The epidemiology of cerebral palsy in term infants

The fetal inflammatory response syndrome: the origins of a concept, pathophysiology, diagnosis, and obstetrical implications

The fetus can deploy a local or systemic inflammatory response when exposed to microorganisms or, alternatively, to non-infection-related stimuli (e.g., danger signals or alarmins). The term "Fetal Inflammatory Response Syndrome" (FIRS) was coined to describe a condition characterized by evidence of a systemic inflammatory response, frequently a result of the activation of the innate limb of the immune response. FIRS can be diagnosed by an increased concentration of umbilical cord plasma or serum acute phase reactants such as C-reactive protein or cytokines (e.g., interleukin-6). Pathologic evidence of a systemic fetal inflammatory response indicates the presence of funisitis or chorionic vasculitis. FIRS was first described in patients at risk for intraamniotic infection who presented preterm labor with intact membranes or preterm prelabor rupture of the membranes. However, FIRS can also be observed in patients with sterile intra-amniotic inflammation, alloimmunization (e.g., Rh disease), and active autoimmune disorders. Neonates born with FIRS have a higher rate of complications, such as early-onset neonatal sepsis, intraventricular hemorrhage, periventricular leukomalacia, and death, than those born without FIRS. Survivors are at risk for long-term sequelae that may include bronchopulmonary dysplasia, neurodevelopmental disorders, such as cerebral palsy, retinopathy of prematurity, and sensorineuronal hearing loss. Experimental FIRS can be induced by intra-amniotic administration of bacteria, microbial products (such as endotoxin), or inflammatory cytokines (such as interleukin-1), and animal models have provided important insights about the mechanisms responsible for multiple organ involvement and dysfunction. A systemic fetal inflammatory response is thought to be adaptive, but, on occasion, may become dysregulated whereby a fetal cytokine storm ensues and can lead to multiple organ dysfunction and even fetal death if delivery does not occur ("rescued by birth"). Thus, the onset of preterm labor in this context can be considered to have survival value. The evidence so far suggests that FIRS may compound the effects of immaturity and neonatal inflammation, thus increasing the risk of neonatal complications and long-term morbidity. Modulation of a dysregulated fetal inflammatory response by the administration of antimicrobial agents, anti-inflammatory agents, or cell-based therapy holds promise to reduce infant morbidity and mortality.

Microbial burden and inflammasome activation in amniotic fluid of patients with preterm prelabor rupture of membranes

Background Intra-amniotic inflammation, which is associated with adverse pregnancy outcomes, can occur in the presence or absence of detectable microorganisms, and involves activation of the inflammasome. Intra-amniotic inflammasome activation has been reported in clinical chorioamnionitis at term and preterm labor with intact membranes, but it has not yet been investigated in women with preterm prelabor rupture of membranes (preterm PROM) in the presence/absence of detectable microorganisms. The aim of this study was to determine whether, among women with preterm PROM, there is an association between detectable microorganisms in amniotic fluid and intra-amniotic inflammation, and whether intra-amniotic inflammasome activation correlates with microbial burden. Methods Amniotic fluids from 59 cases of preterm PROM were examined for the presence/absence of microorganisms through culture and 16S ribosomal RNA (rRNA) gene quantitative real-time polymerase chain reaction (qPCR), and concentrations of interleukin-6 (IL-6) and ASC [apoptosis-associated spec-like protein containing a caspase recruitment domain (CARD)], an indicator of inflammasome activation, were determined. Results qPCR identified more microbe-positive amniotic fluids than culture. Greater than 50% of patients with a negative culture and high IL-6 concentration in amniotic fluid yielded a positive qPCR signal. ASC concentrations were greatest in patients with high qPCR signals and elevated IL-6 concentrations in amniotic fluid (i.e. intra-amniotic infection). ASC concentrations tended to increase in patients without detectable microorganisms but yet with elevated IL-6 concentrations (i.e. sterile intra-amniotic inflammation) compared to those without intra-amniotic inflammation. Conclusion qPCR is a valuable complement to microbiological culture for the detection of microorganisms in the amniotic cavity in women with preterm PROM, and microbial burden is associated with the severity of intra-amniotic inflammatory response, including inflammasome activation.

Clinical chorioamnionitis at term IX: in vivo evidence of intra-amniotic inflammasome activation

Background The inflammasome has been implicated in the mechanisms that lead to spontaneous labor at term. However, whether the inflammasome is activated in the amniotic cavity of women with clinical chorioamnionitis at term is unknown. Herein, by measuring extracellular ASC [apoptosis-associated speck-like protein containing a C-terminal caspase recruitment domain (CARD)], we investigated whether there is in vivo inflammasome activation in amniotic fluid of patients with clinical chorioamnionitis at term with sterile intra-amniotic inflammation and in those with intra-amniotic infection. Methods This was a retrospective cross-sectional study that included amniotic fluid samples collected from 76 women who delivered after spontaneous term labor with diagnosed clinical chorioamnionitis. Intra-amniotic inflammation was defined as an elevated amniotic fluid interleukin (IL)-6 concentration ≥2.6 ng/mL, and intra-amniotic infection was diagnosed by the presence of microbial invasion of the amniotic cavity (MIAC) accompanied by intra-amniotic inflammation. Patients were classified into the following groups: (1) women without intra-amniotic inflammation or infection (n=16); (2) women with MIAC but without intra-amniotic inflammation (n=5); (3) women with sterile intra-amniotic inflammation (n=15); and (4) women with intra-amniotic infection (n=40). As a readout of in vivo inflammasome activation, extracellular ASC was measured in amniotic fluid by enzyme-linked immunosorbent assay. Acute inflammatory responses in the amniotic fluid and placenta were also evaluated. Results In clinical chorioamnionitis at term: (1) amniotic fluid concentrations of ASC (extracellular ASC is indicative of in vivo inflammasome activation) and IL-6 were greater in women with intra-amniotic infection than in those without intra-amniotic inflammation, regardless of the presence of MIAC; (2) amniotic fluid concentrations of ASC and IL-6 were also higher in women with sterile intra-amniotic inflammation than in those without intra-amniotic inflammation, regardless of the presence of MIAC; (3) amniotic fluid concentrations of IL-6, but not ASC, were more elevated in women with intra-amniotic infection than in those with sterile intra-amniotic inflammation; (4) a positive and significant correlation was observed between amniotic fluid concentrations of ASC and IL-6; (5) no differences were observed in amniotic fluid ASC and IL-6 concentrations between women with and without MIAC in the absence of intra-amniotic inflammation; (6) women with intra-amniotic infection had elevated white blood cell counts and reduced glucose levels in amniotic fluid compared to the other three study groups; and (7) women with intra-amniotic infection presented higher frequencies of acute maternal and fetal inflammatory responses in the placenta than those with sterile intra-amniotic inflammation. Conclusion The intra-amniotic inflammatory response, either induced by alarmins or microbes, is characterized by the activation of the inflammasome - as evidenced by elevated amniotic fluid concentrations of extracellular ASC - in women with clinical chorioamnionitis at term. These findings provide insight into the intra-amniotic inflammatory response in women with clinical chorioamnionitis at term.

Maternal obesity and risk of cerebral palsy in children: a systematic review and meta-analysis

AIM

Several studies have examined the links between maternal obesity and the risk of cerebral palsy (CP) in children, with inconsistent results. The aim of our study was to investigate whether maternal obesity is associated with increased risk of CP in offspring by using meta-analysis.

METHOD

PubMed and Web of Science were searched until August 2017. Observational studies relevant to the maternal obesity and risk of CP in children were extracted and compiled. Meta-analyses were performed for different obesity levels and pooled odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

RESULTS

A total of five cohort studies involving 12 324 cases and 7 919 288 participants were included in our meta-analysis. The pooled crude and adjusted ORs (95% CIs) were 1.65 (1.38-1.98) and 1.51 (1.24-1.84) respectively. Additionally, the pooled OR (95% CI) for CP in offspring in relation to maternal obesity class I (body mass index [BMI] 30.0-34.9), class II (BMI 35.0-39.9), and class III (BMI≥40.0) compared with normal weight during prepregnancy or pregnancy was 1.31 (1.15-1.50), 1.65 (1.34-2.02), and 2.37 (1.91-2.94) respectively.

INTERPRETATION

This meta-analysis demonstrated that increasing grades of maternal obesity are associated with a higher risk of CP in offspring.

WHAT THIS PAPER ADDS

Meta-analysis demonstrates a significant positive association between maternal obesity and the risk of cerebral palsy (CP) in children. Subgroup analysis indicates that higher grades of maternal obesity are associated with increasing risk of CP.

Lower limb extension is improved in fast walking condition in children who walk in crouch gait

Background and purpose: The strategies for walking fast have never been reported in children with cerebral palsy who walk in crouch gait. This study aimed to assess to what extent children who walk in crouch gait are able to increase their gait speed and to report the corresponding three-dimensional kinematic adaptations.Methods: Eleven children and adolescents (aged between 7 and 17 years) with bilateral cerebral palsy, who walk in crouch gait, were asked to walk at their self-selected comfortable speed and then as fast as possible without running. The spatio-temporal and kinematic parameters, as well as the center of mass displacements were compared between walking conditions.Results: Children were able to walk 30% faster than their comfortable speed (+0.30 m/s, p = 0.000) by increasing both cadence (+21 step/min, p = 0.000) and step length (+0.05 m, p = 0.001). During the stance phase, pelvis anteversion (+3 Deg, p = 0.010), hip flexion-extension range of motion (+4 Deg, p = 0.002), and knee extension (+5 Deg, p = 0.000) were increased in fast walking. During fast walking, the center of mass showed larger range of vertical displacements (p < 0.05).Conclusions: Children with cerebral palsy who walk in crouch gait increased their walking speed by adopting a less crouched posture. Compared to comfortable walking speed condition, fast walking could be beneficial in rehabilitation to solicit higher lower limbs range of motion.Implications for rehabilitation:Children who walk in crouch gait can walk 30% fasterFast walking required higher hip and knee extensions during stance phaseFast walking could be an interesting training modality to improve the lower limb range of motion of children who walk in crouch gait.

Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis

Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques.   Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia-Pacific (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for any NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.

Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis

Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques.   Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for all NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.

Diffusion tensor imaging detects ventilation-induced brain injury in preterm lambs

Purpose

Injurious mechanical ventilation causes white matter (WM) injury in preterm infants through inflammatory and haemodynamic pathways. The relative contribution of each of these pathways is not known. We hypothesised that in vivo magnetic resonance imaging (MRI) can detect WM brain injury resulting from mechanical ventilation 24 h after preterm delivery. Further we hypothesised that the combination of inflammatory and haemodynamic pathways, induced by umbilical cord occlusion (UCO) increases brain injury at 24 h.

Methods

Fetuses at 124±2 days gestation were exposed, instrumented and either ventilated for 15 min using a high tidal-volume (V_T) injurious strategy with the umbilical cord intact (INJ; inflammatory pathway only), or occluded (INJ+UCO; inflammatory and haemodynamic pathway). The ventilation groups were compared to lambs that underwent surgery but were not ventilated (Sham), and lambs that did not undergo surgery (unoperated control; Cont). Fetuses were placed back in utero after the 15 min intervention and ewes recovered. Twenty-four hours later, lambs were delivered, placed on a protective ventilation strategy, and underwent MRI of the brain using structural, diffusion tensor imaging (DTI) and magnetic resonance spectroscopy (MRS) techniques.

Results

Absolute MRS concentrations of creatine and choline were significantly decreased in INJ+UCO compared to Cont lambs (P = 0.03, P = 0.009, respectively); no significant differences were detected between the INJ or Sham groups and the Cont group. Axial diffusivities in the internal capsule and frontal WM were lower in INJ and INJ+UCO compared to Cont lambs (P = 0.05, P = 0.04, respectively). Lambs in the INJ and INJ+UCO groups had lower mean diffusivities in the frontal WM compared to Cont group (P = 0.04). DTI colour mapping revealed lower diffusivity in specific WM regions in the Sham, INJ, and INJ+UCO groups compared to the Cont group, but the differences did not reach significance. INJ+UCO lambs more likely to exhibit lower WM diffusivity than INJ lambs.

Conclusions

Twenty-four hours after injurious ventilation, DTI and MRS showed increased brain injury in the injuriously ventilated lambs compared to controls. DTI colour mapping threshold approach provides evidence that the haemodynamic and inflammatory pathways have additive effects on the progression of brain injury compared to the inflammatory pathway alone.

Twenty-four percent of patients with clinical chorioamnionitis in preterm gestations have no evidence of either culture-proven intraamniotic infection or intraamniotic inflammation

BACKGROUND

Recent studies on clinical chorioamnionitis at term suggest that some patients with this diagnosis have neither intraamniotic infection nor intraamniotic inflammation. A false-positive diagnosis of clinical chorioamnionitis in preterm gestation may lead to unwarranted preterm delivery.

OBJECTIVE

We sought to determine the frequency of intraamniotic inflammation and microbiologically proven amniotic fluid infection in patients with preterm clinical chorioamnionitis.

STUDY DESIGN

Amniocentesis was performed in singleton pregnant women with preterm clinical chorioamnionitis (<36 weeks of gestation). Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas and assayed for matrix metalloproteinase-8 concentration. Microbial invasion of the amniotic cavity was defined as a positive amniotic fluid culture; intraamniotic inflammation was defined as an elevated amniotic fluid matrix metalloproteinase-8 concentration of >23 ng/mL. Nonparametric and survival techniques were used for analysis.

RESULTS

Among patients with preterm clinical chorioamnionitis, 24% (12/50) had neither microbiologic evidence of intraamniotic infection nor intraamniotic inflammation. Microbial invasion of the amniotic cavity was present in 34% (18/53) and intraamniotic inflammation in 76% (38/50) of patients. The most common microorganisms isolated from the amniotic cavity were the Ureaplasma species. Finally, patients without microbial invasion of the amniotic cavity or intraamniotic inflammation had significantly lower rates of adverse outcomes (including lower gestational age at delivery, a shorter amniocentesis-to-delivery interval, acute histologic chorioamnionitis, acute funisitis, and significant neonatal morbidity) than those with microbial invasion of the amniotic cavity and/or intraamniotic inflammation.

CONCLUSION

Among patients with preterm clinical chorioamnionitis, 24% had no evidence of either intraamniotic infection or intraamniotic inflammation, and 66% had negative amniotic fluid cultures, using standard microbiologic techniques. These observations call for a reexamination of the criteria used to diagnose preterm clinical chorioamnionitis.

Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis

Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques.   Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for all NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.

Clinical chorioamnionitis at term V: umbilical cord plasma cytokine profile in the context of a systemic maternal inflammatory response

OBJECTIVE

Microbial invasion of the fetus due to intra-amniotic infection can lead to a systemic inflammatory response characterized by elevated concentrations of cytokines in the umbilical cord plasma/serum. Clinical chorioamnionitis represents the maternal syndrome often associated with intra-amniotic infection, although other causes of this syndrome have been recently described. The objective of this study was to characterize the umbilical cord plasma cytokine profile in neonates born to mothers with clinical chorioamnionitis at term, according to the presence or absence of bacteria and/or intra-amniotic inflammation.

MATERIALS AND METHODS

A cross-sectional study was conducted, including patients with clinical chorioamnionitis at term (n=38; cases) and those with spontaneous term labor without clinical chorioamnionitis (n=77; controls). Women with clinical chorioamnionitis were classified according to the results of amniotic fluid culture, broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry (PCR/ESI-MS) and amniotic fluid interleukin (IL)-6 concentration into three groups: 1) no intra-amniotic inflammation; 2) intra-amniotic inflammation without detectable microorganisms; or 3) microbial-associated intra-amniotic inflammation. A fetal inflammatory response syndrome (FIRS) was defined as an umbilical cord plasma IL-6 concentration >11 pg/mL. The umbilical cord plasma concentrations of 29 cytokines were determined with sensitive and specific V-PLEX immunoassays. Nonparametric statistical methods were used for analysis, adjusting for a false discovery rate of 5%.

RESULTS

1) Neonates born to mothers with clinical chorioamnionitis at term (considered in toto) had significantly higher median umbilical cord plasma concentrations of IL-6, IL-12p70, IL-16, IL-13, IL-4, IL-10 and IL-8, but significantly lower interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF)-α concentrations than neonates born to mothers with spontaneous term labor without clinical chorioamnionitis; 2) neonates born to mothers with clinical chorioamnionitis at term but without intra-amniotic inflammation had higher concentrations of IL-6, IL-12p70, IL-13, IL-4, IL-5, and IL-8, but lower IFN-γ, than neonates not exposed to clinical chorioamnionitis, suggesting that maternal fever in the absence of intra-amniotic inflammation leads to a change in the fetal cytokine network; 3) there were significant, positive correlations between maternal and umbilical cord plasma IL-6 and IL-8 concentrations (IL-6: Spearman correlation=0.53; P<0.001; IL-8: Spearman correlation=0.42; P<0.001), consistent with placental transfer of cytokines; 4) an elevated fetal plasma IL-6 (>11 pg/mL), the diagnostic criterion for FIRS, was present in 21% of cases (8/38), and all these neonates were born to mothers with proven intra-amniotic infection; and 5) FIRS was associated with a high concentration of umbilical cord plasma IL-8, IL-10 and monocyte chemoattractant protein (MCP)-1.

CONCLUSIONS

Neonates born to mothers with clinical chorioamnionitis at term had higher concentrations of umbilical cord plasma cytokines than those born to mothers without clinical chorioamnionitis. Even neonates exposed to clinical chorioamnionitis but not to intra-amniotic inflammation had elevated concentrations of multiple cytokines, suggesting that intrapartum fever alters the fetal immune response.

Prognostic Predictors for Ambulation in Thai Children With Cerebral Palsy Aged 2 to 18 Years

The objectives of this study were to determine prognostic predictors for ambulation among Thai children with cerebral palsy and identify their ambulatory status. A retrospective cohort study was performed at 6 special schools or hospitals for children with physical disabilities. The prognostic predictors for ambulation were analyzed by multivariable ordinal continuation ratio logistic regression. The 533 participants aged 2 to 18 years were divided into 3 groups: 186 with independent ambulation (Gross Motor Function Classification System [GMFCS I-II]), 71 with assisted ambulation (Gross Motor Function Classification System III), and 276 with nonambulation (Gross Motor Function Classification System IV-V). The significant positive predictors for ambulation were type of cerebral palsy (spastic diplegia, spastic hemiplegia, dyskinesia, ataxia, hypotonia, and mixed type), sitting independently at age 2 years, and eating independently. These predictors were used to develop clinical scoring for predicting the future ability to walk among Thai children with cerebral palsy.

Human Amnion Epithelial Cells Modulate Ventilation-Induced White Matter Pathology in Preterm Lambs

BACKGROUND

Preterm infants can be inadvertently exposed to high tidal volumes (VT) during resuscitation in the delivery room due to limitations of available equipment. High VT ventilation of preterm lambs produces cerebral white matter (WM) pathology similar to that observed in preterm infants who develop cerebral palsy. We hypothesized that human amnion epithelial cells (hAECs), which have anti-inflammatory and regenerative properties, would reduce ventilation-induced WM pathology in neonatal late preterm lamb brains.

METHODS

Two groups of lambs (0.85 gestation) were used, as follows: (1) ventilated lambs (Vent; n = 8) were ventilated using a protocol that induces injury (VT targeting 15 ml/kg for 15 min, with no positive end-expiratory pressure) and were then maintained for another 105 min, and (2) ventilated + hAECs lambs (Vent+hAECs; n = 7) were similarly ventilated but received intravenous and intratracheal administration of 9 × 10(7) hAECs (18 × 10(7) hAECs total) at birth. Oxygenation and ventilation parameters were monitored in real time; cerebral oxygenation was measured using near-infrared spectroscopy. qPCR (quantitative real-time PCR) and immunohistochemistry were used to assess inflammation, vascular leakage and astrogliosis in both the periventricular and subcortical WM of the frontal and parietal lobes. An unventilated control group (UVC; n = 5) was also used for qPCR analysis of gene expression. Two-way repeated measures ANOVA was used to compare physiological data. Student's t test and one-way ANOVA were used for immunohistological and qPCR data comparisons, respectively.

RESULTS

Respiratory parameters were not different between groups. Interleukin (IL)-6 mRNA levels in subcortical WM were lower in the Vent+hAECs group than the Vent group (p = 0.028). IL-1β and IL-6 mRNA levels in periventricular WM were higher in the Vent+hAECs group than the Vent group (p = 0.007 and p = 0.001, respectively). The density of Iba-1-positive microglia was lower in the subcortical WM of the parietal lobes (p = 0.010) in the Vent+hAECs group but not in the periventricular WM. The number of vessels in the WM of the parietal lobe exhibiting protein extravasation was lower (p = 0.046) in the Vent+hAECs group. Claudin-1 mRNA levels were higher in the periventricular WM (p = 0.005). The density of GFAP-positive astrocytes was not different between groups.

CONCLUSIONS

Administration of hAECs at the time of birth alters the effects of injurious ventilation on the preterm neonatal brain. Further studies are required to understand the regional differences in the effects of hAECs on ventilation-induced WM pathology and their net effect on the developing brain.

When is birthweight at term (≥37 weeks' gestation) abnormally low? A systematic review and meta-analysis of the prognostic and predictive ability of current birthweight standards for childhood and adult outcomes

BACKGROUND

Health outcomes throughout the life course have been linked to fetal growth restriction and low birthweight. A variety of measures exist to define low birthweight, with a lack of consensus regarding which predict adverse outcome.

OBJECTIVES

To evaluate the relationship between birthweight standards and childhood and adult outcomes in term-born infants (≥37 weeks' gestation).

SEARCH STRATEGY

MEDLINE (1966-January 2011), EMBASE (1980-January 2011), and the Cochrane Library (2011:1) and MEDION were included.

SELECTION CRITERIA

Studies comprising live term-born infants (gestation ≥37 completed weeks), with weight or other anthropometric measurements recorded at birth along with childhood and adult outcomes.

DATA COLLECTION AND ANALYSIS

Data were extracted to populate 2 × 2 tables relating birthweight standard with outcome, and meta-analysis was performed where possible.

MAIN RESULTS

Fifty-nine articles (2 600 383 individuals) were selected. There was no significant relationship between birthweight <2.5 kg (odds ratio [OR] 0.98, 95% confidence intervals [CI] 0.87-1.10) and composite measure of childhood morbidity. Weight <10th centile on the population nomogram showed a small association (OR 1.49, 95% CI 1.02-2.19) for the same outcome. There was no significant association between either of the above measures and adult morbidity. The relationship between other measures and individual outcomes varied.

AUTHOR'S CONCLUSIONS

The association between low birthweight, by any definition, and childhood and adult morbidity was inconsistent. None of the current standards of low birthweight was a good predictor of adverse outcome.

Clinical chorioamnionitis at term I: microbiology of the amniotic cavity using cultivation and molecular techniques

INTRODUCTION

The objectives of this study were: 1) to determine the amniotic fluid (AF) microbiology of patients with the diagnosis of clinical chorioamnionitis at term using both cultivation and molecular techniques; and 2) to examine the relationship between intra-amniotic inflammation with and without microorganisms and placental lesions consistent with acute AF infection.

METHODS

The AF samples obtained by transabdominal amniocentesis from 46 women with clinical signs of chorioamnionitis at term were analyzed using cultivation techniques (for aerobic and anerobic bacteria as well as genital mycoplasmas) and broad-range polymerase chain reaction (PCR) coupled with electrospray ionization mass spectrometry (PCR/ESI-MS). The frequency of microbial invasion of the amniotic cavity (MIAC), intra-amniotic inflammation [defined as an AF interleukin 6 (IL-6) concentration ≥2.6 ng/mL], and placental lesions consistent with acute AF infection (acute histologic chorioamnionitis and/or acute funisitis) were examined according to the results of AF cultivation and PCR/ESI-MS as well as AF IL-6 concentrations.

RESULTS

1) Culture identified bacteria in AF from 46% (21/46) of the participants, whereas PCR/ESI-MS was positive for microorganisms in 59% (27/46) – combining these two tests, microorganisms were detected in 61% (28/46) of patients with clinical chorioamnionitis at term. Eight patients had discordant test results; one had a positive culture and negative PCR/ESI-MS result, whereas seven patients had positive PCR/ESI-MS results and negative cultures. 2) Ureaplasma urealyticum (n=8) and Gardnerella vaginalis (n=10) were the microorganisms most frequently identified by cultivation and PCR/ESI-MS, respectively. 3) When combining the results of AF culture, PCR/ESI-MS and AF IL-6 concentrations, 15% (7/46) of patients did not have intra-amniotic inflammation or infection, 6.5% (3/46) had only MIAC, 54% (25/46) had microbial-associated intra-amniotic inflammation, and 24% (11/46) had intra-amniotic inflammation without detectable microorganisms. 4) Placental lesions consistent with acute AF infection were significantly more frequent in patients with microbial-associated intra-amniotic inflammation than in those without intra-amniotic inflammation [70.8% (17/24) vs. 28.6% (2/7); P=0.04].

CONCLUSION

Microorganisms in the AF were identified in 61% of patients with clinical chorioamnionitis at term; 54% had microbial-associated intra-amniotic inflammation, whereas 24% had intra-amniotic inflammation without detectable microorganisms.

Treatable inborn errors of metabolism presenting as cerebral palsy mimics: systematic literature review

Background

Inborn errors of metabolism (IEMs) have been anecdotally reported in the literature as presenting with features of cerebral palsy (CP) or misdiagnosed as ‘atypical CP’. A significant proportion is amenable to treatment either directly targeting the underlying pathophysiology (often with improvement of symptoms) or with the potential to halt disease progression and prevent/minimize further damage.

Methods

We performed a systematic literature review to identify all reports of IEMs presenting with CP-like symptoms before 5 years of age, and selected those for which evidence for effective treatment exists.

Results

We identified 54 treatable IEMs reported to mimic CP, belonging to 13 different biochemical categories. A further 13 treatable IEMs were included, which can present with CP-like symptoms according to expert opinion, but for which no reports in the literature were identified. For 26 of these IEMs, a treatment is available that targets the primary underlying pathophysiology (e.g. neurotransmitter supplements), and for the remainder (n = 41) treatment exerts stabilizing/preventative effects (e.g. emergency regimen). The total number of treatments is 50, and evidence varies for the various treatments from Level 1b, c (n = 2); Level 2a, b, c (n = 16); Level 4 (n = 35); to Level 4–5 (n = 6); Level 5 (n = 8). Thirty-eight (57%) of the treatable IEMs mimicking CP can be identified by ready available metabolic screening tests in blood or urine, while the remaining IEMs require more specific and sometimes invasive tests.

Conclusions

Limited by the rare nature of IEMs and incomplete information in the literature, we conclude that (1) A surprisingly large number of IEMs can present with CP symptoms, as ‘CP mimics’, (2) although individually rare, a large proportion of these diseases are treatable such that neurological damage can either be reversed or prevented, (3) clinician awareness of treatable CP mimics is important for appropriate screening, diagnosis, and early intervention, and (4) systematic studies are required to elucidate the collective frequency of treatable IEMs in CP.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-014-0197-2) contains supplementary material, which is available to authorized users.

Epidemiology of severe hearing impairment in a population-based cerebral palsy cohort

BACKGROUND

Comorbidities including hearing impairment occur commonly in individuals with cerebral palsy (CP).

METHODS

Hearing impairment was assessed in a registry-derived population-based sample of children with CP.

RESULTS

Hearing impairment was documented in 12.7% (27 of 212) with less than a quarter of these (or 2.7% overall [6 of 212]) having a severe hearing loss of greater than 70 dB bi-aurally. Those with severe hearing impairment were more likely to be nonambulatory (Gross Motor Function Classification System IV/V; 100% versus 34.0% in the registry; P < 0.001) and have a spastic quadriplegic or dyskinetic CP variant (100% versus 42%, P = 0.001). Severe neonatal hyperbilirubinemia necessitating exchange transfusion demonstrated a striking association with hearing impairment in the context of CP in spite of small observed numbers; three of three had severe hearing loss, accounting for 50% of cases of severe hearing loss.

CONCLUSIONS

These results suggest a specific CP context and antecedent conditions that necessitate a heightened vigilance for the detection and remediation of hearing impairment.

Maternal immune activation and abnormal brain development across CNS disorders

Epidemiological studies have shown a clear association between maternal infection and schizophrenia or autism in the progeny. Animal models have revealed maternal immune activation (mIA) to be a profound risk factor for neurochemical and behavioural abnormalities in the offspring. Microglial priming has been proposed as a major consequence of mIA, and represents a critical link in a causal chain that leads to the wide spectrum of neuronal dysfunctions and behavioural phenotypes observed in the juvenile, adult or aged offspring. Such diversity of phenotypic outcomes in the mIA model are mirrored by recent clinical evidence suggesting that infectious exposure during pregnancy is also associated with epilepsy and, to a lesser extent, cerebral palsy in children. Preclinical research also suggests that mIA might precipitate the development of Alzheimer and Parkinson diseases. Here, we summarize and critically review the emerging evidence that mIA is a shared environmental risk factor across CNS disorders that varies as a function of interactions between genetic and additional environmental factors. We also review ongoing clinical trials targeting immune pathways affected by mIA that may play a part in disease manifestation. In addition, future directions and outstanding questions are discussed, including potential symptomatic, disease-modifying and preventive treatment strategies.

Spectrum of visual disorders in a population-based cerebral palsy cohort

BACKGROUND

Children with cerebral palsy are known to be at increased risk for visual impairment.

METHODS

In a population-based sample drawn from a geographically defined registry, the profile of visual impairment in children with cerebral palsy was investigated.

RESULTS

Close to half (49.8%; 106/213) had a visual impairment. The majority of these individuals had strabismus (55.7%; 59/106) and a slightly lesser fraction had refractive errors (20.7%; 22/106) or severe visual loss (18.9%; 20/106). The vast majority of children with severe visual loss had spastic quadriplegia (83%; 17/20) or were nonambulatory (i.e., Gross Motor Function Classification Scale IV/V, 80%; 16/20).

CONCLUSIONS

Knowledge of this profile will assist practitioners to heighten their appreciation of potential visual disturbances in certain subsets of children with cerebral palsy.

Maternal diagnosis of obesity and risk of cerebral palsy in the child

OBJECTIVE

To examine the association between maternal hospital diagnoses of obesity and risk of cerebral palsy (CP) in the child.

STUDY DESIGN

For all California hospital births from 1991-2001, we linked infant and maternal hospitalization discharge abstracts to California Department of Developmental Services records of children receiving services for CP. We identified maternal hospital discharge diagnoses of obesity (International Classification of Diseases, 9th edition 646.1, 278.00, or 278.01) and morbid obesity (International Classification of Diseases, 9th edition 278.01), and performed logistic regression to explore the relationship between maternal obesity diagnoses and CP.

RESULTS

Among 6.2 million births, 67 200 (1.1%) mothers were diagnosed with obesity, and 7878 (0.1%) with morbid obesity; 8798 (0.14%) children had CP. A maternal diagnosis of obesity (relative risk [RR] 1.30, 95% CI 1.09-1.55) or morbid obesity (RR 2.70, 95% CI 1.89-3.86) was associated with increased risk of CP. In multivariable analysis adjusting for maternal race, age, education, prenatal care, insurance status, and infant sex, both obesity (OR 1.27, 95% CI 1.06-1.52) and morbid obesity (OR 2.56, 95% CI 1.79-3.66) remained independently associated with CP. On stratified analyses, the association of obesity (RR 1.72, 95% CI 1.25-2.35) or morbid obesity (RR 3.79, 95% CI 2.35-6.10) with CP was only significant among women who were hospitalized prior to the birth admission. Adjusting for potential comorbidities and complications of obesity did not eliminate this association.

CONCLUSIONS

Maternal obesity may confer an increased risk of CP in some cases. Further studies are needed to confirm this finding.

Involvement of neuronal IL-1β in acquired brain lesions in a rat model of neonatal encephalopathy

Background

Infection-inflammation combined with hypoxia-ischemia (HI) is the most prevalent pathological scenario involved in perinatal brain damage leading to life-long neurological disabilities. Following lipopolysaccharide (LPS) and/or HI aggression, different patterns of inflammatory responses have been uncovered according to the brain differentiation stage. In fact, LPS pre-exposure has been reported to aggravate HI brain lesions in post-natal day 1 (P1) and P7 rat models that are respectively equivalent - in terms of brain development - to early and late human preterm newborns. However, little is known about the innate immune response in LPS plus HI-induced lesions of the full-term newborn forebrain and the associated neuropathological and neurobehavioral outcomes.

Methods

An original preclinical rat model has been previously documented for the innate neuroimmune response at different post-natal ages. It was used in the present study to investigate the neuroinflammatory mechanisms that underline neurological impairments after pathogen-induced inflammation and HI in term newborns.

Results

LPS and HI exerted a synergistic detrimental effect on rat brain. Their effect led to a peculiar pattern of parasagittal cortical-subcortical infarcts mimicking those in the human full-term newborn with subsequent severe neurodevelopmental impairments. An increased IL-1β response in neocortical and basal gray neurons was demonstrated at 4 h after LPS + HI-exposure and preceded other neuroinflammatory responses such as microglial and astroglial cell activation. Neurological deficits were observed during the acute phase of injury followed by a recovery, then by a delayed onset of profound motor behavior impairment, reminiscent of the delayed clinical onset of motor system impairments observed in humans. Interleukin-1 receptor antagonist (IL-1ra) reduced the extent of brain lesions confirming the involvement of IL-1β response in their pathophysiology.

Conclusion

In rat pups at a neurodevelopmental age corresponding to full-term human newborns, a systemic pre-exposure to a pathogen component amplified HI-induced mortality and morbidities that are relevant to human pathology. Neuronal cells were the first cells to produce IL-1β in LPS + HI-exposed full-term brains. Such IL-1β production might be responsible for neuronal self-injuries via well-described neurotoxic mechanisms such as IL-1β-induced nitric oxide production, or IL-1β-dependent exacerbation of excitotoxic damage.

Feasibility study of a wearable exoskeleton for children: is the gait altered by adding masses on lower limbs?

We are designing a pediatric exoskeletal ankle robot (pediatric Anklebot) to promote gait habilitation in children with Cerebral Palsy (CP). Few studies have evaluated how much or whether the unilateral loading of a wearable exoskeleton may have the unwanted effect of altering significantly the gait. The purpose of this study was to evaluate whether adding masses up to 2.5 kg, the estimated overall added mass of the mentioned device, at the knee level alters the gait kinematics. Ten healthy children and eight children with CP, with light or mild gait impairment, walked wearing a knee brace with several masses. Gait parameters and lower-limb joint kinematics were analyzed with an optoelectronic system under six conditions: without brace (natural gait) and with masses placed at the knee level (0.5, 1.0, 1.5, 2.0, 2.5 kg). T-tests and repeated measures ANOVA tests were conducted in order to find noteworthy differences among the trial conditions and between loaded and unloaded legs. No statistically significant differences in gait parameters for both healthy children and children with CP were observed in the five "with added mass" conditions. We found significant differences among "natural gait" and "with added masses" conditions in knee flexion and hip extension angles for healthy children and in knee flexion angle for children with CP. This result can be interpreted as an effect of the mechanical constraint induced by the knee brace rather than the effect associated with load increase. The study demonstrates that the mechanical constraint induced by the brace has a measurable effect on the gait of healthy children and children with CP and that the added mass up to 2.5 kg does not alter the lower limb kinematics. This suggests that wearable devices weighing 25 N or less will not noticeably modify the gait patterns of the population examined here.

Term neonatal encephalopathy antecedent cerebral palsy: a retrospective population-based study

OBJECTIVE

To compare the clinical profile of term-born cerebral palsy children with or without antecedent moderate to severe neonatal encephalopathy. We hypothesized that antecedent neonatal encephalopathy is associated with a spastic quadriparesis cerebral palsy clinical profile, a higher severity of functional motor impairment, and a greater number of associated comorbidities.

METHODS

Using the Quebec Cerebral Palsy Registry, neurologic subtype, Gross Motor Function Classification System stratification, and comorbidities were compared in children with cerebral palsy with and without antecedent neonatal encephalopathy. Differences between groups were evaluated using chi square analysis for categorical variables and student t test for continuous variables.

RESULTS

We identified 132 children with cerebral palsy born full term over a 4 year-interval (1999-2002 inclusive) within the Quebec Cerebral Palsy Registry, of which 44 (33%) had an antecedent neonatal encephalopathy. Spastic quadriplegia subtype of cerebral palsy and Gross Motor Function Classification System Level III-V (non-independent ambulation) were significantly associated with antecedent neonatal encephalopathy. The mean number of comorbidities experienced was not different in the two groups. Of five documented comorbidities, only severe communication difficulties were found to be associated (p < 0.05) with antecedent neonatal encephalopathy.

CONCLUSION

A pattern of increased neuromotor impairment, functional gross motor severity and possible communication difficulties was found in the 33% of children with cerebral palsy born at term and with a history of neonatal encephalopathy.

Maternal exposure to lipopolysaccharide leads to transient motor dysfunction in neonatal rats

Epidemiological and experimental data implicate maternal infection and inflammation in the etiology of brain white matter injury, which may lead to cerebral palsy in preterm newborns. Our aim was to investigate motor development of the offspring after maternal administration of lipopolysaccharide (LPS). Wistar rats were intraperitoneally injected with Escherichia coli LPS or saline on gestational days 19 and 20. From birth to 3 weeks, pups were tested for neurobehavioral development, neurological signs and reflexes. From 3 to 6 weeks, motor coordination was investigated. At 4 months, animals were tested for locomotion. Brain myelination was assessed by myelin basic protein immunohistochemistry. Days of appearance of several neurological reflexes were significantly delayed, and neonate LPS pups displayed retarded performance in righting, gait and negative geotaxis. At the juvenile stage, LPS animals showed important impairment in coordination. However, although the LPS group performed worse in most tests, they reached vehicle levels by 5 weeks. At 4 months, LPS animals did not show variations in locomotion performances compared to vehicle. No myelination differences have been observed in the brains at adulthood. Maternal LPS administration results in delayed motor development even though these alterations fade to reach control level by 5 weeks. Motor impairments observed at the early stage in this study could be linked to previously reported hypomyelination of the white matter induced by maternal LPS challenge in the neonates. Finally, the normal myelination shown here at adulthood may explain the functional recovery of the animals and suggest either a potential remyelination of the brain or a delayed myelination in LPS pups.

Effect of therapeutic hypothermia on oxidative stress and outcome in term neonates with perinatal asphyxia: a randomized controlled trial

OBJECTIVES

To evaluate in term babies with perinatal asphyxia, the effect of therapeutic hypothermia (TH) on oxidative stress and neurological outcome at discharge.

METHODS

Babies who satisfied inclusion criteria were randomized to TH, with cooling gel packs to a target temperature of 33-34°C for 72 h or normothermia. Blood sample was collected before and after TH for oxidative stress assessment: total antioxidant status (TAS) and malondialdehyde (MDA).

RESULTS

Of 116 babies randomized, there was no statistically significant difference in the baseline TAS and MDA. After 72 h of TH, TAS was significantly higher (p = <0.001) (761.69 ± 114.01 vs. 684.16 ± 88.86) and MDA was significantly lower (p = <0.001) in TH group (1.73 ± 0.66 vs. 5.2 ± 1.06). Risk of developing deficit was lower (p < 0.001) in TH group with relative risk of 0.49 and 95 % confidence interval: 0.29-0.68.

CONCLUSION

TH reduces oxidative stress and improves neurological outcome in perinatal asphyxia.

TRIAL REGISTRATION NUMBER

CTRI/2011/12/002196.

TLR-4-dependent and -independent mechanisms of fetal brain injury in the setting of preterm birth

In this study, we sought to assess how essential activation of toll-like receptor 4 (TLR-4) is to fetal brain injury from intrauterine inflammation. Both wild-type and TLR-4 mutant fetal central nervous system cells were exposed to inflammation using lipopolysaccharide in vivo or in vitro. Inflammation could not induce neuronal injury in the absence of glial cells, in either wild-type or TLR-4 mutant neurons. However, injured neurons could induce injury in other neurons regardless of TLR-4 competency. Our results indicate that initiation of neuronal injury is a TLR-4-dependent event, while propagation is a TLR-4-independent event.

Cerebral palsy among Asian ethnic subgroups

OBJECTIVE

Asians have a reduced risk for cerebral palsy (CP) compared with whites. We examined whether individual Asian subgroups have a reduced risk of CP and whether differences in sociodemographic factors explain disparities in CP prevalence.

METHODS

In a retrospective cohort of 629 542 Asian and 2 109 550 white births in California from 1991 to 2001, we identified all children who qualified for services from the California Department of Health Services on the basis of CP. Asians were categorized as East Asian (Chinese, Japanese, Koreans), Filipino, Indian, Pacific Islander (Guamanians, Hawaiians, and Pacific Islanders), Samoan, or Southeast Asian (Cambodian, Laotian, Thai, Vietnamese).

RESULTS

Overall, CP prevalence was lower in Asians than whites (1.09 vs 1.36 per 1000; relative risk = 0.80, 95% confidence interval [CI] = 0.74-0.87) and ranged from 0.61/1000 in Thai children to 2.08/1000 in Samoan children. Several Asian subgroups had low risk profiles with respect to maternal age, educational attainment, and birth weight. However, after we adjusted for maternal age and education, infant gender, and birth weight, the adjusted risk of CP remained lower in East Asians (odds ratio [OR] = 0.75, 95% CI = 0.65-0.87), Filipinos (OR = 0.87, 95% CI = 0.75-0.99), Indians (OR = 0.59, 95% CI = 0.44-0.80), Pacific Islanders (OR = 0.62, 95% CI = 0.40-0.97), and Southeast Asians (OR = 0.68, 95% CI = 0.57-0.82) compared with whites.

CONCLUSIONS

Most Asian national origin subgroups have a lower rate of CP than whites, and this disparity is unexplained. Additional studies that focus on the cause of ethnic disparities in CP may provide new insights into pathogenesis and prevention.

Observation on validity of the five-tier system for fetal heart rate pattern interpretation proposed by Japan Society of Obstetricians and Gynecologists

OBJECTIVE

To evaluate the five-tier classification of fetal heart rate (FHR) tracings recently proposed by Japan Society of Obstetricians and Gynecologists (JSOG).

METHODS

The database between January and June 2009 was reviewed for women in active labor at ?36 + 0 gestational weeks, with singleton fetuses in cephalic presentation and with umbilical artery blood gas analyses. Continuous FHR tracings were assessed according to the five-tier classification proposed by JSOG, where level 1 is normal, level 2 is subnormal and levels 3?5 are abnormal patterns.

RESULTS

A total of 341 parturient women were eligible for this study protocol. The median (range) of the levels in the first and the second stage of labor were 1 (1-4) and 2 (1-4), respectively (p < 0.001). Both pH and base excess of umbilical artery decreased with higher levels of FHR tracings interpretation (p < 0.01). Interventions resulting in delivery were more necessary in the first stage of labor than in the second stage of labor in cases of levels 3 and more.

CONCLUSIONS

Five-tier system for FHR tracing interpretation proposed by JSOG intercorrelates with the fetal acid-base balance well. Categorization of FHR tracings by uniform diagnostic criteria will be useful to standardize therapeutic strategy by sharing common perception among obstetrical staff.

The Cerebral Palsy Demonstration Project: a multidimensional research approach to cerebral palsy

Cerebral palsy is the most common cause of physical impairment in pediatrics. As a heterogeneous disorder in all its disparate aspects it defies a simplistic research approach that seeks to further our understanding of its mechanisms, outcomes and treatments. Within NeuroDevNet, with its focus on abnormal brain development, cerebral palsy was selected as one of the three neurodevelopmental disabilities to be the focus of a dedicated demonstration project. The Cerebral Palsy Demonstration Project will feature a multi-dimensional approach utilizing epidemiologic, imaging, genetics, animal models and stem cell modalities that will at all times emphasize clinical relevance, translation into practice, and potential synergies between investigators now segregated by both academic disciplines and geographic distance. The objective is to create a national platform of varied complementary and inter-digitated efforts. The specific research plan to enable this will be outlined in detail.

Population case-control study of cerebral palsy: neonatal predictors for low-risk term singletons

OBJECTIVES

For singletons with cerebral palsy (CP) who were born at term, the goals were (1) to determine the proportion not admitted to a Special Care Unit/NICU (NICU), (2) to compare clinical descriptions of those admitted to NICUs and those not admitted, and (3) to identify neonatal predictors of CP among those not admitted to a NICU.

METHODS

A total-population case- (N = 442) control (N = 468) study of, singleton, term-born infants with CP, as ascertained from the Western Australian Cerebral Palsy Register, was performed.

RESULTS

All types of CP were represented among the 67% of term infants with CP (N = 295) who were not admitted to a NICU, which also included 54% of the subjects with the most severe impairments. Independent neonatal predictors were abnormalities of tone (odds ratio [OR]: 7.3 [95% confidence interval [CI]: 2-26.8]), temperature regulation (OR: 4.1 [95% CI: 1.2-14]), consciousness (OR: 3.7 [95% CI: 2-7]), and fontanelles (OR: 4.4 [95% CI: 0.8-23]), requirement for resuscitation (OR: 2.9 [95% CI: 2.2-12.9]), and birth defects (OR: 5.1 [95% CI: 2.4-10]). The risk of CP increased with the number of factors, but 58% of subjects who were not admitted to a NICU exhibited none of these factors.

CONCLUSIONS

Neonatal predictors of CP among term infants not admitted to a NICU were identified. However, 39% of all term singletons with CP were not admitted to a NICU and exhibited none of these predictors.

Racial, ethnic, and socioeconomic disparities in the prevalence of cerebral palsy

OBJECTIVE

Racial and ethnic disparities in cerebral palsy have been documented, but the underlying mechanism is poorly understood. We determined whether low birth weight accounts for ethnic disparities in the prevalence of cerebral palsy and whether socioeconomic factors impact cerebral palsy within racial and ethnic groups.

METHODS

In a retrospective cohort of 6.2 million births in California between 1991 and 2001, we compared maternal and infant characteristics among 8397 infants with cerebral palsy who qualified for services from the California Department of Health Services and unaffected infants.

RESULTS

Overall, black infants were 29% more likely to have cerebral palsy than white infants (relative risk: 1.29 [95% confidence interval: 1.19-1.39]). However, black infants who were very low or moderately low birth weight were 21% to 29% less likely to have cerebral palsy than white infants of comparable birth weight. After we adjusted for birth weight, there was no difference in the risk of cerebral palsy between black and white infants. In multivariate analyses, women of all ethnicities who did not receive any prenatal care were twice as likely to have infants with cerebral palsy relative to women with an early onset of prenatal care. Maternal education was associated with cerebral palsy in a dose-response fashion among white and Hispanic women. Hispanic adolescent mothers (aged <18 years) had increased risk of having a child with cerebral palsy.

CONCLUSIONS

The increased risk of cerebral palsy among black infants is primarily related to their higher risk of low birth weight. Understanding how educational attainment and use of prenatal care impact the risk of cerebral palsy may inform new prevention strategies.

A registry-based assessment of cerebral palsy and cerebral malformations

Cerebral malformations are 1 of the many possible causes of cerebral palsy. In this study, a population-based comprehensive cerebral palsy registry was used to identify children whose cerebral palsy could be attributed to a cerebral malformation. The clinical features of these children were then compared with other children with cerebral palsy. Children with cerebral palsy and cerebral malformation did not differ from those without in terms of the neurological subtype of cerebral palsy or its functional severity as measured by the Gross Motor Function Classification System. There was a difference in the number of cumulative comorbidities experienced by the children with cerebral malformation. In addition, children with cerebral malformation tended to be of greater gestational age and birth weight, or the product of a twin gestation. Children with cerebral palsy attributable to a cerebral malformation represent a distinct clinical pathologic entity with respect to predisposing clinical features and associated comorbidities.

Whole body hypothermia and oxidative stress in babies with hypoxic-ischemic brain injury

According to increasing evidence, hypothermia can significantly improve outcomes in term neonates manifesting asphyxic insult and hypoxic-ischemic encephalopathy. Oxidative stress plays a key role in hypoxic-ischemic and inflammatory brain injuries. We investigated the impact of hypothermia on oxidative stress in babies with hypoxic-ischemic encephalopathy. Term infants were randomly selected for treatment with moderate whole body hypothermia or standard care on normothermia, after perinatal asphyxia. Total hydroperoxides as biochemical markers of oxidative stress, and C-reactive protein as a marker of inflammation, were assayed in blood samples drown at 6, 12, 24, 48, and 72 postnatal hours. In both hypothermic and normothermic groups, total hydroperoxides and C-reactive protein exhibited a continuous increase in the first days after birth. Nevertheless, a tendency was evident for slower and smaller elevations of total hydroperoxides and C-reactive protein in hypothermic compared with normothermic infants. A significant correlation was observed between total hydroperoxides and C-reactive protein in all patients, indicating an association between inflammation and oxidative stress during asphyxia. The slower increase and lower peaks of total hydroperoxides in the hypothermic group support the hypothesis that postasphyxic oxidative stress may be reduced by hypothermia.

Progress toward improved understanding of infection-related preterm birth

Current strategies to prevent infection-related preterm birth and its associated neonatal morbidities have had limited success. Improved understanding of the pathogen-host interactions underlying altered colonization of the lower genital tract is necessary before significant progress can be made. The application of novel diagnostic techniques such as broad range PCR and proteomic analysis contribute to our knowledge of the diversity and abundance of microbial species invading the amniotic cavity as well as the resultant inflammatory response. Preterm infants delivered following intrauterine infection may respond differently to subsequent infectious challenges in the neonatal intensive care unit.

Risk factors for cerebral palsy in term birth infants

PURPOSE

The aim of this study was to identify the antenatal, intrapartum and neonatal risk factors in term birth infants for cerebral palsy (CP) among babies in a hospital-based study.

MATERIALS AND METHODS

The medical records of children with cerebral palsy referred to our Pediatric Rehabilitation Department in Bialystok were reviewed. Antenatal, intrapartum, and neonatal events were compared among 213 children with CP and 280 controls in a retrospective study. We studied live births >36 weeks gestation born between January 1, 1990, and December 31, 2005.

RESULTS

Fifty-seven percent of the infants with CP were male. Spastic tetraplegia 78 (36.61%) and spastic hemiplegia 65 (30.51%) were the dominant types of CP. Factors associated with an increased risk of CP identified as antenatal and intrapartum risk factors were pre-eclampsia, abruptio placenta, and placenta previa. Birth asphyxia occurred significantly more often (p<0.001) in children with CP compared to controls. In the neonatal period, respiratory distress syndrome, meningitis and neonatal seizures were associated with an increased incidence of CP.

CONCLUSION

Our findings confirm that several antenatal, intrapartum and neonatal risk factors for CP in term birth infants contribute to the etiology of CP.

Diagnosis, treatment, and prevention of cerebral palsy

Cerebral palsy is the most prevalent cause of persisting motor function impairment with a frequency of about 1/500 births. In developed countries, the prevalence rose after introduction of neonatal intensive care, but in the past decade, this trend has reversed. A recent international workshop defined cerebral palsy as "a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain." In a majority of cases, the predominant motor abnormality is spasticity; other forms of cerebral palsy include dyskinetic (dystonia or choreo-athetosis) and ataxic cerebral palsy. In preterm infants, about one-half of the cases have neuroimaging abnormalities, such as echolucency in the periventricular white matter or ventricular enlargement on cranial ultrasound. Among children born at or near term, about two-thirds have neuroimaging abnormalities, including focal infarction, brain malformations, and periventricular leukomalacia. In addition to the motor impairment, individuals with cerebral palsy may have sensory impairments, cognitive impairment, and epilepsy. Ambulation status, intelligence quotient, quality of speech, and hand function together are predictive of employment status. Mortality risk increases incrementally with increasing number of impairments, including intellectual, limb function, hearing, and vision. The care of individuals with cerebral palsy should include the provision of a primary care medical home for care coordination and support; diagnostic evaluations to identify brain abnormalities, severity of neurologic and functional abnormalities, and associated impairments; management of spasticity; and care for associated problems such as nutritional deficiencies, pain, dental care, bowel and bladder continence, and orthopedic complications. Current strategies to decrease the risk of cerebral palsy include interventions to prolong pregnancy (eg, 17alpha-progesterone), limiting the number of multiple gestations related to assisted reproductive technology, antenatal steroids for mothers expected to deliver prematurely, caffeine for extremely low birth weight neonates, and induced hypothermia for a subgroup of neonates diagnosed with hypoxic-ischemic encephalopathy.

Animal models of perinatal hypoxic-ischemic brain damage

Animal models are often presumably the first step in determining mechanisms underlying disease, and the approach and effectiveness of therapeutic interventions. Perinatal brain damage, however, evolves over months of gestation, during the rapid maturation of the fetal and newborn brain. Despite marked advances in our understanding of these processes and technologic advances providing an improved window on the timing and duration of injury, neonatal brain injury remains a "moving target" regarding our ability to "mimic" its processes in an animal model. Moreover, interfering with normal processes of development as part of a therapeutic intervention may do "more harm than good." Hence, controversy continues over which animal model can reflect human disease states. Numerous models have provided information regarding the pathophysiology of brain damage in term and preterm infants. Our challenges consist of identifying infants at greatest risk for permanent injury, identifying the timing of injury, and adapting therapies that provide more benefit than harm. A combination of appropriately suitable animal models to conduct these studies will bring us closer to understanding human perinatal damage and the means to treat it.