The changing picture of cerebral dysfunction in early childhood

The complex aetiology of cerebral palsy

Cerebral palsy (CP) is the most prevalent, severe and costly motor disability of childhood. Consequently, CP is a public health priority for prevention, but its aetiology has proved complex. In this Review, we summarize the evidence for a decline in the birth prevalence of CP in some high-income nations, describe the epidemiological evidence for risk factors, such as preterm delivery and fetal growth restriction, genetics, pregnancy infection and other exposures, and discuss the success achieved so far in prevention through the use of magnesium sulfate in preterm labour and therapeutic hypothermia for birth-asphyxiated infants. We also consider the complexities of disentangling prenatal and perinatal influences, and of establishing subtypes of the disorder, with a view to accelerating the translation of evidence into the development of strategies for the prevention of CP.

[Neuropsychomotor developmental delay: conceptual map, term definitions, uses and limitations]

OBJECTIVE:

To retrieve the origin of the term neuropsychomotor developmental delay" (NPMD), its conceptual evolution over time, and to build a conceptual map based on literature review.

DATA SOURCE:

A literature search was performed in the SciELO Brazil, Web of Science, Science Direct, OneFile (GALE), Pubmed (Medline), Whiley Online, and Springer databases, from January of 1940 to January of 2013, using the following keywords: NPMD delay, NPMD retardation, developmental delay, and global developmental delay. A total of 71 articles were selected, which were used to build the conceptual map of the term.

DATA SYNTHESIS:

Of the 71 references, 55 were international and 16 national. The terms developmental delay and global developmental delay were the most frequently used in the international literature and, in Brazil, delayed NPMD was the most often used. The term developmental delay emerged in the mid 1940s, gaining momentum in the 1990s. In Brazil, the term delayed NPMD started to be used in the 1980s, and has been frequently cited and published in the literature. Delayed development was a characteristic of 13 morbidities described in 23 references. Regarding the type of use, 19 references were found, with seven forms of use. Among the references, 34 had definitions of the term, and 16 different concepts were identified.

CONCLUSIONS:

Developmental delay is addressed in the international and national literature under different names, various applications, and heterogeneous concepts. Internationally, ways to improve communication between professionals have been indicated, with standardized definition of the term and use in very specific situations up to the fifth year of life, which was not found in Brazilian publications.

Using postural reactions as a screening test to identify high-risk infants for cerebral palsy: a prospective study

To clarify the predictive value of the seven more commonly used postural reactions (PR) in the 1st year of life regarding the diagnosis of cerebral palsy (CP), we prospectively examined 204 high-risk infants of whom 58 developed CP, 22 had developmental retardation (DR) and 124 were normal at follow-up at 3 years of age. Abnormalities of five or more PR from the 1st month of life were correlated with spastic CP, while five or six abnormal PR were also correlated with athetoid CP. Three or less abnormal PR correlated with a normal outcome. All seven PR tested were significantly abnormal in children with spastic CP from the 1st month compared to normal children. Athetoid children demonstrated abnormalities of the Peiper-Isbert (P-I) reaction and Vojta reaction from the 1st month and of the vertical, horizontal and Collis vertical suspension from the 3rd month. Children with DR had significantly abnormal Collis horizontal and Collis vertical suspension, Vojta reaction and traction response from the 1st month and Peiper-Isbert reaction from the 3rd month. Ataxic children demonstrated significantly abnormal traction response from the 1st month, Collis horizontal reaction from the 7th month and Peiper-Isbert reaction from the 11th month. We conclude that the examination of PR is a useful quantitative and qualitative diagnostic screening tool for high-risk infants from the 1st month of life.

Prospective follow-up of primitive reflex profiles in high-risk infants: clues to an early diagnosis of cerebral palsy

To clarify reflex profiles in the first year of life in connection with categories of neurologic abnormality, eight primitive reflexes (i.e., the palmar grasp reflex, the plantar grasp reflex, the Galant response, the asymmetric tonic neck reflex, the suprapubic extensor reflex, the crossed extensor reflex, the Rossolimo reflex, and the heel reflex) were prospectively examined in 204 high-risk infants, of whom 58 developed cerebral palsy, 22 had developmental retardation, and 124 were normal at follow-up examination at 2 years of age. The change in the retention time of reflex activity for each of these reflexes was characteristic for each category or type of neurologic abnormality: retention of palmar grasp reflex, suprapubic extensor reflex, crossed extensor reflex, Rossolimo reflex, and heel reflex in spastic cerebral palsy, as well as retention of plantar grasp reflex, Galant reflex, and asymmetric tonic neck reflex in athetoid cerebral palsy and somewhat weaker retention of these reflexes in developmental retardation (statistical significance P < .001 compared with normally developed patients). These characteristic changes imply that a presumptive diagnosis can be made in neurologically high-risk infants by examination of the primitive reflexes, which are of specific significance among the other neurologic criteria within the first year of life.

Motor function of infants with spastic hemiplegia

The motor function of 25 children with spastic hemiplegia was examined retrospectively using videotapes recorded at 2-8 months of age. Many infants showed deficient forward movement of the arm and deficient opening of the hand on the affected side. At 7 and 8 months of age, whether the hand was semiflexed or clenched was correlated with the later upper extremity function. In the prone position, most could support their weight on the flexed arm on the affected side. In the supine position, half of the infants could not extend the knee on the affected side. At 2 months of age, asymmetry of the upper and lower extremity movements was not identified. Persistent primitive reflexes and abnormal truncal muscular tone were not recognized in the hemiplegic infants, and did not seem to be signs predicting hemiplegic cerebral palsy.

Primitive reflexes. Their contribution to the early detection of cerebral palsy

In evaluating the infant for significant motor impairment, a framework to organize and analyze data is presented. Five general areas of information are essential: (1) motor milestone attainment, (2) the classic neurological examination, (3) primitive reflex and postural reaction patterns, (4) progressive vs static nature of the dysfunction, and (5) associated evidence for neurological dysfunction and/or structural nervous system damage. A sixth criterion, age of onset, is relevant--but controversial--to making the specific diagnosis of cerebral palsy. The treatment of and prognosis for children with cerebral palsy have been linked to the historical and examination features outlined, particularly primitive reflexes. For the practicing pediatrician, understanding the fundamentals of the primitive reflex/postural reaction transition and achieving clinical facility with the elicitation of these signs represent skills that are readily acquired, easy to incorporate in routine clinical practice, and diagnostically useful.

Primitive reflex profiles in infants: differences based on categories of neurological abnormality

In order to clarify reflex profiles in the first year of life in connection with categories of neurological abnormality, six primitive reflexes, i.e., the crossed extensor reflex, suprapubic extensor reflex, heel reflex, Galant response, asymmetric tonic neck reflex and plantar grasp response, were examined in 458 normal infants, 78 infants with cerebral palsy (CP) and 81 infants with mental retardation (MR), whose diagnoses were confirmed at a later follow-up examination. The change in the mean score for each of these reflexes with age was characteristic for each category or type of neurological abnormality. This implies that a presumptive diagnosis can be made in neurologically high-risk infants by examination of the primitive reflexes. Such reflexes are therefore of specific significance, among other neurological criteria, in infants within the first year of life.

Residual developmental disabilities in children with transient hypertonicity in infancy

Developmental disabilities occurred in children who manifested transient neurologic abnormalities in early infancy. In an attempt to identify associated problems at an earlier age, the neuromotor and developmental progress of 33 children who had transient hypertonicity during early infancy was analyzed. At 2-3 years of age, various developmental abnormalities were identified in more than two-thirds of these children. Delays in speech and language development and also in fine motor/adaptive and behavioral difficulties were most frequently present. Over time, these problems persisted and other disorders also became apparent. At 5 years of age or older, learning disabilities were frequent and associated with language and perceptual problems. None of the patients had epilepsy; mental retardation was present in only 2 children. Our study demonstrates that children with transient hypertonicity in early infancy are at risk for various developmental problems which can be identified as early as 2 years of age. It also indicates that although their severity lessens over time, these developmental abnormalities tend to persist.

The diagnostic value of the neurodevelopmental examination

The neurodevelopmental examination is a pediatric approach to developmental diagnosis that relies on evaluation of multiple streams of development. The value of the neurodevelopmental examination for the early diagnosis of cerebral palsy and mental retardation was studied by a retrospective analysis of prospectively (longitudinally) collected data. Both conditions were found to be accurately diagnosed in the first year of life. For cerebral palsy, sensitivity was 0.81 and specificity 1.00; for mental retardation, sensitivity was 0.56 and specificity 0.96. The trained pediatrician can make early diagnoses of developmental disabilities.

Follow-up of pre-term infants: is correction of the developmental quotient for prematurity helpful?

Developmental quotients, measured on the Griffiths' scales, of 114 preterm infants of less than 34 wk gestation are compared with abnormal neurological findings at 1 yr of cerebral palsy, dystonia, and motor delay. The developmental quotient (DQ) uncorrected for prematurity more readily distinguishes the abnormal infant than the corrected DQ. It is recommended that while developmental follow-up still uses scales originally standardised on older preterm and full-term infants the uncorrected developmental quotient is also used. Ideally normative data on the preterm infant should be compiled as a basis for assessing development in these infants.

Early intervention-fact or fiction?

A group of 50 cerebral-palsied children seen in one clinic between 1952 and 1965 were compared with a second group of 50 seen between 1952 and 1978. The latter group had all been included in a developmental enrichment program at the clinic. The results showed that the later-treated group had had more surgical operations than the earlier group, and at younger ages; that they were able to sit and stand earlier; and that eventually they had greater ambulatory ability. Early intervention also improved family relationships, and parents and siblings became more involved in the team approach to the children's therapy.

Infant neurological abnormalities as indicators of cognitive impairment

In a prospective longitudinal study, 1319 children who had received three neurological examinations during their first year of life were administered measures of cognitive development and academic achievement up to and including 12 years of age. With both social class and birthweight statistically controlled, children identified as neurologically suspect or abnormal on more than one of the infant examinations (N = 22) consistently performed far below control children on measures of intelligence, motor skills, language development and school achievement. Children who had been neurologically suspect or abnormal on only one infant examination (N = 165) performed significantly less well than those never suspected of neurological abnormality in infancy (N = 1132).

The child at risk for learning disorder. Can he be identified during the first year of life?

In a prospective study, observable neurologic signs during the first year of life have been found to be related significantly to seven year neuro logic and psychologic measures which are associated with learning disabilities. Scored ratings of multiple outcome items are being found to be better for identifying these psychoneurologically inefficient chil dren than are isolated measures which reflect stress, such as prema turity or the Apgar rating. From the Collaborative Study schedules a neurologic "at risk" index is being developed. This promises to be help ful for identifying babies who are likely to have a later learning difficulty.