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Panda S, Singh A, Kato H, Kokhanov A. Cerebral Palsy: A Current Perspective. Neoreviews 2024; 25:e350-e360. [PMID: 38821909 DOI: 10.1542/neo.25-6-e350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/25/2023] [Accepted: 01/09/2024] [Indexed: 06/02/2024]
Abstract
Cerebral palsy (CP) is the most common cause of motor disability in children. Insults to the brain at different times lead to diverse injuries. As a result, CP is an extremely heterogeneous clinical diagnosis, presenting differently in each individual and at various ages. With improving survival rates of preterm newborns, increasing active resuscitation of extremely preterm newborns, and widespread availability of extensive genetic testing soon after birth, it is imperative to focus on earlier diagnosis and long-term outcomes of CP. CP is primarily classified into 4 categories based on type of motor impairment, functional ability, distribution, and etiology. As the understanding of CP has evolved significantly in the last 2 decades, the methods of early detection of CP have consequently advanced. Appropriate diagnosis is essential for proper education and counseling of affected families, and introduction of therapeutic interventions as early as possible. In this review, we focus on early brain development and provide an overview of the etiology, classification, diagnosis, early therapeutic options, and prognosis of CP.
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Affiliation(s)
- Sanjeet Panda
- Department of Pediatrics, Division of Neonatology, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Ajay Singh
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, TX
| | - Hugo Kato
- Department of Pediatrics, Division of Neonatology, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Artemiy Kokhanov
- Department of Pediatrics, Division of Neonatology, Texas Tech University Health Sciences Center El Paso, El Paso, TX
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Neel ML. Early detection of cerebral palsy with the Standardized Infant NeuroDevelopmental Assessment versus the General Movements Assessment: Is another assessment the way forward? Dev Med Child Neurol 2024. [PMID: 38693661 DOI: 10.1111/dmcn.15944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Mary Lauren Neel
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Fortin O, Husein N, Oskoui M, Shevell MI, Kirton A, Dunbar M. Risk Factors and Outcomes for Cerebral Palsy With Hypoxic-Ischemic Brain Injury Patterns Without Documented Neonatal Encephalopathy. Neurology 2024; 102:e208111. [PMID: 38422458 DOI: 10.1212/wnl.0000000000208111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/16/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Perinatal hypoxic-ischemic brain injury is a leading cause of term-born cerebral palsy, the most common lifelong physical disability. Diagnosis is commonly made in the neonatal period by the combination of neonatal encephalopathy (NE) and typical neuroimaging findings. However, children without a history of neonatal encephalopathy may present later in childhood with motor disability and neuroimaging findings consistent with perinatal hypoxic-ischemic injury. We sought to determine the prevalence of such presentations using the retrospective viewpoint of a large multiregional cerebral palsy registry. METHODS Patient cases were extracted from the Canadian Cerebral Palsy Registry with gestational age >36 weeks, an MRI pattern consistent with hypoxic-ischemic injury (HII, acute total, partial prolonged, or combined), and an absence of postnatal cause for HII. Documentation of NE was noted. Maternal-fetal risk factors, labor and delivery, neonatal course, and clinical outcome were extracted. Comparisons were performed using χ2 tests and multivariable logistic regression with multiple imputation. Propensity scores were used to assess for bias. RESULTS Of the 170 children with MRI findings typical for HII, 140 (82.4%, 95% confidence interval [CI] 75.7%-87.7%) had documented NE and 29 (17.0%, 95% CI 11.7%-23.6%) did not. The group without NE had more abnormalities of amniotic fluid volume (odds ratio [OR] 15.8, 95% CI 1.2-835), had fetal growth restriction (OR 4.7, 95% CI 1.0-19.9), had less resuscitation (OR 0.03, 95% CI 0.007-0.08), had higher 5-minute Apgar scores (OR 2.2, 95% CI 1.6-3.0), were less likely to have neonatal seizures (OR 0.004, 95% CI 0.00009-0.03), and did not receive therapeutic hypothermia. MRI was performed at a median 1.1 months (interquartile range [IQR] 0.67-12.8 months) for those with NE and 12.2 months (IQR 6.6-25.9) for those without (p = 0.011). Patterns of injury on MRI were seen in similar proportions. Hemiplegia was more common in those without documented NE (OR 5.1, 95% CI 1.5-16.1); rates of preserved ambulatory function were similar. DISCUSSION Approximately one-sixth of term-born children with an eventual diagnosis of cerebral palsy and MRI findings consistent with perinatal hypoxic-ischemic brain injury do not have documented neonatal encephalopathy, which was associated with abnormalities of fetal growth and amniotic fluid volume, and a less complex neonatal course. Long-term outcomes seem comparable with their peers with encephalopathy. The absence of documented neonatal encephalopathy does not exclude perinatal hypoxic-ischemic injury, which may have occurred antenatally and must be carefully evaluated with MRI.
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Affiliation(s)
- Olivier Fortin
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Nafisa Husein
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Maryam Oskoui
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Michael I Shevell
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Adam Kirton
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Mary Dunbar
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
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Hong J, Crawford K, Jarrett K, Triggs T, Kumar S. Five-minute Apgar score and risk of neonatal mortality, severe neurological morbidity and severe non-neurological morbidity in term infants - an Australian population-based cohort study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 44:101011. [PMID: 38292653 PMCID: PMC10825608 DOI: 10.1016/j.lanwpc.2024.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024]
Abstract
Background The aim of this study was to ascertain risks of neonatal mortality, severe neurological morbidity and severe non-neurological morbidity related to the 5-min Apgar score in early term (37+0-38+6 weeks), full term (39+0-40+6 weeks), late term (41+0-41+6 weeks), and post term (≥42+0 weeks) infants. Methods This was a retrospective cohort study of 941,221 term singleton births between 2000 and 2018 in Queensland, Australia. Apgar scores at 5-min were categorized into five groups: Apgar 0 or 1, 2 or 3, 4-6, 7 or 8 and 9 or 10. Gestational age was stratified into 4 groups: Early term, full term, late term and post term. Three specific neonatal study outcomes were considered: 1) Neonatal mortality 2) Severe neurological morbidity and 3) Severe non-neurological morbidity. Poisson multivariable regression models were used to determine relative risk ratios for the effect of gestational age and Apgar scores on these severe neonatal outcomes. We hypothesized that a low Apgar score of <4 was significantly associated with increased risks of neonatal mortality, severe neurological morbidity and severe non-neurological morbidity. Findings Of the study cohort, 0.04% (345/941,221) were neonatal deaths, 0.70% (6627/941,221) were infants with severe neurological morbidity and 4.3% (40,693/941,221) had severe non-neurological morbidity. Infants with Apgar score <4 were more likely to birth at late term and post term gestations and have birthweights <3rd and <10th percentiles. The adjusted relative risk ratios (aRRR) for neonatal mortality and severe neurological morbidity were highest in the Apgar 0 or 1 cohort. For infants in the Apgar 0 or 1 group, neonatal mortality increased incrementally with advancing term gestation: early term (aRRR 860.16, 95% CI 560.96, 1318.94, p < 0.001); full term (aRRR 1835.77, 95% CI 1279.48, 2633.91, p < 0.001); late term (aRRR 1693.61, 95% CI 859.65, 3336.6, p < 0.001) and post term (aRRR 2231.59, 95% CI 272.23, 18293.07, p < 0.001) whilst severe neurological morbidity decreased as gestation progressed: early term (aRRR 158.48, 95% CI 118.74, 211.51, p < 0.001); full term (aRRR 112.99, 95% CI 90.56, 140.98, p < 0.001); late term (aRRR 87.94, 95% CI 67.09, 115.27, p < 0.001) and post term (aRRR 52.07, 95% CI 15.17, 178.70, p < 0.001). Severe non-neurological morbidity was greatest in the full term, Apgar 2-3 cohort (aRRR 7.36, 95% CI 6.2, 8.74, p < 0.001). Interpretation A 5-min Apgar score of <4 was prognostic of neonatal mortality, severe neurological morbidity, and severe non-neurological morbidity in infants born >37 weeks' gestation with the risk greatest in the early term cohort. Funding National Health and Medical Research Council and Mater Foundation.
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Affiliation(s)
- Jesrine Hong
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
- School of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, 50603, Malaysia
| | - Kylie Crawford
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
- School of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
| | - Kate Jarrett
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Tegan Triggs
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
- School of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Level 3, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
- School of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
- NHMRC Centre for Research Excellence in Stillbirth, Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
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Kim F, Maitre N. A Call for Early Detection of Cerebral Palsy. Neoreviews 2024; 25:e1-e11. [PMID: 38161182 DOI: 10.1542/neo.25-1-e1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Cerebral palsy (CP) is the most common physical disability across the lifespan, but historically, CP has not been diagnosed before the age of 2 years. Barriers to early diagnosis ranged from lack of available biomarkers, absence of curative treatments, perceived stigma associated with a lifelong diagnosis, and a desire to rule out other diagnoses first. Most importantly, the fundamental question that remained was whether children would benefit from earlier detection and intervention given the paucity of research. However, evidence-based guidelines published in 2017 demonstrated that the General Movements Assessment, the Hammersmith Infant Neurological Examination, and neuroimaging can be combined with other elements such as a clinical history and standardized motor assessments to provide the highest predictive value for diagnosing CP as early as age 3 months in high-risk newborns. Implementation of these guidelines has been successful in decreasing the age at CP diagnosis, particularly in high-risk infant follow-up clinics with expertise in performing these assessments. Early detection of CP allows for clinical and research opportunities investigating earlier interventions during a critical period of neuroplasticity, with the goal of improving developmental trajectories for children and their families. New guidelines and research are now being developed with a focus on early, targeted interventions that continue to be studied, along with global detection initiatives.
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Affiliation(s)
- Faith Kim
- Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian Children's Hospital of New York, New York, NY
| | - Nathalie Maitre
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
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Saleh MN, Alharbi A, Albalwi A, Alatawi S, Algamdi M, Alshahrani A, Al Bakri B, Almasri N. Characteristics of Children with Cerebral Palsy and Their Utilization of Services in Saudi Arabia. Healthcare (Basel) 2023; 11:2690. [PMID: 37830727 PMCID: PMC10572454 DOI: 10.3390/healthcare11192690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/30/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
The recent emergence of research on cerebral palsy (CP) in developing countries aims to improve knowledge on affected children and the utilization of the available services. This study seeks to describe children with CP in Saudi Arabia and service utilization as per Gross Motor Function Classification System (GMFCS) levels and geographic regions. A cross-sectional survey of 227 children with CP (Mean age 6.3, SD 3.9 years) was conducted. Parents reported on children's demographics, impairments, and service utilization. Half of the children (n = 113, 49.8%) had ≥3 impairments with speech, visual and learning impairments being the most frequent. The total number of impairments differed significantly by GMFCS, F (4, 218) = 8.87, p < 0.001. Most of the children (n = 86, 83.4%) used 2-5 services. Moreover, 139 (62.3%) did not attend school, 147 (65.9%) did not receive occupational therapy, and only 32 (14.3%) received speech therapy. More children in GMFCS level I did not receive neurologist services. Profiles of children and services were described by GMFCS and by regions. This was the first study to describe children with CP and service utilization in Saudi Arabia. Although many impairments affected the children, there was low utilization of related services. Data on service utilization and on unmet needs support a comprehensive approach to rehabilitation and the proper service allocation.
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Affiliation(s)
- Maysoun Nimer Saleh
- Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia; (A.A.); (A.A.); (S.A.); (A.A.)
- Department of Physiotherapy, School of Rehabilitation Sciences, The University of Jordan, Amman 11942, Jordan;
| | - Ahmad Alharbi
- Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia; (A.A.); (A.A.); (S.A.); (A.A.)
| | - Abdulaziz Albalwi
- Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia; (A.A.); (A.A.); (S.A.); (A.A.)
| | - Salem Alatawi
- Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia; (A.A.); (A.A.); (S.A.); (A.A.)
| | - Maaidah Algamdi
- Department of Nursing, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia;
| | - Abdulaziz Alshahrani
- Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk 71491, Saudi Arabia; (A.A.); (A.A.); (S.A.); (A.A.)
| | - Basil Al Bakri
- Department of General Surgery, School of Medicine, The University of Jordan, Amman 11942, Jordan;
| | - Nihad Almasri
- Department of Physiotherapy, School of Rehabilitation Sciences, The University of Jordan, Amman 11942, Jordan;
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Ehrhardt H, Aubert AM, Ådén U, Draper ES, Gudmundsdottir A, Varendi H, Weber T, Zemlin M, Maier RF, Zeitlin J. Apgar Score and Neurodevelopmental Outcomes at Age 5 Years in Infants Born Extremely Preterm. JAMA Netw Open 2023; 6:e2332413. [PMID: 37672271 PMCID: PMC10483322 DOI: 10.1001/jamanetworkopen.2023.32413] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/29/2023] [Indexed: 09/07/2023] Open
Abstract
Importance The Apgar score is used worldwide as an assessment tool to estimate the vitality of newborns in their first minutes of life. Its applicability to estimate neurodevelopmental outcomes in infants born extremely preterm (EPT; <28 weeks' gestation) is not well established. Objective To investigate the association between the Apgar score and neurodevelopmental outcomes in infants born EPT. Design, Setting, and Participants This cohort study was conducted using data from the Effective Perinatal Intensive Care in Europe-Screening to Improve Health in Very Preterm Infants in Europe (EPICE-SHIPS) study, a population-based cohort in 19 regions of 11 European countries in 2011 to 2012. Clinical assessments of cognition and motor function at age 5 years were performed in infants born EPT and analyzed in January to July 2023. Exposures Apgar score at 5 minutes of life categorized into 4 groups (0-3, 4-6, 7-8, and 9-10 points). Main Outcomes and Measures Cognitive and motor outcomes were assessed using the Wechsler Preschool and Primary Scale of Intelligence test of IQ derived from locally normed versions by country and the Movement Assessment Battery for Children-Second Edition. Parents additionally provided information on communication and problem-solving skills using the Ages and Stages Questionnaire, third edition (ASQ-3). All outcomes were measured as continuous variables. Results From the total cohort of 4395 infants born EPT, 2522 infants were live born, 1654 infants survived to age 5 years, and 996 infants (478 females [48.0%]) followed up had at least 1 of 3 outcome measures. After adjusting for sociodemographic variables, perinatal factors, and severe neonatal morbidities, there was no association of Apgar score with IQ, even for scores of 3 or less (β = -3.3; 95% CI, -10.5 to 3.8) compared with the score 9 to 10 category. Similarly, no association was found for ASQ-3 (β = -2.1; 95% CI, -24.6 to 20.4). Congruent results for Apgar scores of 3 or less were obtained for motor function scores for all children (β = -4.0; 95% CI, -20.1 to 12.1) and excluding children with a diagnosis of cerebral palsy (β = 0.8, 95% CI -11.7 to 13.3). Conclusions and Relevance This study found that low Apgar scores were not associated with longer-term outcomes in infants born EPT. This finding may be associated with high interobserver variability in Apgar scoring, reduced vitality signs and poorer responses to resuscitation after birth among infants born EPT, and the association of more deleterious exposures in the neonatal intensive care unit or of socioeconomic factors with greater changes in outcomes during the first 5 years of life.
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Affiliation(s)
- Harald Ehrhardt
- Division of Neonatology and Pediatric Intensive Care Medicine, Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Adrien M. Aubert
- Université Paris Cité, Inserm, National Research Institute for Agriculture, Food and the Environment, Centre for Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Paris, France
| | - Ulrika Ådén
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth S. Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Anna Gudmundsdottir
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Heili Varendi
- University of Tartu, Tartu University Hospital, Tartu, Estonia
| | - Tom Weber
- University of Copenhagen, Copenhagen, Denmark
| | - Michael Zemlin
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Rolf F. Maier
- Children’s Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | - Jennifer Zeitlin
- Université Paris Cité, Inserm, National Research Institute for Agriculture, Food and the Environment, Centre for Research in Epidemiology and Statistics, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Paris, France
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Manzar S. Cerebral palsy and postnatal steroids. Acta Paediatr 2023; 112:1351-1352. [PMID: 36872848 DOI: 10.1111/apa.16742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Affiliation(s)
- Shabih Manzar
- Louisiana State University Health Sciences Center at Shreveport, Shreveport, Louisiana, USA
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