birth in infants >/=37 weeks.

DESIGN

A population-based cohort study of respiratory depression at birth at term and post-term.

SETTING

Nova Scotia, Canada.

POPULATION

All 126 604 nonanomalous, singleton deliveries >/=37 weeks in cephalic presentation from 1988-2002.

METHODS

An analysis of maternal, antenatal, intrapartum, and neonatal factors associated with respiratory depression at birth >/=37 weeks.

MAIN OUTCOME MEASURES

A composite outcome of delay in initiating and maintaining respiration after birth, 5-minute Apgar score </= 3, or neonatal seizures due to hypoxic-ischaemic encephalopathy.

RESULTS

The rate of respiratory depression at birth with delay in respiration was 5.2/1000, with Apgar </= 3 1.0/1000 live births, and with neonatal seizures 0.7/1000. A composite of any of the three respiratory depressions at birth criteria showed comparable low rates with spontaneous delivery (4.4/1000) and elective caesarean (4.8/1000). Compared with elective caesarean delivery, vacuum (13.2/1000, relative risk [RR] 3.97, P < 0.001), forceps (8.8/1000, RR 1.84, P= 0.003), failed vacuum (13.3/1000, RR 2.76, P= 0.005), failed forceps (33.3/1000, RR 6.93, P < 0.001), and caesarean in labour (17.0/1000, RR 3.54, P < 0.001) had significantly higher rates of the composite outcome.

CONCLUSION

Overall, the rate of respiratory depression at birth in the term infant was low and the serious manifestation of seizures was less than 1 in 1000. There was a significant relationship between operative delivery in labour and respiratory depression at birth.

Intrauterine asphyxia: clinical implications for providers of intrapartum care

Advances in science and technology have allowed researchers to gain a better understanding of the pathophysiology leading to long-term neurologic damage in newborns. Intrapartum events are now known to be an infrequent cause of adverse neurologic outcome. Clinicians caring for women during labor must have an understanding of the pathophysiology of intrauterine asphyxia as well as an awareness of the capabilities and limitations of available intrapartum fetal assessment tools to diagnose intrauterine fetal asphyxia or predict neurologic outcome. This article reviews the physiology of acid-base balance and fetal gas exchange as well as the current scientific understanding of the role of intrauterine asphyxia in the pathophysiology of neonatal encephalopathy and cerebral palsy. Recommendations for care and documentation are included.

Intrapartum asphyxia and cerebral palsy: is there a link?

Perinatal hypoxic-ischemic cerebral injury, secondary to interruption of placental blood flow that results in cerebral palsy (CP), is a rare event. The ability to link an intrapartum event to subsequent CP should include a history of a sentinel event during labor, followed by the delivery of a depressed acidemic infant, and the subsequent evolution of neonatal encephalopathy, systemic organ injury, and acute neuroimaging abnormalities.

Risk of cerebral palsy in multiple pregnancies

Multiple compared with singleton gestations have a five- to tenfold increased risk of CP. The increased risk associated with MC placentation has been variously ascribed to transfer of thromboplastin or thromboemboli from the dead to the surviving fetus, exsanguination of the surviving fetus into the low pressure reservoir of the dead fetus, or hemodynamic instability with bidirectional shunting of blood between the two fetuses. An increased risk of CP in assisted reproductive technology gestations is to be expected because of the higher proportion of preterm births. The increase in risk of CP associated with monochorionic placentation will not be observed except for the minority of assisted reproductive technology gestations that undergo monozygotic splitting.

Ante- and perinatal factors for cerebral palsy: case-control study in Estonia

Establishing consistency between cerebral palsy registries in reporting of new cases enables more effective collaboration in terms of researching predisposing factors. To identify antenatal and intrapartum risk factors for cerebral palsy in the Estonian population, we undertook a matched case-control study of 153 children with cerebral palsy, ascertained from a population-based survey. One hundred two maternal, antenatal, and intrapartum variables were initially retrieved from medical records. Main outcome measures were the odds ratio estimates of relative risk of cerebral palsy. As a result of the study, and considering the whole spectrum of severity, the relevant risk factors during pregnancy were bleeding after 20 weeks, anemia in the second half of pregnancy, pregnancy-induced hypertension in the second half of pregnancy, and preeclampsia. The most important intrapartum factors were premature birth, placental abruption, an acute hypoxic event during delivery, and any fetal presentation other than vertex. Predisposing factors related to neonatal condition were an Apgar score < or = 7 at the first and fifth minutes of life, hypoxic-ischemic encephalopathy, and assisted ventilation. Our findings suggest that intrapartum factors, including those hypothetically realized through hypoxic-ischemic pathways, are not of low importance in the etiology of cerebral palsy.

Factors identified during the neonatal period associated with risk of cerebral palsy

OBJECTIVE

To identify factors during the neonatal period that are associated with the subsequent development of cerebral palsy (CP).

DESIGN

Case-control study.

SETTING

Ten hospitals in Victoria, Australia.

SAMPLE

Cases were babies with moderate or severe CP identified from the Victorian Cerebral Palsy Register. Controls were matched with cases for year of birth, plurality, sex, birthweight, gestation and hospital of birth.

METHODS

A range of neonatal variables was compared between cases and controls, initially in a univariate analysis and subsequently in a logistic regression. The analysis was matched where possible. Where missing data prevented a matched analysis, an adjusted unmatched analysis was performed.

MAIN OUTCOME MEASURES

Those neonatal factors making an independent contribution to the risk of CP in both term and preterm infants.

RESULTS

Among babies born at term, 73% of cases and 2% of controls were identified by at least one of the following factors: seizures, congenital abnormalities of the brain and elsewhere, 'other lesions', abnormal muscle tone and meconium aspiration. Among babies born preterm, 68% of cases and 26% of controls were identified by the following factors: seizures, intraventricular haemorrhage, periventricular leukomalacia, 'other lesions' and abnormal muscle tone.

CONCLUSIONS

The neonatal factors which best identify neonates who will subsequently develop CP are different for term and preterm babies. Babies born at term are identified more efficiently than those born preterm. Among term babies especially, some of these factors are clearly of a long-standing nature and are not associated with delivery.

Risk of cerebral palsy in multiple pregnancies

Multiple compared with singleton gestations have a five- to tenfold increased risk of CP. The increased risk associated with MC placentation has been variously ascribed to transfer of thromboplastin or thromboemboli from the dead to the surviving fetus, exsanguination of the surviving fetus into the low pressure reservoir of the dead fetus, or hemodynamic instability with bidirectional shunting of blood between the two fetuses. An increased risk of CP in assisted reproductive technology gestations is to be expected because of the higher proportion of preterm births. The increase in risk of CP associated with monochorionic placentation will not be observed except for the minority of assisted reproductive technology gestations that undergo monozygotic splitting.

Manual skill, hand skill asymmetry, and neuropsychological test performance in schoolchildren with spastic cerebral palsy

Bilateral hand skill assessment with a computerised version of the Peg Moving Task, and neuropsychological testing, were performed in 30 children aged 7 to 8 years with spastic cerebral palsy (CP) and without mental retardation, diplegia (n = 10), right hemiplegia (n = 10), or left hemiplegia (n = 10), and in 30 controls. Compared to controls: (i) 30% of the hemiplegic children showed impairment of the unaffected hand and 70% of the diplegic children showed impairment in both hands; (ii) children with CP were impaired only in oral repetition and in visual-motor tasks. Results of neuropsychological testing were not significantly different between the three groups of children with CP. Right minus left asymmetry in hand skill was not related to neuropsychological testing; however, degree of impairment of the right hand was associated with phonological and metaphonological skills, and of the left hand with visuospatial and counting performance. Hand skill was related to the ability to perform many daily living manual activities. It is concluded that impairment of hand function, rather than the side of the more affected hand, is related to neuropsychological deficits in children with cerebral palsy.

Birth asphyxia and cerebral palsy

There has been a societal presumption that most, if not all, cases of hypoxic ischemic encephalopathy-induced cerebral palsy occur during the 3 hours that are related to the events of labor and delivery; society has tended to overlook the remaining 7000 hours of the pregnancy. As a result of this societal perspective, often times the obstetrician has been targeted unfairly as the person who is responsible for a given child's neurologic injuries. Rather, the entire pregnancy, labor, delivery, and well beyond birth require examination to understand fully the pathophysiologic mechanisms that are responsible for an infant's brain injuries, and their long-term impact on the child.

The ratio of flow velocities in the middle cerebral and internal carotid arteries for the prediction of cerebral palsy in term neonates

OBJECTIVE

This study evaluated whether the ratio of the mean flow velocities in the middle cerebral artery (MCA) and the internal carotid artery (ICA) of neonates in the first days of life can be used to identify future neurodevelopmental disabilities.

METHODS

We observed 127 term neonates without congenital malformations, chromosomal aberrations, intracranial hemorrhage, or early onset sepsis. The mean cerebral blood flow velocities were measured in the right and left ICAs and in the right and left MCAs with a Doppler flowmeter once from day 1 to day 3. The Vm ratio was defined as the mean velocity in the right and left MCAs/mean velocity in the right and left ICAs. Neurologic examinations were performed at 12 months of age in the outpatient follow-up clinic to detect cerebral palsy (CP), and the subjects were divided into 4 groups according to the diagnosis of hypoxic-ischemic encephalopathy (HIE) and neurologic prognosis: HIE- and normal neurologic function, HIE- and CP, HIE+ and normal neurologic function, and HIE+ and CP.

RESULTS

The Vm ratio in infants with the HIE- diagnosis and CP was significantly lower than that in infants with the HIE- diagnosis without CP (P < .05). There was no significant difference between the Vm ratios in infants with the HIE+ diagnosis without CP and infants with the HIE+ diagnosis and CP.

CONCLUSIONS

The Vm ratio might be a useful index in estimating neurologic outcome at birth, especially in neonates without the diagnosis of HIE.