Children with cerebral palsy: severity and trends over time

Cerebral palsy in African paediatric populations: A scoping review

AIM

To review the epidemiology and outcomes of African children with cerebral palsy (CP) over a 21-year period.

METHOD

The PubMed, Scopus, and Web of Science online databases were searched for original research on African children with CP aged 18 years and younger published from 2000 to 2021.

RESULTS

A total of 1811 articles underwent review against explicit criteria; 93 articles were selected for inclusion in the scoping review. The reported prevalence of CP ranged from 0.8 to 10 per 1000 children. Almost half had perinatal risk factors, but up to 26% had no identifiable risk factor. At least one-third of children with CP had one or more comorbidities, most commonly epilepsy, intellectual disability, and malnutrition. African children with CP demonstrated excess premature mortality approximately 25 times that of the general population, predominantly from infections. Hospital-based and younger populations had larger proportions of children with severe impairments. African children with CP had inadequate access to care and education, yet showed functional improvements compared to controls for all evaluated interventions.

INTERPRETATION

The prevalence of CP in Africa remains uncertain. African children with CP have different risk profiles, greater premature mortality, and more severe functional impairments and comorbidities compared to the Global North. Several barriers prevent access to optimal care. Larger African studies on validated and effective interventions are needed.

The Effect of Eight Weeks of Aquatic Exercises on Muscle Strength in Children with Cerebral Palsy: A Case Study

Background

Cerebral palsy in children is considered a non-progressive brain injury due to abnormal brain development. The aim of this study was to investigate the effect of eight weeks of aquatic exercises on muscle strength in children with cerebral palsy.

Materials and Methods

This study was performed on three boys with cerebral palsy with a mean age of 6.5 years. In this research, a single case study method with A1-B-A2 design has been used. After determining the position of the baseline, the intervention began and during 24 sessions of individual intervention, aquatic exercises were presented to the subjects and all three subjects were followed up for 2 consecutive weeks and one month after the end of the intervention. The strength of the flexor muscles of the arms and legs was measured by a power track dynamometer made by JTECK with a threshold of 4.4 N.

Results

Based on the indicators of descriptive statistics and visual analysis, the intervention was effective for all three participants in muscle strength, and the strength of individuals after the intervention has improved compared to the baseline stage (percentage). Information overlap for the first and second participant in the strength of right thigh flexors was 75% and for the third participant was 100%. The strength of the upper and lower torso muscles improved after the end of the training compared to the basic stage.

Conclusion

Aquatic exercises can increase the strength of children with cerebral palsy and provide a favorable environment for children with cerebral palsy.

Understanding physiotherapy and physiotherapy services: exploring the perspectives of adults living with cerebral palsy

PURPOSE

To understand physiotherapy and physiotherapy services from the perspectives of adults with cerebral palsy (CP).

METHODS

Twenty-two adults with CP (15 women, 7 men), from across the UK, aged between 23 and 51 years, Gross Motor Function Classification System I-V, were interviewed about their experiences of physiotherapy and physiotherapy services. Participants were recruited through advertisements placed with relevant national organisations. The interviews were transcribed and analysed according to principles of Reflective Lifeworld Research. A second analysis examined the findings in relation to Donabedian's structure-process-outcome framework for healthcare quality.

RESULTS

Specialist services for adults with CP were described as scarce, unknowable, complex and disconnected through the life course. Specific problems included; structural dimensions such as access to and organisation of services, signposting to services and access to expert advice; process dimensions including a lack of attention to patients' perspectives, needs, priorities, experience and expertise; and outcome dimensions for example the negative impact of physiotherapy service configurations on health, well-being and quality of life.

CONCLUSION

Study findings support grassroots calls to radically improve and increase physiotherapy services for adults with CP. Accessible and widely available specialist services, information and advice across the life course would do much to address unmet need. Implications for RehabilitationAdults with CP found it difficult to identify and access specialised physiotherapy services and to obtain information and advice to help them best manage their condition.Adults with CP need physiotherapy services throughout the different phases of their lives, to meet their present needs, and to anticipate and, where possible, to prevent future needs.Participants highly valued person-centred physiotherapy and we recommend this approach is adopted as the foundational philosophy guiding physiotherapy services and interventions for adults with CP.More specialist physiotherapy services are urgently needed to meet the needs of adults with CP in the UK.

Feasibility of Using Joystick-Operated Ride-on-Toys to Promote Upper Extremity Function in Children With Cerebral Palsy: A Pilot Study

PURPOSE

To evaluate the feasibility of implementation, acceptance, and perceived efficacy of a joystick-operated ride-on-toy intervention to promote upper extremity (UE) function in 3- to 14-year-old children with hemiplegic cerebral palsy.

METHODS

Exit questionnaires were collected from children, caregivers, and clinicians/camp staff following a 3-week ride-on-toy training program incorporated within a summer camp for children with hemiplegic cerebral palsy. Training encouraged children to use their affected UE to maneuver the ride-on-toy. Questionnaires included Likert scale and open-ended questions to assess enjoyment, acceptance, feasibility, and perceived efficacy of the training.

RESULTS

All stakeholder groups indicated that the training was enjoyable. Clinicians/staff and caregivers indicated that the training increased children's motivation to use their affected UE and reported perceived improvements in UE movement control and function following training.

CONCLUSIONS

Our promising preliminary findings call for future research to systematically assess the efficacy of ride-on-toys to promote UE control and function in children with hemiplegic cerebral palsy.Supplemental Digital Content 1 video abstract, available at: http://links.lww.com/PPT/A404.

Parental Distress in the Time of COVID-19: A Cross-Sectional Study on Pediatric Patients with Neuropsychiatric Conditions during Lockdown

The lockdown due to the COVID-19 pandemic has had adverse psychological effects on children and parents. While parenting is essential for positive development, increased parental distress has interfered with children’s wellbeing. In our study, we aimed to identify the predictors of parental distress in families of children with neuropsychiatric disorders during lockdown. Seventy-seven parents of children with neuropsychiatric disorders were asked to fill three online questionnaires (a socio-demographic questionnaire, the Child Behavior Checklist (CBCL) and Parental-Stress-Index (PSI-4-SF) to explore the relationship between parental distress, emotional/behavioral problems in children and quarantine-related factors through univariate analyses and multiple mediation models. Significant positive associations between CBCL-internalizing-problems and all PSI-4-SF subscales, and between CBCL-externalizing-problems and “Difficult Child” subscales were found. “Parent–Child Dysfunctional Interaction” subscale and teachers–child relationship quality resulted negatively associated, as well as the “Difficult Child” subscale and peers–child relationship quality. The effect of teachers–child relationship quality on “Parent–Child Dysfunctional Interaction” was mediated by children internalizing problems, while the effect of peers–child relationship quality on “Difficult Child” by the child internalizing/externalizing problems. Internalizing problems in children with neuropsychiatric disorders were among the strongest predictors of parental stress during lockdown, mediating the indirect effects of quarantine-related factors, thus suggesting the importance of their detection during and after emergency situations to provide assistance and reduce parenting pressure.

First trimester fasting plasma glucose screen in advanced maternal age women: a cost-effectiveness analysis

BACKGROUND

The prevalence of preexisting type 2 diabetes mellitus (T2DM) in the United States is on the rise. Women of advanced maternal age (AMA, ≥35 years) are more likely to have preexisting T2DM in pregnancy because glucose intolerance increases with age. Diabetes in pregnancy is associated with significant maternal and neonatal morbidity and mortality, and earlier treatment initiation improves pregnancy outcomes. However, maternal age is not currently recognized as an independent risk factor that warrants diabetes screening prior to the traditional screen at 24-28 weeks gestation.

OBJECTIVE

To evaluate the cost-effectiveness of screening all AMA women with a first trimester fasting plasma glucose (FPG) test for earlier diagnosis and management of preexisting T2DM.

STUDY DESIGN

A decision-analytic model was created to compare pregnancy outcomes in AMA women who undergo a first trimester FPG test vs third trimester oral glucose tolerance test alone. Probabilities were obtained from the literature. Outcomes examined included preeclampsia, preterm delivery, macrosomia, shoulder dystocia, brachial plexus injury (BPI), intrauterine fetal demise (IUFD), cerebral palsy, and neonatal death. The cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio of the first trimester screening strategy were examined as well. Sensitivity analyses and a Monte Carlo simulation were performed to test the model's robustness.

RESULTS

In AMA women, screening for preexisting T2DM in the first trimester with an FPG test resulted in fewer cases of preeclampsia, preterm delivery, BPI, IUFD, cerebral palsy, and neonatal death compared to performing a third trimester oral glucose tolerance test alone, and is cost-effective. Monte Carlo analysis incorporating the distribution of all probabilities showed that first trimester FPG screening remained cost-effective as long as the incremental cost of initiating diabetes treatment in the first trimester was less than $150,000 and the cost of the FPG screen was less than $2700.

CONCLUSION

Compared to third trimester oral glucose tolerance test alone, performing a first trimester FPG screen in AMA women is cost-saving and more effective.

Effect of robot-assisted gait training on motor functions in adolescent and young adult patients with bilateral spastic cerebral palsy: A randomized controlled trial

BACKGROUND

Robot-assisted gait training (RAGT) allows an intensive gait training in patients with cerebral palsy (CP). There are few evidences on the effectiveness of RAGT in adults with CP.

OBJECTIVE

To assess the effect of RAGT on gross motor function in adolescent and adult patients with bilateral spastic CP and to compare the effect of RAGT with conventional kinesiotherapy.

METHODS

Forty-seven patients (mean age 21.2±5.33 years) with bilateral spastic CP were divided into two groups. Twenty-one patients underwent 20 therapeutic units of RAGT and 26 patients underwent 20 therapeutic units of conventional therapy/training (CON). The following parameters were evaluated before (V1) and after the therapy (V2): dimension A (lying and rolling), B (sitting), C (crawling and kneeling), D (standing), E (walking, running and jumping) of the Gross Motor Function Measure (GMFM-88). In patients in the experimental RAGT group, these parameters were also evaluated 3-4 months later (V3).

RESULTS

Comparing the mean improvements in endpoints in both groups (RAGT vs. CON) after 20 TUs, we observed the statistically significant difference (p < 0.001) and large effect size in all GMFM dimensions and total GMFM improvement in favour of the RAGT group. In RAGT patients, the improvement persisted even 3-4 months after RAGT (p < 0.001).

CONCLUSION

We demonstrated that the intensive RAGT regimen is more effective than conventional therapy in terms of improvements in gross motor functions in adolescent and adult patients with bilateral spastic CP.

The impact of high intensity care around birth on long-term neurodevelopmental outcomes

BACKGROUND

An equitable and affordable healthcare system requires a constant search for the optimal way to deliver increasingly expensive neonatal care. Therefore, evaluating the impact of hospital intensity around birth on long-term health outcomes is necessary if we are to assess the value of high intensity neonatal care against its costs.

METHODS

This study exploits uneven geographical distribution of high intensity birth hospitals across Canada to generate comparisons across similar Cerebral Palsy (CP) related births treated at hospitals with different intensities. We employ a rich dataset from the Canadian Multi-Regional CP Registry (CCPR) and instrumental variables related to the mother's location of residence around birth.

RESULTS

We find that differences in hospitals' intensities are not associated with differences in clinically relevant, long-term CP health outcomes.

CONCLUSIONS

Our results suggest that existing matching mechanism of births to hospitals within large metropolitan areas could be improved by early detection of high risk births and subsequent referral of these births to high intensity birthing centers. Substantial hospitalization costs might be averted to Canadian healthcare system ($16 million with a 95% CI of $6,131,184 - $24,103,478) if CP related births were assigned to low intensity hospitals and subsequently transferred if necessary to high intensity hospitals.

Effects of an intensive voice treatment on articulatory function and speech intelligibility in children with motor speech disorders: A phase one study

Producing speech that is clear, audible, and intelligible to others is a challenge for many children with cerebral palsy (CP) and children with Down syndrome (DS). Previous studies have demonstrated the effectiveness of using the Lee Silverman Voice Treatment (LSVT LOUD®) to increase vocal loudness and improve speech intelligibility in individuals with dysarthria secondary to Parkinson's disease (PD), and some research suggests that it also may be effective for individuals with dysarthria secondary to other conditions, including CP and DS. Although LSVT LOUD targets healthy vocal loudness, there is some evidence of spreading effects to the articulatory system. Acoustic data from two groups of children with secondary motor speech disorders [one with CP (n = 17) and one with DS (n = 9)] who received a full dose of LSVT LOUD and for whom post-treatment intelligibility gains have been previously reported, were analyzed for treatment effects on: 1) vowel duration, 2) acoustic vowel space and 3) the ratio of F2/i/ to F2/u/. Statistically significant changes in vowel duration and acoustic vowel space occurred pre-treatment to 12 weeks post-treatment in the CP group, and increased acoustic vowel space was observed in 5 of the DS participants. The present study provides preliminary evidence of intensive voice treatment spreading effects to the articulatory system in some children with CP and children with DS consistent with previous findings in other populations.

A decision tree model of cerebral palsy based on risk factors

Objective: A risk prediction model of cerebral palsy (CP) was established by a decision tree model to predict the individual risk of CP.Methods: A hospital-based case-control study was conducted with 109 cases of CP and 327 controls without CP. The cases and the controls were obtained from Hunan Children's Hospital. A questionnaire was administered to collect the variables relevant to CP by face to face interviews. Chi-square test was used to identify the factors associated with CP, and a decision tree model was used to construct the prediction model.Results: Univariate analysis showed that there were significant differences between cases group and controls group on maternal age, weight gain during pregnancy, medical treatment during pregnancy, preterm birth, low birth weight and birth asphyxia (all p-values <.05). Three factors, including preterm birth, birth asphyxia, and maternal age >35 years old, entered the decision tree model. The area under the receiver operating characteristic curve (AUC) was 0.722 (95%CI: 0.659-0.784, p < .001).Conclusion: The decision tree prediction model can be used for predicting the individual risk of CP. Further large-scale, population-based cerebral palsy studies are needed to improve the model.

Effect of Robot-Assisted Gait Training in a Large Population of Children With Motor Impairment Due to Cerebral Palsy or Acquired Brain Injury

OBJECTIVE

To evaluate retrospectively the effect of robotic rehabilitation in a large group of children with motor impairment; an additional goal was to identify the effects in children with cerebral palsy (CP) and acquired brain injury (ABI) and with different levels of motor impairment according to the Gross Motor Function Classification System. Finally, we examined the effect of time elapsed from injury on children's functions.

DESIGN

A cohort, pretest-posttest retrospective study was conducted.

SETTING

Hospitalized care.

PARTICIPANTS

A total of 182 children, 110 with ABI and 72 with CP and with Gross Motor Function Classification System (GMFCS) levels I-IV, were evaluated retrospectively.

INTERVENTIONS

Patients underwent a combined treatment of robot-assisted gait training and physical therapy.

MAIN OUTCOME MEASURES

All the patients were evaluated before and after the training using the 6-minute walk test and the Gross Motor Function Measure. A linear mixed model with 3 fixed factors and 1 random factor was used to evaluate improvements.

RESULTS

The 6-minute walk test showed improvement in the whole group and in both ABI and CP. The Gross Motor Function Measure showed improvement in the whole group and in the patients with ABI but not in children with CP. The GMFCS analysis showed that all outcomes improved significantly in all classes within the ABI subgroup, whereas improvements were significant only for GMFCS III in children with CP.

CONCLUSIONS

Children with motor impairment can benefit from a combination of robotic rehabilitation and physical therapy. Our data suggest positive results for the whole group and substantial differences between ABI and CP subgroups, with better results for children with ABI, that seem to be consistently related to time elapsed from injury.

Use of gestational surrogates for women with Eisenmenger syndrome: a cost-effectiveness analysis

Objective: Eisenmenger syndrome (ES) is regarded as a contraindication to pregnancy, with therapeutic abortion recommended in the event of unintended pregnancy. However, women with ES continue to desire and attempt pregnancy despite grave risks to their own health. This study compares the costs and outcomes of pregnancy in women with ES to the use of gestational surrogates in their pregnancies.Study design: A decision-analytic model was built using TreeAge software that compared use of gestational surrogates and pregnancy in women with ES. Maternal death and neonatal outcomes including intrauterine fetal demise, preterm birth, cerebral palsy, and death were assessed. All probabilities and costs were derived from the literature. Utilities were discounted at a rate of 3% across the expected lifespan to generate quality-adjusted life years (QALYs). Univariate and multivariate sensitivity analyses were performed to evaluate the robustness of the model given changes in baseline assumptions.Results: In a theoretical cohort of 1000 women with ES, pregnancy would result in 360 maternal deaths, 100 stillbirths, 477 preterm births, and 157 neonatal deaths . In these highly desired pregnancies, use of gestational surrogates would prevent 99 and 98% of maternal and neonatal death, respectively. Cases and costs of preterm birth and associated cerebral palsy are also significantly reduced. Use of a gestational surrogate would save $518,255 per woman with a gain of 6.77 QALYs, a dominant strategy. The approach is cost-effective up to a cost of surrogacy of $1.2 million and even if the surrogate achieves pregnancy only 30% of the time.Conclusions: The use of surrogate mothers for those with ES is cost-effective and results in significantly improved maternal and neonatal outcomes. These benefits are robust in the face of high surrogacy costs largely due to the marked reduction in maternal mortality and preterm birth. These findings should be used to underscore the importance of broadening health care financing for medically-indicated assisted reproduction.

Preventing childhood and lifelong disability: Maternal dietary supplementation for perinatal brain injury

The majority of brain injuries that lead to cerebral palsy, developmental disability, and mental health disorders have their onset in utero. These lifelong conditions come with great economic and emotional burden as they impact function in nearly all domains of affected individuals' lives. Unfortunately, current therapeutic options are limited. There remains a focus on rescue, rehabilitation, and regeneration after the injury has occurred, rather than aiming to prevent the initial injury. Prevention would imply treating the mother during pregnancy to alter the fetal environment and in turn, treat the fetus. Fear of harming the developing fetus remains as a result of errors of the past such as the release of thalidomide. In this review, we outline evidence from animal studies and clinical trials that have explored maternal dietary supplementation with natural health products (including nutraceuticals and functional foods) for perinatal brain injury prevention. Namely, we discuss magnesium sulphate, creatine, choline, melatonin, resveratrol and broccoli sprouts/sulforaphane. Although clinical trials have only been completed in this realm for magnesium sulphate, results in animal models have been promising, suggesting that this is a productive avenue for further research. Natural health products may provide safe, effective, affordable, and easily accessible prevention of fetal brain injury and resulting lifelong disabilities.

Nutritional intervention and neurodevelopmental outcome in infants with suspected cerebral palsy: the Dolphin infant double-blind randomized controlled trial

AIM

To investigate whether docosahexaenoic acid (DHA), choline, and uridine-5-monophosphate (UMP) supplementation improves neurodevelopmental outcome in infants with suspected cerebral palsy (CP) versus a comparison group of children.

METHOD

Infants aged 1 to 18 months with suspected CP were recruited from UK child development centres. Participants received daily treatment or control supplementation for 2 years (double-blind randomized control design). Stratification was by age, sex, predominant pattern of motor involvement (four limbs or other), and visual impairment (or not). The primary outcome was the cognitive composite score of the Bayley Scales of Infant and Toddler Development, Third Edition (CCS-Bayley-III). Secondary outcomes included language composite and motor composite scores of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III).

RESULTS

Forty infants were recruited; 35 began supplementation, 29 completed 1 to 2 years' supplementation. The treatment group CCS-Bayley-III was non-significantly higher than the comparison group (mean 77.7 [SD 19.2] and 72.2 [SD 19.8] respectively, mean modelled difference 4.4 [-2.8, 11.6]). The treatment group language scores, but not motor scores, were non-significantly higher than for the comparison group.

INTERPRETATION

Most families found supplementation feasible. No statistically significant differences in neurodevelopmental outcome between the treatment and comparison groups were identified. Further investigation of neurodevelopmental outcome after supplementation with DHA, choline, and UMP of infants with suspected CP is warranted.

WHAT THIS PAPER ADDS

This was the first trial of phosphatidylcholine precursor supplementation in infants with suspected cerebral palsy (CP). Families of infants with suspected CP found 2-year nutritional supplementation feasible. There was no statistically significant neurodevelopmental advantage for the treatment group versus the comparison group. However, treatment group cognitive and language advantage were of clinically meaningful magnitude.

Evaluation of hand function in patients with unilateral cerebral palsy who underwent multilevel functional surgery: a retrospective observational study

BACKGROUND

Hemiplegia is the most common form of cerebral palsy. Upper limb is generally more affected than lower one. Indeed, hemiplegic children can spontaneously acquire standing and walking ability, while manipulation remains uncertain, with severe limitations in activity and participation, which define a child's functional status (International Classification of Functioning [ICF]). Several non-surgical tools are currently available to approach upper limb impairments. Studies regarding upper limb multilevel surgery in Hemiplegic Cerebral Palsy are relatively few and inhomogeneous.

AIM

The aim of this study is to propose a surgical approach based on upper limb functional level and manipulation strategy and establish whether multilevel surgery can improve segmental alignment, performance and capacity, that ICF defines as activities and participation qualifiers.

DESIGN

This study is an observational retrospective study.

SETTING

This study involves patients who referred to the Unit of Children Rehabilitation of S. Maria Nuova Institute for Research and Care, in Reggio Emilia (Italy), over a four-year period.

POPULATION

Children affected by hemiplegic cerebral palsy who underwent upper limb multilevel surgery.

METHODS

For each patient, we previously defined functional use of affected upper limb applying the House classification and the Ferrari one of manipulation pattern. Patients are divided into three groups: synergic hand (House 4, 5), imprisoned hand (House 3), excluded hand (House 0). We recorded goals achievement through Goal Attainment Scale and unimanual and bimanual abilities through Melbourne Assessment of Unilateral Upper Limb Function and through Assisting Hand Assessment respectively.

RESULTS

We recorded 16 upper limb multilevel surgical interventions in 13 children and report their results.

CONCLUSIONS

This study suggests that surgery can induce a segmental and/or aesthetic and/or a functional change depending on manipulation pattern. It also underlines the importance to analyze results in term of spontaneous manipulation abilities and daily use.

CLINICAL REHABILITATION IMPACT

This study provides a preliminary guide to plan surgery in relation to segmental deformities and overall manipulation pattern and describes their feasible improvement measures. It also suggests the most useful tools to record goal achievements in modifying manipulation function. Further controlled, randomized and prospective studies are required to support this idea.

Optimal timing of delivery for women with breast cancer, according to cancer stage and hormone status: a decision-analytic model

OBJECTIVE

To compare strategies for the timing of delivery in women with breast cancer and known cancer stage or hormone receptor subtype, and to determine the optimal gestational age for induction in regards to maternal-fetal outcomes.

STUDY DESIGN

A decision-analytic model was designed comparing eight different strategies for scheduled delivery at 30, 31, 32, 33, 34, 35, 36, and 37 weeks gestation. Optimal breast cancer treatment was assumed to be delayed until after delivery. Baseline estimates of the stage- and subtype-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. Univariate sensitivity analyses and Monte Carlo simulations were performed to test the robustness of our model.

RESULTS

For women with stage I-II breast cancer, delivery at 36 weeks yielded the highest number of overall quality-adjusted life years (QALYs), while maternal QALYs were maximized with delivery at 34 weeks. For stage III and IV disease, maternal QALYs were maximized at 31 and 30 weeks, respectively. For women with estrogen or progesterone receptor-positive, human epidermal receptor-2 negative breast cancer, both maternal QALYs and overall QALYs were maximized with delivery at 36 weeks. More aggressive biological phenotypes were similarly associated with optimal delivery at decreasing gestational age. Our model was heavily driven by the baseline probability of maternal death within 5 years, in addition to the expected progression of disease and decreases in survival rates with each week of non-treatment, and remained robust across reasonable ranges for all variables of interest.

CONCLUSIONS

For women with breast cancer diagnosed during pregnancy, decisions regarding timing of delivery should take into consideration both cancer stage and hormone receptor subtype.

The extent of intrauterine growth restriction determines the severity of cerebral injury and neurobehavioural deficits in rodents

Background

Cerebral Palsy (CP) is the most common physical pediatric neurodevelopmental disorder and spastic diplegic injury is its most frequent subtype. CP results in substantial neuromotor and cognitive impairments that have significant socioeconomic impact. Despite this, its underlying pathophysiological mechanisms and etiology remain incompletely understood. Furthermore, there is a need for clinically relevant injury models, which a) reflect the heterogeneity of the condition and b) can be used to evaluate new translational therapies. To address these key knowledge gaps, we characterized a chronic placental insufficiency (PI) model, using bilateral uterine artery ligation (BUAL) of dams. This injury model results in intrauterine growth restriction (IUGR) in pups, and animals recapitulate the human phenotype both in terms of neurobehavioural and anatomical deficits.

Methods

Effects of BUAL were studied using luxol fast blue (LFB)/hematoxylin & eosin (H&E) staining, immunohistochemistry, quantitative Magnetic Resonance Imaging (MRI), and Catwalk neurobehavioural tests.

Results

Neuroanatomical analysis revealed regional ventricular enlargement and corpus callosum thinning in IUGR animals, which was correlated with the extent of growth restriction. Olig2 staining revealed reductions in oligodendrocyte density in white and grey matter structures, including the corpus callosum, optic chiasm, and nucleus accumbens. The caudate nucleus, along with other brain structures such as the optic chiasm, internal capsule, septofimbrial and lateral septal nuclei, exhibited reduced size in animals with IUGR. The size of the pretectal nucleus was reduced only in moderately injured animals. MAG/NF200 staining demonstrated reduced myelination and axonal counts in the corpus callosum of IUGR animals. NeuN staining revealed changes in neuronal density in the hippocampus and in the thickness of hippocampal CA2 and CA3 regions. Diffusion weighted imaging (DWI) revealed regional white and grey matter changes at 3 weeks of age. Furthermore, neurobehavioural testing demonstrated neuromotor impairments in animals with IUGR in paw intensities, swing speed, relative print positions, and phase dispersions.

Conclusions

We have characterized a rodent model of IUGR and have demonstrated that the neuroanatomical and neurobehavioural deficits mirror the severity of the IUGR injury. This model has the potential to be applied to examine the pathobiology of and potential therapeutic strategies for IUGR-related brain injury. Thus, this work has potential translational relevance for the study of CP.

Children with motor impairment related to cerebral palsy: Prevalence, severity and concurrent impairments in China

AIM

Cerebral palsy (CP) is the most common cause of motor impairment in childhood. This study aimed to examine the prevalence, severity and concurrent impairments of CP-related motor impairment among Chinese children.

METHODS

Children with CP-related motor impairment aged 0-17 years were identified through a national population-based survey based on World Health Organization International Classification of Functioning, Disability and Health. Logistic regression models allowing for weights were used to examine individual and family factors in relation to CP-related motor impairment.

RESULTS

The weighted prevalence of CP-related motor impairment was 1.25 per 1000 children (95% confidence interval (CI): 1.16, 1.35) in China. Male children, children in multiples and in families where adults suffered from CP, were more likely to be affected by CP-related motor impairment. For mild, moderate, severe and extremely severe groups of motor impairment, weighted proportions of CP were 14.12% (95%CI: 11.70, 16.95), 20.35% (95%CI: 17.48, 23.56), 27.44% (95%CI: 24.25, 30.87) and 38.09% (95%CI: 34.55, 41.76), respectively; and weighted proportions of concurrent visual, hearing and cognitive impairment were 5.00% (95%CI: 3.59, 6.91), 6.98% (95%CI: 5.34, 9.08) and 71.06% (95%CI: 67.57, 74.31), respectively.

CONCLUSIONS

Gender, multiple births and family adults with CP were significantly associated with CP-related motor impairment in Chinese children. Proportions of CP and concurrent impairments that increased with severity of motor impairment were observed.

Ageing with cerebral palsy; what are the health experiences of adults with cerebral palsy? A qualitative study

OBJECTIVE

To enhance understanding of the experiences of ageing with cerebral palsy (CP) in adulthood with a particular focus on experiences with health services.

DESIGN

A qualitative descriptive methodology was applied to capture adults' views of ageing with CP and related interactions with health services. Semistructured interviews were undertaken with data systematically coded and interpreted by grouping information into categories. Themes that encompassed the categories were identified through thematic analysis.

SETTING

All healthcare settings.

PARTICIPANTS

28 adults (14 women) with CP, aged 37-70 years.

RESULTS

5 themes covered the breadth of participants' experiences: (1) acceptance of change; (2) exploring identity: cerebral palsy as only one part of self; (3) taking charge of help; (4) rethinking the future and (5) interacting with health professionals. Being seen and being heard were the features described in positive healthcare interactions. Participants also valued health professionals who reflected on who holds the knowledge?; demonstrated a willingness to learn and respected participants' knowledge and experience.

CONCLUSIONS

Our findings could, and arguably should, inform more responsive strategies for disabled people in health services and, indeed, all health consumers. Our study supports other findings that impairments related to CP change and, for many, severity of disabling impact increases with age. Increased interactions with health and rehabilitation professionals, as a consequence of these changes, have the potential to impact the person's healthcare experience either positively or negatively. A 'listening health professional' may bridge their knowledge gap and, in recognising the person's own expertise, may achieve three things: a more contextualised healthcare intervention; a better healthcare experience for the person with CP and positive impact on the person's sense of autonomy and identity by recognising their expertise. Future research should identify whether this approach improves the healthcare experience for adults living with CP.

Multidisciplinary rehabilitation for patients with cerebral palsy: improving long-term care

Cerebral palsy (CP) is one of the most frequent causes of child disability in developed countries. Children with CP need lifelong assistance and care. The current prevalence of CP in industrialized countries ranges from 1.5 to 2.5 per 1,000 live births, with one new case every 500 live births. Children with CP have an almost normal life expectancy and mortality is very low. Despite the low mortality rate, 5%-10% of them die during childhood, especially when the severe motor disability is comorbid with epilepsy and severe intellectual disability. Given this life expectancy, children with CP present with a lifelong disability of varying severity and complexity, which requires individualized pathways of care. There are no specific treatments that can remediate the brain damage responsible for the complex clinical-functional dysfunctions typical of CP. There are, however, a number of interventions (eg, neurorehabilitation, functional orthopedic surgery, medication, etc) aimed at limiting the damage secondary to the brain insult and improving these patients' activity level and participation and, therefore, their quality of life. The extreme variability of clinical aspects and the complexity of affected functions determine a multifaceted skill development in children with CP. There is a need to provide them with long-term care, taking into account medical and social aspects as well as rehabilitation, education, and assistance. This long-term care must be suited according to children's developmental stage and their physical, psychological, and social development within their life contexts. This impacts heavily on the national health systems which must set up a network of services for children with CP, and it also impacts heavily on the family as a whole, due to the resulting distress, adjustment efforts, and changes in quality of life. This contribution is a narrative review of the current literature on long-term care for children with CP, aiming at suggesting reflections to improve these children's care.

[Sociodemographic and clinical characteristic of the population attended in the Instituto Teletón de Santiago]

The Institutos Teletón care for 85% of the Chilean child population with neuromusculoskeletal disability, the large percentage concentrating in this population. However, there are no registers that enable a profile to be determined on this population.

OBJECTIVE

To determine the profile of patients attending the Instituto Teletón de Santiago during the year 2012.

PATIENTS AND METHOD

The sociodemographic characteristics were analyzed from the computerised records of the Instituto Teletón de Santiago on active patients who were seen during the year 2012.

RESULTS

A total of 8,959 patients were seen during the study year in the Instituto Teletón de Santiago. As regards socioeconomic level, 33.3% were in extreme poverty, 28.7% to low-middle level. The main clinical diagnoses were cerebral palsy and other encephalopathies that also lead to motor disability, and accounted for 55.4% of the cases.

CONCLUSIONS

As a result of determining this profile, it would be appropriate to encourage the need for a national register of the child population with disability, as well as their particular characteristics in order to make decisions on public policy, as a destination for funds or support programs.

Systematic Review of Cerebral Palsy Registries/Surveillance Groups: Relationships between Registry Characteristics and Knowledge Dissemination

The aims of this study were to provide a comprehensive summary of the body of research disseminated by Cerebral Palsy (CP) registries and surveillance programs from January 2009 through May 2014 in order to describe the influence their results have on our overall understanding of CP. Secondly, registries/surveillance programs and the work they produced were evaluated and grouped using standardized definitions and classification systems.

METHOD

A systematic review search in PubMed, CINAH and Embase for original articles published from 1 January 2009 to 20 May 2014 originating from or supported by population based CP registries and surveillance programs or population based national registries including CP were included. Articles were grouped by 2009 World CP Registry Congress aim, registry/surveillance program classification, geographical region, and the International Classification of Function, Disability and Health (ICF) domain. Registry variables were assessed using the ICF-CY classification.

RESULTS

Literature searches returned 177 articles meeting inclusion criteria. The majority (69%) of registry/surveillance program productivity was related to contributions as a Resource for CP Research. Prevention (23%) and Surveillance (22%) articles were other areas of achievement, but fewer articles were published in the areas of Planning (17%) and Raising the Profile of CP (2%). There was a range of registry/surveillance program classifications contributing to this productivity, and representation from multiple areas of the globe, although most of the articles originated in Europe, Australia, and Canada. The domains of the ICF that were primarily covered included body structures and function at the early stages of life. Encouragingly, a variety of CP registry/surveillance program initiatives included additional ICF domains of participation and environmental and personal factors.

INTERPRETATION

CP registries and surveillance programs, including novel non-traditional ones, have significantly contributed to the understanding of how CP affects individuals, families and society. Moving forward, the global CP registry/surveillance program community should continue to strive for uniformity in CP definitions, variables collected and consistency with international initiatives like the ICF so that databases can be consolidated for research use. Adaptation to new technologies can improve access, reduce cost and facilitate information transfer between registrants, researchers and registries/surveillance programs. Finally, increased efforts in documenting variables of individuals with CP into adulthood should be made in order to expand our understanding of CP across the lifespan.

Optimising nutrition to improve growth and reduce neurodisabilities in neonates at risk of neurological impairment, and children with suspected or confirmed cerebral palsy

Background

Neurological impairment is a common sequelae of perinatal brain injury. Plasticity of the developing brain is due to a rich substrate of developing neurones, synaptic elements and extracellular matrix. Interventions supporting this inherent capacity for plasticity may improve the developmental outcome of infants following brain injury. Nutritional supplementation with combination docosahexaenoic acid, uridine and choline has been shown to increase synaptic elements, dendritic density and neurotransmitter release in rodents, improving performance on cognitive tests. It remains elusive whether such specific ‘neurotrophic’ supplementation enhances brain plasticity and repair after perinatal brain injury.

Methods/Design

This is a two year double-blind, randomised placebo controlled study with two cohorts to investigate whether nutritional intervention with a neurotrophic dietary supplement improves growth and neurodevelopmental outcomes in neonates at significant risk of neurological impairment (the D1 cohort), and infants with suspected or confirmed cerebral palsy (the D2 cohort).

120 children will be randomised to receive dietetic and nutritional intervention, and either active supplement or placebo. Eligible D1 neonates are those born <30⁺⁶ weeks gestation with weight <9^th centile, ≤30⁺⁶ weeks gestation and Grade II, III or IV Intra-Ventricular Haemorrhage or periventricular white matter injury, or those born at 31-40⁺²⁸ weeks gestation, with Sarnat grade I or II or III Hypoxic Ischaemic Encephalopathy or neuroimaging changes compatible with perinatal brain injury. Eligible D2 infants are those aged 1-18 months with a suspected or confirmed clinical diagnosis of cerebral palsy. The primary outcome measure is composite cognitive score on the Bayley Scales of Infant and Toddler Development III at 24 months. Secondary outcomes include visuobehavioural and visual neurophysiological assessments, and growth parameters including weight, height, and head circumference.

Discussion

This is the first study to supplement neonates and infants with perinatal brain injury with the combination of factors required for healthy brain development, throughout the period of maximal brain growth. A further study strength is the comprehensive range of outcome measures employed. If beneficial, supplementation with brain phosphatide precursors could improve the quality of life of thousands of children with perinatal brain injury.

Trial registration

Current Controlled trials: ISRCTN39264076 (registration assigned 09/11/2012), ISRCTN15239951 (registration assigned 23/04/2010).

Assessment and management of the communication difficulties of children with cerebral palsy: a UK survey of SLT practice

BACKGROUND

Communication difficulties are common in cerebral palsy (CP) and are frequently associated with motor, intellectual and sensory impairments. Speech and language therapy research comprises single-case experimental design and small group studies, limiting evidence-based intervention and possibly exacerbating variation in practice.

AIMS

To describe the assessment and intervention practices of speech-language therapist (SLTs) in the UK in their management of communication difficulties associated with CP in childhood.

METHODS & PROCEDURES

An online survey of the assessments and interventions employed by UK SLTs working with children and young people with CP was conducted. The survey was publicized via NHS trusts, the Royal College of Speech and Language Therapists (RCSLT) and private practice associations using a variety of social media. The survey was open from 5 December 2011 to 30 January 2012.

OUTCOMES & RESULTS

Two hundred and sixty-five UK SLTs who worked with children and young people with CP in England (n = 199), Wales (n = 13), Scotland (n = 36) and Northern Ireland (n = 17) completed the survey. SLTs reported using a wide variety of published, standardized tests, but most commonly reported assessing oromotor function, speech, receptive and expressive language, and communication skills by observation or using assessment schedules they had developed themselves. The most highly prioritized areas for intervention were: dysphagia, alternative and augmentative (AAC)/interaction and receptive language. SLTs reported using a wide variety of techniques to address difficulties in speech, language and communication. Some interventions used have no supporting evidence. Many SLTs felt unable to estimate the hours of therapy per year children and young people with CP and communication disorders received from their service.

CONCLUSIONS & IMPLICATIONS

The assessment and management of communication difficulties associated with CP in childhood varies widely in the UK. Lack of standard assessment practices prevents comparisons across time or services. The adoption of a standard set of agreed clinical measures would enable benchmarking of service provision, permit the development of large-scale research studies using routine clinical data and facilitate the identification of potential participants for research studies in the UK. Some interventions provided lack evidence. Recent systematic reviews could guide intervention, but robust evidence is needed in most areas addressed in clinical practice.

Congenital cytomegalovirus is associated with severe forms of cerebral palsy and female sex in a retrospective population-based study

AIM

Congenital cytomegalovirus (cCMV) infection can result in poor outcomes including cerebral palsy (CP). The aim of this study was to describe the incidence and comorbidities of CP reported to the Australian Cerebral Palsy Register (ACPR) as attributed to cCMV infection.

METHOD

This was a retrospective population-based study. Cases were drawn from Australian state CP registers with population level ascertainment, 1993 to 2003 (n=2265; 56.4% males, Gross Motor Function Classification System [GMFCS] ratings available for Victorian cases only: 70% GMFCS levels I to III and 30% GMFCS levels IV to V). Clinical data were extracted and cases with cCMV reported as a known cause were compared with cases where cCMV was not reported.

RESULTS

Children with cCMV (n=34; 12 males, 22 females; mean [SD] gestational age, 36.4 wk [4.4], range 24-41 wk) accounted for 1.5% of CP cases; 2.9 per 100,000 live births, (95% confidence intervals 1.9-3.9). When compared with CP cases where cCMV was not reported, proportionally, more CP cases with cCMV were born to younger mothers (p<0.001), were female (64% vs 43%, p=0.014), had spastic quadriplegia (73% vs 21%, p<0.001), required wheeled mobility i.e. GMFCS IV or V (78% vs 28%, p<0.001), had epilepsy (70% vs 30%, p<0.001), deafness (40% vs 2%, p<0.001), functional blindness (20% vs 5%, p<0.001), and severe communication impairment (71% vs 25%, p<0.001).

INTERPRETATION

cCMV is an important potentially preventable cause of CP and is associated with severe disability and female sex in cases reported to the ACPR. Future studies utilising prospective sample collection for cCMV testing are needed to confirm these findings.

Health, functioning, and participation of adolescents and adults with cerebral palsy: a review of outcomes research

With medical advances, more individuals with cerebral palsy (CP) syndromes who reside in developed countries are surviving to adolescence and adulthood. However, there continues to be a paucity of research examining long-term health, functional activities, and participatory outcomes over their life-course. This article reviews the current literature assessing adult outcomes for individuals with CP within the framework of the International Classification of Functioning (ICF), Disability, and Health model of enablement. Preliminary data over the last decade indicate that among adults with cerebral palsy without intellectual disability, 60-80% completed high school, 14-25% completed college, up to 61% were living independently in the community, 25-55% were competitively employed, and 14-28% were involved in long term relationships with partners or had established families. These outcomes occurred with biomedical advances in the management of spasticity, deformity, and medical co-morbidities, as well as with concurrent policy initiatives to increase access to a continuum of habilitative and education services. Although we have incomplete population data to inform comprehensive life-course planning, there are opportunities to create clinical and translational community networks with improved measures of functioning and participation that can better inform us about the factors influencing lifespan development of people with CP.

Differences in standing balance between patients with diplegic and hemiplegic cerebral palsy

Maintaining standing postural balance is important for walking and handling abilities in patients with cerebral palsy. This study included 23 patients with cerebral palsy (seven with spastic diplegia and 16 with spastic hemiplegia), aged from 7 to 16 years of age. Standing posture balance measurements were performed using an AMTI model OR6-7 force platform with the eyes open and closed. Patients with diplegic cerebral palsy exhibited greater center of pressure displacement areas with the eyes open and greater center of pressure sway in the medial-lateral direction with the eyes open and closed compared with hemiplegic patients. Thus, diplegic patients exhibited weaker postural balance control ability and less standing stability compared with hemiplegic cerebral palsy patients.

Outpatient respiratory management of the child with severe neurological impairment

Most paediatricians will have faced the challenge of managing respiratory problems in the child with severe neurological impairment. These children are under-represented in clinical trials, and data is therefore often extrapolated from other groups, for example children with cystic fibrosis. This means that robust evidence for respiratory management in children with severe neurological impairment is often lacking. Here we have attempted to piece together the existing evidence to provide a rational approach to the management of respiratory problems in children with severe neurological impairment. We also hope to highlight areas of uncertainty, in order to aid honest discussions with families. The respiratory management of the child with neuromuscular disease is beyond the scope of this article.

The association between neurodevelopmental disability and economic outcomes during mid-childhood

BACKGROUND

There is a paucity of evidence on the association between childhood disability and economic outcomes. This study estimates the economic costs and health utilities associated with neurodevelopmental impairment or serious neurodevelopmental disability during the 11th year of life.

METHODS

Standardized tests of cognitive ability and clinical assessments of functional abilities were performed on participants of a whole population study of extremely preterm children and term-born controls (EPICure). Profiles of children's use of health, social and education services, and descriptions of their health status using the Health Utilities Index Mark 2 and Mark 3 health status classification systems, were extracted from detailed questionnaires completed by the main parent. Descriptive and multiple regression techniques were used to explore the association between neurodevelopmental impairment or serious neurodevelopmental disability and two sets of economic outcomes; economic costs and health utilities.

RESULTS

Mean health and social service costs over the 12-month period were estimated at £577 [standard error (SE): £141] among children without neurodevelopmental impairment, £831 (£112) among children with a mild neurodevelopmental impairment, £1053 (£176) among children with a moderate neurodevelopmental impairment and £1662 (£316) among children with a severe neurodevelopmental impairment. Mean health and social service costs were estimated at £1223 (£157) and £695 (£92) among children with and without serious neurodevelopmental disability, respectively. After controlling for clinical and sociodemographic confounders, mild, moderate and severe neurodevelopment impairment increased health and social service costs by an average of £397 (95% CI: £86, £707; P= 0.012), £655 (95% CI: £167, £1144; P= 0.009) and £1065 (95% CI: -£113, £2243; P= 0.076), respectively. Cost differences were accentuated when broader public sector costs were considered. The mean (SE) Health Utilities Index Mark 3 multi-attribute utility score for the children with neurodevelopmental disability was 0.652 (0.039), compared with 0.923 (0.009) for children without neurodevelopmental disability, generating a mean difference in utility score of 0.272 (95% CI: 0.220, 0.323) that was statistically significant (P < 0.001).

CONCLUSIONS

Our data should act as a significant new resource for economic analysts modelling the overall economic impact of childhood neurodevelopment impairment or disability or the cost-effectiveness of interventions targeted at neurodevelopmentally impaired or disabled children.

Brain magnetic resonance imaging and motor and intellectual functioning in 86 patients born at term with spastic diplegia

AIM

To investigate the association between magnetic resonance imaging (MRI) patterns and motor function, epileptic episodes, and IQ or developmental quotient in patients born at term with spastic diplegia.

METHOD

Eighty-six patients born at term with cerebral palsy (CP) and spastic diplegia (54 males, 32 females; median age 20 y, range 7-42 y) among 829 patients with CP underwent brain MRI between 1990 and 2008. The MRI and clinical findings were analysed retrospectively. Intellectual disability was classified according to the Enjoji developmental test or the Wechsler Intelligence Scale for Children (3rd edition).

RESULTS

The median ages at diagnosis of CP, assignment of Gross Motor Function Classification System (GMFCS) level, cognitive assessment, and MRI were 2 years (range 5 mo-8 y), 6 years (2 y 8 mo-19 y), 6 years (1 y 4 mo-19 y), and 7 years (10 mo-30 y) respectively. MRI included normal findings (41.9%), periventricular leukomalacia, hypomyelination, and porencephaly/periventricular venous infarction. The frequency of patients in GMFCS levels III to V and intellectual disability did not differ between those with normal and abnormal MRI findings. Patients with normal MRI findings had significantly fewer epileptic episodes than those with abnormal ones (p=0.001).

INTERPRETATION

Varied MRI findings, as well as the presence of severe motor dysfunction and intellectual disability (despite normal MRI), suggest that patients born at term with spastic diplegia had heterogeneous and unidentified pathophysiology.

Clinical prognostic messages from a systematic review on cerebral palsy

OBJECTIVE

To summarize evidence on the rates of co-occurring impairments, diseases, and functional limitations with cerebral palsy into succinct clinical messages.

METHODS

A search was conducted of the databases PubMed, Medline, CINAHL, and PsycINFO, and the results were supplemented with hand searches. Two independent reviewers determined whether retrieved abstracts met the following inclusion criteria: human subjects; >90% were children or adults with cerebral palsy; published after 1999; and population-based data. Articles were appraised, analyzing design, participants, level of evidence, rates of impairments, and functional implications. Methodologic quality was rated by using a standardized checklist.

RESULTS

A total of 1366 papers were identified in the search; 82 were appraised and 30 were included in the meta-analyses. High-level evidence existed, as rated on the Oxford 2011 LEVELS OF EVIDENCE: 97% of prevalence studies were level 1. The data were of a moderate to high quality grade (with the exception of sleep disorders), allowing plain English clinical messages to be developed.

CONCLUSIONS

Among children with cerebral palsy, 3 in 4 were in pain; 1 in 2 had an intellectual disability; 1 in 3 could not walk; 1 in 3 had a hip displacement; 1 in 4 could not talk; 1 in 4 had epilepsy; 1 in 4 had a behavior disorder; 1 in 4 had bladder control problems; 1 in 5 had a sleep disorder; 1 in 5 dribbled; 1 in 10 were blind; 1 in 15 were tube-fed; and 1 in 25 were deaf.

The risk of intrauterine fetal death in the small-for-gestational-age fetus

OBJECTIVE

We sought to evaluate the risk of intrauterine fetal death (IUFD) in small-for-gestational-age (SGA) fetuses.

STUDY DESIGN

We analyzed a retrospective cohort of all births in the United States in 2005, as recorded in a national database. We calculated the risk of IUFD within 3 sets of SGA threshold categories as well as within non-SGA pregnancies using the number of at-risk fetuses as the denominator.

RESULTS

The risk of IUFD increased with gestational age and was inversely proportional to percentile of birthweight for gestational age. The risk for IUFD in those <3rd percentile was as high as 58.0 IUFDs per 10,000 at-risk fetuses, 43.9 for <5th percentile, and 26.3 for <10th percentile compared to 5.1 for non-SGA gestations.

CONCLUSION

There is an increase in the risk of IUFD in SGA fetuses compared to non-SGA fetuses at all gestational ages with the greatest risk demonstrated in the lowest percentile cohort evaluated.

Characteristics of children with cerebral palsy in the ORACLE children study

AIMS

We have identified an excess of children with cerebral palsy (CP) born to women who received antibiotic treatment for spontaneous preterm labour (SPL). This nested study investigated the profile of impairment among children with CP in the ORACLE Children Study (OCS), and contrasted outcomes with those in 4Child, a population CP registry.

METHOD

The study group comprised 167 children aged from 7 to 10 years (100 males, 67 females) with CP from the OCS, who were subdivided into a preterm rupture of membranes (PROM) group (87 children) and an SPL group (80 children). The OCS sought follow-up information regarding the health and behaviour of surviving children at 7 years of age in the UK using a parent-report postal questionnaire. Families provided further information to define wider aspects of function and were offered a physiotherapy assessment.

RESULTS

The prevalence of CP was higher among children in the OCS than among those in 4Child (standardized morbidity ratios: SPL group, 3.12 [95% confidence interval {CI} 2.47-3.87); PROM group: 1.56 (CI 1.24-1.92)]. The proportion of children with CP born after 32 weeks of gestation was higher in in the SPL group (73%) than in the PROM group (30%); the prevalence of CP was higher in the SPL group than in the PROM group or 4Child. Children with CP in the OCS tended to have similar distributions of neuroimpairment as children in 4Child, but motor impairment and associated vision and hearing problems were found to be less severe.

INTERPRETATION

The pattern of CP in both the PROM and the SPL groups was similar, but functional outcomes were milder, compared with children with CP in the general population. However, in these groups the risk of CP was increased independently of gestational age. This is consistent with findings that ongoing inflammatory damage can cause CP.

Neuroprotection of VEGF-expression neural stem cells in neonatal cerebral palsy rats

Cerebral palsy (CP) is a very common neural system development disorder that can cause physical disability in human. Here, we studied the neuroprotective effect of vascular endothelial growth factor (VEGF)-transfected neural stem cells (NSCs) in newborn rats with cerebral palsy (CP). Seven-day-old Sprague-Dawley rats were randomly divided into four groups: sham operation (control group), PBS transplantation (PBS group), VEGF+NSCs transplantation (transgene NSCs group) and NSCs transplantation groups (NSCs group). PBS, Transgene NSCs and NSCs groups respectively received stereotactic injections of PBS, lentiviral vector (pGC-FU-VEGF) infected NSCs or a NSCs suspension in the left sensory-motor cortex 3 days after CP model was established. The NSCs activity, their impacts on neural cell growth and apoptosis, brain development and animal behaviors were examined on the animals up to age 35-days. As expected, unilateral carotid artery occlusion plus hypoxia (cerebral palsy model) resulted in severe neural developmental disorders, including slowed growth, increased in cortical neuron apoptosis, decreased cerebral cortex micro-vessel density and retarded behavior developments. Transplantation of NSCs not only resulted in increases in VEGF protein expression in rat brains, but also largely prevented the behavioral defects and brain tissue pathology that resulted from cerebral palsy procedure, with animals received VEGF transfected NSCs always being marginally better than these received un-transfected cells. In conclusion, NSCs transplantation can partially prevent/slow down the brain damages that are associated with CP in the newborn rats, suggesting a new possible strategy for CP treatment.

Children with cerebral palsy: racial disparities in functional limitations

BACKGROUND

Previous studies of the frequency of cerebral palsy in the United States have found excess prevalence in black children relative to other groups. Whether the severity of cerebral palsy differs between black and white children has not previously been investigated.

METHODS

A population-based surveillance system in 4 regions of the United States identified 476 children with cerebral palsy among 142,338 8-year-old children in 2006. Motor function was rated by the Gross Motor Function Classification System and grouped into 3 categories of severity. We used multiple imputation to account for missing information on motor function and calculated the race-specific prevalence of each cerebral palsy severity level.

RESULTS

The prevalence of cerebral palsy was 3.7 per 1000 black children and 3.2 per 1000 white children (prevalence odds ratio [OR] = 1.2 [95% confidence interval = 1.0-1.4]). When stratified by severity of functional limitation, the racial disparity was present only for severe cerebral palsy (black vs. white prevalence OR=1.7 [1.1-2.4]). The excess prevalence of severe cerebral palsy in black children was evident in term and very preterm birth strata.

CONCLUSION

Black children in the United States appear to have a higher prevalence of cerebral palsy overall than white children, although the excess prevalence of cerebral palsy in black children is seen only among those with the most severe limitations. Further research is needed to explore reasons for this disparity in functional limitations; potential mechanisms include racial differences in risk factors, access to interventions, and under-identification of mild cerebral palsy in black children.

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.

Neurodevelopmental outcomes in very low-birth-weight infants in Korea: 1998-2007 vs 1989-1997

The authors reviewed the medical records of very low-birth-weight infants admitted from 1998 to 2007 and compared neurodevelopmental outcomes with their previously reported data from 1989 to 1997. The recent group included 824 infants, and the previous group included 471 infants. Neurodevelopmental outcomes were classified into cerebral palsy and non-cerebral palsy neurodevelopmental impairment. In the recent group, the survival rate was significantly higher (79.4% vs 66.2%), the rate of cerebral palsy was lower (7.9% vs 10.5%), and the rate of non-cerebral palsy neurodevelopmental impairment was higher (6.0% vs 4.5%) but not significant. The survival rate increased significantly over time, but there was no significant change in neurodevelopmental outcomes over time. Multivariate analysis indicated that abnormal neurosonographic findings, using assisted ventilation, vaginal delivery, and abnormal brainstem auditory evoked potential, were associated with increased risk for cerebral palsy.

Ethics in health care services for young persons with neurodevelopmental disabilities: a focus on cerebral palsy

In this article we review and discuss some of the key ethical and social challenges that young persons with cerebral palsy face in health care delivery. We identify and explain these challenges, some of which are rarely discussed in contemporary medicine and biomedical ethics, partly because they are not considered genuine "ethical" challenges per se. Most of these challenges are heavily shaped by broader social context and institutional practices, which highlights the importance of nonbiological aspects of the care of young persons with cerebral palsy from an ethics standpoint.

Decreasing incidence and severity of cerebral palsy in prematurely born children

OBJECTIVE

To examine incidence and severity of cerebral palsy (CP), and associated factors among preterm survivors (gestational age <34 weeks), admitted to a neonatal intensive care unit from 1990-2005.

STUDY DESIGN

Eighteen antenatal, perinatal and postnatal factors were analyzed. The cohort was divided in four birth periods: 1990-1993 (n=661), 1994-1997 (n=726), 1998-2001 (n=723), and 2002-2005 (n=850). The Gross Motor Function Classification System was used as primary outcome measure (mean age: 32.9 ± 5.3 months). Logistic regression analyses were used.

RESULTS

CP incidence decreased from 6.5% in period I, to 2.6%, 2.9% and 2.2% (P<.001) in period II-IV, respectively. Simultaneously, cystic periventricular leukomalacia (c-PVL) decreased from 3.3% in period I to 1.3% in period IV (P=.004). Within the total cohort (n=3287), c-PVL grade III decreased from 2.3% in period I to 0.2% in period IV (P=.003). The number of children with Gross Motor Function Classification System levels III-V decreased from period I to IV (P=.035). Independent risk factors for CP were c-PVL and severe intraventricular hemorrhage, whereas antenatal antibiotics, presence of an arterial line, Caesarean section, and gestational age were independent protective factors.

CONCLUSION

CP incidence and severity decreased from 1990-1993 onward, which could be attributed to a reduction of 93% in severe c-PVL.

Development of non-verbal intellectual capacity in school-age children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) are at greater risk for a limited intellectual development than typically developing children. Little information is available which children with CP are most at risk. This study aimed to describe the development of non-verbal intellectual capacity of school-age children with CP and to examine the association between the development of non-verbal intellectual capacity and the severity of CP.

METHODS

A longitudinal analysis in a cohort study was performed with a clinic-based sample of children with CP. Forty-two children were assessed at 5, 6 and 7 years of age, and 49 children were assessed at 7, 8 and 9 years of age. Non-verbal intellectual capacity was assessed by Raven's Coloured Progressive Matrices (RCPM). Severity of CP was classified by the Gross Motor Function Classification System, type of motor impairment and limb distribution. manova for repeated measurements was used to analyse time effects and time × group effects on both RCPM raw scores and RCPM intelligence quotient scores.

RESULTS

The development of non-verbal intellectual capacity was characterised by a statistically significant increase in RCPM raw scores but no significant change in RCPM intelligence quotient scores. The development of RCPM raw scores was significantly associated with the severity of CP. Children with higher levels of gross motor functioning and children with spastic CP showed greater increase in raw scores than children with lower levels of gross motor functioning and children with dyskinetic CP.

CONCLUSIONS

Children with CP aged between 5 and 9 years show different developmental trajectories for non-verbal intellectual capacity, which are associated with the severity of CP. The development of non-verbal intellectual capacity in children with less severe CP seems to resemble that of typically developing children, while children with more severe CP show a limited intellectual development compared to typically developing children.

Low birth weight and respiratory hospitalizations in adolescence

OBJECTIVE

Some low birth weight survivors are at increased risk of respiratory disease. We studied whether low birth weight was associated with hospitalization for respiratory illness in adolescence and to what degree bronchopulmonary dysplasia, cerebral palsy, and other comorbidities accounted for this association.

METHODS

We performed a population-based retrospective cohort study using Washington State birth certificates from 1987 to 1994 to identify exposed (low birth weight) and unexposed (normal birth weight) subjects. Normal birth weight subjects were randomly selected from birth certificates, frequency matched to low birth weight subjects by birth year. Deaths prior to age 12 were excluded. The primary exposure was low birth weight: subcategorized as moderately-low-birth weight (1,500-2,499 g) and very-low-birth weight (<1,500 g). The primary outcome was the first respiratory related hospitalization between the ages of 12-20. Respiratory hospitalizations were defined by ICD-9 discharge diagnosis codes.

RESULTS

After adjustment, the hazard ratio for hospitalization was 1.39 for moderately-low-birth weight (95% CI 1.17-1.65, P < 0.001) and 2.52 for very-low-birth weight (1.80-3.53, P < 0.001). Controlling for bronchopulmonary dysplasia attenuated the risk for very-low-birth weight to 1.76 (1.17-2.64; P = 0.006). A similar attenuation was seen after controlling for cerebral palsy [HR 1.49 (1.02-2.18), P = 0.04], suggesting that some of the risk is mediated through these diagnoses. Among moderately-low-birth weight survivors, controlling for these diagnoses had less of an effect.

CONCLUSIONS

Low birth weight was associated with an increased risk of respiratory hospitalizations in adolescence. Comorbidities explained some of this risk. However, low birth weight remained independently associated with an increased risk of hospitalization.

Prevalence of podiatric conditions seen in Special Olympics athletes: Structural, biomechanical and dermatological findings

BACKGROUND

Podiatric conditions are frequently seen in persons with intellectual disabilities. Unfortunately, many are not detected or addressed. This study attempts to determine the prevalence of a variety of selected podiatric conditions in Special Olympics athletes and compare the findings to studies of a similarly matched general population.

METHODS

Screenings from 1580 Special Olympics athletes participating in a sampling of United States competitions in 2004-2006 were used for the analysis. The athletes voluntarily underwent a foot screening which followed the standardized Special Olympics Fit Feet protocol.

RESULTS

The most commonly identified conditions included overpronated gait, abducted gait, restriction in both the ankle and the first metatarsal phalangeal joint, pes planus, metatarsus adductus, brachymetatarsia, hallux abducto valgus, onychomycosis, onychocryptosis and tinea pedis.

DISCUSSION/CONCLUSION

The prevalence of all the structural conditions was notably higher than a similarly matched general population and both conditions and biomechanical/gait findings associated with ligamentous laxity like pes planus and hallux abducto valgus had especially high prevalence rates. Restricted motion in the ankle and first metatarsal phalangeal joint was surprising and may indicate some athletes have intellectual disabilities with contractures. The higher rates of dermatophyte related conditions may reflect increased exposure from the athletic competition environment, immunocompromise, issues with hygiene or both. Higher rates of onychocryptosis in the athletes may be due to ill fitting shoes and/or hygiene issues.

Speech, expressive language, and verbal cognition of preschool children with cerebral palsy in Iceland

AIM

The aim of this study was to describe speech, expressive language, and verbal cognition of children with cerebral palsy (CP).

METHOD

A population study included 152 Icelandic children with congenital CP (74 males, 78 females; mean age 5y 5mo, range 4y-6y 6mo). Children who spoke in sentences, phrases, or one-word utterances were categorized as verbal. Speech was classified as normal, mild dysarthria, or severe dysarthria. Cognition was reported as IQ (Wechsler Preschool and Primary Scale of Intelligence - Revised) or developmental quotient (DQ).

RESULTS

Most children (81%) had spastic CP and bilateral symptoms (76%); 74 (49%) were at Gross Motor Function Classification System (GMFCS) level I, 27% at levels II and III, and 24% at levels IV and V (p<0.001). One hundred and twenty-eight children (84%) communicated verbally whereas 24 were nonverbal. Nonverbal status and severe dysarthria were associated with greater motor impairment (GMFCS; p<0.001). Twenty-five children (16%) had severe dysarthria. Most (88%) of the nonverbal children had multiple disabilities compared with 18% of the verbal group (p<0.001). Median (interquartile range) verbal IQ was 93 (73-104) and performance IQ 77 (61-94; p<0.001). Sixty-eight children (45%) had normal verbal cognition and almost a quarter of the children with severe dysarthria had a full-scale IQ/DQ of 70.

INTERPRETATION

Most children with CP express sentences and almost half of them have normal verbal IQ. Nonverbal status frequently indicates multiple impairments whereas severe dysarthria may be associated with normal cognition.

An Attempt to Standardize Kurjak's Antenatal Neurodevelopmental Test: Osaka Consensus Statement

Analysis of the dynamics of fetal behavior in comparison with morphological studies has led to the conclusion that fetal behavioral patterns are directly reflecting developmental and maturational processes of fetal central nervous system (CNS). Four-dimensional ultrasound (4D US) offers a practical means for assessment of both the brain function and structure. The visualization of fetal activity in utero by 4D US could allow distinction between normal and abnormal behavioral patterns which might make possible the early recognition of fetal brain impairment. That new technology enabled introduction of Kurjak's antenatal neurodevelopmental test (KANET) in low- and high-risk pregnancies. In order to make the test reproducible, the standardization of the test was proposed in Osaka, Japan, during the International Symposium on Fetal Neurology of International Academy of Perinatal Medicine.

The KANET should be performed in the 3rd trimester from 28th to 38th week of gestation. The assessment should last from 15 to 20 minutes, and the fetuses should be examined when awake. If the fetus is sleeping, the assessment should be postponed for 30 minutes or for the next day between 14 and 16 hours. In cases of definitely abnormal or borderline score, the test should be repeated every two weeks till delivery. New modified KANET test should be used with eight instead of 10 parameters: Facial and mouth movements are combined in one category, isolated hand movements and hand to face movements are combined in one category. The score should be the same for abnormal fetuses 0 to 5, borderline score is from 6 to 13 and normal score is 14 or above.

After 4D US assessment of behavioral patterns in the fetuses from high-risk pregnancies, it is very important to continue with follow-up after delivery in infants who were borderline or abnormal as fetuses. Postnatal assessment of neonates includes initial neurological assessment according to Amiel-Tison's methodology (Amiel-Tison Neurological Assessment at Term, ATNAT) in the early neonatal period and every two weeks in preterm infants till discharge and at the postmenstrual age (PMA) between 37 and 40 weeks. If ATNAT is borderline or abnormal, initial assessment of general movements at the age of 36 to 38 weeks of PMA should be performed, than at writhing age (between 46 and 52 weeks), and at the fidgety age after 54 weeks of PMA. If the finding of fidgety movements is mildly abnormal or definitely abnormal, then one more assessment should be done in 2 to 4 weeks till PMA of 58 weeks. Brain ultrasonography should be performed in the first week of life and every 2 weeks afterward till discharge. In severely affected infants with grade 3 and above intraventricular hemorrhage, and those highly suspicious of hypoxic ischemic brain damage, magnetic resonance (MR) should be done if available. Infants should be followed until the age of at least 24 months when diagnosis of disabling or nondisabling cerebral palsy can be ultimately made. Infants with CP should be reassessed at the age of 6 years.

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.

[Cerebral palsy and perinatal asphyxia (I--diagnosis)]

Cerebral palsy (CP) is a group of disorders of the development of movement and posture, causing activity limitations, that are attributed to nonprogressing disturbances that occurred in the developing fetal or infant brain. The motor abnormalies are often accompanied by disturbances of sensation, perception, cognition, behavior and/or by a seizure disorder. The prevalence of CP has not decreased in developed countries over the past 30 years, despite the widespread use of electronic fetal heart rate monitoring and a 5- to 6-fold increase in the cesarean delivery rate. In the term newborn, CP may be attributed to perinatal asphyxia in case of metabolic acidosis in the cord blood (pH<7,00 and base deficit>12 mmol/L), followed by a moderate or severe neonatal encephalopathy within 24 hours and a further neurological impairement characterized by spastic quadriplegia and dyskinesia/dystonia. Dating the time of fetal asphyxia during delivery is possible when there are acute catastrophic complications during labor and unexpected acute or progressive fetal heart rate anomalies after a normal admission test, when there is a need for intensive neonatal resuscitation, a multi-organ failure within 72 hours of birth and visualization of acute non focal cerebral abnormalities, mainly by early magnetic resonance imaging (MRI). MRI sequences show either a brain-damaged pattern of the central basal ganglia, thalami and posterior limbs of internal capsules with relative cortical sparing, in acute, near-total asphyxial insults manifested by a continuous bradycardia or a pattern of cortical injury in the watershed zones and relative sparing of the central grey matter, in prolonged partial asphyxia, manifested by late or atypical variable decelerations with progressive fetal tachycardia, loss of reactivity and absent fluctuation. Prolongation of either type of asphyxial insult results in more global brain damage. In order to differentiate a CP occurring after perinatal asphyxia from other neurological sequelae in relation with infection, hemorrhage, stroke, malformations, genetic or metabolic diseases, it is essential that a definitive information from the brain by MRI and an extensive histological examination of the placenta are at disposal.