Perinatal care with a view to preventing cerebral palsy

Cause-Specific Secular Trends and Prevention Measures of Post-Neonatally Acquired Cerebral Palsy in Victoria and Western Australia 1975-2014: A Population-Based Observational Study

AIM

To describe the timing and causes of post-neonatally acquired cerebral palsy (PNN-CP) and map the implementation of relevant preventive strategies against cause-specific temporal trends in prevalence.

METHODS

Data for a 1975-2014 birth cohort of children with PNN-CP (brain injury between 28 days and 2 years of age) were drawn from the Victorian and Western Australian CP Registers. Descriptive statistics were used to report causal events and timing. Poisson regression models were used to investigate the strength of evidence for cause-specific temporal trends in prevalence. Preventive strategies were mapped alongside cause-specific trends.

RESULTS

Amongst 512 children, causes of PNN-CP included infections (31%, n = 157), head injuries (24%, n = 121) and cerebrovascular accidents (CVAs) (23%, n = 119). Infections were the only main causal group of PNN-CP that declined significantly (p = 0.014). Fifty two percent (n = 267) of the PNN-CP cohort acquired their brain injury before 6 months of age, the majority having an infectious cause (57%, n = 90). Improved clinical care and a range of preventive strategies, including childhood vaccination programs, occurred during this period.

CONCLUSION

Infants under 6 months are a priority group for preventive strategies for PNN-CP. Declining temporal trends were observed for PNN-CP caused by infection, and the causal subgroup of CVAs associated with surgery. Interventions aimed at further reducing the risk of head injury, CVAs and infections, are needed to reduce the prevalence of PNN-CP.

Nutritional risk screening and nutritional assessment for children with cerebral palsy: A review of the current research status and future directions

BACKGROUND

Although the primary impairment involved in Cerebral palsy (CP) is motor function, malnutrition is also common. However, there is a lack of tool recommendations for early malnutrition risk screening in children with CP, and the means of nutritional intervention for children with CP are also limited.

METHODS

This study systematically searched the literature about clinical nutrition related content of cerebral palsy in Pubmed, MEDLINE, Embase, and the Cochrane Library in Jan 2024 and by hand searching, and we checked reference lists and citations to identify additional studies. Search terms include cerebral palsy, children, diagnosis, prediction, malnutrition, nutritional risk screening, nutritional assessment, nutritional support. Additions are marked in red in the modified version.

RESULTS

The timing of diagnosis of CP has been moving forward, and some new diagnostic tools have been developed. Nutritional status is correlated with regional economic level, but there is still a malnutrition rate of nearly 30 % in developed countries. Severe restrictions in terms of gross motor function, swallowing dysfunction, feeding difficulties, cognitive impairment, and insufficient energy intake are common risk factors for malnutrition in children with CP. Z-score should be calculated in combination with measurement indicators in the assessment of physical development of children with CP. The nutritional outcomes of children with CP can be improved by various means, including diversified a Nutrition Support Team (NST) interventions.

CONCLUSIONS

The incidence of malnutrition in children with CP is high, which needs to be paid more attention. More effective malnutrition risk screening tools need to be developed for children with CP to guide the implementation of comprehensive and personalized nutritional interventions and improve malnutrient-related outcomes.

Direct healthcare costs for people with cerebral palsy in the Brazilian unified health system between 2015 and 2019

BACKGROUND

Estimate the costs of inpatient and outpatient care for people with Cerebral Palsy (CP) in Brazil.

RESEARCH DESIGN AND METHODS

Health records of people with CP in the Hospital and Outpatient Information Systems of Brazil between 2015 and 2019 were analyzed. Variables analyzed were gender, age, ICD, Intensive Care Unit (ICU) use, total cost, and ICU cost. Costs were adjusted for inflation and converted to dollars. Linear regression analysis was performed to investigate the association between social and clinical variables and direct costs.

RESULTS

A total direct cost of approximately $166 million to the National Health System was identified, with $7.08 million/year and $26.1 million/year of inpatient and outpatient costs, respectively. The healthcare was primarily for children up to 14 years of age. The ICD 'spastic quadriplegic CP' received the most attendance. Rehabilitation was responsible for 75% of the outpatient care, with physiotherapy standing out. Increased age, use of ICU, and the types of CP are related to increased cost.

CONCLUSIONS

Healthcare for people with CP produced expressive costs for the Brazilian public health system, mainly with outpatient procedures and rehabilitation, with children being the most attended. Estimating these costs assist in better resource allocation for more effective healthcare provision.

Cerebral palsy in Australia: birth prevalence, 1995-2016, and differences by residential remoteness: a population-based register study

OBJECTIVE

To examine recent changes in the birth prevalence of cerebral palsy in Australia; to examine the functional mobility of children with cerebral palsy by residential remoteness.

STUDY DESIGN

Population-based register study; analysis of Australian Cerebral Palsy Register (ACPR) data.

SETTING, PARTICIPANTS

Children with cerebral palsy born in Australia, 1995-2016, and included in the ACPR at the time of the most recent state/territory data provision (31 July 2022).

MAIN OUTCOME MEASURES

Change in birth prevalence of cerebral palsy, of cerebral palsy acquired pre- or perinatally (in utero to day 28 after birth), both overall and by gestational age group (less than 28, 28-31, 32-36, 37 or more weeks), and of cerebral palsy acquired post-neonatally (day 29 to two years of age); gross motor function classification by residential remoteness.

RESULTS

Data for 10 855 children with cerebral palsy born during 1995-2016 were available, 6258 of whom were boys (57.7%). The birth prevalence of cerebral palsy in the three states with complete case ascertainment (South Australia, Victoria, Western Australia) declined from 2.1 (95% confidence interval [CI], 1.9-2.4) cases per 1000 live births in 1995-1996 to 1.5 (95% CI, 1.3-1.7) cases per 1000 live births in 2015-2016. The birth prevalence of pre- or perinatally acquired cerebral palsy declined from 2.0 (95% CI, 1.7-2.3) to 1.4 (95% CI, 1.2-1.6) cases per 1000 live births; statistically significant declines were noted for all gestational ages except 32-36 weeks. The decline in birth prevalence of post-neonatally acquired cerebral palsy, from 0.15 (95% CI, 0.11-0.21) to 0.08 (95% CI, 0.05-0.12) cases per 1000 live births, was not statistically significant. Overall, 3.4% of children with cerebral palsy (307 children) lived in remote or very remote areas, a larger proportion than for all Australians (2.0%); the proportion of children in these areas who required wheelchairs for mobility was larger (31.3%) than that of children with cerebral palsy in major cities or regional areas (each 26.1%).

CONCLUSIONS

The birth prevalence of cerebral palsy declined markedly in Australia during 1995-2016, reflecting the effects of advances in maternal and perinatal care. Our findings highlight the need to provide equitable, culturally safe access to antenatal services for women, and to health and disability services for people with cerebral palsy, across Australia.

Functioning profile and related impairments of children and adolescents with cerebral palsy - PartiCipa Brazil preliminary results

BACKGROUND

Limited information is available about functioning and related impairments of children and adolescents with Cerebral Palsy (CP) in low- and middle-income countries (LMIC) like Brazil. The aim of this study is to describe the characteristics, functioning, and impairments of Brazilian children and adolescents with CP.

METHODS

Cross-sectional preliminary study as part of the PartiCipa Brazil multicentered cohort study. Families of children and adolescents with CP from Brazil, 4 months to 15 years, were enrolled. They responded to an online survey with questions about their child's health condition, impairments, contextual factors, and functioning according to the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS). Data were described as frequencies, percentages, means, and standard deviations, according to age bands.

RESULTS

Of the 404 participants (6.5±3.6 years) enrolled in this preliminary analysis, 54.7% are male, 90.4% under 12 years of age, 77.7% have bilateral CP, 49% in GMFCS levels IV and V, and 50.7% in MACS levels II and V. Most participants are from Southeast (63.4%) and Centre-west (19.5%) of Brazil. Regarding the impairments and functioning limitations: 1 in 2 did not talk; 1 in 2 has epilepsy; 2 of 5 reports pain, 1 of 4 has visual impairments, 3 out of 5 did not feed themselves, 1 out of 20 has a hearing impairment and 1 of 4 did not go to school.

CONCLUSION

This first preliminar Brazilian study shows a high prevalence of children at MACS levels II and V and GMFCS levels IV and V, representing almost half of the group, indicating more impairments and limitations than children/adolescents from high-income countries. This study provides a preliminary deeper understanding of the key impairments and limitations in activities among children and adolescents with CP from various Brazilian regions.

Cerebral palsy as a childhood-onset neurological disorder caused by both genetic and environmental factors

Cerebral palsy (CP) is a clinical term used to describe a spectrum of movement and posture disorders resulting from non-progressive disturbances in the developing fetal brain. The clinical diagnosis of CP does not include pathological or aetiological defining features, therefore both genetic and environmental causal pathways are encompassed under the CP diagnostic umbrella. In this review, we explore several genetic causal pathways, including both monogenic and polygenic risks, and present evidence supporting the multifactorial contributions to CP. Historically, CP has been associated with various risk factors such as pre-term birth, multiple gestation, intrauterine growth restriction (IUGR), maternal infection, and perinatal asphyxia. Thus, we also examine genetic predispositions that may contribute to these risk factors. Understanding the specific aetiology of CP enables more tailored treatments, especially with the increasing potential for early genetic testing.

The impact of low-energy, partially hydrolysed enteral formula on gastrointestinal symptoms and weight in children with neurological impairment: a multicentre retrospective study

BACKGROUND

Neurological impairment (NI) relates to disorders of the central nervous system. The specific aetiology of NI varies but includes genetic, congenital abnormalities or brain injury. In children with severe NI, feeding impairments can lead to undernutrition, and some children require a feeding tube. Although tube feeding improves overall nutritional status, it has also been associated with excess body fat. Commercially available enteral formulas that are low in energy, hydrolysed and nutritionally adequate for protein and micronutrients are available to mitigate gastrointestinal symptoms and obesity.

METHODS

This is a retrospective multicentre study of children who attended NI clinics between January 2022 and July 2023. Data were collected before and 1 month after receiving a low-energy, partially hydrolysed enteral formula (0.6 kcal/mL) on demographic data (age, sex, ethnicity and NI diagnosis), anthropometric measurements (weight, height, weight-for-age Z-score, height-for-age Z-score, body mass index [BMI] Z-score) and feed regimen (feed volume, total fluids and type of formula/supplements).

RESULTS

Dietitians collected data on 28 children, the median age was 7 years (interquartile range [IQR] 3, 8). The most frequently recorded NI was cerebral palsy, in 13 of 28 children (48%). Before the formula switch, the most frequently reported gastrointestinal symptom was constipation, in 13 of 28 children. Within 1 month of switching to a low-energy, hydrolysed formula, 10 of the 13 (77%) children reported an improvement in constipation. Before the formula switch, all 28 children were experiencing excessive weight gain. After the formula was switched to low-energy, hydrolysed formula, dietitians reported that 20 of the 28 (76%) children's weight either stabilised or reduced after 1 month. There was no statistically significant difference in weight-for-age Z-score or BMI Z-scores postswitch of formula (p-value 0.1 and 0.09, respectively). Fibre intake increased significantly from 3.3 to 8.1 g/day (p-value < 0.01) after formula switch. The number of children whose feed regimens were simplified after switching to a low-energy, partially hydrolysed formula was 24 of 28 (91%).

CONCLUSIONS

Children with an NI who have gastrointestinal symptoms may benefit from a low-energy, hydrolysed enteral formula to maximise feed tolerance and promote healthy weight gain. In addition, changing to a low-energy, hydrolysed formula may simplify feed regimens by eliminating the need for additional electrolytes, multivitamins and fluid boluses. Healthcare professionals should be knowledgeable about the effectiveness and availability of a low-energy, hydrolysed formula.

The Prevalence and Risk Analysis of Cerebral Palsy and Other Neuro-Psychological Comorbidities in Children with Low Birth Weight in Taiwan: A Nationwide Population-Based Cohort Study

Background: This study evaluated early childhood comorbidities of cerebral palsy (CP) in low birth weight (LBW) children and assessed the impact of maternal bio-psychosocial factors on CP risk in preterm infants of varying birth weights (BWs). Methods: Data from 15,181 preterm infants (2009-2013) and 151,810 controls were analyzed using Taiwan's National Health Insurance Research Database. CP prevalence and LBW-associated comorbidities were examined, and odds ratios (ORs) were calculated. Results: This study confirmed increasing prematurity and LBW rates in Taiwan, with LBW infants showing higher CP prevalence. Significant maternal risk factors included age extremes (<20 and >40 years). LBW infants exhibited higher risks for respiratory, circulatory, nervous system, and psycho-developmental comorbidities compared with controls, with the lowest BW having even higher ORs. Maternal factors such as family income, the number of hospital admissions, and length of hospital stay were remarkably correlated with BW and subsequent complications. Each additional gestational week crucially reduced the risk of complications in premature infants. Conclusions: LBW infants are at a higher risk for CP and various comorbidities, with maternal bio-psychosocial factors playing a critical role. Addressing these factors in prenatal care and interventions is essential to improve outcomes for premature infants.

Maternal body mass index and cerebral palsy in children: A systematic review and dose-response meta-analysis

BACKGROUND

Accumulating studies indicate that maternal obesity is associated with the risk of cerebral palsy (CP); however, their conclusions have been inconsistent.

OBJECTIVES

To quantitatively estimate the association between maternal body mass index (BMI) and CP in offspring.

DATA SOURCES

PubMed, Embase and Web of Science.

STUDY SELECTION AND DATA EXTRACTION

Articles published up to 18 September 2022 were searched that reported the correlation between maternal BMI and CP in children. Two reviewers independently extracted data and critically assessed articles.

SYNTHESIS

Pooled relative risks (RR) and 95% confidence intervals (CI) were estimated by the random-effects model. Subgroup analysis and meta-regression were performed to explore sources of heterogeneity.

RESULTS

In total, 11 articles (8,407,668 participants) were identified for inclusion in our meta-analysis. For maternal underweight, no significant association was found with CP risk (RR 1.11, 95% CI 0.90, 1.38). The risk of CP was increased by 25% (RR 1.25, 95% CI 1.06, 1.47), 38% (RR 1.38, 95% CI 1.18, 1.61) and 127% (RR 2.27, 95% CI 1.82, 2.83) for maternal overweight, obesity and obesity grade 3, respectively. In addition, we observed a positive linear dose-response relationship, with the pooled risk of cerebral palsy in offspring increasing by 3% with each unit increase in maternal BMI.

CONCLUSION

This meta-analysis indicates that the risk of CP in offspring grew with maternal overweight or obesity grades increasing, and was positively correlated with maternal BMI.

Neonatal hyperbilirubinemia and repercussions on neurodevelopment: A systematic review

BACKGROUND

Accumulation of bilirubin above normal levels is considered a neurological risk factor for both premature and full-term newborns. This systematic review aimed to determine the effect of neonatal hyperbilirubinemia on neurodevelopment in preterm and full-term newborns.

METHODS

PubMed, EMBASE, Cochrane Library, CINAHL, PsycINFO, Scopus and Lilacs databases were searched for articles published until 1 June 2022. The quality of cohort and case-control studies was assessed with the Newcastle-Ottawa Scale, and the MINCir scale was used to evaluate the methodological quality of therapy studies or the therapeutic procedures. Premature neonates without neurological conditions and those born at term with hyperbilirubinemia as the sole risk factor were included. Studies reporting one or more neurodevelopmental outcomes were included with an inter-group comparison of a hyperbilirubinemia group versus a non-hyperbilirubinemia or non-pathological hyperbilirubinemia group. The main outcomes were auditory function, visual function, cognitive function, motor function, behavior, global development and neurological risk.

RESULTS

The search identified 951 studies, 19 of which (n = 2210 newborns) were finally included. Fifteen of the cohort and case-control studies presented low risk of bias, and six studies showed high methodological quality. Within the preterm population, hyperbilirubinemia as the sole risk factor was not shown to affect neurodevelopment. Auditory, neurological and motor development alterations were found in the population of full-term newborns with hyperbilirubinemia, which were more evident during the first year of life.

CONCLUSIONS

Elevated bilirubin levels may be a trigger for the onset of neurodevelopmental disorders in full-term infants during the first year of life. More studies are warranted in the preterm population with hyperbilirubinemia to draw conclusions about its impact on their neurodevelopment.

The Relationship between General Movements and Risk Factors in Moderate-Late Preterm Infants: A Prospective Cohort Study

INTRODUCTION

Moderate-late preterm infants constitute the largest segment of preterm births globally. While previously considered to have a low neurological risk, recent research has uncovered an elevated incidence of neurodevelopmental conditions in this group. This study aimed to assess the relationship between the general movement assessment and birth-related risk factor-based tools in moderate-late preterm infants.

METHODS

A prospective cohort study of 65 moderate-late preterm infants in a neonatal intensive care unit involved the evaluation of general movements, the Nursery Neurobiologic Risk Score, and the Perinatal Risk Inventory. Associations were analyzed using Fisher's exact test, Spearman's correlation was used for ordinal variables, and backward stepwise logistic regression was used to identify predictor variables for the assessments.

RESULTS

The findings indicated a high prevalence of normal (41%) and poor (52%) repertoire patterns during the writhing period. While no significant associations were found between the three assessments, a slight approximation emerged between dysmorphic traits and patterns (p = 0.053). Furthermore, an extended period of ventilation correlated with a higher likelihood of developing a cramped synchronized pattern and there was a correlation between both risk factor-based tools (p < 0.001).

CONCLUSIONS

This research enhances our understanding of the early impact on general movement assessments in moderate-late preterm infants. While no clear relationship emerged between general movement assessment and risk factor-based tools, there was a subtle connection noted with dysmorphic traits. A longer ventilation duration was linked to a higher risk of developing cramped synchronized patterns.

Parent Experiences in the NICU and Transition to Home

Families (n = 12) with infants born at <29 weeks gestation shared their experiences while in the NICU and transitioning home. Parents were interviewed 6-8 weeks after NICU discharge, including some during the acute phase of the COVID-19 pandemic. Findings regarding the parent experience in the NICU were focused around challenges navigating parent-infant separation, social isolation, communication difficulties, limited knowledge of preterm infants, mental health challenges. Parents also discussed supports that were present and supports they wished were present, as well as the impact of COVID-19 on their experiences. In the transition to home, primary experiences included the sudden nature of the transition, anxiety around discharge preparation, and the loss of the support from nursing staff. During the first few weeks at home, parents expressed joy and anxiety, particularly around feeding. The COVID-19 pandemic limited emotional, informational, and physical support to parents and resulted in limited mutual support from other parents of infants in the NICU. Parents of preterm infants in the NICU present with multiple stressors, rendering attending to parental mental health crucial. NICU staff need to address logistical barriers and familial priorities impacting communication and parent-infant bonding. Providing multiple opportunities for communication, participating in caretaking activities, and meeting other families can be important sources of support and knowledge for parents of very preterm infants.

Development of a Bedside Tool to Predict the Diagnosis of Cerebral Palsy in Term-Born Neonates

Importance

Cerebral palsy (CP) is the most common abnormality of motor development and causes lifelong impairment. Early diagnosis and therapy can improve outcomes, but early identification of infants at risk remains challenging.

Objective

To develop a CP prognostic tool that can be applied to all term neonates to identify those at increased risk of developing CP.

Design, Setting, and Participants

This case-control study used data from the Canadian Cerebral Palsy Registry (data collected from January 2003 to December 2019) for children with CP and the Alberta Pregnancy Outcomes and Nutrition study (mothers enrolled from May 2009 to September 2012; data extracted in 2020) for controls. There were 2771 children with CP and 2131 controls evaluated; 941 and 144, respectively, were removed for gestational age less than 37 weeks at birth, 565 with CP removed for incomplete data, and 2 controls removed for a diagnosis of CP. Data were analyzed from April to August 2022.

Exposures

Potential risk factors were selected a priori based on the literature, including maternal, intrapartum, and infant characteristics.

Main Outcomes and Measures

Diagnosis of CP, defined as a disorder of motor function due to a nonprogressive brain abnormality before age 1 year and classified by Gross Motor Function Classification System levels I to V.

Results

Of 3250 included individuals, 1752 (53.9%) were male, and the median (IQR) gestational age at birth was 39 (38-40) weeks. Encephalopathy was present in 335 of 1184 infants with CP (28%) and 0 controls. The final prediction model included 12 variables and correctly classified 75% of infants, with a sensitivity of 56% (95% CI, 52-60) and specificity of 82% (95% CI, 81-84). The C statistic was 0.74 (95% CI, 71-76). Risk factors were found to be additive. A proposed threshold for screening is probability greater than 0.3, with a sensitivity of 65% (95% CI, 61-68) and specificity of 71% (95% CI, 69-73). The prognostic tool identified 2.4-fold more children with CP than would have presented with encephalopathy (odds ratio, 13.8; 95% CI, 8.87-22.65; P < .001).

Conclusions and Relevance

In this case-control study, a prognostic model using 12 clinical variables improved the prediction of CP compared with clinical presentation with encephalopathy. This tool can be applied to all term newborns to help select infants for closer surveillance or further diagnostic tests, which could improve outcomes through early intervention.

Global prevalence of cerebral palsy: A systematic analysis

AIM

To determine trends and current estimates in regional and global prevalence of cerebral palsy (CP).

METHOD

A systematic analysis of data from participating CP registers/surveillance systems and population-based prevalence studies (from birth year 1995) was performed. Quality and risk of bias were assessed for both data sources. Analyses were conducted for pre-/perinatal, postnatal, neonatal, and overall CP. For each region, trends were statistically classified as increasing, decreasing, heterogeneous, or no change, and most recent prevalence estimates with 95% confidence intervals (CI) were calculated. Meta-analyses were conducted to determine current birth prevalence estimates (from birth year 2010).

RESULTS

Forty-one regions from 27 countries across five continents were represented. Pre-/perinatal birth prevalence declined significantly across Europe and Australia (11 out of 14 regions), with no change in postneonatal CP. From the limited but increasing data available from regions in low- and middle-income countries (LMICs), birth prevalence for pre-/perinatal CP was as high as 3.4 per 1000 (95% CI 3.0-3.9) live births. Following meta-analyses, birth prevalence for pre-/perinatal CP in regions from high-income countries (HICs) was 1.5 per 1000 (95% CI 1.4-1.6) live births, and 1.6 per 1000 (95% CI 1.5-1.7) live births when postneonatal CP was included.

INTERPRETATION

The birth prevalence estimate of CP in HICs declined to 1.6 per 1000 live births. Data available from LMICs indicated markedly higher birth prevalence.

WHAT THIS PAPER ADDS

• Birth prevalence of pre-/perinatal cerebral palsy (CP) in high-income countries (HICs) is decreasing. • Current overall CP birth prevalence for HICs is 1.6 per 1000 live births. • Trends in low- and middle-income countries (LMICs) cannot currently be measured. • Current birth prevalence in LMICs is markedly higher than in HICs. • Active surveillance of CP helps to assess the impact of medical advancements and social/economic development. • Population-based data on prevalence and trends of CP are critical to inform policy.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Review on Prevention of Cerebral Palsy from the Perspective of Social Pediatrics

Cerebral palsy is a static encephalopathy with multiple etiologies. Several interventions toward perinatal risk factors, intrapartum asphyxia, and head injury or infection have been evaluated in order to deal with irreversible brain damage. Antenatal-intrapartum and neonatal interventions mainly focus on preventing hypoxia, oxidative stress, inflammation, and growth restriction. Among these preventive interventions, magnesium sulfate for neuroprotection of the fetus in women at risk of preterm birth and therapeutic hypothermia (cooling of body or just brain) for newborns with hypoxic-ischemic encephalopathy have effectively reduced cerebral palsy risk. There is still a lack of literature on the effectiveness of preventive interventions toward postnatally acquired brain injury. Social pediatricians are concerned with identifying, reducing, or eliminating risk factors of cerebral palsy and encourage a comprehensive approach to providing integrated and personalized care to children with cerebral palsy with the support of their families and communities.

Declining trends in birth prevalence and severity of singletons with cerebral palsy of prenatal or perinatal origin in Australia: A population-based observational study

AIM

To investigate temporal trends in birth prevalence, disability severity, and motor type for singletons with prenatal or perinatally acquired cerebral palsy (CP).

METHOD

Numerator data, number of children with CP born a singleton between 1995 and 2014, confirmed at 5 years of age, were drawn from three state registers with population-level ascertainment. Birth prevalence estimates and 95% confidence intervals (CI) were calculated per 1000 singleton live births for the three states combined, overall, by gestational age group, by dichotomized disability severity, and spastic laterality. Poisson regression models were used to analyse trends. Using data from all eight registers, trends in the proportional distribution of CP subtypes overall and stratified by gestational age were examined.

RESULTS

Birth prevalence of CP declined from 1.8 (95% CI 1.6-2.0) in 1995 to 1996 to 1.2 (95% CI 1.1-1.4) in 2013 to 2014 (average 5% per 2-year epoch, p < 0.001). Declines in birth prevalence were observed across all gestational age groups with the largest decline in children born at <28 weeks (average 8% per epoch, p < 0.001). Prevalence of moderate-severe disability declined for children born at <28 and ≥37 weeks (average 11% and 7% per epoch respectively, p < 0.001). The proportions of bilateral spastic CP declined (p < 0.001) at <28 weeks (p = 0.014) and ≥37 weeks (p < 0.001). The proportion of children with dyskinesia increased (28-31 weeks: p = 0.021, 32-36 weeks: p = 0.001, and ≥37 weeks: p < 0.001).

INTERPRETATION

Birth prevalence of CP and moderate-severe disability (<28 and ≥37 weeks) declined in Australian singletons between 1995 and 2014, reflecting changes in prenatal and perinatal care over time.

WHAT THIS PAPER ADDS

Declines in birth prevalence of prenatal or perinatally acquired cerebral palsy were observed for singletons born in Australia between 1995 and 2014. These declines were evident across all gestational age groups. Declines in birth prevalence of moderate-severe disability were observed for children born at <28 weeks and ≥37 weeks.

A Review on Recent Advances of Cerebral Palsy

This narrative review summarizes the latest advances in cerebral palsy and identifies where more research is required. Several studies on cerebral palsy were analyzed to generate a general idea of the prevalence of, risk factors associated with, and classification of cerebral palsy (CP). Different classification systems used for the classification of CP on a functional basis were also analyzed. Diagnosis systems used along with the prevention techniques were discussed. State-of-the-art treatment strategies for CP were also analyzed. Statistical distribution was performed based on the selected studies. Prevalence was found to be 2-3/1000 lives; the factors that can be correlated are gestational age and birth weight. The risk factors identified were preconception, prenatal, perinatal, and postnatal categories. According to the evidence, CP is classified into spastic (80%), dyskinetic (15%), and ataxic (5%) forms. Diagnosis approaches were based on clinical investigation and neurological examinations that include magnetic resonance imaging (MRI), biomarkers, and cranial ultrasound. The treatment procedures found were medical and surgical interventions, physiotherapy, occupational therapy, umbilical milking, nanomedicine, and stem cell therapy. Technological advancements in CP were also discussed. CP is the most common neuromotor disability with a prevalence of 2-3/1000 lives. The highest contributing risk factor is prematurity and being underweight. Several preventions and diagnostic techniques like MRI and ultrasound were being used. Treatment like cord blood treatment nanomedicine and stem cell therapy needs to be investigated further in the future to apply in clinical practice. Future studies are indicated in the context of technological advancements among cerebral palsy children.

Prioritizing indigenous health equity in health registers: an environmental scan of strategies for equitable ascertainment and quality data

BACKGROUND

Cerebral palsy (CP) registers serve as instrumental tools to support development of care pathways, preventative strategies, and health gains. Such health gains, however, are not always universal, with Indigenous health inequities common. To support Indigenous health, health registers need complete, consistent, and high-quality data. The aim of this study was to identify perceived barriers to the ascertainment of Indigenous peoples on health registers and to collate strategies supporting comprehensive ascertainment and achievement of high-quality Indigenous data.

METHODS

Environmental scanning methods were utilized within a Kaupapa Māori theoretical framework, which aims to produce research that is transformational and supportive of Indigenous health gain. Knowledge and insights were obtained from CP registers in countries with Indigenous populations and complemented by information from health registers in Aotearoa New Zealand (NZ). Data collection methods included an online survey and scan of organizational websites. Data extraction focused on general information about the register, barriers to ascertainment, and strategies to support ascertainment and high data quality.

RESULTS

52 registers were identified, 20 completed the survey and 19 included in the study (CP registers, n = 10, NZ health registers, n = 9). Web scan data were included for the other 32 registers (CP registers, n = 21, NZ health registers, n = 11). Indigenous health equity was identified in the visions and aims of only two health registers. Ethnicity data collection was identified in nearly three quarters of survey respondents and a limited number of organizational websites. Over half of survey respondents described system, health provider/service, or workforce barriers to ascertainment. Strategies were categorized into collaboration, health provider/service, workforce, and systems-levels. Indigenous-specific strategies were limited and focused on personal behaviour and access to registration.

CONCLUSIONS

CP and other health registers can have a significant role in identifying and addressing Indigenous health inequities. However, this is not currently an overt priority for many registers in this study and few registers describe ascertainment and data quality strategies specific to Indigenous peoples. Significant opportunity exists for health registers to be accountable and to implement approaches to support Indigenous health equity, address structural determinants of inequities, and achieve health gain for all.

Epidemiology of Cerebral Palsy among Children and Adolescents in Arabic-Speaking Countries: A Systematic Review and Meta-Analysis

BACKGROUND

Studies on cerebral palsy among children and adolescents in Arabic-speaking countries are scarce. In this systematic review, we aimed to describe the epidemiology of cerebral palsy among children and adolescents in Arabic-speaking countries in terms of prevalence, risk factors, motor types, and rehabilitation.

METHODS

Six key bibliographic databases were searched for relevant literature published to 17 July 2021. Titles and abstracts were screened for potential inclusion and two independent reviewers screened the full texts of potential articles following pre-defined inclusion/exclusion criteria. The included studies were evaluated independently by three reviewers. The risk of bias was assessed, and data were extracted and analysed.

RESULTS

A total of 32 studies from 7 countries met our inclusion criteria. The prevalence of cerebral palsy in Arabic-speaking countries was 1.8/1000 live births (95% CI: 1.2-2.5). Spastic cerebral palsy was the most common motor type, representing 59.8% (95% CI: 46.2-72.7) of pooled estimates. This included children with spastic quadriplegia, diplegia, and hemiplegia; 25.1% (95% CI: 18.2-32.8), 16.2% (95% CI: 11.4-23.3), and 10.4% (95% CI: 7.3-13.8), respectively. Consanguinity was high and represented 37.7% (95% CI: 29.3-46.6). Only one included study reported the types of rehabilitation received (e.g., physiotherapy and assistance devices).

CONCLUSIONS

This paper provides a summary of the epidemiology of cerebral palsy in Arabic-speaking countries and highlights areas for future research. There is still a substantial knowledge gap on the epidemiology of cerebral palsy in these regions. Countries in the Arab region should follow examples of countries that have successfully established cerebral palsy registries to generate evidence on epidemiology of cerebral palsy and opportunities for prevention.

Declining prevalence of cerebral palsy in children born at term in Denmark

AIM

To investigate reasons for the declining prevalence of cerebral palsy (CP) in children born at term in Denmark by evaluating obstetric and neonatal factors associated with CP, and their changes over time.

METHOD

In this cohort study, we included 987 495 children (504 600 [51.1%] males and 482 895 [48.9%] females) born after 37 completed gestational weeks during birth years 1997 to 2013. Risk ratios of CP for each factor were calculated with log-binominal regression analyses. Significant factors were evaluated concerning their development in prevalence over time.

RESULTS

In the antenatal period, there were significant associations with an increased risk of CP and high maternal body mass index (BMI), smoking during pregnancy, nulliparity, male sex, gestational age, and low birthweight. In the study period, fewer females smoked during pregnancy and fewer children were born post-term, dropping from 22.6% to 11.4% and 9.4% to 2.5% respectively. Conversely, the proportion of females with high BMI increased. Most significant risk factors were found in the neonatal period, with an increase in children with diagnosed birth defects and children admitted to neonatal care.

INTERPRETATION

Reasons for the declining prevalence of CP appear to be multifactorial and likely include the decline in maternal smoking and children born post-term along with centralization and advances in neonatal treatment.

Tool Use for Early Detection of Cerebral Palsy: A Survey of Spanish Pediatric Physical Therapists

PURPOSE

The purpose of this study was to assess the use of diagnostic assessment tools in pediatric physical therapy practice in Spain. Best practice recommendations indicate the timely use of key assessment tools to reduce the age of diagnosis of cerebral palsy (CP).

METHODS

Pediatric physical therapists currently working in Spain in early intervention were recruited through targeted physical therapy entities. They were invited to complete the purpose-developed electronic survey, consisting of 45 multiple-choice questions, with 5 thematic blocks.

RESULTS

Results from 140 anonymous respondents were analyzed. The average reported age when CP was suspected was 12.6 months. Most used the child's clinical history (88.1%), the Alberta Infant Motor Scale (41.3%), and Vojta Assessment Procedure (32.1%) to assess and detect CP. General Movements Assessment (25.7%) and Hammersmith Infant Neurological Examination (28.4%) were used infrequently.

CONCLUSIONS

Currently, pediatric physical therapists in Spain rely on clinical history and outdated tools to identify children with CP.Digital Abstract available at: http://links.lww.com/PPT/A361 (English).Digital Abstract available at: http://links.lww.com/PPT/A362 (Spanish).

Epidemiology and pathogenesis of stroke in preterm infants: A systematic review

BACKGROUND

Perinatal stroke is one of the principal causes of cerebral palsy (CP) in preterm infants. Stroke in preterm infants is different from stroke in term infants, given the differences in brain maturation and the mechanisms of injury exclusive to the immature brain. We conducted a systematic review to explore the epidemiology and pathogenesis of periventricular hemorrhagic infarction (PVHI), perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) in preterm infants.

METHODS

Studies were identified based on predefined study criteria from MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE electronic databases from 2000 -2019. Results were combined using descriptive statistics.

RESULTS

Fourteen studies encompassed 546 stroke cases in preterm infants between 23 -36 weeks gestational ages and birth weights between 450 -3500 grams. Eighty percent (436/546) of the stroke cases were PVHI, 17%(93/546) were PAIS and 3%(17/546) were CSVT. Parietal PVHI was more common than temporal and frontal lobe PVHI. For PAIS, left middle cerebral artery (MCA) was more common than right MCA or cerebellar stroke. For CSVT partial or complete thrombosis in the transverse sinus was universal. All cases included multiple possible risk factors, but the data were discordant precluding aggregation within a meta-analysis.

CONCLUSION

This systematic review confirms paucity of data regarding the etiology and the precise causal pathway of stroke in preterm infants. Moreover, the preterm infants unlike the term infants do not typically present with seizures. Hence high index of clinical suspicion and routine cUS will assist in the timely diagnosis and understanding of stroke in this population.