Cerebral palsy life expectancy

The everydayness of falling: consequences and management for adults with cerebral palsy across the life course

PURPOSE

To explore the cause, influences and consequences of falling for adults with cerebral palsy (CP) across their life course, and how this is managed.

MATERIALS AND METHODS

We used interview data from a multimethod UK study exploring the effects of ageing with CP and healthcare across the life course. Twenty-six participants were recruited and interviewed using various digital platforms to maximise inclusive participation in the UK. Follow-up email semi-structured interviews were conducted to further explore experiences of falls. Transcribed interviews were analysed thematically.

RESULTS

Falling and fear of falling (FoF) is problematic for over half of the participants in the sample. They perceived falls and FoF as limiting their participation, autonomy and independence in employment, social and cultural activities. Participants used their own management strategies, due to limited specialist interventions or practitioner knowledge to manage or prevent falls. Practices, such as the use of a wheelchair or avoiding activities prompted changes to relationships and identity.

CONCLUSIONS

Falling for adults with CP happens earlier in life compared to the general population. Adults with CP may benefit from specialist falls prevention services to help maintain muscle strength and balance. Research is needed to evaluate effective interventions for people with CP.

Inhibitory Synaptic Influences on Developmental Motor Disorders

During development, GABA and glycine play major trophic and synaptic roles in the establishment of the neuromotor system. In this review, we summarise the formation, function and maturation of GABAergic and glycinergic synapses within neuromotor circuits during development. We take special care to discuss the differences in limb and respiratory neuromotor control. We then investigate the influences that GABAergic and glycinergic neurotransmission has on two major developmental neuromotor disorders: Rett syndrome and spastic cerebral palsy. We present these two syndromes in order to contrast the approaches to disease mechanism and therapy. While both conditions have motor dysfunctions at their core, one condition Rett syndrome, despite having myriad symptoms, has scientists focused on the breathing abnormalities and their alleviation-to great clinical advances. By contrast, cerebral palsy remains a scientific quagmire or poor definitions, no widely adopted model and a lack of therapeutic focus. We conclude that the sheer abundance of diversity of inhibitory neurotransmitter targets should provide hope for intractable conditions, particularly those that exhibit broad spectra of dysfunction-such as spastic cerebral palsy and Rett syndrome.

Day-to-Day Variability of Clinical Feeding and Swallowing Performance in School-Age Self-Feeding Children With Cerebral Palsy

PURPOSE

We aimed to examine the day-to-day variability of feeding and swallowing performance and mealtime duration in school-age self-feeding children with spastic cerebral palsy (SCP) across 15 days.

METHOD

Thirteen children with SCP (ages 5;10 [years;months]-17;6) participated. Children were divided into unilateral (UCP, n = 6) and bilateral (BCP, n = 7) SCP groups. Feeding/swallowing assessments using the Dysphagia Disorder Survey (DDS) were conducted and total mealtime durations (TMDs) were calculated for all days. DDS Part 1 (factors related to feeding) and DDS Part 2 (signs of oropharyngeal difficulties) components were rated. Mixed-effects models were used to compare group means and estimate between- and within-subject variances in each group. Likelihood ratio tests were used to determine best covariance structure and compare variance types across groups.

RESULTS

Within-subject variance for all three variables, DDS Part 1, 2, and TMD, across days was larger in the BCP group than the UCP group (Part 1: p = .0036, Part 2: p = .0002, and TMD: p = .0005) and the between-subject variance was larger in the BCP group for DDS Part 2 (p = .0362). The UCP group presented with lower (milder) DDS scores (Part 1: p = .0160; Part 2: p = .0141) and shorter TMD (p = .0077) than the BCP group across days. Furthermore, both groups exhibited greater variability in DDS Part 2 than 1 (p < .0001).

CONCLUSION

These preliminary results emphasize the need to account for day-to-day variability when evaluating swallowing especially in children with BCP and provide preliminary ranges of performance that could be useful for clinical prognosis and future treatment research.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21669611.

Diaphragm Muscle Function in a Mouse Model of Early Onset Spasticity

Spasticity is a common symptom in many developmental motor disorders, including spastic cerebral palsy (sCP). In sCP, respiratory dysfunction is a major contributor to morbidity and mortality, yet it is unknown how spasticity influences respiratory physiology or diaphragm muscle (DIAm) function. To investigate the influence of spasticity on DIAm function, we assessed in vivo transdiaphragmatic pressure (Pdi - measured using intra-esophageal and intragastric pressure catheters under conditions of eupnea, hypoxia/hypercapnia and occlusion) including maximum Pdi (Pdimax via bilateral phrenic nerve stimulation), ex vivo DIAm specific force and fatigue (using muscle strips stimulated with platinum plate electrodes) and type-specific characteristics of DIAm fiber cross-sections (using immunoreactivity against myosin heavy chain slow and 2A) in spa and wildtype mice. Spa mice show reduced Pdimax, reduced DIAm specific force, altered fatigability and atrophy of type IIx/IIb fibers. These findings suggest marked DIAm dysfunction may underlie the respiratory phenotype of sCP.

Factors for changes in self-care and mobility capabilities in young children with cerebral palsy involved in regular outpatient rehabilitation care

Background

Assessing prognosis of self-care and mobility capabilities in children with cerebral palsy (CP) is important for goal setting, treatment guidance and meaningful professional-caregiver conversations.

Aims

Identifying factors associated with changes in self-care and mobility capabilities in regular outpatient multidisciplinary paediatric CP rehabilitation care.

Methods and procedures

Routinely monitored longitudinal data, assessed with the Paediatric Evaluation of Disability Inventory (PEDI-Functional-Skills-Scale, FSS 0–100) was retrospectively analysed. We determined contributions of age, gross-motor function, bimanual-arm function, intellectual function, education type, epilepsy, visual function, and psychiatric comorbidity to self-care and mobility capability changes (linear-mixed-models).

Outcomes and results

For 90 children (53 boys), in all Gross-Motor-Function-Classification-System (GMFCS) levels, 272 PEDI's were completed. Mean PEDI–FSS–scores at first measurement (median age: 3,2 years) for self-care and mobility were 46.3 and 42.4, and mean final FSS-scores respectively were 55.1 and 53.1 (median age: 6,5 years). Self-care capability change was significantly associated with age (2.81, p < 0.001), GMFCS levels III-V (-9.12 to -46.66, p < 0.01), and intellectual impairment (-6.39, p < 0.01). Mobility capability change was significantly associated with age (3.25, p < 0.001) and GMFCS levels II-V (-6.58 to -47.12, p < 0.01).

Conclusions and implications

Most important prognostic factor for self-care and mobility capabilities is GMFCS level, plus intellectual impairment for self-care. Maximum capability levels are reached at different ages, which is important for individual goal setting and managing expectations.

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Capabilities of children with CP improve modestly over time in outpatient rehabilitation.

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Children with more severe CP reach maximum mobility and self-care levels at an earlier age.

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After this maintaining capabilities is more realistic than improvement.

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Important prognostic factors are GMFCS level and intellectual impairment.

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Routine monitoring can aid goal setting and expectation management in communication with families.

Diaphragm neuromuscular transmission failure in a mouse model of an early-onset neuromotor disorder

The spa transgenic mouse displays spasticity and hypertonia that develops during the early postnatal period, with motor impairments that are remarkably similar to symptoms of human cerebral palsy. Previously, we observed that spa mice have fewer phrenic motor neurons innervating the diaphragm muscle (DIAm). We hypothesize that spa mice exhibit increased susceptibility to neuromuscular transmission failure (NMTF) due to an expanded innervation ratio. We retrogradely labeled phrenic motor neurons with rhodamine and imaged them in horizontal sections (70 µm) using confocal microscopy. Phrenic nerve-DIAm strip preparations from wild type and spa mice were stretched to optimal length, and force was evoked by phrenic nerve stimulation at 10, 40, or 75 Hz in 330-ms duration trains repeated each second (33% duty cycle) across a 120-s period. To assess NMTF, force evoked by phrenic nerve stimulation was compared to force evoked by direct DIAm stimulation superimposed every 15 s. Total DIAm fiber number was estimated in hematoxylin and eosin-stained strips. Compared to wild type, spa mice had over twofold greater NMTF during the first stimulus train that persisted throughout the 120 s period of repetitive activation. In both wild type and spa mice, NMTF was stimulation-frequency dependent. There was no difference in neuromuscular junction morphology or the total number of DIAm fibers between wild type and spa mice, however, there was an increase innervation ratio (39%) in spa mice. We conclude that early-onset developmental neuromotor disorders impair the efficacy of DIAm neuromuscular transmission, likely to contribute to respiratory complications.NEW & NOTEWORTHY Individuals with motor control deficits, including cerebral palsy (CP) often have respiratory impairments. Glycine-receptor mutant spa mice have early-onset hypertonia, and limb motor impairments, similar to individuals with CP. We hypothesized that in the diaphragm of spa mice, disruption of glycinergic inputs to MNs would result in increased phrenic-DIAm neuromuscular transmission failure. Pathophysiologic abnormalities in neuromuscular transmission may contribute to respiratory dysfunction in conditions where early developmental MN loss or motor control deficits are apparent.

Is sensory-level electrical stimulation effective in cerebral palsy children with dysphagia? A randomized controlled clinical trial

Dysphagia is one of the common findings in children with cerebral palsy (CP). Electrical stimulation (ES) has been demonstrated to positively contribute to swallowing functions, particularly in adult patients with various neurological disorders. Therefore, the objective of this study was to assess the effects of sensory-level ES treatment combined with conventional dysphagia rehabilitation in pediatric age group CP patients who had any oropharyngeal dysphagia symptoms and/or findings. Participants were randomly assigned to either the experimental group (Group 1, n = 52) who underwent intermittent galvanic stimulation to bilateral masseter muscles for 5 days/week, for 4 weeks combined with conventional dysphagia rehabilitation or the control group (Group 2, n = 50) who received sham stimulation with conventional dysphagia rehabilitation. The experimental group achieved significantly more improvement in swallowing functions including drooling, tongue movements, chewing, eating large food ability, feeding duration, as well as dysphagia screen test and dysphagia level, compared to control group. This study suggested that sensory-level ES might be a useful and safe therapeutic modality to improve oropharyngeal symptoms, symptom severity and dysphagia level in children with CP and dysphagia. Further research is needed to determine the long-term effects of ES on dysphagia, especially in different neurological disorders such as CP.

Transition to adult care for young people with cerebral palsy

Cerebral palsy (CP) is associated with a high burden of comorbid respiratory disease subsequent to multiple risk factors associated with increasing levels of disability. Correspondingly, respiratory disease is the leading cause of death in CP, including amongst young people who are transitioning or who have just transitioned between paediatric and adult healthcare services. Therefore, consideration of both preventive and therapeutic respiratory management is integral to transition in patients with CP, as summarised in this review.

Why individuals with cerebral palsy are at higher risk for respiratory complications from COVID-19

Respiratory dysfunction is a leading cause of morbidity and mortality in individuals with cerebral palsy (CP). In children and adults with CP, movement and physical function is always affected. Yet, many clinicians overlook potential for impaired movement and function of the diaphragm muscle (DIAm) in individuals with CP. Since individuals with pre-existing respiratory disorders are at greater risk for respiratory complications if they contract COVID-19, understanding potential risks to individuals with CP is important. In this review we present research on respiratory function and DIAm force generation in children with CP. We compare this clinical work to basic science research investigating phrenic motor neuron and DIAm motor unit dysfunction in an animal model with CP symptoms, the spa mouse. Finally, we integrate the clinical and basic science work in respiratory function in CP, discussing potential for individuals with CP to have severe respiratory symptoms from COVID-19.

Premature mortality in children aged 6-9 years with neurological impairments in rural Kenya: a cohort study

BACKGROUND

Neurological impairments might significantly contribute to reduced life expectancy in low-income and middle-income countries (LMICs). There are no empirical studies of premature mortality in children with neurological impairments in Africa. This study estimated the risk of premature mortality in children with neurological impairments and identified risk factors and causes of death.

METHODS

We did a cohort study based on a two-stage epidemiological survey in the Kilifi Health and Demographic Surveillance System (Kilifi, Kenya). Study participants were children aged 6-9 years. In the first stage, five trained field workers administered a low-cost screening tool to a random sample of households. In the second stage, we assessed for neurological impairments in five domains (epilepsy, cognitive impairments, vision impairments, hearing impairments, and motor impairments) using comprehensive clinical evaluation and extensive neuropsychological assessments. From the two-stage survey we identified a cohort of children with neurological impairment and a cohort of matched controls. We also enrolled an age-matched sample from the general population. The primary outcome was all-cause mortality. Mortality rates, standardised mortality ratio (SMR), and hazard ratios (HR) for risk factors were estimated and causes of death identified.

FINDINGS

We enrolled 306 children with neurological impairment, 9912 survey controls, and 22 873 age-matched participants from the general population, and followed up the cohorts between June 1, 2001, and Aug 31, 2018. Median follow-up was 14·5 years (IQR 8·6-17·2). 11 (3·9%) of 284 children with neurological impairment, 92 (1·0%) of 9009 controls, and 272 (1·2%) of 22 873 participants in the general population sample died during the follow-up. Overall mortality rates were 309·8 per 100 000 person-years of observation (95% CI 126·7-492·9) in children with neurological impairment, 80·8 per 100 000 person-years of observation (64·3-97·3) in controls, and 98·8 per 100 000 person-years of observation (87·1-110·6) in the general population sample (mortality rate ratio 3·83, 95% CI 2·05-7·16, p<0·001, compared with controls; 3·13, 1·71-5·72, p<0·001, compared with the general population). Mortality risk in children with neurological impairment was not dependent on the severity of impairment (p=0·291) nor on a specific neurological impairment domain (p=0·205). The overall risk of death adjusted for age and sex was higher in children with neurological impairment compared with controls (HR 4·24, 95% CI 2·26-7·94, p=0·002). An SMR of 3·15 (95% CI 1·66-5·49) was obtained after using the general population sample as the reference for indirect standardisation. In multivariable risk factor analysis, developmental delay (adjusted HR 18·92, 95% CI 2·23-160·44, p=0·007) and severe malnutrition (20·92, 3·14-139·11, p=0·002) increased the risk of mortality in children with neurological impairment. Infections such as HIV/AIDS and accidents were common among all decedents.

INTERPRETATION

The risk of premature mortality was higher in children diagnosed with neurological impairments compared with the general population and was increased by developmental delay and severe malnutrition. Child development and nutritional status should be assessed in all children in LMICs and tailored interventions started to improve outcomes.

FUNDING

Wellcome Trust, DELTAS Africa Initiative.

Health characteristics and health care trajectory of polyhandicaped person before and after 1990

INTRODUCTION

Polyhandicap is defined as the combination of severe mental impairment and severe motor deficit resulting in reduced mobility and an extreme reduction in autonomy. Over the last 20years, care management for these patients has become more structured, however, their care pathway is not always optimal.

OBJECTIVE

To describe/compare the health characteristics, treatment and history of the care pathways of subjects who received care before and after 1990.

METHOD

Multicentre cross-sectional study, population studied: patients with polyhandicap: (i) causal brain damage<3years, (ii) severe mental impairment, (iii) motor disability, (iv) reduced mobility, (v) extreme restriction of autonomy.

DATA COLLECTED

clinical and medical, care procedures, treatments, history of care pathways.

RESULTS

Patients are divided into 2 groups: 545 patients who received care after 1990 and 330 before 1990. Older patients present more recurrent urinary infections, slow transit, behavioural disorders and pain, and are prescribed a greater number of drugs. For those who received care before 1990, the age of admission to an establishment is lower, with one-third receiving a consultation dedicated to the transition from paediatric to adult teams.

DISCUSSION/CONCLUSION

The care sector for patients with polyhandicap makes it possible to meet their needs throughout their lives, however, there is still progress to be made in terms of formalisation and of coordinating the care pathway in order to facilitate the transition from paediatric to adult services/establishments.

Survival and mortality in cerebral palsy: observations to the sixth decade from a data linkage study of a total population register and National Death Index

Background

Likely duration of survival of children described as having cerebral palsy is of considerable interest to individuals with cerebral palsy, their families, carers, health professionals, health economists and insurers. The aim of this paper is to describe patterns of survival and mortality to the sixth decade in a geographically defined population of people with cerebral palsy stratified according to the clinical description of their impairments in early childhood.

Methods

Identifiers of persons born in Western Australia 1956–2011, registered with cerebral palsy on the Western Australian Register of Developmental Anomalies and surviving at least 12 months, were linked to the Australian National Death Index in December 2014. Patterns of mortality were investigated using survival analysis methods.

Results

Of 3185 eligible persons, 436 (13.7%) had died. Of that sample the 22% with the mildest impairment had survival patterns similar to the general population. Mortality increased with increasing severity of impairment. Of 349 (75%) with available cause of death data, 58.6% were attributed to respiratory causes, including 171 (49%) to pneumonia at a mean age of 14.6 (sd 13.4) years of which 77 (45%) were attributed to aspiration.

For the most severely impaired, early childhood mortality increased in succeeding decades of birth cohorts from 1950s to 1990 with 20% dying by 4 years of age in the 1981–1990 birth cohort; it then decreased for subsequent birth cohorts, 20% mortality not being attained until 15 years of age. However by 20 years of age mortality of the most severely impaired born in the 1991–2000 birth cohort exceeded that of all other birth cohorts.

Remaining life expectancies by age to 50 years have been estimated for two strata with more severe impairments.

Conclusion

For 22% of individuals with cerebral palsy with mild impairment survival to 58 years is similar to that of the general population. Since 1990 mortality for those with severe cerebral palsy in Western Australia has tended to shift from childhood to early adulthood.

Extrapolating published survival curves to obtain evidence-based estimates of life expectancy in cerebral palsy

Studies reporting long-term survival probabilities for cohorts of persons with cerebral palsy provide evidence-based information on the life expectancy of those cohorts. Some studies have provided estimates of life expectancy based on extrapolation of such evidence, whereas many others have opted not to do so. Here we review the basic methods of life table analysis necessary for performing such extrapolations, and apply these methods to obtain evidence-based estimates of life expectancy from several studies that do not report such estimates themselves.

Ventilatory function in children with severe motor disorders using night-time postural equipment

AIM

Night-time postural equipment (NTPE) can prevent hip subluxation in children with severe motor disorders (SMDs). However, it is unclear how it affects ventilatory function. The aims of the study were to determine how NTPE use affects ventilatory function and to compare night-to-night variability of ventilatory function in children with SMDs and typically developing healthy children.

METHOD

Fifteen NTPE users (six males, nine females), aged 1 to 19 years (mean age 8y 7mo) alternated sleep condition between NTPE and sleeping unsupported for 14 nights. In all but two participants, gross motor function was classified as Gross Motor Function Classification System (GMFCS) level V; in the other two it was level IV. Oxyhaemoglobin saturation (SpO2 ) was monitored each night and transcutaneous CO2 (PtcCO2 ) for one night in each sleep condition. In 17 healthy children of similar age, home SpO2 only was monitored for seven nights.

RESULTS

In 13 of 15 NTPE users and 12 of the 17 typically developing children, SpO2 monitoring was satisfactorily completed. Of the children with SMDs, two had mean SpO2 levels below the treatment threshold for supplemental oxygen, which was uniquely associated with use of NTPE in only one participant, and three had nocturnal hypoventilation, which was uniquely associated with NTPE use in only one case. Night-to-night SpO2 variability was higher in children with SMDs than in typically developing children.

INTERPRETATION

NTPE may impair or enhance ventilatory function in a minority of children. Owing to night-to-night variability in SpO2 , at least three nights of monitoring are recommended to determine optimal positioning for effective ventilation before and after NTPE introduction.

Long-term survival of children with cerebral palsy in Okinawa, Japan

AIM

The aim of this study was to describe the survival prognosis of children with cerebral palsy (CP) in Okinawa, Japan.

METHOD

A cohort study was conducted on all children with CP born between 1988 and 2005 in Okinawa, Japan. Survival proportions were determined with a life table and Kaplan-Meier survival curves were plotted. The effect of each predictor variable was estimated using Cox regression analysis.

RESULTS

This study included 580 children with CP (332 males, 248 females). In the cohort, 119 (20.5%) children were classified in Gross Motor Function Classification System (GMFCS) level I, 65 (11.2%) were classified in level II, 40 (6.9%) in level III, 189 (32.6%) in level IV, 166 (28.6%) in level V and GMFCS level was unknown for one. Of the 34 children who died, 29 were classified in GMFCS level V and GMFCS level was unknown for one. Mean age at start of follow-up was 24.5 months (SD 2.6 mo); mean length of follow-up was 8 years 8 months (standard error of the mean 0.214 y). The 5 year- and 18-year survival percentages of the entire cohort were 98% and 89% respectively. In children with CP, significantly lower survival rates were associated with multiple factors, including a birthweight of at least 2500 g (p=0.009), a gestational age of at least 37 weeks (p=0.004), and the most severe gross motor limitation, GMFCS level V (p<0.001). However, multivariate analysis showed GMFCS level V was the only significant predictor variable (p<0.001) for survival of CP.

INTERPRETATION

This study is the first to describe survival of children with CP in Japan. Our results are similar to those previously reported in other countries. These results are important in planning adequate provision of social and medical services for individuals with CP.

Decision making among different treatment options for neurologically impaired boys with undescended testis: a multinational pediatric survey

OBJECTIVE

To determine the attitude of referring pediatricians towards the decision of treatment modalities for undescended testis (UDT) in neurologic impaired boys (NIB).

METHODS AND MATERIALS

An online questionnaire was offered to registered pediatricians in Austria and Germany for online completion.

RESULTS

221 male (61.6%) and 138 female (38.4%) pediatricians completed the survey; 326 (90.8%) believe that UDT should be treated according to national guidelines; 31 (8.6%) believe that UDT should be treated according to the parental wish, whereas only 2 (0.6%) tend to no treatment at all. Tumor prophylaxis, further sexual life, legal concerns, risks of anesthesia, and the choice of the parents have major impact on the perception of UDT. Moreover, fertility and limited life expectancy seem to be of minor importance only. In general, Pearson χ2 test could not identify age and sex of pediatricians as significant predictor of how the importance of the treatment of UDT is appraised.

CONCLUSION

From the pediatric point of view UDT in NIB is an important issue and should be treated according to guidelines. Nevertheless, this study indicates the problems in decision-making and choosing the best management for UDT in NIB. Undoubtedly, further ethical discussion is needed to optimize treatment of UDT in NIB.

Bronchiectasis in chronic pulmonary aspiration: risk factors and clinical implications

INTRODUCTION

Bronchiectasis is a well-known sequela of chronic pulmonary aspiration (CPA) that can result in significant respiratory morbidity and death. However, its true prevalence is unknown because diagnosis requires high resolution computed tomography which is not routinely utilized in this population. This study describes the prevalence, time course for development, and risk factors for bronchiectasis in children with CPA.

MATERIALS AND METHODS

Using a cross-sectional design, medical records were reviewed for all patients with swallow study or airway endoscopy-confirmed aspiration in our airway center over a 21 month period. All patients underwent rigid and flexible bronchoscopy, and high resolution chest computed tomography. Prevalence, distribution, and risk factors for bronchiectasis were identified.

RESULTS

One hundred subjects age 6 months to 19 years were identified. Overall, 66% had bronchiectasis, including 51% of those less than 2 years old. The youngest was 8 months old. Severe neurological impairment (OR 9.45, P<0.004) and history of gastroesophageal reflux (OR 3.36, P=0.036) were identified as risk factors. Clinical history, exam, and other co-morbidities did not predict bronchiectasis. Sixteen subjects with bronchiectasis had repeat chest computed tomography with 44% demonstrating improvement or resolution.

DISCUSSION

Bronchiectasis is highly prevalent in children with CPA and its presence in young children demonstrates that it can develop rapidly. Early identification of bronchiectasis, along with interventions aimed at preventing further airway damage, may minimize morbidity and mortality in patients with CPA.

Statistician expert witnesses in agreement on relative hazards

‘If anticoagulants had been administered sooner, my client would not have died’ was a central claim put to us, as statistician expert witnesses, by a Claimant's and Defendant's lawyers. To assist other litigants, and without identifying the specific case, we set out the study types that contribute to the evidence base, and their limitations. We then explain why it is difficult to adduce evidence about the relative risk of dying from pulmonary embolism within 12 hours of admission to accident and emergency even when it is well accepted that anticoagulation reduces the risk of dying within the next seven days of patients at objectively confirmed risk of pulmonary embolism. No matter how much we may want an answer, or how tragic an individual outcome, we can only work from the available evidence or work to improve the evidence base, which needs to be resourced.

Cost-effectiveness analysis of a system-based approach for managing neonatal jaundice and preventing kernicterus in Ontario

OBJECTIVE

To evaluate the incremental cost-effectiveness of a system-based approach for the management of neonatal jaundice and the prevention of kernicterus in term and late-preterm (≥35 weeks) infants, compared with the traditional practice based on visual inspection and selected bilirubin testing.

STUDY DESIGN

Two hypothetical cohorts of 150,000 term and late-preterm neonates were used to compare the costs and outcomes associated with the use of a system-based or traditional practice approach. Data for the evaluation were obtained from the case costing centre at a large teaching hospital in Ontario, supplemented by data from the literature.

RESULTS

The per child cost for the system-based approach cohort was $176, compared with $173 in the traditional practice cohort. The higher cost associated with the system-based cohort reflects increased costs for predischarge screening and treatment and increased postdischarge follow-up visits. These costs are partially offset by reduced costs from fewer emergency room visits, hospital readmissions and kernicterus cases. Compared with the traditional approach, the cost to prevent one kernicterus case using the system-based approach was $570,496, the cost per life year gained was $26,279, and the cost per quality-adjusted life year gained was $65,698.

CONCLUSION

The cost to prevent one kernicterus case using the system-based approach is much lower than previously reported in the literature.

Survival after spinal cord injury: a systematic review

Spinal cord injury (SCI) leading to neurological deficits produces long-term effects that persist over a lifetime. Survival analysis of patients with SCI, at individual and population level, is important for public health management and the assessment of treatment achievements. The current study evaluated survival following traumatic and non-traumatic SCI worldwide. A systematic review was conducted, and all included papers were assessed for quality using a purposely designed assessment form. Survival data were presented in Kaplan-Meier curves and compared using the log-rank test. Sixteen studies were included of which 11 concerned traumatic SCI, four non-traumatic SCI, and one both. Crude standard mortality rates (SMRs) revealed that overall mortality in SCI is up to three times higher than in the general population. Survival rates were statistically significantly lower in non-traumatic SCI than in traumatic SCI (log-rank p = 0.000). Age at injury, neurological level, extent of lesion, and year of injury have been described as predictors of survival. Causes of death stem from secondary complications, with failure of the respiratory system being the leading cause. This is the first systematic literature review on survival analysis following SCI worldwide. An increase in survival over time was found. However, the SMRs of individuals with SCI still exceed those of an age-matched non-disabled population, mainly due to secondary complications. Lower survival rates were observed in non-traumatic SCI compared with traumatic SCI.

Health inequity in children and youth with chronic health conditions

BACKGROUND

Over the last decades, there have been great advances in health care delivered to children with chronic conditions, but not all children have benefitted equally from them.

OBJECTIVES

To describe health inequities experienced by children with chronic health conditions.

METHODS

We performed a literature review of English-language studies identified from the Medline, Centers for Disease Control and Prevention, National Cancer Institute, and Cystic Fibrosis Foundation Web sites that were published between January 1985 and May 2009, included children aged 0 to 18 years, and contained the key words "incidence," "prevalence," "survival," "mortality," or "disparity" in the title or abstract for the following health conditions: acute leukemia, asthma, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders, cerebral palsy, cystic fibrosis, diabetes mellitus, Down syndrome, HIV/AIDS, major congenital heart defects, major depressive disorder, sickle cell anemia, spina bifida, and traumatic brain injury.

RESULTS

Black children had higher rates of cerebral palsy and HIV/AIDS, were less likely to be diagnosed with ADHD, had more emergency department visits, hospitalizations, and had higher mortality rates associated with asthma; and survived less often with Down syndrome, type 1 diabetes, and traumatic brain injury when compared with white children. Hispanic children had higher rates of spina bifida from Mexico-born mothers, had higher rates of HIV/AIDS and depression, were less likely to be diagnosed with ADHD, had poorer glycemic control with type 1 diabetes, and survived less often with acute leukemia compared with white children.

CONCLUSIONS

Serious racial and ethnic health and health care inequities persist for children with chronic health conditions.

Multiplicity and early gestational age contribute to an increased risk of cerebral palsy from assisted conception: a population-based cohort study

BACKGROUND

This paper assesses the risk of cerebral palsy (CP) in children born after assisted conception compared with children born after natural conception (NC).

METHODS

This population based follow-up study included all 588,967 children born in Denmark from 1995 to 2003. Assisted conception was defined as IVF, with or without ICSI, and ovulation induction (OI), with or without subsequent insemination.

RESULTS

There were 33 139 (5.6%) children born in Denmark from 1995 to 2003 as a result of assisted conception and through to June 2009, 1146 (0.19%) children received a CP diagnosis. Children born after assisted conception had an increased risk of a CP diagnosis, crude hazard rate ratio (HRR) 1.90 (95% CI: 1.57-2.31) compared with NC children. Divided into IVF and OI children compared with NC children, the risk was HRR 2.34 (95% CI: 1.81-3.01) and HRR 1.55 (95% CI: 1.17-2.06), respectively. When we included the intermediate factors multiplicity and gestational age in multivariate models, the risk of CP in assisted conception disappeared. In general, children with CP born after assisted conception had similar CP subtypes and co-morbidities as children with CP born after NC.

CONCLUSION

The risk of CP is increased after both IVF and OI. The increased risk of CP in children born after assisted conception, and in particular IVF, is strongly associated with the high proportion of multiplicity and preterm delivery in these pregnancies. A more widespread use of single embryo transfer warrants consideration to enhance the long-term health of children born after IVF.

Cerebral palsy and aging

Cerebral palsy (CP), the most common major disabling motor disorder of childhood, is frequently thought of as a condition that affects only children. Deaths in children with CP, never common, have in recent years become very rare, unless the child is very severely and multiply disabled. Thus, virtually all children assigned the diagnosis of CP will survive into adulthood. Attention to the adult with CP has been sparse, and the evolution of the motor disorder as the individual moves through adolescence, young adulthood, middle age, and old age is not well understood. Nor do we know what happens to other functional domains, such as communication and eating behavior, in adults with CP. Although the brain injury that initially causes CP by definition does not progressively worsen through the lifetime, the effects of CP manifest differently throughout the lifespan. The aging process must inevitably interact with the motor disorder, but we lack systematic, large-scale follow-up studies of children with CP into adulthood and through adulthood with thorough assessments performed over time. In this paper we summarize what is known of the epidemiology of CP throughout the lifespan, beginning with mortality and life expectancy, then survey what is known of functioning, ability, and quality of life of adults with CP. We conclude by describing a framework for future research on CP and aging that is built around the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) and suggest specific tools and approaches for conducting that research in a sound manner.