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Chen A, Dyck Holzinger S, Oskoui M, Shevell M. Losing a diagnosis of cerebral palsy: a comparison of variables at 2 and 5 years. Dev Med Child Neurol 2020; 62:83-88. [PMID: 31273776 DOI: 10.1111/dmcn.14309] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 01/08/2023]
Abstract
AIM This study aims to identify characteristics at 2 years of age that differ between children with confirmed cerebral palsy (CP) and a non-CP diagnosis by 5 years of age. METHOD This was a retrospective cohort analysis. A CP diagnosis may be considered a 'probable' diagnosis at 2 years, which is often 'confirmed' at 4 or 5 years, particularly in the context of CP registries. A total of 1683 children with a diagnosis of CP or probable CP at 2 years of age were identified from the Canadian Cerebral Palsy Registry, of whom 48 received a non-CP diagnosis at 5 years ('non-confirmed CP'). Perinatal adversity, preterm birth status, Gross Motor Function Classification System (GMFCS) level, presence of comorbidities, magnetic resonance imaging (MRI) findings, and initial CP motor type were compared between the two groups by univariate and logistic regression analyses. RESULTS χ2 analysis and multivariate analysis both confirmed that children with a non-CP diagnosis by 5 years of age were more likely to have a normal MRI (χ2 odds ratio [OR]=7.8, 95% confidence interval [CI]=3.8-16.1; OR=5.4, 95% CI=2.4-12.5), ataxic-hypotonic (χ2 OR=10.1, 95% CI=4.9-21.2; OR=6.1, 95% CI=2.2-16.2) or dyskinetic CP (χ2 OR=2.7, 95% CI=1.2-5.9; OR=2.9, 95% CI=1.0-7.6), born at term (χ2 OR=3.7, 95% CI=1.7-8.0; OR=3.6, 95% CI=1.0-12.1), and lack perinatal adversity (χ2 OR=4.1, 95% CI=1.6-10.7; OR=3.4, 95% CI=1.0-11.7). INTERPRETATION Normal MRI, ataxic-hypotonic or dyskinetic CP, lack of perinatal adversity, and term birth are associated with a higher odds of non-CP diagnosis by 5 years of age, thus potentially enhancing diagnostic work-up. WHAT THIS PAPER ADDS Normal magnetic resonance imaging (MRI) at 2 years was associated with a non-cerebral palsy (CP) diagnosis by 5 years. Diagnosis of ataxic-hypotonic or dyskinetic CP motor subtype at 2 years was associated with a non-CP diagnosis by 5 years. Perinatal adversity and preterm birth were rarer with a non-CP diagnosis by 5 years.
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Affiliation(s)
- Anjellica Chen
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sasha Dyck Holzinger
- Canadian Cerebral Palsy Registry, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Maryam Oskoui
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Department of Neurology & Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Michael Shevell
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Department of Neurology & Neurosurgery, McGill University, Montreal, Quebec, Canada
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Zhao M, Dai H, Deng Y, Zhao L. SGA as a Risk Factor for Cerebral Palsy in Moderate to Late Preterm Infants: a System Review and Meta-analysis. Sci Rep 2016; 6:38853. [PMID: 27958310 PMCID: PMC5153647 DOI: 10.1038/srep38853] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 11/11/2016] [Indexed: 11/09/2022] Open
Abstract
Small for gestational age (SGA) is an established risk factor for cerebral palsy (CP) in term infants. However, there is conflicting data on the association between SGA and CP in moderate to late preterm infants. The aim of the article was to explore the relationship between SGA and CP in the moderate to late preterm infants and its strength by meta-analysis. We performed a system search in OVID (EMBASE and MEDLINE) and WANFANG from inception to May 2016. The study-specific risk estimates were pooled using the random-effect model. A total of seven studies were included in the meta-analysis, consisting of three cohort and four case-control studies. A statistically significant association was found between SGA and CP in moderate to late premature infants (OR: 2.34; 95% CI: 1.43-3.82). The association were higher in the several subgroups: 34-36 week gestational age (OR: 3.47; 95% CI: 1.29-9.31), SGA < 2SDs (OR: 3.48; 95% CI: 1.86-6.49), and malformation included in CP (OR: 3.00; 95% CI: 1.71-5.26). In moderate to late premature infants, SGA is a convenient and reliable predictor for CP. More studies are needed to explore the underlying mechanisms between SGA and CP association.
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Affiliation(s)
- Mengwen Zhao
- Department of Pediatrics, the Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Hongmei Dai
- Department of Pediatrics, the Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Yuanying Deng
- Department of Pediatrics, the Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Lingling Zhao
- Department of Pediatrics, the Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
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van Lieshout P, Candundo H, Martino R, Shin S, Barakat-Haddad C. Onset factors in cerebral palsy: A systematic review. Neurotoxicology 2016; 61:47-53. [PMID: 27045882 DOI: 10.1016/j.neuro.2016.03.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 03/31/2016] [Indexed: 12/31/2022]
Abstract
Studies have noted several factors associated with the occurrence of Cerebral Palsy (CP), yet considerable uncertainty remains about modifiable factors related to disease onset. A systematic review was performed to identify existing systematic reviews and primary studies pertaining to targeted factors associated with the onset of CP. The following databases were searched: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Scopus, Web of Science, Cochrane Database of Systematic Reviews, CINHAL, ProQuest Dissertations & Theses, Huge Navigator, AARP Ageline. Variations of MeSH and keyword search terms were used. Critical appraisal was conducted on selected articles. Data extraction targeted reported factors, risk estimates, and 95% confidence intervals (CI). Findings identified two systematic reviews and three meta- analyses, as well as 83 studies of case control, cohort, and cross-sectional methodological designs. Selected studies indicated that lower gestational age was associated with the onset of CP. Medical diagnoses for the mother, in particular chorioamnionitis, was found to be positively associated with onset of CP. Preeclampsia was reported to be either inconclusive or positively associated with CP onset. Low birth weight predominantly indicated a positive association with the onset of CP, while male gender showed mixed findings. The combination of male gender with pre-term or low birth weight was also found to be positively associated with CP. Evidence was identified in the literature pertaining to specific factors relating to the onset of CP, in particular showing positive associations with lower gestational age and low birth weight.
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Affiliation(s)
- Pascal van Lieshout
- Department of Speech Language Pathology, University of Toronto, Canada; Department of Psychology, University of Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Canada; Rehabilitation Sciences Institute, University of Toronto, Canada; Toronto Rehabilitation Institute, University Health Network, Canada.
| | - Hamilton Candundo
- Faculty of Health Sciences, University of Ontario Institute of Technology, Canada
| | - Rosemary Martino
- Department of Speech Language Pathology, University of Toronto, Canada; Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Canada; Rehabilitation Sciences Institute, University of Toronto, Canada
| | - Sabina Shin
- Faculty of Health Sciences, University of Ontario Institute of Technology, Canada; Department of Pediatrics, McMaster University, Canada
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Streja E, Miller JE, Wu C, Bech BH, Pedersen LH, Schendel DE, Uldall P, Olsen J. Disproportionate fetal growth and the risk for congenital cerebral palsy in singleton births. PLoS One 2015; 10:e0126743. [PMID: 25974407 PMCID: PMC4431832 DOI: 10.1371/journal.pone.0126743] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 04/07/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate the association between proportionality of fetal and placental growth measured at birth and the risk for congenital cerebral palsy (CP). STUDY DESIGN We identified all live-born singletons born in Denmark between 1995 and 2003 and followed them from 1 year of age until December 31st, 2008. Information on four indices of fetal growth: ponderal index, head circumference/ abdominal circumference ratio, cephalization index and birth weight/ placenta weight ratio was collected. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). All measurements were evaluated as gestational age and sex specific z-scores and in z-score percentile groups, adjusted for potential confounders, and stratified on gestational age groups (<32, 32-36, 37-38, 39, 40, ≥ 41 weeks). RESULTS We identified 503,784 singleton births, of which 983 were confirmed cases of CP. Head/ abdominal circumference ratio (aHR:1.12; 95%CI:1.07-1.16) and cephalization index (aHR:1.14; 95%CI:1.11-1.16) were associated with the risk of CP irrespective of gestational age. Birth weight-placental weight ratio was also associated with CP in the entire cohort (aHR:0.90; 95%CI:0.83-0.97). Ponderal index had a u-shaped association with CP, where both children with low and high ponderal index were at higher risk of CP. CONCLUSIONS CP is associated with disproportions between birth weight, birth length, placental weight and head circumference suggesting pre and perinatal conditions contribute to fetal growth restriction in children with CP.
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Affiliation(s)
- Elani Streja
- Department of Epidemiology, School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
- * E-mail:
| | - Jessica E. Miller
- Department of Epidemiology, School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
| | - Chunsen Wu
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bodil H. Bech
- Section of Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Lars Henning Pedersen
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Section of Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Diana E. Schendel
- Section of Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
- National Centre for Register-based Research, Department of Economics and Business, Aarhus University, Aarhus, Denmark
- Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus, Denmark
| | - Peter Uldall
- The Danish Cerebral Palsy Registry, National Institute of Public Health, Southern University, Copenhagen, Denmark
- Pediatric Department, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jørn Olsen
- Department of Epidemiology, School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Section of Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
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Freire G, Shevell M, Oskoui M. Cerebral palsy: phenotypes and risk factors in term singletons born small for gestational age. Eur J Paediatr Neurol 2015; 19:218-25. [PMID: 25596065 DOI: 10.1016/j.ejpn.2014.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 12/03/2014] [Accepted: 12/09/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Children born small for gestational age (SGA) are at increased risk of developing cerebral palsy (CP). The pathophysiology behind this association remains unclear. We compare the clinical profile of children with CP born SGA to other children with CP. We hypothesize that differences noted will support antenatal causes of CP in children born SGA. METHODS We conducted a retrospective cohort study of term singletons with CP, extracting data from the Canadian Cerebral Palsy Registry. SGA was determined as birth weight for gestational age and sex below the tenth percentile. RESULTS Mothers of children with CP born SGA were more likely to be of African-American ethnicity (RR 2.54, 95% CI 1.20-5.39), have intrauterine infections (RR 2.22, 95% CI 1.09-4.50) and have gestational hypertension (RR 1.78, 95% CI 1.06-3.00). Children with CP born SGA had smaller head circumferences at birth (p < 0.001) and higher frequencies of emergency cesarean-section (RR 1.53, 95% CI 1.22-1.92), birth asphyxia (RR 1.53, 95% CI 1.0-2.32), and placental abnormalities (RR 1.45, 95% CI 1.00-2.10). Children with CP born SGA had greater fine motor (RR 1.46, 95% CI 1.02-2.11), gross motor (RR 1.53, 95% CI 1.12-2.10) and communication impairment (RR 1.24, 95% CI 1.10-1.40), and a higher frequency of cognitive impairment (RR 1.33, 95% CI 1.06-1.69). CONCLUSION Children with CP born SGA have different clinical factors and phenotypic profiles than other children with CP. These differences support the hypothesis of antenatal and perinatal causes of CP in children born SGA. Future case control studies would be desired to further define this causal pathway.
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Affiliation(s)
- Gabrielle Freire
- Department of Pediatrics, CHU Ste-Justine, McGill University, Canada
| | - Michael Shevell
- Departments of Pediatrics and Neurology & Neurosurgery, McGill University, Canada
| | - Maryam Oskoui
- Departments of Pediatrics and Neurology & Neurosurgery, McGill University, Canada.
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Phan Duy A, El Khabbaz F, Renolleau C, Aberchich J, Heneau A, Pham H, Baud O. Retard de croissance intra-utérin et cerveau en développement. Arch Pediatr 2013; 20:1034-8. [DOI: 10.1016/j.arcped.2013.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
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Halliday HL. Neonatal management and long-term sequelae. Best Pract Res Clin Obstet Gynaecol 2009; 23:871-80. [PMID: 19632899 DOI: 10.1016/j.bpobgyn.2009.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Accepted: 03/26/2009] [Indexed: 01/21/2023]
Abstract
Intrauterine or fetal growth restriction is best defined by using customised birth weight percentiles based upon the growth potential for an individual infant. Growth restriction in utero may be classified as asymmetric or symmetric depending upon the duration of the process. Asymmetric growth restriction is caused by placental insufficiency, maternal hypertensive conditions, long-standing maternal diabetes, smoking, living at altitude or multiple gestation. Symmetric growth restriction may be due to congenital infections, chromosomal or other abnormalities, fetal alcohol syndrome, low socioeconomic status or be constitutional. The underlying cause of growth restriction often predicts the potential adverse effects on the foetus and newborn and later effects in childhood and adulthood. With placental insufficiency, there may be chronic or acute on chronic fetal hypoxia with birth asphyxia and hypothermia, neonatal hypoglycaemia, polycythaemia and coagulopathy. Management is directed at prevention or early treatment of these conditions. In contrast, symmetrically growth-restricted infants should be examined carefully to look for congenital infections and malformations that may need specific interventions. Infants with constitutional short stature generally do not need any specific management. Feeding of growth-restricted infants is important to overcome deficiencies incurred in utero. Most infants show catch-up growth although about 10% do not. Those with excessive catch-up growth may be at greatest risk of developing insulin resistance in adulthood leading to diabetes, obesity and heart disease. The so-called fetal origins of disease may actually have a postnatal onset related more to excessive weight gain in infancy. There is still controversy over the indications for growth hormone treatment in growth-restricted infants who remain of short stature in early childhood. Intrauterine growth restriction is also associated with a five- to seven-fold increased risk of cerebral palsy probably due to chronic placental insufficiency.
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Affiliation(s)
- Henry L Halliday
- Perinatal Medicine, Royal Maternity Hospital, and Department of Child Health, Queen's University Belfast, Belfast, Northern Ireland.
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Jacobsson B, Ahlin K, Francis A, Hagberg G, Hagberg H, Gardosi J. Cerebral palsy and restricted growth status at birth: population-based case-control study. BJOG 2008; 115:1250-5. [PMID: 18715410 DOI: 10.1111/j.1471-0528.2008.01827.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the association between growth status at birth and subsequent development of cerebral palsy in preterm and term infants. DESIGN Population-based case-controlled study. SETTING Cerebral palsy register in Western Sweden. Subjects Cohort of 334 singletons born between 1983 and 1990, with cerebral palsy diagnosed from age 4, and 668 singletons matched for gestation, gender and delivery unit. METHOD Growth status at birth was determined using small for gestational age (SGA) categories, with customised birthweight percentiles (SGAcust) based on the Swedish population. MAIN OUTCOME MEASURES Proportion of babies that were SGAcust, comparing cases and controls in three gestational age categories: early preterm (24-33 weeks), late preterm (34-36 weeks) and term (37+ weeks). RESULTS Of the 334 children with cerebral palsy, 87 (26.6%) were born early preterm, 27 (8.1%) late preterm and 218 (66%) at term. Children who had been born at term were more likely to have been SGA <1st customised percentile (SGAcust1) than their matched controls (OR 6.6, 95% CI 2.3-18.6). In contrast, children with cerebral palsy born preterm were not more likely to have been SGAcust1 (OR 0.9, 95% CI 0.4-1.9), and this applied to early preterm as well as late preterm births. For less severely small babies (SGA between 1st and 5th customised percentiles), the association with cerebral palsy remained significant for term births (OR 5.2, 95% CI 2.7-10.1) but was again not significant for preterm births. CONCLUSIONS Term singletons with severely SGA birthweights had a five- to seven-fold risk of developing cerebral palsy compared with gestational age-matched infants with birthweights within normal limits. For children born preterm, SGA was not more likely to be present in cases than in controls. These findings support the concept of cerebral palsy as a multifactorial condition and highlight the importance of antenatal surveillance of fetal growth.
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Affiliation(s)
- B Jacobsson
- Perinatal Center, Department of Obstetrics and Gynaecology, Institute for the Health of Women and Children, Sahlgrenska University Hospital, Sweden
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Hemming K, Colver A, Hutton JL, Kurinczuk JJ, Pharoah POD. The influence of gestational age on severity of impairment in spastic cerebral palsy. J Pediatr 2008; 153:203-8, 208.e1-4. [PMID: 18534232 DOI: 10.1016/j.jpeds.2008.02.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 02/04/2008] [Accepted: 02/22/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the association between severity of impairment and gestational age in unilateral and bilateral spastic cerebral palsy, and to determine whether the influence of gestational age is independent of deviations from optimal birth weight. STUDY DESIGN The study group was a United Kingdom cohort of 4772 cases of spastic cerebral palsy born between 1960 and 1997, with information on birth demographics and severity of impairment. Generalized additive models were used to determine the proportions of cases severely impaired, by gestational age, and to determine whether gestational age or deviations from optimal birth weight better predicts severity of impairment. RESULTS For unilateral spastic cerebral palsy, the proportions of severe impairments did not vary with gestational age. In contrast, for bilateral spastic cerebral palsy, the proportions of severe motor or cognitive impairments increased with increasing gestational age (e.g., from 20% to 50% between weeks 30 and 40 for cognitive impairment). For spastic cerebral palsy, gestational age is at least as good as deviation from optimal birth weight in predicting severity. CONCLUSIONS The severity of impairment increases with increasing gestational age in bilateral spastic cerebral palsy. This suggests differing etiologies in term and preterm infants and supports the theory that the developing brain is better able to compensate after a cerebral insult.
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Affiliation(s)
- Karla Hemming
- Department of Statistics, University of Warwick, Coventry, UK.
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Thorngren-Jerneck K, Herbst A. Perinatal factors associated with cerebral palsy in children born in Sweden. Obstet Gynecol 2007; 108:1499-505. [PMID: 17138786 DOI: 10.1097/01.aog.0000247174.27979.6b] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify perinatal factors associated with cerebral palsy (CP). METHODS This was a case-control study based on the Swedish Medical Birth Registry and the Swedish Hospital Discharge Registry, including 2,303 infants born in Sweden 1984-1998 with a diagnosis of CP and 1.6 million infants without this diagnosis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Infants born preterm had a highly increased risk for CP, and constituted 35% of all cases; OR 34 (95% CI 29-39) in weeks 23-27, OR 37 (95% CI 32-42) in weeks 28-29, OR 26 (95% CI 23-30) in weeks 30-31, and OR 3.9 (95% CI 3.4-4.4) in weeks 32-36. Boys had a higher risk (sex ratio 1.36:1), particularly before term (sex ratio 1.55:1). Other factors associated with CP were being small or large for gestational age at birth, abruptio placentae (OR 8.6, 95% CI 5.6-13.3), maternal insulin-dependent diabetes mellitus type 1 (OR 2.1, 95% CI 1.4-3.1), preeclampsia (OR 1.5, 95% CI 1.3-2.4), being a twin (OR 1.4, 95% CI 1.1-1.6), maternal age older than 40 years (OR 1.4, 95% CI 1.1-1.8) or 35-39 years (OR 1.2, 95% CI 1.1-1.4), primiparity (OR 1.2, 95% CI 1.1-1.3), and smoking (OR 1.2, 95% CI 1.1-1.3). In term infants, low Apgar scores were associated with a high risk for CP; OR 62 (95% CI 52-74) at score 6 at 5 minutes, OR 498 (95% CI 458-542) at score 3. Other factors associated with CP in term infants were breech presentation at vaginal birth (OR 3.0, 95% CI 2.4-3.7), instrumental delivery (OR 1.9, 95% CI 1.6-2.3), and emergency cesarean delivery (OR 1.8, 95% CI 1.6-2.0). CONCLUSION Preterm birth entails a high risk for CP, but 65% of these children are born at term. Several obstetric factors and low Apgar scores are associated with CP. LEVEL OF EVIDENCE II-2.
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Strijbis EMM, Oudman I, van Essen P, MacLennan AH. Cerebral Palsy and the Application of the International Criteria for Acute Intrapartum Hypoxia. Obstet Gynecol 2006; 107:1357-65. [PMID: 16738164 DOI: 10.1097/01.aog.0000220544.21316.80] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To apply objective criteria for the identification of acute intrapartum hypoxia in a cohort of cerebral palsy cases and to identify other cerebral palsy-related pathologies. METHODS A cohort of all 235 neonates with cerebral palsy from a single Australian tertiary care center born between 1986 and 2003. Cases were identified from the South Australian Cerebral Palsy Register. Maternal and pediatric case notes were audited with application of the 2003 American College of Obstetricians and Gynecologists/American Academy of Pediatrics criteria to identify acute intrapartum hypoxia. RESULTS Data were available for analysis in 213 cases (91%). Major antenatal or pediatric cerebral palsy-related pathologies were identified in 98.1% of all these cases. An isolated acute intrapartum hypoxic event was defined as likely in only 2 of the 46 neonates born at term and none born preterm. Neonatal nucleated red blood cell counts were often high in neonates born preterm and following antenatal pathologies. CONCLUSION Cerebral palsy was seldom preceded by acute intrapartum hypoxia but antenatal cerebral palsy-related pathologies are often detectable. The objective American College of Obstetricians and Gynecologists/American Academy of Pediatrics criteria are useful to audit cerebral palsy causation and exclude primary intrapartum hypoxia. LEVEL OF EVIDENCE II-3.
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Affiliation(s)
- Eva M M Strijbis
- Discipline of Obstetrics and Gynaecology, University of Adelaide, at the Women's and Children's Hospital, Adelaide, South Australia, Australia
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Abstract
When birth weight for gestation is used as a surrogate for intrauterine growth, the prevalence of cerebral palsy varies continuously in a reversed J shape, with steep increases in the risk for infants lighter and heavier than the optimum size. Patterns of size-at-birth specific risk for cerebral palsy differ between male and female infants, as do the patterns for more severe versus milder cases. Although these excess risks with abnormal size at birth imply antenatal precursors, it is not clear whether or how intrauterine growth is involved in any of the suspected causal pathways resulting in cerebral palsy. The implication for clinicians is that serial measures of in utero growth may provide an important indicator of fetal health.
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Affiliation(s)
- Stephen Jarvis
- Institute of Child Health, School of Clinical Medical Services, University of Newcastle, Newcastle upon Tyne, UK.
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Livinec F, Ancel PY, Marret S, Arnaud C, Fresson J, Pierrat V, Rozé JC, Escande B, Thiriez G, Larroque B, Kaminski M. Prenatal Risk Factors for Cerebral Palsy in Very Preterm Singletons and Twins. Obstet Gynecol 2005; 105:1341-7. [PMID: 15932827 DOI: 10.1097/01.aog.0000161375.55172.3f] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify the main prenatal risk factors for cerebral palsy in very preterm singletons and twins. METHODS The data were from the Epipage study, which included all very preterm children (< 33 weeks) born in 1997 in 9 regions of France. The analysis included 1,954 children for whom a medical questionnaire was completed at the age of 2 years (83% of the surviving children). The risk factors studied were pregnancy complications and specific factors in twins (type of placenta and death of cotwin). Logistic regression analysis was carried out for singletons and generalized estimating equation models used for twins. RESULTS The proportion of cerebral palsy was 8% in singletons and 9% in twins. For singletons, spontaneous preterm labor (adjusted odds ratio [OR] 3.4, 95% confidence interval [CI] 1.7-6.7), preterm premature rupture of membranes (PPROM) with short latency (adjusted OR 4.9, 95% CI 2.0-11.8), and prolonged PPROM (adjusted OR 2.7, 95% CI 1.4-5.3) were associated with a higher risk of cerebral palsy than was hypertension. No such link was found between these pregnancy complications and cerebral palsy in twins. For twins, a monochorionic placenta (OR 1.9, 95% CI 1.0-3.6) increased the risk of cerebral palsy, but the OR became nonsignificant after adjustment (OR 1.7, 95% CI 0.8-3.4). CONCLUSION In very preterm singletons, spontaneous preterm labor and PPROM increased the risk of cerebral palsy compared with hypertension.
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Affiliation(s)
- Florence Livinec
- Research Unit on Perinatal Health and Women's Health, INSERM U149, Villejuif, France.
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Abstract
Regulation of fetal growth is multifactorial and complex. Diverse factors, including intrinsic fetal conditions as well as maternal and environmental factors, can lead to intrauterine growth restriction (IUGR). The interaction of these factors governs the partitioning of nutrients and rate of fetal cellular proliferation and maturation. Although IUGR is probably a physiologic adaptive response to various stimuli, it is associated with distinct short- and long-term morbidities. Immediate morbidities include those associated with prematurity and inadequate nutrient reserve, while childhood morbidities relate to impaired maturation and disrupted organ development. Potential long-term effects of IUGR are debated and explained by the fetal programming hypothesis. In formulating a comprehensive approach to the management and follow-up of the growth-restricted fetus and infant, physicians should take into consideration the etiology, timing, and severity of IUGR. In addition, they should be cognizant of the immediate perinatal response of the growth-restricted infant as well as the childhood and long-term associated morbidities. A multi disciplinary approach is imperative, including early recognition and obstetrical management of IUGR, assessment of the growth-restricted newborn in the delivery room, possible monitoring in the neonatal intensive care unit, and appropriate pediatric follow-up. Future research is necessary to establish effective preventive, diagnostic, and therapeutic strategies for IUGR, perhaps affecting the health of future generations.
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Affiliation(s)
- Dara Brodsky
- Beth Israel Deaconess Medical Center and Children's Hospital, Harvard Medical School, Department of Newborn Medicine, Boston, MA 02215, USA.
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16
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Abstract
The evidence for outcome following fetal growth restriction (FGR) has previously been inferred from studies, based on babies who were born small for gestational age (SGA). Great care is required when evaluating studies in this area due to a number of potential confounders. It does appear, however, that FGR is associated with an increased risk of poor neurological outcome. This includes an increased risk of cerebral palsy in babies greater than 32 weeks' gestation. Below 32 weeks, the effects of prematurity appear to negate the effects of FGR. FGR is also associated with cognitive deficit and behaviour problems. Babies with poor prenatal head growth appear to have a worse cognitive outcome. However, the role of 'fetal brain sparing' remains unclear, as impaired cognitive outcome is still evident in babies with appropriate head growth. Recent studies, which have identified FGR more accurately using fetal growth standards, have found an increased incidence of major intracranial injury and other adverse neonatal outcomes, which had previously been thought to occur less frequently in FGR babies. FGR is also associated with poor postnatal growth. The majority of children with FGR demonstrate catch-up growth in the first 2 years of life. Children who fail to demonstrate catch-up growth have a high risk of long-term growth problems. There is evidence of impaired growth hormone activity in some children with FGR who have persistent poor growth in the postnatal period.
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Affiliation(s)
- Michael Yanney
- Academic Division of Child Health, Queen's Medical Centre, Floor E, East Block, Nottingham NG7 2UH, UK
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Roelants-van Rijn AM, van der Grond J, Stigter RH, de Vries LS, Groenendaal F. Cerebral structure and metabolism and long-term outcome in small-for-gestational-age preterm neonates. Pediatr Res 2004; 56:285-90. [PMID: 15181199 DOI: 10.1203/01.pdr.0000132751.09067.3f] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the present study, we compared brain development and metabolism of small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA) infants using proton magnetic resonance spectroscopy ((1)H-MRS). We tested the hypothesis that intrauterine growth retardation caused by placental insufficiency is associated with changes in cerebral metabolism and is followed by an adverse neurodevelopmental outcome at the age of 2 y. Twenty-six AGA and 14 SGA (birth weight <P 2.3) preterm infants with no major ultrasound abnormalities were enrolled prospectively. At 32 and 41 wk postmenstrual age, (1)H-MRS and magnetic resonance imaging were performed. For (1)H-MRS, a volume of interest was placed in the basal ganglia and in the periventricular white matter. Using echo times of 31 and 144 ms N-acetylaspartate/choline (NAA/Cho), lactate/Cho, myo-inositol/Cho (mI/Cho), and glutamate-glutamine-gamma-aminobutyric acid/Cho (Glx/Cho) ratios were compared between AGA and SGA groups. Griffiths' developmental quotient (DQ) values were assessed at 24 mo corrected age. Griffiths' DQ (AGA, 104 +/- 10; SGA, 99 +/- 9) and brain development assessed using magnetic resonance imaging showed no significant differences between both AGA and SGA groups, and NAA/Cho, Lac/Cho, mI/Cho, and Glx/Cho ratios were not significantly different between the groups. NAA/Cho ratios increased from 32 to 41 wk, whereas mI/Cho ratios decreased in both groups. No differences in cerebral metabolism, brain development, and DQ values between AGA and severely SGA infants could be demonstrated.
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Affiliation(s)
- Ariadne M Roelants-van Rijn
- Wilhelmina Children's Hospital/University Medical Center Utrecht, Department of Neonatology, Room KE 04.123.1, Lundlaan 6, 3584 EA Utrecht, The Netherlands.
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Spinillo A, Montanari L, Sanpaolo P, Bergante C, Chiara A, Fazzi E. Fetal Growth and Infant Neurodevelopmental Outcome After Preterm Premature Rupture of Membranes. Obstet Gynecol 2004; 103:1286-93. [PMID: 15172866 DOI: 10.1097/01.aog.0000127706.78192.95] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the prognostic values of fetal size before birth and fetal growth during the latency period in patients with preterm premature rupture of the membranes (PROM). METHODS A prospective cohort study of 69 singleton pregnancies complicated by prolonged (14 days or more) PROM (24 to 31 weeks of gestation). Measures of fetal size and growth were compared with corresponding expected values from our reference curves. The correlations between deviations from expected measures of fetal size and growth, short-term neonatal complications, and infant neurodevelopmental outcome at 2 years were studied by univariate methods and logistic regression. RESULTS The mean gestational ages and standard deviations at membrane rupture and at birth were 27.9 +/- 2.4 and 31.5 +/- 2.1 weeks. At a corrected age of 2 years, of the 65 (94.2%) survivors, 3 infants (4.6%) had cerebral palsy, 13 (20%) had minor neurodevelopmental impairment, and 49 (75.4%) were judged to have had normal development. Compared with surviving infants without a major handicap, the group of infants who died and those with cerebral palsy had lower proportions of expected birth weight (0.766 +/- 0.1 as compared with 0.859 +/- 0.13, P =.029), head (0.869 +/- 0.07 as compared with 0.950 +/- 0.07, P =.05), and abdominal (0.793 +/- 0.04 as compared with 0.888 +/- 0.1, P =.001) circumference growth during latency period. In logistic regression analysis, lower-than-expected ultrasound measures of fetal abdominal circumference before birth (odds ratio 1.09; 95% confidence interval 1.01, 1.18) or of abdominal circumference growth during the latency period (odds ratio 1.1; 95% confidence interval 1.01, 1.2) were significantly associated with an increased likelihood of an infant neurodevelopmental abnormality at 2-year follow-up. CONCLUSION In pregnancies complicated by preterm PROM, lower-than-expected measures of fetal size and fetal growth were associated with an increased rate of infant neurodevelopmental outcome at 2-year follow-up. LEVEL OF EVIDENCE II-2
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Affiliation(s)
- Arsenio Spinillo
- Department of Obstetrics and Gynecology, University of Pavia, IRCCS Policlinico S. Matteo, Piazzale Golgi, 27100 Pavia, Italy.
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Jarvis S, Glinianaia SV, Torrioli MG, Platt MJ, Miceli M, Jouk PS, Johnson A, Hutton J, Hemming K, Hagberg G, Dolk H, Chalmers J. Cerebral palsy and intrauterine growth in single births: European collaborative study. Lancet 2003; 362:1106-11. [PMID: 14550698 DOI: 10.1016/s0140-6736(03)14466-2] [Citation(s) in RCA: 248] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cerebral palsy seems to be more common in term babies whose birthweight is low for their gestational age at delivery, but past analyses have been hampered by small datasets and Z-score calculation methods. METHODS We compared data from ten European registers for 4503 singleton children with cerebral palsy born between 1976 and 1990 with the number of births in each study population. Weight and gestation of these children were compared with reference standards for the normal spread of gestation and weight-for-gestational age at birth. FINDINGS Babies of 32-42 weeks' gestation with a birthweight for gestational age below the 10th percentile (using fetal growth standards) were 4-6 times more likely to have cerebral palsy than were children in a reference band between the 25th and 75th percentiles. In children with a weight above the 97th percentile, the increased risk was smaller (from 1.6 to 3.1), but still significant. Those with a birthweight about 1 SD above average always had the lowest risk of cerebral palsy. A similar pattern was seen in those with unilateral or bilateral spasticity, as in those with a dyskinetic or ataxic disability. In babies of less than 32 weeks' gestation, the relation between weight and risk was less clear. INTERPRETATION The risk of cerebral palsy, like the risk of perinatal death, is lowest in babies who are of above average weight-for-gestation at birth, but risk rises when weight is well above normal as well as when it is well below normal. Whether deviant growth is the cause or a consequence of the disability remains to be determined.
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Crawford MA, Golfetto I, Ghebremeskel K, Min Y, Moodley T, Poston L, Phylactos A, Cunnane S, Schmidt W. The potential role for arachidonic and docosahexaenoic acids in protection against some central nervous system injuries in preterm infants. Lipids 2003; 38:303-15. [PMID: 12848275 DOI: 10.1007/s11745-003-1065-1] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The risk of central nervous, visual, and auditory damage increases from 2/1000 live births in the normal birthweight to > 200/1000 as birthweight falls below 1500 g. Such babies are most likely to be born preterm. Advances in infant care have led to increasing numbers of very-low-birthweight, preterm infants surviving to school age with moderate to severe brain damage. Steroids are one of the current treatments, but they cause significant, long-term problems. The evidence reported here suggests an additional approach to protecting the very preterm infant by supporting neurovascular membrane integrity. The complications of preterm, very-low-birthweight babies include bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular hemorrhage, periventricular leukomalacia, and necrotizing enterocolitis, all of which have a vascular component. Arachidonic acid (AA) and DHA are essential, structural, and functional constituents of cell membranes. They are especially required for the growth and function of the brain and vascular systems, which are the primary biofocus of human fetal growth. Molecular dynamics and experimental evidence suggest that DHA could be the ligand for the retinoid X receptor (RXR) in neural tissue. RXR activation is an obligatory step in signaling to the nucleus and in the regulation of gene expression. Very preterm babies are born with minimal fat stores and suboptimal circulating levels of these nutrients. Postnatally, they lose the biomagnification of the proportions of AA and DHA by the placenta for the fetus. No current nutritional management repairs these deficits. The placental biomagnification profile highlights AA rather than DHA. The resultant fetal FA profile closely resembles that of the vascular endothelium and not the brain. Without this nourishment, cell membrane abnormalities would be predicted. We present a scientific rationale for a common pathogenic process in the complications of prematurity.
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MESH Headings
- Animals
- Arachidonic Acid/pharmacology
- Brain/growth & development
- Brain/pathology
- Central Nervous System Diseases/blood
- Central Nervous System Diseases/drug therapy
- Central Nervous System Diseases/pathology
- Central Nervous System Diseases/prevention & control
- Docosahexaenoic Acids/pharmacology
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/physiology
- Female
- Gene Expression/drug effects
- Humans
- Infant, Low Birth Weight/blood
- Infant, Low Birth Weight/growth & development
- Infant, Newborn
- Infant, Premature/blood
- Infant, Premature/growth & development
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/pathology
- Infant, Premature, Diseases/prevention & control
- Membrane Lipids/physiology
- Neuroprotective Agents/pharmacology
- Pregnancy
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Affiliation(s)
- M A Crawford
- Institute of Brain Chemistry and Human Nutrition, The London Metropolitan University, North Campus, London N7 8DB, United Kingdom.
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21
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O'Shea TM. Cerebral palsy in very preterm infants: new epidemiological insights. MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 2002; 8:135-45. [PMID: 12216057 DOI: 10.1002/mrdd.10032] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The focus of this review is on new insights from recent epidemiological research on cerebral palsy in preterm infants. These include: 1) a better understanding of issues related to diagnosis and classification; 2) new information about the brain abnormalities underlying cerebral palsy in preterm infants; and 3) a better understanding of biological mechanisms that may underlie previously described epidemiological associations. Ongoing efforts to improve the diagnosis and classification of cerebral palsy have been enhanced by findings from serial examinations of cohorts of very preterm infants. Cranial ultrasonography through the anterior fontanelle of very preterm infants has provided information about grossly evident brain damage, found in about one-half of preterm infants who develop cerebral palsy. Insights into the pathophysiologic basis for certain epidemiologic associations have come from studies of experimental brain damage in animals and clinical studies of neurologic disorders in adults. Much of the current epidemiological research into the causes of cerebral palsy in preterm infants has focused on two potential mechanisms of brain damage. One mechanism involves insufficient cerebral perfusion; the other, cytokine-mediated damage, potentially triggered by events such as maternal infection (e.g., intrauterine or periodontal infection), neonatal infection (e.g., sepsis and necrotizing enterocolitis), and neonatal oxygen- or ventilator-induced lung injury. In addition to the preterm infant's increased exposure to such damaging factors, the high frequency of cerebral palsy in these infants might be due, in part, to insufficient levels of developmentally regulated protective substances, such as thyroid hormone and glucocorticoids. Models of causation currently are being investigated using recently developed methods for quantifying, with small quantities of blood, biomolecules that are suspected to either promote or protect against brain damage in the neonate. Clinical investigations now under way can be expected to identify strategies to be tested in clinical trials that could lower the risk of cerebral palsy in very preterm infants.
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MESH Headings
- Brain/abnormalities
- Brain/blood supply
- Cerebral Palsy/classification
- Cerebral Palsy/diagnosis
- Cerebral Palsy/epidemiology
- Cerebral Palsy/etiology
- Child, Preschool
- Comorbidity
- Cytokines/adverse effects
- Encephalitis/epidemiology
- Encephalitis/immunology
- Europe/epidemiology
- Humans
- Hypoxia-Ischemia, Brain/epidemiology
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/classification
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/etiology
- Infant, Premature
- Infections/epidemiology
- Infections/immunology
- Ultrasonography, Doppler, Transcranial
- United States/epidemiology
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Affiliation(s)
- T Michael O'Shea
- Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Dammann O, Dammann CE, Allred EN, Veelken N. Fetal growth restriction is not associated with a reduced risk for bilateral spastic cerebral palsy in very-low-birthweight infants. Early Hum Dev 2001; 64:79-89. [PMID: 11440821 DOI: 10.1016/s0378-3782(01)00183-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the influence of confounding and sampling bias on the relationship between fetal growth restriction in a very-low-birthweight-defined cohort (VLBW, < or =1500 g) and bilateral spastic cerebral palsy (BSCP) at early school-age. METHODS Three hundred twenty-four of 407 long-term survivors of a regional cohort of VLBW newborns were followed until age 6 years. We categorized as small for gestational age (SGA) all infants whose birthweight Z-score was below -2 relative to published reference values. Uni- and multivariable logistic regression models were fit to estimate the risk of BSCP associated with SGA in the total sample, in subsamples defined by gestational age, and in a gestational age-matched case-control sample. RESULTS In the total sample, no child below 28 weeks was SGA, and no child above 32 weeks had an appropriate birthweight for gestational age (AGA). The prevalence of BSCP was 14% in AGA and 2% in SGA infants. In both uni- and multivariable logistic regression analyses of the total sample, SGA was associated with a prominently reduced risk of BSCP (odds ratios range from 0.1 to 0.2, all 95% confidence limits exclude 1.0). However, analyses performed in samples defined by different gestational age cutoffs (24--31 weeks, 28--31 weeks) and in a sample using three gestational age-matched controls per BSCP-case did not show a protection by growth restriction (odds ratios range from 0.8 to 2.2, all 95% confidence limits include 1.0). CONCLUSIONS In VLBW-defined samples, the apparent protective effect of SGA for BSCP can be explained, at least in part, by the highly skewed distribution of SGA over the available gestational age range. From this follows that study cohorts should be defined by gestational age and not by birthweight. In distorted samples like this one, even controlling for gestational age does not reduce the illusion of a reduced cerebral palsy risk for growth restricted infants. Only restriction of the sample by gestational age and/or matching for gestational age reveals the absence of this apparent protective effect.
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Affiliation(s)
- O Dammann
- Neuroepidemiology Unit, CA505, Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Saliba E, Marret S. Cerebral white matter damage in the preterm infant: pathophysiology and risk factors. SEMINARS IN NEONATOLOGY : SN 2001; 6:121-33. [PMID: 11483018 DOI: 10.1053/siny.2001.0043] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Based on clinical, epidemiologic, and experimental studies, the aetiology of white matter damage, specifically periventricular leukomalacia (PVL), is multifactorial and involves pre- and perinatal factors possibly including genetic factors, hypoxic-ischaemic insults, infection, excess cytokines, free radical production, increased excitatory amino acid release, and trophic factor deficiencies. The article summarizes research findings about the aetiology of white matter damage and cerebral palsy in preterm infants. The information is organized according to specific antecedents, for which we present epidemiological and neurobiological data. The most important prenatal factor appears to be intrauterine infection. We discuss the evidence supporting the hypothesis that the foetal inflammatory response contributes to neonatal brain injury and later developmental disability. We recently established an animal model of excitotoxic lesions in the developing mouse brain. Brain damage was induced by intra-cortical injections of ibotenate, a glutamatergic agonist. When administered on post-natal day 5 ibotenate induced the formation of white matter cysts. Our animal model could be used to further explore the mechanisms involved in the formation of PVL. Potentially preventive strategies will be discussed.
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Affiliation(s)
- E Saliba
- INSERM U 316, Department of Neonatology, Centre Hospitalier Universitaire, Tours, France.
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Abstract
Research from the last two decades provides directions for efforts to prevent CP in VLBW infants. The pathogenesis of CP seems to involve factors operating both during pregnancy and in the neonatal period. The most important prenatal factor appears to be intrauterine infection. Perinatal infection and other risk factors, such as the death of a co-twin, placental abruption, and cerebral ischemia, could trigger a cytokine cascade resulting in damage to the developing brain. The low frequency of intrauterine infection in mothers with preeclampsia might explain the apparent protective effect of this disorder. If the brain damage attributed to intrauterine infection and other risk factors involves cytokines as intermediates, then blockade of the proinflammatory cascade or promotion of endogenous inhibitors might prevent CP. Other potentially preventive strategies include corticosteroids given to mothers (but not those given to neonates) and thyroid hormone.
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Affiliation(s)
- T M O'Shea
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Arpino C, Curatolo P, Stazi MA, Pellegri A, Vlahov D. Differing risk factors for cerebral palsy in the presence of mental retardation and epilepsy. J Child Neurol 1999; 14:151-5. [PMID: 10190264 DOI: 10.1177/088307389901400303] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Whether the combined diagnosis of cerebral palsy with mental retardation or with mental retardation and epilepsy reflects more severe manifestations of the spectrum of cerebral palsy, or whether these conditions reflect overlapping outcomes related to different exposure, remains an open question. At two centers, in Rome and Conegliano, Italy, 51 children with combined cerebral palsy, mental retardation, and epilepsy, 31 children with both cerebral palsy and mental retardation, and 48 with cerebral palsy alone were identified and examined, and their mothers interviewed. The triple diagnosis group was significantly more likely than the other two groups to have a history of neonatal convulsions and a history of epilepsy in first-degree relatives, but less likely to have a mother's age at delivery greater than 33 years, a birthweight less than 1500 g, or gestational age less than 32 weeks. The dual diagnosis group was more likely than the other two groups to have maternal education of less than 8 years. These data suggest the possibility of different etiopathogenetic pathways for various presentations of cerebral palsy.
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Affiliation(s)
- C Arpino
- Pediatric Neurology Unit, University of Rome, Tor Vergata, Italy
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26
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Spinillo A, Capuzzo E, Cavallini A, Stronati M, De Santolo A, Fazzi E. Preeclampsia, preterm delivery and infant cerebral palsy. Eur J Obstet Gynecol Reprod Biol 1998; 77:151-5. [PMID: 9578271 DOI: 10.1016/s0301-2115(97)00246-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the association between preeclampsia and cerebral palsy among preterm infants. STUDY DESIGN A cohort study of 345 singleton preterm (24 to 33 weeks gestation) infants delivered at an institution where no mothers received magnesium sulphate. We investigated the relationship of preeclampsia to the development of infant cerebral palsy (spastic quadriplegia, hemiplegia or diplegia) at two years' corrected age. Potential confounders were controlled for by politomous logistic regression analysis. RESULTS The prevalence of cerebral palsy in surviving infants from normotensive and preeclamptic pregnancies was 13.4% (38/284) and 3.3% (2/61), respectively (P=0.026 by Fisher exact test). After control for potential confounders (gestational age, infant gender, birthweight standard deviation score, mode of delivery), the likelihood of infant cerebral palsy was reduced by preeclampsia (odds ratio 0.16, 95% confidence interval=0.04-0.74 for infants from preeclamptic versus normotensive pregnancies being palsied). CONCLUSION Among preterm infants, the protective effect of preeclampsia against cerebral palsy is manifest in the absence of magnesium sulphate utilization.
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Affiliation(s)
- A Spinillo
- Department of Obstetrics and Gynaecology, IRCCS Policlinico San Matteo, Pavia, Italy
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Affiliation(s)
- M Collins
- Department of Epidemiology, College of Human Medicine, Michigan State University, East Lansing 48824-1316, USA
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Abstract
OBJECTIVES To analyse completeness and validity of data in the Cerebral Palsy Register in Denmark, 1979-1982. METHODS Completeness has been assessed by comparing data from The Danish National Patient Register (DNPR) with the cases included in the Cerebral Palsy Register (CPR). Agreement between 12 variables in the CPR and obstetrical medical records has been analysed using kappa-statistics. RESULTS Of 468 children in the DNPR, only 237 fulfilled the inclusion criteria of the CPR; and 35 (15%) of these cases had not been reported to the CPR. Data agreement was generally good, but gestational age was subject to a systematic error, and urinary infections in pregnancy (kappa = 0.43) and placental abruption (kappa = 0.52) were seriously under-reported in the CPR. CONCLUSIONS Completeness of the Cerebral Palsy Register in Denmark, 1979-1982, has been assessed to maximal 85%, emphasizing the impact of using supplementary case ascertainment sources in the future. Validity of data varied according to definition and significance of the specific variable.
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Affiliation(s)
- M Topp
- Department of Obstetrics and Gynecology 537, Hvidovre Hospital, Denmark
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