Analysis by gestational age of cerebral palsy in singleton births in north-east England 1970-94

Live births with cerebral palsy at a tertiary maternity hospital: incidence and associated risk factors over a 17-year period

The aim of this retrospective study was to establish the incidence and associated risk factors for cerebral palsy (CP) at a tertiary maternity hospital in the UK between 2000-2016. We identified CP patients from our electronic coding system using ICD codes. Multiple independent variables for all live births born during this period were included in a univariate and multivariate logistic regression (LR) to identify associations between these and CP. We identified 130 CP children out of 87318 live births. Univariate LR determined male sex, birth weight <2500 g, gestational age of ≤36 weeks, Small-for-gestational-age, 1-and 5-minute Apgar score <9, neonatal intensive care unit (NICU) admission, multiple births, breech, emergency Caesarean section and delivery between 16.00-20.00 as significant risk factors. In the multivariate LG male sex, 1-minute Apgar <9, 5-minute Apgar <5 and admission to NICU remained as significant risk factors. The risk for delivery between 16.00-19.59 was nearly significant. There was a significant association between NICU admission and moderate-severe CP. Our CP incidence of 0.149% is at the lower end of the incidence spectrum of international comparisons.Impact StatementWhat is already known on this subject? The historic reported incidence of cerebral palsy (CP) ranges from 1.1 to 3.6 cases per 1000 live births, with birth weight <2500g, birth <28 weeks of gestation, Apgar scores ≤4 and male sex having been associated with an increased incidence.What do the results of this study add? This is a large series of live births from a tertiary maternity hospital with a comparative low CP incidence of 0.149%, despite the hospital dealing with many complex pregnancies and deliveries. We identified that already an Apgar score of <9 at 1 minute (significant) and births between 16.00-20.00 (non-significant) were associated with an increased risk to develop CP but not with a specific day of the week.What are the implications of these findings for clinical practice and/or future research? Our significant association between a 1-minute Apgar score of <9 and CP stresses the importance of immediate efficient resuscitation already for babies with a 1-minute score as high as 8. The increased CP risk for deliveries between 16.00-19.59 may be linked to staffing issues and needs further exploration.What this paper addsNew data from a single maternity hospitalAnalysis of risk factorsGMFCS distribution.

No. 376-Magnesium Sulphate for Fetal Neuroprotection

OBJECTIVE

The objective is to provide guidelines for the use of antenatal magnesium sulphate for fetal neuroprotection of the preterm infant.

OPTIONS

Antenatal magnesium sulphate administration should be considered for fetal neuroprotection when women present at ≤33 + 6 weeks with imminent preterm birth, defined as a high likelihood of birth because of active labour with cervical dilatation ≥4 cm, with or without preterm pre-labour rupture of membranes, and/or planned preterm birth for fetal or maternal indications. There are no other known fetal neuroprotective agents.

OUTCOMES

The outcomes measured are the incidence of cerebral palsy (CP) and neonatal death.

EVIDENCE

Published literature was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library in December 2017, using appropriate controlled vocabulary and key words (magnesium sulphate, cerebral palsy, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Antenatal magnesium sulphate for fetal neuroprotection reduces the risk of "death or CP" (relative risk [RR] 0.85; 95% confidence interval [CI] 0.74-0.98; 4 trials, 4446 infants), "death or moderate-severe CP" (RR 0.85; 95% CI 0.73-0.99; 3 trials, 4250 infants), "any CP" (RR 0.71; 95% CI 0.55-0.91; 4, trials, 4446 infants), "moderate-to-severe CP" (RR 0.60; 95% CI 0.43-0.84; 3 trials, 4250 infants), and "substantial gross motor dysfunction" (inability to walk without assistance) (RR 0.60; 95% CI 0.43-0.83; 3 trials, 4287 women) at 2 years of age. Results were consistent between trials and across the meta-analyses. There is no anticipated significant increase in health care-related costs because women eligible to receive antenatal magnesium sulphate will be judged to have imminent preterm birth.

VALIDATION

Australian National Clinical Practice Guidelines were published in March 2010 by the Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal magnesium sulphate was recommended for fetal neuroprotection in the same dosage as recommended in these guidelines. However, magnesium sulphate was recommended only at <30 weeks gestation, based on 2 considerations. First, no single gestational age subgroup was considered to show a clear benefit. Second, in the face of uncertainty, the committee felt it was prudent to limit the impact of their clinical practice guidelines on resource allocation. In March 2010, the American College of Obstetricians and Gynecologists issued a Committee Opinion on magnesium sulphate for fetal neuroprotection. It stated that "the available evidence suggests that magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants." No official opinion was given on a gestational age cut-off, but it was recommended that physicians develop specific guidelines around the issues of inclusion criteria, dosage, concurrent tocolysis, and monitoring in accordance with 1 of the larger trials. Similarly, the World Health Organization also strongly recommends use of magnesium sulphate for fetal neuroprotection in its 2015 recommendations on interventions to improve preterm birth outcomes but cites further researching on dosing regimen and re-treatment.

SPONSORS

Canadian Institutes of Health Research (CIHR).

SUMMARY STATEMENT

RECOMMENDATIONS.

School Age Neurological and Cognitive Outcomes of Fetal Growth Retardation or Small for Gestational Age Birth Weight

Children who were growth restricted in utero (FGR) and are born small for gestational age (SGA) may experience poorer long term neurological and cognitive outcomes. Those also born preterm may have particular difficulties. The objective of this paper was to review the literature on school age neurocognitive outcome for term and preterm children that was published in the last 15 years. Considering term born children first, there is evidence that these children are at higher risk for Cerebral Palsy (CP) than those born appropriate for gestational age (AGA); information on neuromotor function in the absence of CP is somewhat contradictory. With regards to cognitive outcome, the most common finding was that being born SGA and/or FGR at term does not impact negatively on general intellectual functioning, commonly assessed by IQ scores. There was some indication that they may experience particular problems with attention. With regards to children born preterm, the risk of CP appears not to be increased compared to those preterms born AGA. For preterm children who do not develop CP, motor outcome is more affected by post-natal and post-neonatal brain growth than intrauterine growth. In contrast to term born children, preterm SGA and/or FGR children are at increased risk of cognitive and behavioral difficulties, and in common with term born children, are at higher risk than their AGA counterparts of difficulties with attentional control. In conclusion, preterm born SGA and/or FGR children are at higher risk of neurodevelopmental problems in the school years. It is important to continue to follow up children into the school age years because these difficulties may take time to emerge, and may be more visible in the more demanding school environment.

Are Extremely Low Gestational Age Newborns Born to Obese Women at Increased Risk of Cerebral Palsy at 2 Years?

The authors hypothesized that the risk of cerebral palsy at 2 years in children born extremely preterm to overweight and obese women is increased relative to the risk among children born to neither overweight nor obese women. In a multicenter prospective cohort study, the authors created multinomial logistic regression models of the risk of diparetic, quadriparetic, and hemiparetic cerebral palsy that included the prepregnancy body mass index of mothers of 1014 children born extremely preterm, cerebral palsy diagnoses of children at 2 years, as well as information about potential confounders. Overweight and obese women were not at increased risk of giving birth to a child who had cerebral palsy. The risk ratios associated with overweight varied between 1.1 for quadriparesis (95% CI = 0.5, 2.1) to 2.0 for hemiparesis (95% CI = 0.4, 9.8). The risk ratios associated with obesity varied between 0.7 for diparesis (95% CI = 0.2, 2.5) to 2.5 for hemiparesis (95% CI = 0.4, 13).

Gender Affects Long-Term Neurological Outcome of Neonates

OBJECTIVE

We evaluated the possible association between fetal gender and long-term pediatric neurological morbidity.

METHODS

We performed a population-based retrospective cohort analysis comparing the risk of long-term neurological morbidity (up to age 18 years) of children born during the years 1991 to 2013 according to their gender. Neurological morbidity evaluated included hospitalizations in childhood involving pervasive developmental disorder, obstructive sleep apnea, cerebral palsy, epilepsy, and infantile spasms and disorders of eating as recorded in the hospital files. Multiple pregnancies and fetal congenital malformations were excluded. Kaplan-Meier survival curves were constructed to compare the cumulative neurological morbidity over the study period. A Cox proportional hazards model was used to control for obstetrical confounders, including gestational age at birth, birth weight, and maternal factors.

RESULTS

During the study period, 240,953 newborns were included in the long-term analysis: 51.0% (n = 122,840) males and 49.0% (n = 118,113) females. Hospitalizations for neurological problems (up to age 18 years) were significantly more common in males compared with females (1.1% vs 0.8%, respectively, odds ratio 1.31, 95% confidence interval 1.2 to 1.4, P < 0.001). Specifically, pervasive developmental disorder and obstructive sleep apnea were found to be significantly more common in males, and cerebral palsy reached borderline significance (0.1% vs 0.04%, odds ratio 1.39, 95% confidence interval 0.9 to 1.9, P = 0.06). The Kaplan-Meier survival curves demonstrated males to have a significantly higher cumulative incidence of total neurological morbidity as well as of pervasive developmental disorder and obstructive sleep apnea (all log-rank test P values <0.001). In the Cox regression model, male gender exhibited an independent association with long-term neurological morbidity, while adjusting for birth weight, gestational age, and other confounding variables (adjusted hazard ratio 1.29, 95% confidence interval 1.2 to 1.4, P < 0.001).

CONCLUSION

Males are at an increased risk for pediatric neurological morbidity independent of gestational age at birth and birth weight.

Melatonin for women in pregnancy for neuroprotection of the fetus

BACKGROUND

Melatonin is an antioxidant with anti-inflammatory and anti-apoptotic effects. Animal studies have supported a fetal neuroprotective role for melatonin when administered maternally. It is important to assess whether melatonin, given to the mother, can reduce the risk of neurosensory disabilities (including cerebral palsy) and death, associated with fetal brain injury, for the preterm or term compromised fetus.

OBJECTIVES

To assess the effects of melatonin when used for neuroprotection of the fetus.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016).

SELECTION CRITERIA

We planned to include randomised controlled trials and quasi-randomised controlled trials comparing melatonin given to women in pregnancy (regardless of the route, timing, dose and duration of administration) for fetal neuroprotection with placebo, no treatment, or with an alternative agent aimed at providing fetal neuroprotection. We also planned to include comparisons of different regimens for administration of melatonin.

DATA COLLECTION AND ANALYSIS

Two review authors planned to independently assess trial eligibility, trial quality and extract the data.

MAIN RESULTS

We found no randomised trials for inclusion in this review. One study is ongoing.

AUTHORS' CONCLUSIONS

As we did not identify any randomised trials for inclusion in this review, we are unable to comment on implications for practice at this stage.Although evidence from animals studies has supported a fetal neuroprotective role for melatonin when administered to the mother during pregnancy, no trials assessing melatonin for fetal neuroprotection in pregnant women have been completed to date. However, there is currently one ongoing randomised controlled trial (with an estimated enrolment target of 60 pregnant women) which examines the dose of melatonin, administered to women at risk of imminent very preterm birth (less than 28 weeks' gestation) required to reduce brain damage in the white matter of the babies that were born very preterm.Further high-quality research is needed and research efforts should directed towards trials comparing melatonin with either no intervention (no treatment or placebo), or with alternative agents aimed at providing fetal neuroprotection (such as magnesium sulphate for the very preterm infant). Such trials should evaluate maternal and infant short- and longer-term outcomes (including neurosensory disabilities such as cerebral palsy), and consider the costs of care.

Early onset preeclampsia and cerebral palsy: a double hit model?

BACKGROUND

Cerebral palsy (CP) is a late sequel of pregnancy, and the role of preeclampsia is debatable.

OBJECTIVE

The aims of this study were to determine the association between preeclampsia and cerebral palsy and to determine the risk factors for the development of cerebral palsy in these patients.

STUDY DESIGN

A retrospective population-based cohort study was designed that included 229,192 singleton pregnancies. The study population was divided into 2 groups: (1) patients with preeclampsia (n = 9749) and (2) normotensive gestations (n = 219,443). Generalized Estimating Equation multiple logistic regression models were performed to study the associations among preeclampsia, small for gestational age, gestational age at delivery, and the risk factors for the development of cerebral palsy in neonates of women with preeclampsia.

RESULTS

The rate of cerebral palsy was double in patients with preeclampsia than in the normotensive group (0.2% vs 0.1%; P = .015); early onset preeclampsia and small for gestational age were independent risk factors for the subsequent development of cerebral palsy (odds ratio, 8.639 [95% confidence interval, 4.269-17.480]; odds ratio, 2.737 [95% confidence interval, 1.937-3.868], respectively). A second model was conducted to determine the risk factors for the development of cerebral palsy in women with preeclampsia. Birth asphyxia, complications of prematurity, and neonatal infectious morbidity, but not small for gestational age or gestational age at delivery, were independent risk factors for the development of cerebral palsy.

CONCLUSION

In a comparison with normal pregnant women, the rate of cerebral palsy is double among patients with preeclampsia, especially those with early-onset disease. Early-onset preeclampsia is an independent risk factor for cerebral palsy. Among women with preeclampsia, the presence of neonatal infectious morbidity, birth asphyxia, and complications of prematurity are independent risk factors for the development of cerebral palsy, which further supports the role of a multi-hit model in the pathogenesis of this syndrome.

The neurological outcomes of cerebellar injury in premature infants

AIM

Cerebellar injury is a characteristic injury associated with preterm infants. However, the impact of cerebellar injury on the development of preterm infants is unclear.

METHOD

We reviewed magnetic resonance image studies of preterm infants with cerebral palsy retrospectively and evaluated the developmental outcomes.

RESULTS

Cerebellar injury was recognized in 9 (2.4%) of 381 patients with cerebral palsy who were born preterm. The median gestational age was 26 (range 23-32) weeks and the median birth weight was 938 (range 492-1450) g. Seven of the nine patients had severe symmetric injuries to the inferior cerebellar hemispheres, resulting in a pancake-like appearance of the residual upper cerebellum. Supratentorial lesions were also recognized: periventricular leukomalacia in seven; atrophy of the basal ganglia in two; and intraventricular hemorrhage in two. Importantly, the motor dysfunction was related to the reduction in the white matter volume and severity of basal ganglia atrophy, but not to the cerebellar injury. Four of the nine patients could walk without limitations despite extensive cerebellar disruption. Only four patients could speak meaningful words during the study and only one spoke two-word sentences.

INTERPRETATION

The patients with cerebellar injury might have a communication handicap, rather than altered motor function. Prematurity-related cerebellar complications require more attention in terms of cognitive and speech function, in addition to neuromotor development.

Immediate Effect of Training at the Onset of Reaching in Preterm Infants: Randomized Clinical Trial

The authors' aim was to investigate the immediate effect of a single specific training session (serial varied practice), of short duration on the kinematic parameters of reaching, in the period of the emergence of the skill in preterm and low birth weight infants. The study included 16 infants of both sexes, born at a mean gestational age of 32.13 (±1.36) weeks and mean birth weight of 1720.94 (±358.46) g. The infants were randomly divided into 2 groups: experimental and control. The experimental group was given a 5-min training session in reaching, while the control group received no training. The results showed significant differences in peak velocity in the intra (Z = -2.10, p = .036) and intergroup (U = 9.00, p = .016) evaluations, which decreased in the experimental group after training. Cohen's d test for clinical relevance suggested that the specific, short duration training proved effective in promoting slower reaches, with greater adjustment and lower number of units of movement. These results are positive for preterm infants given that these parameters more closely resemble the typical development of mature reaching behaviors in term infants, which suggests that this protocol of reaching training (serial varied practice) could be used as an evidence-based intervention strategy.

Influence of antenatal magnesium sulfate application on cord blood levels of brain-derived neurotrophic factor in premature infants

AIM

To investigate the influence of antenatal magnesium sulfate (MgSO4) application on cord blood brain-derived neurotrophic factor (BDNF) levels - the first-line neuroprotection for preventing cerebral palsy in prematurely born infants.

SUBJECTS AND METHODS

A randomized controlled trial was conducted by observing 72 pregnant women who were divided into three groups: group I (preterm pregnancy with MgSO4), group II (preterm pregnancy without MgSO4), and group III (full-term pregnancy as control group). Groups I and II were selected by block permutation randomization on subjects. Inclusion criteria consisted of preterm pregnancy at 34 weeks of gestation or less who were in labor or having planned terminations and receiving antenatal corticosteroids. Exclusion criteria consisted of previous complications caused by MgSO4, previous history of antenatal MgSO4 application in the current pregnancy infant was born before 4 h administration of MgSO4 or unborn more than 72 h after maximum course of antenatal MgSO4 of 24 h, prolonged antenatal MgSO4 treatment (>24 h), refusal to participate, and emergent adverse events during the study. Group I was given intravenous MgSO4; initial dose was 4 g, which was maintained at 1 g/h up to maximum of 24 h. Meanwhile, groups II and III were not given any special treatment. BDNF was examined by ELISA by taking 5 mL cord blood sample shortly after birth. The result was statistically measured by ANOVA.

RESULTS

The cord blood BDNF levels in premature infants with antenatal MgSO4 was significantly higher than in premature infants without antenatal MgSO4 (11,568 vs. 5027 pg/mL, P=0.000). Moreover, the result was statistically comparable to full-term infants (11,568 vs. 13,300 pg/mL, P=0.085).

CONCLUSION

The application of antenatal MgSO4 in preterm delivery increased cord blood BDNF levels, which could have a potential role on fetal neuroprotection. Further investigation is needed.

Magnesium sulphate for fetal neuroprotection: a cost-effectiveness analysis

BACKGROUND

The aim of this study was to assess the cost-effectiveness of administering magnesium sulphate to patients in whom preterm birth at < 32+0 weeks gestation is either imminent or threatened for the purpose of fetal neuroprotection.

METHODS

Multiple decision tree models and probabilistic sensitivity analyses were used to compare the administration of magnesium sulphate with the alternative of no treatment. Two separate cost perspectives were utilized in this series of analyses: a health system and a societal perspective. In addition, two separate measures of effectiveness were utilized: cases of cerebral palsy (CP) averted and quality-adjusted life years (QALYs).

RESULTS

From a health system and a societal perspective, respectively, a savings of $2,242 and $112,602 is obtained for each QALY gained and a savings of $30,942 and $1,554,198 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is imminent. From a health system perspective and a societal perspective, respectively, a cost of $2,083 is incurred and a savings of $108,277 is obtained for each QALY gained and a cost of $28,755 is incurred and a savings of $1,494,500 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is threatened.

CONCLUSIONS

Administration of magnesium sulphate to patients in whom preterm birth is imminent is a dominant (i.e. cost-effective) strategy, no matter what cost perspective or measure of effectiveness is used. Administration of magnesium sulphate to patients in whom preterm birth is threatened is a dominant strategy from a societal perspective and is very likely to be cost-effective from a health system perspective.

Magnesium sulphate at 30 to 34 weeks' gestational age: neuroprotection trial (MAGENTA)--study protocol

Background

Magnesium sulphate is currently recommended for neuroprotection of preterm infants for women at risk of preterm birth at less than 30 weeks’ gestation, based on high quality evidence of benefit. However there remains uncertainty as to whether these benefits apply at higher gestational ages.

The aim of this randomised controlled trial is to assess whether giving magnesium sulphate compared with placebo to women immediately prior to preterm birth between 30 and 34 weeks’ gestation reduces the risk of death or cerebral palsy in their children at two years’ corrected age.

Methods/design

Design: Randomised, multicentre, placebo controlled trial.

Inclusion criteria: Women, giving informed consent, at risk of preterm birth between 30 to 34 weeks’ gestation, where birth is planned or definitely expected within 24 hours, with a singleton or twin pregnancy and no contraindications to the use of magnesium sulphate.

Trial entry & randomisation: Eligible women will be randomly allocated to receive either magnesium sulphate or placebo.

Treatment groups: Women in the magnesium sulphate group will be administered 50 ml of a 100 ml infusion bag containing 8 g magnesium sulphate heptahydrate [16 mmol magnesium ions]. Women in the placebo group will be administered 50 ml of a 100 ml infusion bag containing isotonic sodium chloride solution (0.9%). Both treatments will be administered through a dedicated IV infusion line over 30 minutes.

Primary study outcome: Death or cerebral palsy measured in children at two years’ corrected age.

Sample size: 1676 children are required to detect a decrease in the combined outcome of death or cerebral palsy, from 9.6% with placebo to 5.4% with magnesium sulphate (two-sided alpha 0.05, 80% power, 5% loss to follow up, design effect 1.2).

Discussion

Given the magnitude of the protective effect in the systematic review, the ongoing uncertainty about benefits at later gestational ages, the serious health and cost consequences of cerebral palsy for the child, family and society, a trial of magnesium sulphate for women at risk of preterm birth between 30 to 34 weeks’ gestation is both important and relevant for clinical practice globally.

Trial registration

Australian New Zealand Clinical Trials Registry - ACTRN12611000491965

Continuity between fetal and neonatal neurobehavior

The human brain is very sensitive to environmental changes affecting its growth and development. Environmental changes influence neonatal behavior after birth, enabling continuity between prenatal and postnatal behavior, but postnatal adaptation could be considered as discontinuity. Thus there is the question of environmental discontinuity between intrauterine conditions characterized by existence of microgravity and extrauterine life with gravity as a developmental condition sine qua non. Four-dimensional ultrasound is currently being assessed as a functional prenatal screening test for detection of neurological impairment in utero. The Kurjak Antenatal Neurodevelopmental Test (KANET) combines the assessment of fetal behavior, general movements, and three out of four signs that have been postnatally considered as symptoms of possible neurodevelopmental impairment (neurological thumb, overlapping sutures and small head circumference). Although the KANET has been tested on normal and high-risk pregnancies, the significance of the test for detection and prevention of neurodevelopmental disability is still questionable.

Recent advances in understanding the endocrinology of human birth

The timing of human birth has a crucial impact upon the survival of the fetus. New knowledge on the regulation of human birth includes the role of endogenous retroviruses in the formation of the syncytiotrophoblast cells and consequently the secretion of corticotrophin releasing hormone, a hormone linked to gestational length determination. miRNAs have been identified that mediate progesterone withdrawal at labor by suppressing progesterone-induced transcription factors. Progress has also been made in understanding how the contractile machinery of the uterine myocytes is activated at labor and the role of small heat-shock proteins in this process. From this work, new therapeutic targets have been identified that may be used to regulate the onset of labor and improve neonatal mortality.

Antenatal magnesium individual participant data international collaboration: assessing the benefits for babies using the best level of evidence (AMICABLE)

BACKGROUND

The primary aim of this study is to assess, using individual participant data (IPD) meta-analysis, the effects of administration of antenatal magnesium sulphate given to women at risk of preterm birth on important clinical outcomes for their child such as death and neurosensory disability. The secondary aim is to determine whether treatment effects differ depending on important pre-specified participant and treatment characteristics, such as reasons at risk of preterm birth, gestational age, or type, dose and mode of administration of magnesium sulphate.

METHODS

DESIGN

The Antenatal Magnesium Individual Participant Data (IPD) International Collaboration: assessing the benefits for babies using the best level of evidence (AMICABLE) Group will perform an IPD meta-analysis to answer these important clinical questions. SETTING/TIMELINE: The AMICABLE Group was formed in 2009 with data collection commencing late 2010.

INCLUSION CRITERIA

Five trials involving a total 6,145 babies are eligible for inclusion in the IPD meta-analysis. PRIMARY STUDY OUTCOMES: For the infants/children: Death or cerebral palsy. For the women: Any severe maternal outcome potentially related to treatment (death, respiratory arrest or cardiac arrest).

DISCUSSION

Results are expected to be publicly available in 2012.

Different magnesium sulphate regimens for neuroprotection of the fetus for women at risk of preterm birth

BACKGROUND

The effectiveness of antenatal magnesium sulphate for neuroprotection of the fetus, infant, and child prior to very preterm birth, when given to women considered at risk of preterm birth, has been established. There is currently no consensus as to the regimen to use in terms of the dose, duration, the use of repeat dosing and timing.

OBJECTIVES

To assess the comparative effectiveness and adverse effects of different magnesium sulphate regimens for neuroprotection of the fetus in women considered at risk of preterm birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2011).

SELECTION CRITERIA

Randomised trials comparing different magnesium sulphate regimens when used for neuroprotection of the fetus in women considered at risk of preterm birth. We planned to include cluster trials. We planned to exclude quasi-randomised trials and those with a crossover design. We planned to include trials published as full-text papers, along with those published in abstract form only.

DATA COLLECTION AND ANALYSIS

We planned that at least two review authors would assess trial eligibility.

MAIN RESULTS

No eligible completed trials were identified.

AUTHORS' CONCLUSIONS

Although strong evidence supports the use of antenatal magnesium sulphate for neuroprotection of the fetus prior to very preterm birth, no trials comparing different treatment regimens have been completed. Research should be directed towards comparisons of different dosages and other variations in regimens, evaluating both maternal and infant outcomes.

Intrauterine growth restriction and cerebral palsy

Intrauterine growth restriction (IUGR) can be described as condition in which fetus fails to reach his potential growth. It is common diagnosis in obstetrics, and carries an increased risk of perinatal mortality and morbidity. Moreover, IUGR has lifelong implications on health, especially on neurological outcome. There is a need for additional neurological assessment during monitoring of fetal well-being, in order to better predict antenatally which fetuses are at risk for adverse neurological outcome. Studies have revealed that the behavior of the fetus reflects the maturational processes of the central nervous system (CNS). Hence, ultrasound investigation of the fetal behavior can give us insight into the integrity and functioning of the fetal CNS. Furthermore, investigations carried out using modern method, four-dimensional (4D) sonography, have produced invaluable details of fetal behavior and its development, opening the door to a better understanding of the prenatal functional development of the CNS. Based on previous observations and several years of investigation, our reaserch group has proposed a new scoring system for the assessment of fetal neurological status by 4D sonography named Kurjak antenatal neurodevelopmental test (KANET). The value of KANET in distinguishing fetal brain and neurodevelopmental alterations due to the early brain impairment in utero is yet to be assessed in large population studies. However, preliminary results are very encouraging.

Cerebral palsy registers and high-quality data: an evaluation of completeness of the 4Child register using capture-recapture techniques

BACKGROUND

As the survival of very preterm and low-birthweight infants increases, so does the importance of monitoring the birth prevalence of childhood impairments; disease registers provide a means to do so for these rare conditions. High levels of ascertainment for disease research registers have become increasingly difficult to achieve in the face of additional challenges posed by consent and confidentiality issues. 4Child - Four Counties Database of Cerebral Palsy, Vision Loss and Hearing Loss in Children has been collecting data and monitoring these three major childhood impairments since 1984.

METHODS

This study used capture-recapture and related techniques to identify areas which are particularly affected by low ascertainment, to estimate the magnitude of missing cases on the 4Child register and to provide birth prevalence estimates of cerebral palsy which allow for these missing cases.

RESULTS

Estimates suggest that while overall around 27% of cerebral palsy cases were not reported to 4Child, ascertainment for severely motor-impaired children (93% complete) and those born in two of the four counties was good (Oxfordshire: 90%, Northamptonshire: 94%). After allowing for missing cases, adjusted estimates of cerebral palsy birth prevalence for 1984-1993 were 3.0 per 1000 live births versus 2.5 per 1000 live births in 1994-2003.

CONCLUSIONS

Capture-recapture techniques can identify areas of poor ascertainment and add to information around the provision of cerebral palsy birth prevalence estimates. Despite variation in ascertainment over time, capture-recapture estimates supported a decline in cerebral palsy birth prevalence between the earlier and later study periods in the four English counties of the geographical area covered by 4Child.

Outcome at 4.5 years of children born after expectant management of early-onset hypertensive disorders of pregnancy

OBJECTIVE

The objective of the study was to describe neurodevelopmental outcome at the age of 4.5 years in 216 children, born after expectant management of severe early-onset hypertensive complications of pregnancy.

STUDY DESIGN

This was a prospective follow-up study until age 4.5 years from maternal admission onward. Developmental outcome measurements included child intelligence quotient and behavioral, motor, and neurological outcome. Abnormal composite outcome (perinatal mortality or abnormal developmental outcome) was studied in relation to gestational age (GA), birthweight (BW), and perinatal variables.

RESULTS

Fetal and neonatal mortality was 9% and 8%, respectively. Of the 178 survivors, 149 (84%) were seen for follow-up. Mean GA was 31.4 weeks and 90% were born growth restricted. Abnormal developmental outcome occurred in 20% and abnormal composite outcome in 37%.

CONCLUSION

Perinatal mortality or abnormal child development occurs in one third of pregnancies with early-onset and severe hypertensive complications and is highest in the lowest GA and BW ranges.

Trends in prevalence of cerebral palsy in children born with a birthweight of 2,500 g or over in Europe from 1980 to 1998

Time trends for cerebral palsy (CP) prevalence in children born > or =2,500 g vary across studies and scarce data exist on trends by subtype of CP. The objective of this study was to describe changes in prevalence of CP in infants born > or =2,500 g between 1980 and 1998 in Europe. Data were collated from the SCPE (Surveillance of Cerebral Palsy in Europe collaboration) common database. Poisson regression was used to test for change in prevalence over time. Birth year and register effects were explored and trends in prevalence were estimated by CP subtype and severity. Four thousand and two children with CP and birthweight > or =2,500 g were recorded in 15 population based-registers. The overall prevalence of CP was 1.16 per 1,000 live births (99% CI, 0.88-1.48) in 1980 and 0.99 (CI, 0.80-1.20) in 1998. The trend was not significant (P = .14), except in two registers. However, there were significant changes in the prevalence of spastic CP subtypes, with a decrease in the bilateral spastic form (P < .001), and an increase in the unilateral spastic form (P = .004). There was a concurrent reduction in neonatal mortality of children with birthweight > or =2,500 g: from 1.7 (CI, 1.4-2.1) to 0.9 (CI, 0.7-1.1) per 1,000 live births. In conclusion, for children born with birthweight > or =2,500 g, the prevalence of CP in Europe was stable in spite of changes by subtype and a significant decrease in neonatal mortality.

Influence of gestational age on nosologic CP characteristics in a high-risk population

The aim of this study is to investigate the interrelationship between gestational age (GA) and nosologic characteristics (type, distribution and severity) of cerebral palsy (CP) in a cohort of high-risk infants. One thousand ninety-nine consecutively neonatal intensive care unit-admitted high-risk infants (i.e., all infants with a GA less than 30 weeks and specified infants with GA >or= 30 weeks with a complicated neonatal course and/or brain lesion) were prospectively assessed up to the corrected age of 2 years or more. In 177 (16%) of these infants, CP was diagnosed. Of these infants, 26 were extremely preterm infants (GA 23-27 weeks), 62 very preterm (28-31 weeks), 36 moderately preterm (32-36) and 53 term infants (GA >or= 37 weeks). Spastic CP was significantly more present in the three preterm groups (77%, 90% and 72%, respectively) compared with the term ones (42%). At variance, dyskinetic CP was present in nearly half of the term group (47%) and remarkably less in all three preterm age groups (12%, 7% and 22%, respectively). Ataxic CP (7%) was of rare occurrence in all age groups. Distributive classification showed that bilateral spastic CP gradually dropped from 100% in the extremely preterm group down to 50% in the term infants. Inversely, unilateral spastic CP rises steeply with advancing GA. Severity of CP was significantly associated with birth year period in favour of mild CP. In high-risk neonates, dyskinetic CP increases steeply with increasing GA, whereas spastic CP decreases. Bilateral and unilateral involvements are gradually and oppositely changing with gestational age. It is tempting to explain the maturity-related association by gestational age-specific brain injuries.

The ELGAN study of the brain and related disorders in extremely low gestational age newborns

BACKGROUND

Extremely low gestational age newborns (ELGANs) are at increased risk for structural and functional brain abnormalities.

AIM

To identify factors that contribute to brain damage in ELGANs.

STUDY DESIGN

Multi-center cohort study.

SUBJECTS

We enrolled 1506 ELGANs born before 28 weeks gestation at 14 sites; 1201 (80%) survived to 2 years corrected age. Information about exposures and characteristics was collected by maternal interview, from chart review, microbiologic and histological examination of placentas, and measurement of proteins in umbilical cord and early postnatal blood spots.

OUTCOME MEASURES

Indicators of white matter damage, i.e. ventriculomegaly and echolucent lesions, on protocol cranial ultrasound scans; head circumference and developmental outcomes at 24 months adjusted age, i.e., cerebral palsy, mental and motor scales of the Bayley Scales of Infant Development, and a screen for autism spectrum disorders.

RESULTS

ELGAN Study publications thus far provide evidence that the following are associated with ultrasongraphically detected white matter damage, cerebral palsy, or both: preterm delivery attributed to preterm labor, prelabor premature rupture of membranes, or cervical insufficiency; recovery of microorganisms in the placenta parenchyma, including species categorized as human skin microflora; histological evidence of placental inflammation; lower gestational age at delivery; greater neonatal illness severity; severe chronic lung disease; neonatal bacteremia; and necrotizing enterocolitis.

CONCLUSIONS

In addition to supporting a potential role for many previously identified antecedents of brain damage in ELGANs, our study is the first to provide strong evidence that brain damage in extremely preterm infants is associated with microorganisms in placenta parenchyma.

Heart rate characteristics and neurodevelopmental outcome in very low birth weight infants

BACKGROUND

Sepsis in very low birth weight (VLBW) infants has been associated with an increased risk of adverse developmental outcome. We have identified abnormal heart rate characteristics (HRCs) that are predictive of impending sepsis, and we have developed a summary measure of an infant's abnormal HRCs during the neonatal hospitalization that we refer to as the cumulative HRC score (cHRC).

OBJECTIVE

In this study, we tested the hypothesis that increasing cHRC is associated with an increasing risk of adverse neurodevelopmental outcome in VLBW infants.

METHOD

Data were collected on 65 VLBW infants whose HRCs were monitored while in the neonatal intensive care unit and who were examined at 12 to 18 months adjusted age. Using the Bayley Scale of Infant Development-II, we identified delays in early cognitive function (i.e., Mental Developmental Index <70) and psychomotor development (i.e., Psychomotor Developmental Index <70). Cerebral palsy (CP) was diagnosed using a standard neurological examination.

RESULT

Increasing cHRC score was associated with an increased risk of CP (odds ratio per 1 standard deviation increase in cHRC: 2.6, 95% confidence limits: 1.42, 5.1) and delayed early cognitive development [odds ratio: 2.3 (1.3; 4.3)]. These associations remain statistically significant when adjusted for major cranial ultrasound abnormality. There was an association of increasing cHRC and delayed psychomotor development, which did not reach statistical significance [odds ratio: 1.7 (1.0, 3.0)].

CONCLUSION

Among VLBW infants, the cumulative frequency of abnormal HRCs, which can be assessed non-invasively in the neonatal intensive care unit, is associated with an increased risk of adverse neurodevelopmental outcome.

Trends in prevalence and characteristics of cerebral palsy among Icelandic children born 1990 to 2003

AIM

To describe trends in cerebral palsy (CP) prevalence, severity, and associated impairments among 139 Icelandic children (65 males, 74 females) born from 1990 to 1996 (period one) and 1997 to 2003 (period two).

METHOD

A population-based study using systematically collected data on motor functioning and associated impairments of children with CP. Mean age at assessment was 5 years 5 months (SD 7.68 mo) in period one and 5 years 5 months (SD 10.44 mo) in period two. Infants with postneonatal CP were excluded.

RESULTS

Prevalence of CP per 1000 live births was 2.2 in period one and 2.3 in period two (p=0.862); it decreased from 1.5 to 0.9 for children born at term, was stable for preterm births, but increased from 33.7 to 114.6 for very preterm births (p=0.002). Concurrently, neonatal and infant mortality rates decreased in Iceland. The proportion of children born preterm increased over time (p=0.002), whereas improvements in gross motor function assessed with the Gross Motor Function Classification System were confined to term births (p=0.009). The proportion of children with diplegia increased, accompanied by a decrease in the proportion with quadriplegia (p=0.047). Furthermore, among term births there was a significant reduction over time in the proportion of children with epilepsy (p=0.030) and in the proportion with two or more associated impairments (p=0.030).

INTERPRETATION

Although CP prevalence remained stable over 14 years, we observed a decrease in prevalence and severity of the disability among term births.

Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus

BACKGROUND

Epidemiological and basic science evidence suggests that magnesium sulphate before birth may be neuroprotective for the fetus.

OBJECTIVES

To assess the effects of magnesium sulphate as a neuroprotective agent when given to women considered at risk of preterm birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2008).

SELECTION CRITERIA

Randomised controlled trials of antenatal magnesium sulphate therapy in women threatening or likely to give birth at less than 37 weeks' gestational age. For one subgroup analysis, studies were broadly categorised by the primary intent of the study into "neuroprotective intent", or "other intent (maternal neuroprotective - pre-eclampsia)", or "other intent (tocolytic)".

DATA COLLECTION AND ANALYSIS

At least two authors assessed trial eligibility and quality, and extracted data.

MAIN RESULTS

Five trials (6145 babies) were eligible for this review. Antenatal magnesium sulphate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their child (Relative Risk (RR) 0.68; 95% Confidence interval (CI) 0.54 to 0.87; five trials; 6145 infants). There was also a significant reduction in the rate of substantial gross motor dysfunction (RR 0.61; 95% CI 0.44 to 0.85; four trials; 5980 infants). No statistically significant effect of antenatal magnesium sulphate therapy was detected on paediatric mortality (RR 1.04; 95% CI 0.92 to 1.17; five trials; 6145 infants), or on other neurological impairments or disabilities in the first few years of life. Overall there were no significant effects of antenatal magnesium therapy on combined rates of mortality with cerebral palsy, although there were significant reductions for the neuroprotective groups RR 0.85; 95% CI 0.74 to 0.98; four trials; 4446 infants, but not for the other intent subgroups. There were higher rates of minor maternal side effects in the magnesium groups, but no significant effects on major maternal complications.

AUTHORS' CONCLUSIONS

The neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established. The number of women needed to be treated to benefit one baby by avoiding cerebral palsy is 63 (95% confidence interval 43 to 87). Given the beneficial effects of magnesium sulphate on substantial gross motor function in early childhood, outcomes later in childhood should be evaluated to determine the presence or absence of later potentially important neurological effects, particularly on motor or cognitive function.

Influence of gestational age on the type of brain injury and neuromotor outcome in high-risk neonates

This study was an investigation of a possible correlation between either the gestational age (GA) and type of brain injury or between the gestational age and type, distribution and severity of cerebral palsy (CP). Four hundred sixty-one children with a birthweight > or = 1250 g and GA > or = 30 weeks with a complicated neonatal period and/or brain injury on serial cerebral ultrasound were selectively followed at the regional Center for Developmental Disorders. The children were divided into a preterm and term group. There were 40 children with cerebral palsy in the preterm group and 38 children with cerebral palsy in the term group. Various types of brain injury diagnosed by echography were nosologically classified. The type, distribution and severity of cerebral palsy were also registered. The type of brain injury most frequently occurring in the term group was hypoxic-ischemic injury to the basal ganglia (39%), focal ischemia (18%), subcortical hemorrhage (13%) and parasagittal cerebral injury (10%). In the preterm group 39% of the children with cerebral palsy had periventricular leukomalacia, 24% intraventricular hemorrhage and 18% persistent flares. There was a significant correlation between the GA and type of brain injury (P < 0.001; Cramer's V = 0.76) and between the GA and type (P = 0.004; Cramer's V = 0.47) and distribution (P < 0.001; Cramer's V = 0.55) of CP. There was no significant correlation between the GA and severity of CP. The type of brain injury detected by serial ultrasound during the neonatal period, as well as the type and location of CP detected during later childhood, are all GA-dependent in at-risk newborn infants with a birthweight of > or = 1,250 g and GA > or = 30 weeks.

Prevalence, type, distribution, and severity of cerebral palsy in relation to gestational age: a meta-analytic review

The aim of this review is to determine the relationship between gestational age (GA) and prevalence, type, distribution, and severity of cerebral palsy (CP). Epidemiological studies with cohorts expressed by GA were assessed. A comprehensive meta-analysis and meta-regression was performed on four fetal age categories. Studies of children with CP as a target population were added. Twenty-six articles met the inclusion criteria. The prevalence of CP decreases significantly with increasing GA category: 14.6% at 22 to 27 weeks' gestation, 6.2% at 28 to 31 weeks, 0.7% at 32 to 36 weeks, and 0.1% in term infants. Interestingly, a significant decrease in prevalence of CP starts only from a GA of 27 weeks onwards. In preterm infants, spastic CP is predominant. In term infants, the non-spastic form of CP is more prevalent than in preterm infants. Bilateral spastic CP is most prevalent in both preterm and term infants. However, the proportion of unilateral spastic CP in term infants is substantial. No relationship could be detected between severity of CP and GA. There is a strong need for an international, well-described, and generally accepted classification system for subtypes and severity of CP.

Differences in rates and short-term outcome of live births before 32 weeks of gestation in Europe in 2003: results from the MOSAIC cohort

OBJECTIVES

Advances in perinatal medicine increased survival after very preterm birth in all countries, but comparative population-based data on these births are not readily available. This analysis contrasts the rates and short-term outcome of live births before 32 weeks of gestation in 10 European regions.

METHODS

The Models of Organizing Access to Intensive Care for Very Preterm Births (MOSAIC) study collected prospective data on all very preterm births in 10 European regions covering 494,463 total live births in 2003. The analysis sample was live births between 24 and 31 weeks of gestation without lethal congenital anomalies (N = 4908). Outcomes were rates of preterm birth, in-hospital mortality, intraventricular hemorrhage grades III and IV or cystic periventricular leukomalacia and bronchopulmonary dysplasia. Mortality and morbidity rates were standardized for gestational age and gender.

RESULTS

Live births between 24 and 31 weeks of gestation were 9.9 per 1000 total live births with a range from 7.6 to 13.0 in the MOSAIC regions. Standardized mortality was doubled in high versus low mortality regions (18%-20% vs 7%-9%) and differed for infants < or = 28 weeks of gestation as well as 28 to 31 weeks of gestation. Morbidity among survivors also varied (intraventricular hemorrhage/periventricular leukomalacia ranged from 2.6% to < or = 10% and bronchopulmonary dysplasia from 10.5% to 21.5%) but differed from mortality rankings. A total of 85.2 very preterm infants per 10,000 total live births were discharged from the hospital alive with a range from 64.1 to 117.1; the range was 10 to 31 per 10,000 live births for infants discharged with a diagnosis of neurologic or respiratory morbidity.

CONCLUSIONS

Very preterm mortality and morbidity differed between European regions, raising questions about variability in treatment provided to these infants. Comparative follow-up studies are necessary to evaluate the impact of these differences on rates of cerebral palsy and other disabilities associated with preterm birth.

Movement training advances the emergence of reaching in infants born at less than 33 weeks of gestational age: a randomized clinical trial

BACKGROUND AND PURPOSE

This study had 2 purposes: (1) to compare the emergence of reaching in infants born full-term and infants born at less than 33 weeks of gestational age and (2) to evaluate the effectiveness of a movement training program on the emergence of reaching in this preterm population.

PARTICIPANTS

Twenty-six infants born at less than 33 weeks of gestational age and with a birth weight less than 2,500 g were randomly assigned to receive 20 minutes of daily movement training (PT-M group) or daily social training (PT-S group) and were compared with 13 infants born full-term (FT-S group).

METHODS

Reaching and hand-object interactions were tested every other week for 8 weeks. At each visit, infants were allowed six 30-second opportunities to contact a midline toy.

RESULTS

The FT-S and PT-M groups reached earlier and more consistently than the PT-S group. Specifically, the subjects in the FT-S group contacted the toy for longer durations and with an open, ventral surface of their hand. The PT-M group demonstrated increases in the number of hand-object contacts, the number of consistent reaches, and the percentage of time interacting with the toy and the surface of hand-object contact.

DISCUSSION AND CONCLUSION

This project demonstrates that there are early gross motor skill differences in infants born at less than 33 weeks of gestational age. A caregiver-based daily training program, however, is effective at lessening some, but not all, of these differences over the short term.

Cerebral palsy

Extreme prematurity confers about a 100-fold increase in the risk of cerebral palsy (CP), relative to birth at term gestation. Although CP is primarily a disorder of movement, many children with this disorder have other impairments which may affect their quality of life and life expectancy. Epidemiologic and clinical studies of cerebral palsy have benefited from recent efforts to develop greater uniformity of definition and classification. Particularly noteworthy is the development of the Gross Motor Function Classification System, which is a reliable and valid measure used with increasing frequency in observational and experimental studies. Also of great importance are efforts to quantify reliably the quality of life for children with cerebral palsy, thereby providing a target for medical and community interventions that aim to increase participation and well-being among affected children. During the late 1970s and early 1980s, the rate of CP actually rose, presumably as a result of increased survival of especially vulnerable infants who otherwise would have died. In developed countries over the past two decades (late 1980s to present), CP rates have been either stable or decreasing. Although considerable effort is being directed at prevention, the only perinatal interventions for which there is strong evidence of a beneficial effect on both mortality and the risk of CP is antenatal treatment of the mother with glucocorticoid.

Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus

BACKGROUND

Epidemiological and basic science evidence suggests that magnesium sulphate before birth may be neuroprotective for the fetus.

OBJECTIVES

To assess the effectiveness and safety of magnesium sulphate as a neuroprotective agent when given to women considered at risk of preterm birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2006), CENTRAL (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to October 2006), EMBASE (1980 to October 2006), Current Contents (1992 to October 2006), references of retrieved articles, and abstracts submitted to the Society for Pediatric Research (1996 to 2006).

SELECTION CRITERIA

Randomised controlled trials of antenatal magnesium sulphate therapy given to women threatening or likely to give birth at less than 37 weeks' gestational age.

DATA COLLECTION AND ANALYSIS

We independently extracted data regarding clinical outcomes including paediatric mortality, neurologic outcome of survivors (including blindness, deafness, cerebral palsy and major neurosensory disability), and maternal complications and side-effects. At least two authors assessed trial eligibility and quality, and extracted data.

MAIN RESULTS

Four trials (3701 babies) were eligible for this review. No statistically significant effect of antenatal magnesium sulphate therapy was detected on any major paediatric outcome, including mortality (e.g., paediatric mortality relative risk (RR) 0.97; 95% confidence interval (CI) 0.74 to 1.28; four trials; 3701 infants), and neurological outcomes in the first few years of life, including cerebral palsy (RR 0.77; 95% CI 0.56 to 1.06; four trials; 3701 infants), neurological impairments or disabilities. There were also no significant effects of antenatal magnesium therapy on combined rates of mortality with neurologic outcomes. There was a significant reduction in the rate of substantial gross motor dysfunction (RR 0.56; 95% CI 0.33 to 0.97; two trials; 2848 infants). There were higher rates of minor maternal side-effects in the magnesium groups, but no significant effects on major maternal complications.

AUTHORS' CONCLUSIONS

The role for antenatal magnesium sulphate therapy as a neuroprotective agent for the preterm fetus is not yet established. Given the possible beneficial effects of magnesium sulphate on gross motor function in early childhood, outcomes later in childhood should be evaluated to determine the presence or absence of later potentially important neurologic effects, particularly on motor or cognitive function. Further information will be available from one of the studies where outcomes are being evaluated again at eight to nine years of age, and from another trial currently in progress.

Neonatal and 5-Year Outcomes After Birth at 30–34 Weeks of Gestation

OBJECTIVE

To evaluate the rates of in-hospital death, neonatal complications, and 5-year outcomes of infants born at 30-34 weeks of gestation.

METHODS

In nine regions of France, all 2,020 stillbirths and live births at 30, 31, and 32 weeks in 1997 and all 457 births at 33 and 34 weeks in April and October 1997 were recorded. Survivors were evaluated at 5 years of age.

RESULTS

Increasing gestational age from 30 to 34 weeks was associated with progressive decreases in in-hospital mortality (from 8.1% to 0.4%) and neonatal complications (respiratory distress syndrome, 43.8% to 2.6%; maternofetal infections, 7.2% to 2.6%; and severe white matter injury, 5.5% to 1.3%). Although infants at 33 and 34 weeks of gestation rarely experienced necrotizing enterocolitis, bronchopulmonary dysplasia, or nosocomial infections, they still required endotracheal ventilation, antibiotics, or parenteral nutrition. At 5 years of age, older gestational age was associated with significant decreases in rates of cerebral palsy (6.3% at 30 weeks and 0.7% at 34 weeks) and mild to severe cognitive impairments (35.3% at 30 weeks and 23.9% at 34 weeks). In singletons, preterm rupture of membranes or preterm labor carried an increased risk of cerebral palsy but not of cognitive impairment.

CONCLUSION

Neonates born at 30-34 weeks experienced substantial morbidity and often required admission to neonatal intensive care units. These outcomes suggest that prolonging pregnancies beyond 34 weeks may be desirable whenever possible. Infants born at 30-34 weeks should be carefully monitored to ensure prompt detection and management of neurodevelopmental impairment.

Cost of transferring one through five embryos per in vitro fertilization cycle from various payor perspectives

OBJECTIVE

We sought to examine the costs of transferring one through five embryos per in vitro fertilization cycle from each of three perspectives: society, the infertile couple, and the insurer.

METHODS

Data from the 2003 Assisted Reproductive Technology Report was used to create Markov decision analytic models stratified by maternal age subgroup. We modeled both total costs, cost-effectiveness (cost per live birth), and clinical outcomes: multiple births, preterm deliveries, and cerebral palsy.

RESULTS

From a societal and insurer perspective, it was least expensive to transfer one embryo. For women aged younger than 35 years, it cost society 80% more to transfer five rather than one embryo at a time (total cost 39,212 dollars compared with 21,661 dollars). For women aged older than 42 years, it cost 13% more (29,102 dollars compared with 25,723 dollars). From a parental perspective, it was least expensive to transfer between two and five embryos, depending on maternal age. One-embryo transfers markedly improved clinical outcomes. For example, two compared with one-embryo transfers for women aged younger than 35 years reduced preterm birth and cerebral palsy rates by 55% and 41%, respectively. Univariable sensitivity analysis and Monte Carlo simulation showed our results to be robust.

CONCLUSION

Transferring one embryo per cycle is the least expensive strategy from a societal perspective, especially for younger women, yet it is the most expensive option from a parental perspective. To reduce in vitro fertilization-associated multiple birth rates, public policy must address these disparate financial incentives.

Cerebral palsy and intrauterine growth

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.

Cerebral palsy among very preterm children in relation to gestational age and neonatal ultrasound abnormalities: the EPIPAGE cohort study

OBJECTIVE

To estimate the prevalence of cerebral palsy at 2 years of age among children born very preterm, according to gestational age, infant gender, plurality, and neonatal cranial ultrasound abnormalities.

METHODS

All infants born between 22 and 32 weeks of gestation in 9 regions of France in 1997 were included in this prospective, population-based, cohort study. The main outcome measure was cerebral palsy prevalence at 2 years. Of the 2364 survivors eligible for follow-up evaluation, 1954 (83%) were assessed at 2 years of age.

RESULTS

Among the 1954 children assessed at 2 years, 8.2% had cerebral palsy. Bilateral spastic cerebral palsy, hemiplegia, and monoplegia accounted for 72%, 9%, and 10% of cases, respectively. Fifty percent of the children with cerebral palsy walked independently at the age of 2, 31% were unable to walk but could sit independently, and 19% could not sit (unable to maintain head and trunk control). The prevalence of cerebral palsy was 20% at 24 to 26 weeks of gestation, compared with 4% at 32 weeks. On the basis of ultrasound findings in the neonatal period, we found that 17% of children with isolated grade III intraventricular hemorrhage and 25% of children with white matter damage (ie, ventricular dilation, persistent echodensities, or cystic periventricular leukomalacia) had cerebral palsy, compared with 4% of children with normal ultrasound scans.

CONCLUSIONS

Despite recent improvements in survival rates, cerebral palsy remains highly prevalent among very preterm children. Severe cranial ultrasound abnormalities predict motor disability strongly, but one third of infants with cerebral palsy had no ultrasound abnormalities.

Maternal infection and risk of cerebral palsy in term and preterm infants

OBJECTIVE

We tested the hypothesis that term and preterm infants exposed to maternal infection at the time of delivery are at increased risk of developing cerebral palsy (CP).

STUDY DESIGN

A population-based case-control study was conducted using Washington State birth certificate data linked to hospital discharge data. Cases (688) were children <or=6 years old, singleton births, hospitalized during 1987 to 1999 with an ICD-9 diagnosis code for CP. Controls were 3,068 singleton birth infants randomly selected from birth records for the same years without CP-related hospitalizations. Infection information was available only for the birth hospitalization.

RESULTS

Infants of women who had any infection during their hospitalization for delivery were at increased risk of CP (odds ratio (OR) 3.1, 95% confidence interval (CI) 2.3 to 4.2). This was observed for term deliveries (OR 1.8, 95% CI 1.1 to 2.8) and preterm deliveries (OR 2.3, 95% CI 1.3 to 4.2).

CONCLUSIONS

Our results suggest that maternal infection is a risk factor for CP in both term and preterm infants.

Improved outcome for very low birth weight multiple births

This study describes time trends for very low birth weight multiple births in relation to very low birth weight singletons. Two cohorts of very low birth weight (less than 1250 gm) children recruited between 1983-85 (cohort 1, n = 115) and 1992-94 (cohort 2, n = 144) were compared. The Bayley Scales of Infant Development and a standardized neurologic examination were administered at 2 years corrected age. Neurodevelopmental outcome did not change between cohort 1 and 2 for singletons. For multiple births, mean Mental Developmental Index increased after adjustment for neonatal risk factors [adjusted mean (standard deviation) 81.8 (11.7) to 96.5 (18.6), analysis of covariance P = 0.007]. The prevalence of cerebral palsy decreased, however not significantly [adjusted odds ratio (95% confidence interval) 0.3 (0.1-1.5), P = 0.14]. The proportion of disease-free survival (no cerebral palsy and no developmental delay) increased for multiple births (7-37%, P = 0.002), but not for singletons. In cohort 2, neurodevelopmental outcome of multiple births was similar to that of singletons. The cognitive outcome of very low birth weight multiple births improved, possibly because of changes in perinatal practice. However, neurodevelopmental outcome was similar to that of very low birth weight singletons who were unaffected by changes in neonatal care with high proportions of motor delay and cerebral palsy.

Handicap neuro-sensoriel grave de l’enfant grand prématuré

OBJECTIVE

Advances in perinatal care have resulted in a sharply increasing survival rate among very preterm infants. However, there is some concern about the later neurodevelopmental outcome of those infants who survive. In this paper, we review the prevalence estimates of motor (cerebral palsy), sensorineural and cognitive impairments and their recent time-trends in very preterm infants.

METHOD

A review of studies describing neurodevelopmental outcome of very preterm infants in Europe, Australia and America North.

RESULTS

The gestational age-specific prevalences of cerebral palsy (CP) were 72-86 for extremely preterm children (<28 weeks), 32-60 for very preterm (28-31 weeks) and 5-6 for moderate preterm (32-36 weeks), and 1.3-1.5 for term children per 1000. The live birth prevalence for CP remained unchanged in extremely and very preterm infants since 1990. The prevalence estimates of moderate and severe cognitive impairments are 15 to 25% in very preterm children. Less than 4% of very preterm infants develop severe hearing or visual loss.

CONCLUSION

This review indicates that very preterm infants have high risk of disability. Most studies have been conducted between 1985 and 1995. Thus, these results should be interpreted with caution before generalisation to recent cohorts.

Paediatric consequences of fetal growth restriction

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.

Does the risk of cerebral palsy increase or decrease with increasing gestational age?

BACKGROUND: It is generally accepted that the risk of cerebral palsy decreases with increasing gestational age of live born infants. However, recent studies have shown that cerebral palsy often has prenatal antecedents including congenital malformations, vascular insults and maternal infection. Cerebral palsy is therefore better viewed as occurring among fetuses, rather than among infants. We explored the epidemiologic implications of this change in perspective. METHODS: We used recently published data from Shiga Prefecture, Japan and from North-East England to examine the pattern of gestational age-specific rates of cerebral palsy under these alternative perspectives. We first calculated gestational age-specific rates of cerebral palsy as per convention, by dividing the number of cases of cerebral palsy identified among live births within any gestational age category by the number of live births in that gestational age category. Under the alternative formulation, we calculated gestational age-specific rates of cerebral palsy by dividing the number of cases of cerebral palsy identified among live births within any gestational age category by the number of fetuses who were at risk of being born at that gestation and being afflicted with cerebral palsy. RESULTS: Under the conventional formulation, cerebral palsy rates decreased with increasing gestational age from 63.9 per 1,000 live births at <28 weeks gestation to 0.9 per 1,000 live births at 37 or more weeks gestation. When fetuses were viewed as potential candidates for cerebral palsy, cerebral palsy rates increased with increasing gestational age from 0.08 per 1,000 fetuses at risk at <28 weeks gestation to 0.9 per 1,000 fetuses at risk at 37 or more weeks gestation. CONCLUSIONS: The fetuses-at-risk approach is the appropriate epidemiologic formulation for calculating the gestational age-specific rate of cerebral palsy from a causal perspective. It shows that the risk of cerebral palsy increases as gestational duration increases. This compelling view of cerebral palsy risk may help refocus research aimed at understanding and preventing cerebral palsy.

Postural adjustments in preterm infants at 4 and 6 months post-term during voluntary reaching in supine position

Gradually it is getting clear that motor development - in particular balance control - in so-called "low-risk" preterm infants often differs from that in full-term infants. However, little is known on the etiology and pathophysiology of these problems. The aim of this study was to evaluate postural behavior during reaching by means of kinetic and kinematic measurements. Preterm infants (n = 32) without cerebral palsy were investigated longitudinally at the corrected ages of 4 and 6 mo. Thirteen age-matched full-term infants served as controls. Cognitive and motor development were assessed by means of the quality of General Movements (GMs) at 4 mo and Bayley scales at 6 and 12 mo. The infants were lying supine on a forceplate reaching for a toy and the kinetics of the total body's Center of Pressure (COP) was measured in cranial-caudal and medial-lateral direction. The analysis focused on COP displacement, Vmax and oscillatory changes of the COP displacement during reaching. The kinematic analysis of reaching focused on movement units, Vmax and a compound kinematic variable reflecting the quality of reaching. The results showed that preterm infants showed a remarkable "still" postural behavior, which differed significantly from the mobile COP behavior of the full-term infants. More "still" postural behavior at 6 mo was associated with a better quality of reaching movements and with normal GMs at 4 mo. We concluded that "still" postural behavior is an adequate postural strategy of preterm infants. But it might be that this postural behavior is an indicator of later dysfunction.