Bilateral spastic cerebral palsy--a comparative study between south-west Germany and western Sweden. I: Clinical patterns and disabilities

Cranial MRI beyond the Neonatal Period and Neurodevelopmental Outcomes in Neonatal Encephalopathy Due to Perinatal Asphyxia: A Systematic Review

BACKGROUND

Magnetic resonance imaging (MRI) including diffusion-weighted imaging within seven days after birth is widely used to obtain prognostic information in neonatal encephalopathy (NE) following perinatal asphyxia. Later MRI could be useful for infants without a neonatal MRI or in the case of clinical concerns during follow-up. Therefore, this review evaluates the association between cranial MRI beyond the neonatal period and neurodevelopmental outcomes following NE.

METHODS

A systematic literature search was performed using PubMed and Embase on cranial MRI between 2 and 24 months after birth and neurodevelopmental outcomes following NE due to perinatal asphyxia. Two independent researchers performed the study selection and risk of bias analysis. Results were separately described for MRI before and after 18 months.

RESULTS

Twelve studies were included (high-quality n = 2, moderate-quality n = 6, low-quality n = 4). All reported on MRI at 2-18 months: seven studies demonstrated a significant association between the pattern and/or severity of injury and overall neurodevelopmental outcomes and three showed a significant association with motor outcome. There were insufficient data on non-motor outcomes and the association between MRI at 18-24 months and neurodevelopmental outcomes.

CONCLUSIONS

Cranial MRI performed between 2 and 18 months after birth is associated with neurodevelopmental outcomes in NE following perinatal asphyxia. However, more data on the association with non-motor outcomes are needed.

Measuring intellectual ability in cerebral palsy: The comparison of three tests and their neuroimaging correlates

Standard intelligence scales require both verbal and manipulative responses, making it difficult to use in cerebral palsy and leading to underestimate their actual performance. This study aims to compare three intelligence tests suitable for the heterogeneity of cerebral palsy in order to identify which one(s) could be more appropriate to use. Forty-four subjects with bilateral dyskinetic cerebral palsy (26 male, mean age 23 years) conducted the Raven's Coloured Progressive Matrices (RCPM), the Peabody Picture Vocabulary Test-3rd (PPVT-III) and the Wechsler Nonverbal Scale of Ability (WNV). Furthermore, a comprehensive neuropsychological battery and magnetic resonance imaging were assessed. The results show that PPVT-III gives limited information on cognitive performance and brain correlates, getting lower intelligence quotient scores. The WNV provides similar outcomes as RCPM, but cases with severe motor impairment were unable to perform it. Finally, the RCPM gives more comprehensive information on cognitive performance, comprising not only visual but also verbal functions. It is also sensitive to the structural state of the brain, being related to basal ganglia, thalamus and white matter areas such as superior longitudinal fasciculus. So, the RCPM may be considered a standardized easy-to-administer tool with great potential in both clinical and research fields of bilateral cerebral palsy.

Clinical and genetic findings in a series of Italian children with pure hereditary spastic paraplegia

BACKGROUND

hereditary spastic paraplegias (HSP) are a group of neurodegenerative disorders characterized by progressive lower extremity spastic weakness. SPG7, SPG4 and SPG3A are some of the autosomal genes recently found as mutated in recessive or dominant forms of HSP in childhood. SPG31 is more often associated with a pure spastic paraplegia phenotype, but genotype-phenotype correlation is still unclear. The aims of the current study was: (i) to verify the mutational frequency of SPG4, SPG3A, SPG31 and SPG7 genes in our very-well-selected childhood sample, and (ii) to improve our knowledge about the clinical and electrophysiological HSP phenotypes and their possible correlation with a specific mutation.

METHODS

a sample of 14 Italian children affected by pure HSP (mean age at diagnosis 5.9 years) was extensively investigated with electrophysiological, neuroradiological and genetic tests.

RESULTS

three SPG4 mutations were identified in three patients: two novel missense mutations, both sporadic, and one multiexonic deletion already reported. A novel large deletion in SPG31 gene involving exons 2-5 was also detected in one young patient. No mutations in the SPG7 and in the SPG3A genes were found.

CONCLUSIONS

our data confirm that HSP represent a heterogeneous group of genetic neurodegenerative disorders, also in sporadic or autosomal recessive early onset forms. Multiplex Ligation-dependent Probe Amplification-based mutation screening for SPG4 and SPG31 genes would be added to sequencing-based screening of SPG4, SPG31 and SPG3A genes in the routine diagnosis of HSP children.

Using the manual ability classification system in young adults with cerebral palsy and normal intelligence

PURPOSE

The study aimed to establish whether the manual ability classification system (MACS), a valid classification system for manual ability in children with cerebral palsy (CP), is applicable in young adults with CP and normal intelligence.

SUBJECTS

The participants (n = 83) were young adults with CP and normal intelligence and had a mean age of 19.9 years.

METHOD

In this study, inter observer reliability of the MACS was determined. We investigated relationships between the MACS level and patient characteristics (such as the gross motor function classification system (GMFCS) level, limb distribution of the spastic paresis and educational level) and with functional activities of the upper extremity (assessed with the Melbourne assessment, the Abilhand questionnaire and the domain self-care of the functional independence measure (FIM)). Furthermore, with a linear regression analysis it was determined whether the MACS is a significant determinant of activity limitations and participation restrictions.

RESULTS

The reliability was good (intraclass correlation coefficient 0.83). The Spearman correlation coefficients with GMFCS level, limb distribution of the spastic paresis and educational level were 0.53, 0.46, and 0.26, respectively. MACS level correlated moderately with outcome measures of functional activities (correlations ranging from -0.38 to -0.55). MACS level is, in addition to the GMFCS level, an important determinant for limitations in activities and restrictions in participation.

CONCLUSION

We conclude that the MACS is a feasible method to classify manual ability in young adults with CP and normal intelligence with a good manual ability.

Classification systems in cerebral palsy

Because of increasing interest in conducting large-scale, multicenter investigations into the epidemiology of cerebral palsy and its prevention and treatment, efforts have been made to establish a standard definition and classification systems for cerebral palsy. In recent years there has also been increased focus on measurement of functional status of patients and new classifications for gross and fine motor function have been developed. The purpose of this article is to update the orthopaedic community on the current classification systems for patients with cerebral palsy. This information will be of value to surgeons in determining patients' suitability for certain treatments and will also assist them in reviewing current literature in cerebral palsy.

Comparison of impact on mood, health, and daily living experiences of primary caregivers of walking and non-walking children with cerebral palsy and provided community services support

Many children with cerebral palsy (CP), especially non-walkers, were previously reported to have cold extremities, pain, sleeping disorders, constipation, and impaired well-being - besides accompanying impairments. Most children had had one or more of these symptoms for more than 1 year, and the symptoms were largely untreated. This study (1) describes mood, health, and daily life experiences of the children's parents; (2) explains impact that the child's impairments and symptoms have on the family; and (3) investigates community services support. Information in this study was gathered from parents of 106 children, ages 5-16, with CP, who lived in northern Sweden. Compared with parents of walkers, parents with non-walking children and several disorders were more frequently anxious for their children's physical and psychological health; often experienced restricted time for themselves; reported frequent daily living interferences; and stated that their health was affected due to the child's health. 10 percent of all families reported that their need of community services support was unmet. To improve health and to provide good community services support for the entire family, regular follow-up and evaluation of the child's treatment and family support are important.

Risk factors for epilepsy in children with cerebral palsy

The purpose of the study was to identify predictive risk factors for epilepsy among children with cerebral palsy. We conducted a retrospective study of the clinical characteristics of children with cerebral palsy and epilepsy in comparison to those of children with cerebral palsy without epilepsy. The examined parameters included: the prevalence and the age of onset of the seizures, the clinical subgroup of cerebral palsy and subtype of epileptic seizures. We looked for possible risk factors including the presence of neonatal seizures, the imaging findings, the gestational age at delivery, the adjusted birth weight, the mode of delivery, the Apgar scores, and the head size as well as the presence of consanguinity. Epilepsy occurred in 33% of the studied children. Almost 50% of the epileptic children had their first seizure within the first 12 months of life. Neonatal seizures were strong predictors for epilepsy (p<0.001). Presence of at least one abnormal structural finding (particularly brain atrophy) was also a significant predictor of epilepsy (p<0.003). Low Apgar score at 5 min after birth and birth at term were also found more frequently among patients with epilepsy, although when adjusted with other risk factors, Apgar score did not reach statistical significance. The mode of delivery, head circumference, adjusted birth weight, gender and ethnic group, consanguineous marriage and prematurity were not found to be risk factors for the occurrence of epilepsy in these children.

Clinical presentation, associated disorders and aetiological moments in Cerebral Palsy: A Dutch population-based study

PURPOSE

Cerebral Palsy (CP) contains varying clinical presentations, associated disorders and aetiological moments. Quantitative data and trends on these aspects were lacking in The Netherlands.

METHOD

Within a population-based study on prevalence, presentation and functioning of Dutch children with CP born in the years 1977-1988, individual history taking, examination and medical file checking was done by experienced clinicians. Clinical subtypes, motor disability, important co-morbidity (mental retardation, visual disability and epilepsy) were recorded, aetiological moments identified if possible. By comparing the four most recent years with the earlier years possible trends were studied.

RESULTS

A quarter of children beforehand recorded as CP did not meet inclusion criteria after individual examination. Spastic subtypes accounted for over 90% of all CP cases: bilateral spastic cerebral palsy as a group are the majority although spastic hemiplegia is percentage-wise the largest individual clinical subtype. Epilepsy and mental retardation are common. Clinical patterns and associated disorders remained rather constant comparing earlier to more recent birth years.

CONCLUSIONS

An early diagnosis of CP may be challenged. General clinical patterns remained rather constant in following years, as did most studied items. Even if this study revealed a prevalence rise, no aspect stood out as a possible explanation for this prevalence rise. Comparable studies performed elsewhere showed similar findings.

Cerebral palsy: Incidence and clinical features in Saudi Arabia

The purpose of this work is to analyse the cerebral palsy (CP) incidence, aetiology, birthweight, types and/or subdiagnosis and associated impairments, individually or in combination, in children at Riyadh Military Hospital (RMH). The study covered the birth year period 1984 - 2003, during which 99,788 live births were recorded at Riyadh Military Hospital (RMH). Incidence ratio and clinical features of 412 positive cases of cerebral palsied children between 1 - 10 years old were investigated. Medical information was collected from patient files at the medical records department. The incidence of CP was 0.41%. The five intervals of the study period gave a pattern of decreasing percentage incidence. The case distribution according to birth weight, aetiology, duration and subdiagnoses was studied. It could be concluded that livebirth incidence of cerebral palsied patients in Saudi Arabia was relatively high as compared to most other studies. Severe disability due to cerebral palsy was associated with impairments such as mental retardation, epilepsy and visual impairments, often found in combinations.

Importance of speech production for phonological awareness and word decoding: the case of children with cerebral palsy

The goal of this longitudinal study was to investigate the precursors of early reading development in 52 children with cerebral palsy at kindergarten level in comparison to 65 children without disabilities. Word Decoding was measured to investigate early reading skills, while Phonological Awareness, Phonological Short-term Memory (STM), Speech Perception, Speech Production and Nonverbal Reasoning were considered reading precursors. Children with cerebral palsy lag behind on all reading precursors at the beginning of the second year of kindergarten. For the children without disabilities, early reading skills in Grade 1 were best predicted by Phonological Awareness and Phonological STM while Speech Production was the most important predictor of early reading success for the children with cerebral palsy, followed by Phonological Awareness and Speech Perception. Furthermore, for children with cerebral palsy, Speech Production appears to dominate reading development, as Speech Production measured at the beginning of the second year of kindergarten was strongly predictive of all other reading precursors measured at the end of the second year of kindergarten. The results of this study reveal that children with cerebral palsy with additional speech impairments are at risk for limited literacy development. Clinical implications are discussed.

Neuropsychologic impairment in bilateral cerebral palsy

The lower-than-average cognitive performance of individuals with bilateral cerebral palsy found in previous studies does not always refer to an abnormal performance or clinically significant impairment. We aimed to establish the percentage of persons with bilateral cerebral palsy who present neuropsychologic impairment, and its relationship to perinatal data and motor signs. Forty children, adolescents, and adults (age range, 6-38 years; 15 females and 25 males) with bilateral cerebral palsy were neuropsychologically assessed. Vocabulary was impaired in 85% of participants, language comprehension in 13-48%, visuoperceptual abilities in 60%, visuospatial abilities in 90%, short-term memory in 21-58%, declarative memory in 47-67%, and praxis comprehension in 20%, with executive deficits in 58-74%. Perinatal data (intrauterine growth and birth weight) contributed to explaining memory impairment. Among cerebral palsy subtypes (spastic, mixed, and dyskinetic), forms of impairment differed only in short-term verbal memory. No persons with dyskinetic cerebral palsy experienced impairment in immediate memory or working visual memory. We conclude that visuospatial deficit is the most frequent impairment in people with bilateral cerebral palsy. Moreover, short-term memory impairment seems sensitive to perinatal complications, and differs among bilateral cerebral palsy subtypes.

Functional activities of the upper extremity of young adults with cerebral palsy: a limiting factor for participation?

PURPOSE

To assess functional activities of the upper extremity of young adults with cerebral palsy (CP) and to determine their relations with participant characteristics and participation.

METHOD

Assessment of functional activities of the upper extremity was performed on 103 participants (aged 16-20 years) with the Melbourne assessment and the Abilhand Questionnaire. Participation was measured with the Life Habits Questionnaire. Participant characteristics included age, gender, limb distribution of the spastic paresis, educational level and gross and fine motor function. Relations among these variables were studied by means of correlation coefficients and linear regression analysis.

RESULTS

Limitations in functional activities of the upper extremity were related to the limb distribution of the spastic paresis and were especially present in quadriplegic participants. Significant correlations between participant characteristics and measures of functional activities were present. Limitations in functional activities of the upper extremity, measured with the Abilhand Questionnaire, were an important determinant for participation, in addition to the gross motor function and educational level.

CONCLUSION

Limitations in functional activities of the upper extremity are an important determinant for restrictions in participation in young adults with CP. It is recommended to include assessment of functional activities of the upper extremity in patients with CP.

Comorbidities and clinical determinants of outcome in children with spastic quadriplegic cerebral palsy

The objective of this study was to determine the major comorbidities in patients with spastic quadriplegic (SQ) cerebral palsy (CP) and their possible clinical associations. Medical records of patients with SQ CP from a pediatric neurology practice over a 14-year period were retrospectively and systematically reviewed. Variables examined included demographics, prenatal, perinatal, and postnatal risk factors. Comorbidities documented included those involving hearing, vision, feeding status, and epilepsy. Binomial logistic regression analyses were applied to identify clinical associations of the comorbidities. Ninety-two children were included in this study of whom 39 were born preterm. Mean age of presentation was 2 months (SD 3.5) and males comprised 60% of the group. A total of 57% had a Gross Motor Function Classification Score (GMFCS) of Level IV or V. The four documented comorbidities occurred at a high frequency: 66 out of 83 children (80%) had a visual impairment with 13 (21%) having a substantial impairment; 37 out of 86 children (40%) had a hearing deficit; 43 out of 92 children (47%) had epilepsy; and 29 (33%) required assisted feeding. A GMFCS Level of IV or V and documented microcephaly was associated with the need for assisted feeding (odds ratio [OR] 8.1; 95% confidence interval [CI] 2.1-29.8, p=0.002 and OR 4.9, 95% CI 1.7-14.8, p=0.004 respectively). Epilepsy was associated with the occurrence of neonatal encephalopathy (OR 2.3, 95% CI 1.0-55; p=0.05), microcephaly (OR 4.9, 95% CI 1.6-14.8; p=0.004), periventricular leukomalacia (OR 7.4, 95% CI 1.6-35.0; p=0.012), and perinatal asphyxia (OR 3.6, 95% CI 1.5-8.9; p=0.005). There is a high frequency of comorbidity in the setting of SQ CP which can impact on quality of life and burdens of care. Few clinical associations of this burden appear, thus necessitating systematic programmatic follow-up of these children to facilitate early identification and intervention.

Parental perception of cold extremities and other accompanying symptoms in children with cerebral palsy

Cold extremities have been noted in non-walking children with cerebral damage compared with healthy controls. Whether this is a general problem in children with cerebral palsy (CP) and associated with other symptoms is unknown. This study describes accompanying symptoms such as cold extremities, constipation, pain, sleeping disorders and impaired well-being in children with CP as well as treatment the children have undergone. Associations between cold extremities and other symptoms borne by the children were analysed and discussed. From information in postal surveys received from parents of children with CP, 107 children (60 boys and 47 girls) aged 5-13 years, mean 11 years 8 months (SD 2 years 11 months), were described and analysed. Besides neurological impairments, many children had cold extremities and pain, sleeping disorders, constipation, and impaired well-being. Most children had had one or more of these symptoms for over 1 year but the symptoms were largely untreated. Non-walkers generally had more symptoms than walkers. Although pain, constipation, and sleeping disorders may have different underlying causes in children with CP, these symptoms might also be mediated or aggravated by dysfunction in the autonomic nervous system. To improve the child's well-being, early recognition and treatment of accompanying symptoms is important.

Cerebral palsy

Extreme prematurity confers about a 100-fold increase in the risk of cerebral palsy (CP), relative to birth at term gestation. Although CP is primarily a disorder of movement, many children with this disorder have other impairments which may affect their quality of life and life expectancy. Epidemiologic and clinical studies of cerebral palsy have benefited from recent efforts to develop greater uniformity of definition and classification. Particularly noteworthy is the development of the Gross Motor Function Classification System, which is a reliable and valid measure used with increasing frequency in observational and experimental studies. Also of great importance are efforts to quantify reliably the quality of life for children with cerebral palsy, thereby providing a target for medical and community interventions that aim to increase participation and well-being among affected children. During the late 1970s and early 1980s, the rate of CP actually rose, presumably as a result of increased survival of especially vulnerable infants who otherwise would have died. In developed countries over the past two decades (late 1980s to present), CP rates have been either stable or decreasing. Although considerable effort is being directed at prevention, the only perinatal interventions for which there is strong evidence of a beneficial effect on both mortality and the risk of CP is antenatal treatment of the mother with glucocorticoid.

Growth and development are similar in VLBW children born appropriate and small for gestational age: an interim report on 97 preschool children

AIM

To investigate growth and development in a cohort of children born with very low birth weight (VLBW) treated at a single tertiary neonatal unit.

METHODS

We studied 97 children born between January 1995 and July 1997 with BW <1,500 g. At follow-up (mean age 3.7 years) anthropometric data and data on neurological status, motor, speech and language development were collected. Small for gestational age (SGA) was defined as weight and/or length at birth <10th percentile; shortness at follow-up was defined as height <10th percentile.

RESULTS

Comparison was made between the appropriate for gestational age (AGA) (n = 46) and SGA (n = 51) groups. At follow-up, 23 AGA and 35 SGA children were short, had a smaller head circumference (-1.9 vs -0.8 SDS), were lighter at birth (BW -1.3 vs -0.7 SDS), and had a higher rate of broncho-pulmonary dysplasia (BPD) (28 vs 12); no differences in neonatal characteristics or neurological status were evident. A higher frequency of motor delay occurred in the 'short' group. Short children also had a smaller head circumference (HC) (-1.6 vs -0.7). Short SGA children had a higher frequency of BPD, smaller HC (-2.1 vs -1.0), and a slightly higher proportion of suspicious neurological findings, motor delay, and speech and language delay (n.s.).

CONCLUSIONS

Preterm VLBW infants, whether AGA or SGA at birth, face the risk of being short at preschool age. Height outcome is probably influenced by postnatal factors. Our data also suggest that short stature is associated with developmental difficulties in this population.

Bilateral spastic cerebral palsy--prevalence through four decades, motor function and growth

The aim was to depict changes in the prevalence and severity of bilateral spastic cerebral palsy (CP) over a 40-year period. Another objective was to characterise the group born in 1991-1998 with respect to gross motor function, spasticity and growth. Data were obtained from the CP register of western Sweden and rehabilitation records.

RESULTS

After a rise to 1.27 per 1000 live births in 1983-1986, the prevalence decreased significantly, in children born both preterm and at term, to 0.69 in 1995-1998. After 1975, more children were born preterm than at term. There was a significant decrease in severe bilateral spastic CP during the same period, mainly in children born at term. In all, 46% of the children born at term and 33% of those born preterm had a severe motor impairment, i.e. no walking ability. In the 167 children born in 1991-1998, the gross motor function classification system (GMFCS) level was I in 14%, II in 34%, III in 10%, IV in 25% and V in 17%. The GMFCS level correlated with the gross motor function measure (GMFM) and the Ashworth spasticity scores, as well as with the deviation in postnatal weight and height. We conclude that the prevalence of bilateral spastic CP has decreased since the mid-1980s, parallel to a reduction in the severity of the motor impairment. Children born preterm have predominated since the mid-1970s. The severity of the motor impairment correlated with the degree of spasticity, GMFM and growth. The percentage of children who were underweight was substantial.

Factors associated with epilepsy in children with periventricular leukomalacia

Children with cerebral palsy associated with periventricular leukomalacia frequently develop unprovoked epileptic seizures. This article reports an analysis of risk factors for epilepsy in children with radiologically confirmed periventricular leukomalacia. This cohort was screened for epilepsy and for an array of clinical and demographic factors. Of 154 subjects with radiologically confirmed periventricular leukomalacia, 40 (26.0%) had epilepsy. In the epileptic group, radiologic pathology other than periventricular leukomalacia was uncommon. Significant associations were found between epilepsy and cerebral palsy patterns other than spastic diparesis, mental handicap, cortical visual impairment, neonatal seizures, and severe periventricular leukomalacia. Only the presence of neonatal seizures was significantly associated with epilepsy once other risk factors were controlled in the regression model. Some previous studies have shown an association between neonatal seizures and later epilepsy for cerebral palsy in general. This is the first report of such an association for a single predominant type of cerebral pathology.

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.

Case gender and severity in cerebral palsy varies with intrauterine growth

BACKGROUND

There is an unexplained excess of cerebral palsy among male babies. There is also variation in the proportion of more severe cases by birth weight. It has recently been shown that the rate of cerebral palsy increases as intrauterine size deviates up or down from an optimum about one standard deviation heavier than population mean weight-for-gestation.

AIMS

To determine whether the gender ratio or the severity of cases also varies with intrauterine size.

METHODS

A total of 3454 cases of cerebral palsy among single births between 1976 and 1990 with sufficient data to assign case severity (based on intellectual impairment and walking ability) and to compare weight-for-gestation at birth to sex specific fetal growth standards, were aggregated from nine separate registers in five European countries.

RESULTS

The greater the degree to which growth deviates either up or down from optimal weight-for-gestation at birth, the higher is the rate of cerebral palsy, the larger is the proportion of male cases, and the more severe is the functional disability. Compared to those with optimum growth the risk of more severe cerebral palsy in male babies is 16 times higher for those with a birth weight below the 3rd centile and four times higher when birth weight is above the 97th centile. In contrast, for mild cerebral palsy in female babies the excess risks at these growth extremes are about half these magnitudes.

CONCLUSIONS

Among singleton children with cerebral palsy, abnormal intrauterine size, either small or large, is associated with more severe disability and male sex.

Aging with cerebral palsy

Before the mid-twentieth century, few people with CP survived to adulthood. Now, 65% to 90% of children with CP survive. Because of improvements in intensive care techniques leading to the increased survival of very low-birth-weight infants and the increased longevity of the general population, there are a large number of disabled adults requiring medical care. Adults with CP have medical and social issues that are unique to them. Although there is an increasing awareness of the rights of people with disabilities, there is more work to be done particularly as relates to the cost and availability of adaptive equipment and exercise. In recent years, more attention has been given to studying the needs of this growing part of the population. However, much remains to be investigated to improve the quality of life for these patients.

Use of botulinum toxin in pediatric spasticity (cerebral palsy)

Local injection of botulinum toxin (BT) is a well-established treatment option for spastic movement disorders in children. BT blocks the release of acetylcholine from the axon terminal into the synaptic cleft of the motor endplate resulting in paresis of the injected musculature. Such localised, temporary chemodenervation of affected muscles can lead to functional gains and may improve the child's daily routine and rehabilitative care. We summarise state-of-the-art treatment of spasticity in children with BT type A, addressing critical issues and introducing recent advances, such as sonography-guided injection of BT and the distal injection of the psoas muscle without the need for general anaesthesia. First-hand experience with BT type B in children is presented.

Postnatally acquired cytomegalovirus infection via breast milk: effects on hearing and development in preterm infants

BACKGROUND

In preterm infants there is a high risk of transmission of cytomegalovirus (CMV) via breast milk from seropositive mothers with reactivation of the virus during lactation. There is little information about the long term sequel of early postnatally acquired CMV infection in pre-term infants. This study aimed to investigate whether there was an increased frequency of impaired neurodevelopmental outcome and sensorineural hearing loss in preterm infants with postnatally acquired CMV infection through transmission by CMV-positive breast milk.

METHODS

Twenty-two preterm infants [median birth weight, 1020 g (range, 600 to 1870 g); median gestational age, 27.6 weeks (range, 23.6 to 32 weeks] with early postnatally acquired CMV infection by breast-feeding (onset of viruria between Days 23 and 190 postnatally) were compared with 22 CMV-negative preterm infants individually matched for gestational age, birth weight, gender, intracranial hemorrhage and duration of ventilation. At 2 to 4.5 years of age, follow-up assessments were conducted consisting of neurologic examination, neurodevelopmental assessment and detailed audiologic tests.

RESULTS

None of the children had sensorineural hearing loss. There was no difference between the groups with regard to neurologic, speech and language or motor development.

CONCLUSION

The results of this study suggest that early postnatally acquired CMV infection via CMV-positive breast milk does not have a negative effect on neurodevelopment and hearing in this group of patients. Because we studied a small number of infants, further follow-up studies are warranted in preterm infants with early postnatally acquired CMV infection.

Cerebral palsy registries

Cerebral palsy (CP) registers appear to be appropriate tools for answering questions regarding the prevalence and characteristics of this common childhood disability. Registers are population databases issuing from multiple sources, relying on a clear definition and inclusion and exclusion criteria of CP, and requiring a mix of skills with the collaboration of obstetricians, pediatricians, and epidemiologists. In Europe alone there are 18 different CP registers or population data collections on CP, and collaborative research efforts exist through a European network. Data collection on CP has also been done in Australia (register), the United States (surveys), and Canada (register). Beside monitoring trends, other public health contributions of CP registers might be to reduce the frequency of CP and to improve the quality of life of children with CP. CP registers are useful to clinicians by enabling them to identify subgroups of children requiring specific etiologic investigations, and also to provide more accurate information to the parents of children with CP.

Macropremies: underprivileged newborns

The focus of neonatal intensive care has been on very low birthweight infants, who comprise only 1.4% of neonates. Too little attention is paid to moderately preterm infants that we call macropremies or moderately low birthweight infants (MLBW, with birthweights 1500-2500 grams). Admitting over half MLBW infants to normal nurseries presumes that they have few needs and an excellent prognosis similar to fullterm newborns. It does not take into account the macropremie's vulnerability to complications of prematurity due to immature organ systems. Obstetricians are increasingly willing to deliver these infants prematurely for signs of fetal distress. As many as 25% of children with cerebral palsy referred to a disability clinic in Paris were MLBW, with hypoxic-ischemic-inflammatory associated disorders in one-third. The majority of MLBW infants who required neonatal intensive care at a tertiary care center in Baltimore had complications of prematurity: 47% had respiratory problems, 20% had feeding intolerance and 9% had hypoglycemia. MLBW infants comprise 5-7% of the neonatal population but account for 14% of neonatal deaths, 18-37% of children with cerebral palsy and 7-12% of children with mental retardation. Increasing the level of neonatal care for the macropremie's transition to extrauterine life would be economically feasible if it prevented as few as 30% of cases of major disability. A change in attitude towards this low risk (but not risk free) group of MLBW infants will both reduce morbidity and improve their health and neurodevelopmental outcome. It includes: 1) Providing an intermediate level of neonatal care for a short duration, with close monitoring and prompt intervention as needed, and 2) Neonatal neurodevelopmental screening to allow focused neurodevelopmental followup of MLBW infants with abnormalities.

Prevalence of cerebral palsy in The Netherlands (1977-1988)

Children with cerebral palsy (CP) and their families often make strong demands on diagnostic, therapeutic, technical and social facilities. Prevalence estimates are needed to improve treatment and services. As recent Dutch data are not available, the present study aimed to assess the population prevalence of CP in the Netherlands. A representative Dutch area with 1.2 million inhabitants of which 172,000 were born between 1977 and 1988 was studied. To ascertain the children with CP from these birth years, medical practices (such as rehabilitation centres, paediatric and child neurological departments) were consecutively asked to contact their (supposed) CP cases. Next, a parents' organisation and finally regional news media assisted in the ascertainment. In total, 170 'supposed' CP cases underwent an expert examination. Of these 170, 127 children proved to be definite CP-cases, yielding a 'crude' average prevalence of 0.74 per 1,000 inhabitants (95% CI: 0.61-0.87). Under-ascertainment was recognised and quantified. Accordingly, the population prevalence of CP over the birth year period 1977-1988 was calculated as 1.51 per 1,000 inhabitants (average over the 12 birth years). The calculated CP prevalence rose significantly over time: from 0.77 (1977-1979) to 2.44 (1986-1988). This trend is in accordance with other studies.

Cerebral palsy in Northern Ireland: 1981--93

This paper describes the method of compilation of the Northern Ireland Cerebral Palsy Register (NICPR) and outlines the epidemiology of cerebral palsy (CP) in Northern Ireland in 1981--93 based on an analysis of 784 cases. Multiple and overlapping sources of notification were used to compile the NICPR. Each case was followed up with a standardised assessment completed at age 5 years and validated by a paediatrician. Over 70% of cases were multiply notified, and paediatricians were the most important source of notification. Cases of CP most likely to be under-ascertained included those very mildly affected, cases who died before the register began (death certificates were searched but found to be unreliable) and cases who moved out of the area before their diagnosis was confirmed. The prevalence of CP for the birth period 1981--93 was 2.24 per 1000 livebirths [95% CI 2.08, 2.40]. There were no statistically significant temporal or geographic variations in the rate of CP. Almost half the cases of CP were of low birthweight (<2500 g), and this proportion increased during 1987--89, but decreased (P < 0.01) more recently (1990--93). The proportion of cases weighing <1000 g trebled from 3% in 1981--83 to 10% in 1990--93 (P < 0.01). The most common CP subtype was bilateral spastic cerebral palsy (55%). Just over a quarter (29%) of cases were unable to walk (with/without aids), and one-fifth (22%) had no useful hand/arm function. Almost half (49%) the cases had at least one other impairment (intellectual, sensory impairment or active seizures) in association with their CP. Prevalence rates and the pattern of disability in populations of people with CP can only be evaluated on the basis of the methods of case definition and ascertainment. We have demonstrated the methods necessary to ensure valid, standard and detailed information on CP for the purposes of surveillance, service planning and research.

Otoacoustic emissions and auditory assessment in infants at risk for early brain damage

The importance of early hearing screening has long been recognized, as the prognosis for the hearing impaired child is improved when the diagnosis is made as early as possible, and the intervention is begun immediately. For clinical screening of hearing impairment, the recording of otoacoustic emissions was recommended. As some risk factors for early brain damage are at the same time also risk factors for dysfunction of auditory system, we presumed that infants at risk for brain damage have hearing impairment more frequently than the rest of the population of the same age. We were interested in the role of otoacoustic emission testing during the assessment of auditory function in these infants. There were 110 infants at risk for brain damage included in the study. After thorough otorhinolaryngological examination, auditory function was estimated by recording of otoacoustic emissions, tympanometry, pure tone audiometry and, when necessary, auditory brainstem responses. Otoacoustic emissions were recorded by Madsen-Electronics Celesta 503 in an acoustically treated sound room. We registered spontaneous as well as transient and distortion product otoacoustic emissions. The neurologist formed two groups with different degrees of neurological risk. The collected results of auditory function were compared with the degree of neurological risk. For the statistical analysis, the procedure chi(2) and Fischer test were used. Spontaneous otoacoustic emission was detected in 38.2% of examinees. Evoked otoacoustic emissions were registered in 87.3% of infants. The testing had to be repeated in 32.7% of infants. We observed evoked otoacoustic emissions to be present also in a child with sensorineural hearing impairment and no auditory brainstem responses. Up to 32.7% of infants at risk for brain damage were hard of hearing. Conductive hearing loss was discovered with 25.4% of infants, and eight (7.3%) had sensorineural hearing impairment. In the group of examinees with only risk factors 3.6% had sensorineural impairment and in a group with abnormal motor development, there were 18.5% with that kind of hearing loss. Fischer test confirmed a statistically significant difference between the groups. Infants at risk for brain damage have more frequently impaired auditory function than their peers. For this reason, it is especially important to focus attention on the hearing condition when dealing with this population. Recording of evoked otoacoustic emissions is very helpful in pediatric audiometry, but any interpretation of the results should consider the possibility of auditory neuropathy.

MRI findings and sensorimotor development in infants with bilateral spastic cerebral palsy

The correlation between MRI findings and sensorimotor development was investigated in a group of 48 infants with bilateral spastic cerebral palsy (CP). The ages at MRI examination and cognitive assessment were fairly homogeneous (mean 15 months and 17 months, respectively). The following MRI parameters were scored: size of lateral ventricles, extension of white matter lesions and of white matter reduction, thinning of corpus callosum, presence and size of cystic areas, dimension of subarachnoid spaces and presence of cortical abnormalities. Cognitive assessment included Griffiths Developmental Scales and Uzgiris-Hunt Scales. The patients were subdivided into six classes according to intellectual level (DSM-III-R). For the whole group a highly significant correlation was found between all MRI parameters and the level of cognitive development. This result was probably due to the inclusion of 14 untestable, severely mentally retarded infants, who showed very severe MRI abnormalities. However, when the untestable infants were excluded from the analysis, it was the presence of cysts and the entity of white matter reduction that correlated with both Griffiths Scales and Uzgiris-Hunt Scales. These results indicate the clinical value of MRI findings and particularly of white matter abnormalities for early identification of sensorimotor impairment in infants with bilateral spastic CP.

The changing panorama of cerebral palsy--bilateral spastic forms in particular

Our Swedish population-based cerebral palsy (CP) project started 25 years ago and today covers the birth years 1954-1990, with over 1400 CP cases. This large series (1, 2, 3) has opened new perspectives on time trends and aetiological background factors, where two areas of successively increasing knowledge stand out as particularly helpful. One is the growing amount of biological and clinical data from the continuously increasing cohorts of surviving very preterm infants, the other is the rapidly expanding and refined information from neuroimaging. Bilateral spastic CP (BSCP), including spastic and ataxic diplegia, tetraplegia and spastic-dyskinetic CP, is the most prevalent clinical group of CP syndromes, present in around 75% of preterm and 45% of term CP, and has shown the most significant prevalence changes over time. In this presentation we, therefore, focus on BSCP, also analysed in a collaborative study between southwest Germany and western Sweden and recently presented in a series of four papers (4, 5, 6, 7).

Bilateral spastic cerebral palsy--a comparative study between southwest Germany and western Sweden. II: Epidemiology

Epidemiological data of a collaborative study on children with bilateral spastic cerebral palsy (BSCP) between south-west Germany and western Sweden are reported. The study period covered the birth years 1975 to 1986. Overall, the rate of BSCP increased during the birth year periods 1975-77 and 1978-80, but decreased thereafter. The rise was due to an increase of BSCP in low-birthweight (LBW) children, especially very LBW (VLBW) children. Mortality rates in LBW, and particularly VLBW, children decreased significantly during the whole study period in both countries. The BSCP rate, after the initial increase, showed a decrease during the second half of the study period in LBW children. Results are interpreted in favour of a predominantly prenatal aetiology in normal-birthweight and of a predominantly peri- and neonatal aetiology in LBW children.