Apgar score and hospitalization for epilepsy in childhood: a registry-based cohort study

Clinical features associated with epilepsy occurrence, resolution, and drug resistance in children with cerebral palsy: A population-based study

AIM

To investigate clinicoradiological features associated with epilepsy, its resolution, and drug resistance in children with cerebral palsy (CP).

METHOD

Data were gathered from the New South Wales/Australian Capital Territory CP Register, encompassing children with CP born between 2003 and 2015 (n = 1916). Clinical features and the severity of impairments were compared among three groups: children with current epilepsy (n = 604), those with resolved epilepsy by age 5 years (n = 109), and those without epilepsy (n = 1203). Additionally, a subset of the registry cohort attending Children's Hospital Westmead (n = 256) was analysed to compare epilepsy and treatment characteristics between drug-responsive (n = 83) and drug-resistant groups (n = 147) using logistic regression and hierarchical cluster analysis.

RESULTS

Manual Ability Classification System levels IV and V, intellectual impairment, and vision impairment were found to be associated with epilepsy in children with CP on multivariable analysis (p < 0.01). Moderate to severe intellectual impairment and bilateral spastic CP were independent positive and negative predictors of epilepsy persistence at the age of 5 years respectively (p < 0.05). Microcephaly and multiple seizure types were predictors of drug-resistant epilepsy (area under the receiver operating characteristic curve of 0.83; 95% confidence interval 0.77-0.9). Children with a known genetic cause (14%) and CP epilepsy surgery group (4.3%) formed specific clinical subgroups in CP epilepsy.

INTERPRETATION

Our study highlights important clinical associations of epilepsy, its resolution, and treatment response in children with CP, providing valuable knowledge to aid in counselling families and identifying distinct prognostic groups for effective medical surveillance and optimal treatment.

WHAT THIS PAPER ADDS

Severe motor and non-motor impairments in cerebral palsy (CP) increase epilepsy risk. Epilepsy more likely resolves in bilateral spastic and milder CP impairments. Epilepsy in CP often manifests at an early age with multiple seizure types and high drug resistance. Children with a known genetic cause and CP epilepsy surgery group represent distinct clinical subgroups.

Correlation of the Apgar Score with Dental Caries in 3- to 5-year-old Iranian Children

Background

Dental caries is a serious health condition in children. Poor diet, poor oral hygiene, and unique anatomy of the primary teeth can all contribute to the development of caries in primary teeth. Developmental structural defects in teeth during the fetal period and the first year after birth are believed to increase caries susceptibility. This study aimed to assess the correlation of the Apgar score with dental caries in 3- to 5-year-old Iranian children.

Methods

This retrospective, descriptive, cross-sectional study was conducted at the Pediatric Dental Clinic of Tehran Dental School in 2022. A total of 123 eligible children between 3-5 years were enrolled. The parents were requested to fill out a checklist regarding the information of demographics, birth and infancy condition and Apgar score of children. The children underwent clinical dental examination, and their dmft was recorded. Data were analyzed by the Pearson and regression tests. P values < 0.1 were considered statistically significant.

Results

The Pearson test showed that the 1-minute (P = 0.000) and 5-minute (P = 0.000) Apgar scores had a significant correlation with dmft. The regression analysis of demographic and birth factors revealed significant correlations between duration of breastfeeding (P = 0.066) and age of initiation of toothbrushing (P = 0.019) with dmft. Also, birth weight (P = 0.026) and mother's educational level (P = 0.090) had significant correlations with the Apgar score.

Conclusion

The results indicated a significant correlation between the Apgar score and dental caries. Thus, newborns with lower Apgar scores are recommended to receive more regular oral and dental care services.

Increasing trends in a low 5-min Apgar score among (near) term singletons: a Dutch nationwide cohort study

OBJECTIVE

To investigate trends in low Apgar scores in (near) term singletons using the Dutch Perinatal Registry.

METHODS

In a cohort of 1,583,188 singletons liveborn ≥35 weeks of gestation in the period 2010-2019, we studied trends in low 5-min Apgar scores (<7 and <4) using Cochrane Armitage trend tests.

RESULTS

The proportion of infants with low Apgar scores <7 and <4 increased significantly between 2010-2019 (1.04-1.42% (p < 0.001), 0.17-0.19% (p = 0.009), respectively). Neonatal mortality remained unchanged. Induction of labour, epidural analgesia and planned caesarean section showed an increasing trend. Instrumental vaginal delivery and emergency caesarean section were performed less frequently over time, but these intervention subgroups showed the highest relative increase in infants with low Apgar scores.

CONCLUSIONS

In the Netherlands, the risk of a low 5-min Apgar score increased over the last decade. The highest relative increase was observed in subgroups of instrumental vaginal delivery and emergency caesarean section.

Identification of drug resistance in a validated cohort of incident epilepsy patients in the Danish National Patient Register

OBJECTIVE

The main purposes of this study were to validate the epilepsy diagnosis in incident epilepsy cases in the Danish National Patient Registry (DNPR), which contains information on nearly 9 000 000 individuals, and to identify persons in the validated cohort who fulfilled the International League Against Epilepsy (ILAE) criteria for drug-resistant epilepsy (DRE).

METHODS

We reviewed a random sample of medical records from all individuals registered with a first diagnosis of epilepsy (International Classification of Diseases, 10th Revision [ICD-10]: G40) or seizures (ICD-10: G41, R56, or F445) in the Central Denmark Region from 2010 to 2019. In persons with a validated incident epilepsy diagnosis, we determined the proportion with DRE at the latest contact. We performed logistic regression analyses to identify clinical factors that correlated with risk of DRE.

RESULTS

Of 20 723 persons with a first diagnosis of epilepsy (n = 11 812) or seizures (n = 8911), we reviewed the medical records of n = 1067 with incident epilepsy and n = 610 with incident seizures. Among those with a register diagnosis of epilepsy, the diagnosis was confirmed in 838 cases (45% females, mean age at onset = 42.4 years), providing a positive predictive value (PPV) of 79% (95% confidence interval [CI] = 76%-81%). The PPV of focal epilepsy was 86% (95% CI = 82%-89%), and the PPV of generalized epilepsy was 71% (95% CI = 61%-80%). Of 740 patients with confirmed incident epilepsy and ≥1 year of follow-up, 103 (14%) fulfilled the definition of DRE, 476 (64%) were drug responsive, and 161 (22%) had undefined responsiveness. In multivariable logistic regression analysis, early age at epilepsy onset, cognitive impairment, and a history of status epilepticus were associated with DRE.

SIGNIFICANCE

In the DNPR, we found a PPV of the epilepsy diagnosis of 79%. Among persons with confirmed epilepsy, 14% fulfilled ILAE criteria for DRE. Early age at epilepsy onset, cognitive impairment, and a history of status epilepticus were independently associated with drug resistance.

Five-minute Apgar score and outcomes in neonates of 24-28 weeks' gestation

OBJECTIVES

To assess associations between 5 min Apgar score and mortality and severe neurological injury (SNI) and to report test characteristics in preterm neonates.

DESIGN, SETTING AND PATIENTS

Retrospective cohort study of neonates 24⁰ to 28⁶ weeks' gestation born between 2007 and 2016 and admitted to neonatal units in 11 high-income countries.

EXPOSURE

5 min Apgar score.

MAIN OUTCOME MEASURES

In-hospital mortality and SNI defined as grade 3 or 4 periventricular/intraventricular haemorrhage or periventricular leukomalacia. Outcome rates were calculated for each Apgar score and compared after adjustment. The diagnostic characteristics and ORs for each value from 0 versus 1-10 to 0-9 versus 10, with 1-point increments were calculated.

RESULTS

Among 92 412 included neonates, as 5 min Apgar score increased from 0 to 10, mortality decreased from 60% to 8%. However, no clear increasing or decreasing pattern was identified for SNI. There was an increase in sensitivity and decrease in specificity for both mortality and SNI associated with increasing scores. The Apgar score alone had an area under the curve of 0.64 for predicting mortality, which increased to 0.73 with the addition of gestational age.

CONCLUSIONS

In neonates of 24-28 weeks' gestation admitted to neonatal units, higher 5 min Apgar score was associated with lower mortality in a graded manner, while the association with SNI remained relatively constant at all scores. Among survivors, low Apgar scores did not predict SNI.

Epilepsy-Related Outcomes in Children With Neonatal Cerebellar Injury

OBJECTIVE

Acute brain injury is a frequent perinatal neurologic complication that can involve the cerebellum. Although short-term outcomes of infants with neonatal cerebellar injury are well described, neurologic sequelae in older children are underreported. Here, we describe epilepsy-related outcomes in young children who suffered from neonatal cerebellar injuries.

METHODS

In-house automated software identified patients with neonatal brain injuries who were evaluated at our institution both as neonates (≤28 days) and as children (≥1 year). Neonatal hospital course, neuroimaging, and outcomes related to epilepsy were reviewed from the medical record. Patients were stratified into 2 groups based on neonatal brain injuries: those with cerebellar injury and those without cerebellar involvement.

RESULTS

Of the 282 neonates followed through childhood over the decade-long study period, 33 (12%) experienced neonatal brain injury. All 33 cases involved supratentorial injury, and 5 (15%) also included cerebellar injury. The development of epilepsy was significantly less likely in the group with cerebellar involvement (40%) compared to that with cerebellar sparing (82%; P = 0.043). In some cases, children with cerebellum-sparing injuries required admission for seizure control and developed drug-resistant epilepsy as well as status epilepticus. These outcomes occurred less frequently in the group with cerebellar involvement.

CONCLUSIONS

Epilepsy-related sequelae may occur less frequently when the cerebellum is involved in neonatal brain injury. Larger prospective studies are needed to clarify how cerebellocortical networks impact functional brain connectivity and epilepsy longitudinally.

Risk factors for neonatal seizures: A case-control study in the province of Parma, Italy

PURPOSE

The present study evaluated the risk factors for electroencephalographic (EEG)-confirmed seizures during the whole neonatal period in preterm and term neonates born in the province of Parma between January 2009 and December 2014.

METHODS

We selected as cases the infants that presented EEG-confirmed neonatal seizures (NS). Two population controls for each case were matched by gestational age (GA), sex, hospital, and period of birth. Information on the mother, the pregnancy, the labor and delivery, and the neonates were taken from the Emilia-Romagna Certificate of Delivery Assistance database and from hospital charts and ICD-9-CM codes.

RESULTS AND INTERPRETATION

In the 6-year period of this study, 22 patients were recorded with NS. The association between at least one pregnancy complication and at least one neonatal complication, a low Apgar score, the need for resuscitation at birth, intraventricular hemorrhages (IVH) grades II-IV for preterm, and acute perinatal asphyxia/hypoxic-ischemic encephalopathy (HIE) for term infants were all statistically significant among cases. Neonates presenting these risk factors are more prone to develop NS and have to be strictly monitored.

Factors Associated with Apgar Score among Newborns Delivered by Cesarean Sections at Gandhi Memorial Hospital, Addis Ababa

BACKGROUND

Newborns can be assessed clinically using the Apgar score test to quickly and summarily assess the health of newborn physical condition immediately after delivery and to determine any immediate need for extra medical or emergency care. This study is aimed at assessing factors associated with Apgar score among newborns delivered by cesarean sections and factors associated with Apgar score.

METHOD

Institutional-based cohort study design was conducted. All eligible study participants were included. Training was given for data collectors and supervisors. Regular supervision and follow-up was made. Data was entered into Epi Info version 7 computer software by investigators and was transported to SPSS version 20 computer program for analysis. Bivariate and multivariate analysis was used to identify factors associated with Apgar score.

RESULT

A total 354 newborn babies were included into the study. Majority of baby had low Apgar score at one minute and high Apgar score at five minutes. About 30.2% of newborn baby had Apgar score below seven minutes. On the other hand, about 12.8% of all newborns had low Apgar score at five minutes. It had been found that those neonates who were born when skin incision to delivery time is greater than three minutes were about fourfolds more likely to have low Apgar score than those who were born when skin incision to delivery time is less than three minutes (AOR 3.645) (95% CI (0.116-26.421)).

CONCLUSION

Newborn babies have a low Apgar score at one minute as compared to five minutes. But low Apgar score at five minutes has long-term sequel. Therefore, it is very important to reduce factors associated with low Apgar score at both minutes.

The primary prevention of epilepsy: A report of the Prevention Task Force of the International League Against Epilepsy

Among the causes of epilepsy are several that are currently preventable. In this review, we summarize the public health burden of epilepsy arising from such causes and suggest priorities for primary epilepsy prevention. We conducted a systematic review of published epidemiologic studies of epilepsy of 4 preventable etiologic categories-perinatal insults, traumatic brain injury (TBI), central nervous system (CNS) infection, and stroke. Applying consistent criteria, we assessed the quality of each study and extracted data on measures of risk from those with adequate quality ratings, summarizing findings across studies as medians and interquartile ranges. Among higher-quality population-based studies, the median prevalence of active epilepsy across all ages was 11.1 per 1000 population in lower- and middle-income countries (LMIC) and 7.0 per 1000 in high-income countries (HIC). Perinatal brain insults were the largest attributable fraction of preventable etiologies in children, with median estimated fractions of 17% in LMIC and 15% in HIC. Stroke was the most common preventable etiology among older adults with epilepsy, both in LMIC and in HIC, accounting for half or more of all new onset cases. TBI was the attributed cause in nearly 5% of epilepsy cases in HIC and LMIC. CNS infections were a more common attributed cause in LMIC, accounting for about 5% of all epilepsy cases. Among some rural LMIC communities, the median proportion of epilepsy cases attributable to endemic neurocysticercosis was 34%. A large proportion of the overall public health burden of epilepsy is attributable to preventable causes. The attributable fraction for perinatal causes, infections, TBI, and stroke in sum reaches nearly 25% in both LMIC and HIC. Public health interventions addressing maternal and child health care, immunizations, public sanitation, brain injury prevention, and stroke prevention have the potential to significantly reduce the burden of epilepsy.

Characteristics and factors associated with hospitalization in early childhood: 2004 Pelotas (Brazil) birth cohort

Hospitalization is a frequent event in early childhood. In Brazil, the National Household Sample Survey of 2008 showed a 9% hospitalization rate among children in the first four years of life. The study aimed to describe the characteristics of hospitalization in the first six years of life and analyze the early factors associated with hospitalization in a birth cohort in southern Brazil. A zero-inflated Poisson model was used to simultaneously examine the effects of co-variables for the occurrence of a given event and to count events. The frequency of at least one episode of hospitalization during the study period was 33.4% (95%CI: 31.8-34.9), and was highest in the first year (19.1%; 95%CI: 17.9-20.4), remaining stable at approximately 10% between the first and fourth years, decreasing to 8.4% (95%CI: 7.6-9.4) between the fourth and sixth years. diseases of the respiratory system were among the leading causes of hospitalization, followed by infectious and parasitic diseases. History of prior hospitalization was one of the most important predictors of odds of hospitalization and risk of multiple hospitalizations. In early childhood, birth weight, gestational age, Apgar score, sex, and type of pregnancy were inversely associated with hospitalization, and environmental characteristics such as maternal smoking in pregnancy, mother's skin color, and low family income were associated statistically with number of hospitalizations. The results point to the importance of focusing efforts on reducing hospitalizations from diseases of the respiratory system, especially in children under one year.

Maternal Body Mass Index in Early Pregnancy and Risk of Epilepsy in Offspring

Importance

There is growing concern about the long-term neurologic effects of prenatal exposure to maternal overweight and obesity. The causes of epilepsy are poorly understood and, in more than 60% of the patients, no definitive cause can be determined.

Objectives

To investigate the association between early pregnancy body mass index (BMI) and the risk of childhood epilepsy and examine associations between obesity-related pregnancy and neonatal complications and risks of childhood epilepsy.

Design, Setting, and Participants

A population-based cohort study of 1 441 623 live single births at 22 or more completed gestational weeks in Sweden from January 1, 1997, to December 31, 2011, was conducted. The diagnosis of epilepsy as well as obesity-related pregnancy and neonatal complications were based on information from the Sweden Medical Birth Register and National Patient Register. Multivariate Cox proportional hazards regression models were used to estimate adjusted hazard ratios (HRs) and 95% CIs after adjusting for maternal age, country of origin, educational level, cohabitation with partner, height, smoking, maternal epilepsy, and year of delivery. Data analysis was conducted from June 1 to December 15, 2016.

Main Outcomes and Measures

Risk of childhood epilepsy.

Results

Of the 1 421 551 children born between January 1, 1997, and December 31, 2011, with covariate information available, 7592 (0.5%) were diagnosed with epilepsy through December 31, 2012. Of these 3530 (46.5%) were female. The overall incidence of epilepsy in children aged 28 days to 16 years was 6.79 per 10 000 child-years. Compared with offspring of normal-weight mothers (BMI 18.5 to <25.0), adjusted HRs of epilepsy by maternal BMI categories were as follows: overweight (BMI 25.0 to <30.0), 1.11 (95% CI, 1.04-1.17); obesity grade I (BMI 30.0 to <35.0), 1.20 (95% CI, 1.10-1.31); obesity grade II (BMI 35.0 to <40.0), 1.30 (95% CI, 1.12-1.50); and obesity grade III (BMI≥40.0), 1.82 (95% CI, 1.46-2.26). The rates of epilepsy were considerably increased for children with malformations of the nervous system (adjusted HR, 46.4; 95% CI, 42.2-51.0), hypoxic ischemic encephalopathy (adjusted HR, 23.6; 95% CI, 20.6-27.1), and neonatal convulsions (adjusted HR, 33.5; 95% CI, 30.1-37.4). The rates of epilepsy were doubled among children with neonatal hypoglycemia (adjusted HR, 2.10; 95% CI, 1.90-2.33) and respiratory distress syndrome (adjusted HR, 2.43; 2.21-2.66), and neonatal jaundice was associated with more than a 50% increased risk of epilepsy (adjusted HR, 1.47; 95% CI, 1.33-1.63). The elevated risk of epilepsy in children of overweight or obese mothers was not explained by obesity-related pregnancy or neonatal complications.

Conclusions and Relevance

The rates of childhood epilepsy increased with maternal overweight or obesity in a dose-response manner. Given that overweight and obesity are modifiable, prevention of obesity may be an important public health strategy to reduce the incidence of childhood epilepsy.

Prenatal exposure to antiepileptic drugs and use of primary healthcare during childhood: a population-based cohort study in Denmark

OBJECTIVE

Prenatal exposure to antiepileptic drugs (AEDs) has been associated with adverse outcomes in the offspring such as congenital malformations and neuropsychiatric disorders. The objective of this study was to investigate whether prenatal exposure to AEDs is also associated with more frequent use of primary healthcare during childhood.

DESIGN

Population-based cohort study.

SETTING

Nationwide national registers in Denmark.

PARTICIPANTS

All live-born singletons in Denmark during 1997-2012 identified in the Danish National Patient Register and followed until 31 December 2013 (n=963 010). Information on prenatal exposure to AEDs for maternal indication of epilepsy and other neurological conditions was obtained from the Danish Register of Medicinal Product Statistics.

MAIN OUTCOME MEASURES

The primary outcome measure was the number and type of contacts with the general practitioner (GP), excluding routine well-child visits and vaccinations. The secondary outcome measure was specific services provided at the GP contact. The association between prenatal exposure to AEDs and contacts with the GP was estimated by using negative binomial regression adjusting for sex and date of birth of the child, maternal age, cohabitation status, income, education, substance abuse, depression, severe psychiatric disorders and use of antipsychotics, antidepressants and insulin.

RESULTS

Children exposed prenatally to AEDs (n=4478) had 3% (95% CI 0 to 5%) more GP contacts during the study period than unexposed children. This was primarily accounted for by the number of phone contacts. Within each year of follow-up, exposed children tended to have more contacts than unexposed children, but the differences were small. We found no difference between exposed and unexposed children with regard to specific services provided at the GP contact. For the individual AEDs, we found that exposure to valproate or oxcarbazepine was associated with more GP contacts.

CONCLUSIONS

We found only minor differences between prenatally AED-exposed and unexposed children in the number of GP contacts.

Asphyxia, Neurologic Morbidity, and Perinatal Mortality in Early-Term and Postterm Birth

BACKGROUND AND OBJECTIVES

Neonatal outcomes vary by gestational age. We evaluated the association of early-term, full-term, and postterm birth with asphyxia, neurologic morbidity, and perinatal mortality.

METHODS

Our register-based study used retrospective data on 214 465 early-term (37(+0)-38(+6) gestational weeks), 859 827 full-term (39(+0)-41(+6)), and 55 189 postterm (≥42(+0)) live-born singletons during 1989-2008 in Finland. Asphyxia parameters were umbilical cord pH and Apgar score at 1 and 5 minutes. Neurologic morbidity outcome measures were cerebral palsy (CP), epilepsy, intellectual disability, and sensorineural defects diagnosed by the age of 4 years. Newborns with major congenital anomalies were excluded from perinatal deaths.

RESULTS

Multivariate analysis showed that, compared with full-term pregnancies, early-term birth increased the risk for low Apgar score (<4) at 1 and 5 minutes (odds ratio 1.03, 95% confidence interval 1.03-1.04 and 1.24, 1.04-1.49, respectively), CP (1.40, 1.27-1.55), epilepsy (1.14, 1.06-1.23), intellectual disability (1.39, 1.27-1.53), sensorineural defects (1.24, 1.17-1.31), and perinatal mortality (2.40, 2.14-2.69), but risk for low umbilical artery pH ≤7.10 was decreased (0.83, 0.79-0.87). Postterm birth increased the risk for low Apgar score (<4) at 1 minute (1.26, 1.26-1.26) and 5 minutes (1.80, 1.43-2.34), low umbilical artery pH ≤7.10 (1.26, 1.19-1.34), and intellectual disability (1.19, 1.00-1.43), whereas risks for CP (1.03, 0.84-1.26), epilepsy (1.00, 0.87-1.15), sensorineural defects (0.96, 0.86-1.07), and perinatal mortality (0.91, 0.69-1.22) were not increased.

CONCLUSIONS

Early-term birth was associated with low Apgar score, increased neurologic morbidity, and perinatal mortality. Asphyxia and intellectual disability were more common among postterm births, but general neurologic morbidity and perinatal mortality were not increased.

Assessment of the association between Apgar scores and seizures in infants less than 1 year old

PURPOSE

The study aimed to assess the association between Apgar scores at 1 and 5 min after birth and seizures in infants less than 1 year old.

METHODS

We conducted a retrospective, observational, hospital-based study by utilising medical records from the Chung-Ang University Hospital admissions from January 2006 to May 2015 in order to identify infants less than 1 year old who had a history of seizures. Using electronic medical records, infants who were diagnosed with infantile seizures at the Chung-Ang University Hospital from January 2006 to May 2015 were included in the seizure group (n=93), and a control group consisting of 296 age-matched cases without a history of seizures was selected from a group of infants born at Chung-Ang University Hospital during the same study period.

RESULTS

We found that Apgar scores were significant risk factors for infantile seizures. Apgar scores differed depending on gestational age and birth weight. We found strong associations between Apgar scores and infantile seizures in the full-term and the normal-birth weight groups (bodyweight ≥2.5 kg), regardless of delivery mode. The Apgar scores were inversely correlated with the EEG class, and only the 1-min Apgar scores were correlated with MRI findings.

CONCLUSION

Low Apgar scores are significant perinatal risk factors for infantile seizures, especially in full-term and normal-birth weight infants, and have a strong negative linear relationship with EEG and brain MRI results in the seizure group.

Five-minute Apgar score and educational outcomes: retrospective cohort study of 751,369 children

BACKGROUND

The Apgar score is used worldwide for assessing the clinical condition and short-term prognosis of newborn infants. Evidence for a relationship with long-term educational outcomes is conflicting. We investigated whether Apgar score at 5 min after birth was associated with additional support needs (ASN) and educational attainment.

METHODS

Data on pregnancy, delivery and later educational outcomes for children attending Scottish schools between 2006 and 2011 were collated by linking individual-level data from national educational and maternity databases. The relationship between Apgar score and overall ASN, type-specific ASN and educational attainment was assessed using binary, multinomial and generalised ordinal logistic regression models, respectively. Missing covariate data were imputed.

RESULTS

Of the 751,369 children eligible, 9741 (1.3%) had a low or intermediate Apgar score and 49,962 (6.6%) had ASN. Low Apgar score was independently associated with overall ASN status (adjusted OR for Apgar ≤3, OR 1.52 95% CI 1.35 to 1.70), as well as ASN due to cognitive (OR 1.26, 95% CI 1.09 to 1.47), sensory (OR 2.49 95% CI 1.66 to 3.73) and motor (OR 3.57, 95% CI 2.86 to 4.47) impairments. There was a dose-response relationship between Apgar score and overall ASN status: of those scoring 0-3, 10.1% had ASN, compared with 9.1% of those scoring 4-7 and 6.6% of those scoring 7-10. A low Apgar score was associated with lower educational attainment, but this was not robust to adjustment for confounders.

CONCLUSIONS

Apgar scores are associated with long-term as well as short-term prognoses, and with educational as well as clinical outcomes at the population level.

Apgar-score in children prenatally exposed to antiepileptic drugs: a population-based cohort study

OBJECTIVES

It is unknown if prenatal exposure to antiepileptic drugs (AEDs) increases the risk of low Apgar score in offspring.

SETTING

Population-based study using health registers in Denmark.

PARTICIPANTS

We identified all 677 021 singletons born in Denmark from 1997 to 2008 and linked the Apgar score from the Medical Birth Register with information on the women's prescriptions for AEDs during pregnancy from the Danish Register of Medicinal Product Statistics. We used the Danish National Hospital Registry to identify mothers diagnosed with epilepsy before birth of the child. Results were adjusted for smoking and maternal age.

RESULTS

Among 2906 children exposed to AEDs, 55 (1.9%) were born with an Apgar score ≤7 as compared with 8797 (1.3%) children among 674 115 pregnancies unexposed to AEDs (adjusted relative risk (aRR)=1.41 (95% CI 1.07 to 1.85). When analyses were restricted to the 2215 children born of mothers with epilepsy, the aRR of having a low Apgar score associated with AED exposure was 1.34 (95% CI 0.90 to 2.01) When assessing individual AEDs, we found increased, unadjusted RR for exposure to carbamazepine (RR=1.86 (95% CI 1.01 to 3.42)), valproic acid (RR=1.85 (95% CI 1.04 to 3.30)) and topiramate (RR=2.97 (95% CI 1.26 to 7.01)) when compared to unexposed children.

CONCLUSIONS

Prenatal exposure to AEDs was associated with increased risk of being born with a low Apgar score, but the absolute risk of a low Apgar score was <2%. Risk associated with individual AEDs indicate that the increased risk is not a class effect, but that there may be particularly high risks of a low Apgar score associated with certain AEDs.

Adverse perinatal outcomes for advanced maternal age: a cross-sectional study of Brazilian births

OBJECTIVES

To investigate the risk of adverse perinatal outcomes in women aged ≥41 years relatively to those aged 21-34.

METHODS

Approximately 8.5 million records of singleton births in Brazilian hospitals in the period 2004-2009 were investigated. Odds ratios were estimated for preterm and post-term births, for low Apgar scores at 1 min and at 5 min, for asphyxia, for low birth weight, and for macrosomia.

RESULTS

For pregnant women ≥41, increased risks were identified for preterm births, for post-term births (except for primiparous women with schooling ≥12 years), and for low birth weight. When comparing older vs. younger women, higher educational levels ensure similar risks of low Apgar score at 1 min (for primiparous mothers and term births), of low Apgar score at 5 min (for term births), of macrosomia (for non-primiparous women), and of asphyxia.

CONCLUSION

As a rule, older mothers are at higher risk of adverse perinatal outcomes, which, however, may be mitigated or eliminated, depending on gestational age, parity, and, especially, on the education level of the pregnant woman.

Epileptic and cognitive changes in children with cerebral palsy: an Egyptian study

BACKGROUND

Cerebral palsy (CP) is the most frequent cause of motor handicap among children.

AIM OF THE STUDY

We aim to study the relation of epilepsy in children with CP to various risk factors that affect the development of seizures.

PATIENTS AND METHODS

In a cross-sectional, descriptive, population-based, case-control study, 98 children with CP (48 children with CP with epilepsy, and 50 children with CP without epilepsy) were compared with 180 children without CP or seizures. The children lived in two regions in Egypt: the Al-Kharga District-New Valley and El-Quseir city-Red Sea. These cases were subjected to meticulous neurological assessment, brain magnetic resonance imaging, electroencephalography, and Stanford-Binet (4th edition) examination. Multinomial logistic regression was used to assess the risk factors.

RESULTS

Epilepsy was diagnosed in 48.9% of all cases of CP. Mental subnormality was observed more frequently in children with epilepsy than in those without epilepsy (84.6% versus 66.7%). The frequency of epilepsy was highest in patients with the spastic quadriplegic type of illness (58.3%). Multinomial logistic regression revealed that prematurity (<32 weeks of pregnancy), low birth weight (<2.5 kg at birth), neonatal seizures, jaundice, and cyanosis were significantly associated with CP with epilepsy.

CONCLUSION

CP is associated with a high percentage of seizure disorders. Prematurity, low birth weight, neonatal seizures, cyanosis, and jaundice are significant risk factors among patients with CP with epilepsy compared to patients with CP without epilepsy or a healthy control group.

Infertility treatment and umbilical cord length-novel markers of childhood epilepsy?

Background

Epilepsy is one of the most common neurologic disorders of childhood, affecting about 0.4−0.8% of all children up to the age of 20.

Methodology

A population-based retrospective cohort study. Aim was to determine incidence and identify perinatal and reproductive risk factors of epilepsy in children born between 1989 and 2008 among women (n = 43,389) delivered in Kuopio University Hospital. Risk factors of childhood epilepsy were determined by using logistic regression analysis.

Principal Findings

The incidence of childhood epilepsy was 0.7% (n = 302 of 43,389). Maternal epilepsy, major congenital anomalies and use of assisted reproductive technology (ART) were associated with 4.25-, 3.61-, and 1.67- fold increased incidence of childhood epilepsy. A 10 cm increase in umbilical cord length was associated with a 15% decrease in the incidence of epilepsy (adjusted OR 0.85, 95% CI 0.78−0.94). However, the above reproductive factors accounted for less than 2% of total incidence, whereas maternal epilepsy proved to be the highest risk factor.

Conclusions

Perinatal and reproductive factors were shown to be minor risk factors of childhood epilepsy, implying that little can be done in obstetric care to prevent childhood epilepsy. Infertility treatment and umbilical cord length, independent of gestational age and congenital malformations, may be novel markers of childhood epilepsy.

Maternal use of antibiotics, hospitalisation for infection during pregnancy, and risk of childhood epilepsy: a population-based cohort study

Background

Maternal infection during pregnancy may be a risk factor for epilepsy in offspring. Use of antibiotics is a valid marker of infection.

Methodology/Principal Findings

To examine the relationship between maternal infection during pregnancy and risk of childhood epilepsy we conducted a historical cohort study of singletons born in northern Denmark from 1998 through 2008 who survived ≥29 days. We used population-based medical databases to ascertain maternal use of antibiotics or hospital contacts with infection during pregnancy, as well as first-time hospital contacts with a diagnosis of epilepsy among offspring. We compared incidence rates (IR) of epilepsy among children of mothers with and without infection during pregnancy. We examined the outcome according to trimester of exposure, type of antibiotic, and total number of prescriptions, using Poisson regression to estimate incidence rate ratios (IRRs) while adjusting for covariates. Among 191 383 children in the cohort, 948 (0.5%) were hospitalised or had an outpatient visit for epilepsy during follow-up, yielding an IR of 91 per 100 000 person-years (PY). The five-year cumulative incidence of epilepsy was 4.5 per 1000 children. Among children exposed prenatally to maternal infection, the IR was 117 per 100 000 PY, with an adjusted IRR of 1.40 (95% confidence interval (CI): 1.22–1.61), compared with unexposed children. The association was unaffected by trimester of exposure, antibiotic type, or prescription count.

Conclusions/Significance

Prenatal exposure to maternal infection is associated with an increased risk of epilepsy in childhood. The similarity of estimates across types of antibiotics suggests that processes common to all infections underlie this outcome, rather than specific pathogens or drugs.

Factors affecting epilepsy development and epilepsy prognosis in cerebral palsy

A study was conducted between November 2006 and October 2009 to determine the factors predicting the presence and prognosis of epilepsy in patients with cerebral palsy. We enrolled 2 groups of patients: 42 with cerebral palsy in group 1 and 56 patients with cerebral palsy and epilepsy in group 2. The subjects in group 2 were considered to have good epilepsy prognosis if they were free of seizures for the previous year; otherwise they were considered to have poor epilepsy prognosis. In group 2, neonatal epilepsy, family history of epilepsy, and moderate to severe mental retardation were significantly higher than in group 1 (P < 0.05). In univariate analysis, neonatal seizures, epileptic activity as measured by electroencephalography, and polytherapy were found to be predictors of poor epilepsy prognosis. Additionally, the need for long-term medication to control seizures unfavorably affects prognosis. In logistic regression analysis, neonatal seizure and interictal epileptic activity in electroencephalography were found to be independent predictors of poor epilepsy outcome. In addition, logistic regression analysis revealed that increasing age reduces the success of epilepsy treatment. Neonatal seizures, family history of epilepsy, and mental retardation were found to be important and independent predictors of development of epilepsy in patients with cerebral palsy.

Apgar score and dental caries risk in the primary dentition of five year olds

BACKGROUND

Conditions in utero and early life underlie risk for several childhood disorders. This study tested the hypothesis that the Apgar score predicted dental caries in the primary dentition.

METHODS

A retrospective cohort study conducted in 2003 examined associations between conditions at birth and early life with dental caries experience at five years. Dental examination data for a random sample of five-year-old South Australian children were obtained from School Dental Service electronic records. A questionnaire mailed to the parents obtained information about neonatal status at delivery (five-minute Apgar score, birthweight, plurality, gestational age) and details about birth order, weaning, and behavioural, familial and sociodemographic characteristics.

RESULTS

Of the 1398 sampled children with a completed questionnaire (response rate=64.6%), 1058 were singleton term deliveries among whom prevalence of dental caries was 40.1%. In weighted log-binomial regression analysis, children with an Apgar score of <=8 relative to a score of 9-10 had greater probability of dental caries in the primary dentition after adjusting for sociodemographic and behavioural covariates and water fluoridation concentration (adjusted PR=1.47, 95% CI=1.11, 1.95).

CONCLUSIONS

Readily accessible markers of early life, such as the Apgar score, may guide clinicians in identifying children at potentially heightened risk for dental caries and aid decision-making in allocating preventive services.

Risk factors for epilepsy in children with cerebral palsy

The purpose of the study was to identify predictive risk factors for epilepsy among children with cerebral palsy. We conducted a retrospective study of the clinical characteristics of children with cerebral palsy and epilepsy in comparison to those of children with cerebral palsy without epilepsy. The examined parameters included: the prevalence and the age of onset of the seizures, the clinical subgroup of cerebral palsy and subtype of epileptic seizures. We looked for possible risk factors including the presence of neonatal seizures, the imaging findings, the gestational age at delivery, the adjusted birth weight, the mode of delivery, the Apgar scores, and the head size as well as the presence of consanguinity. Epilepsy occurred in 33% of the studied children. Almost 50% of the epileptic children had their first seizure within the first 12 months of life. Neonatal seizures were strong predictors for epilepsy (p<0.001). Presence of at least one abnormal structural finding (particularly brain atrophy) was also a significant predictor of epilepsy (p<0.003). Low Apgar score at 5 min after birth and birth at term were also found more frequently among patients with epilepsy, although when adjusted with other risk factors, Apgar score did not reach statistical significance. The mode of delivery, head circumference, adjusted birth weight, gender and ethnic group, consanguineous marriage and prematurity were not found to be risk factors for the occurrence of epilepsy in these children.

Febrile seizures and cognitive function in young adult life: a prevalence study in Danish conscripts

OBJECTIVE

To examine the association between febrile seizures and cognitive performance in early adulthood.

STUDY DESIGN

This is a population-based study using data linked from health-care databases and conscript records of Danish men born from 1977 to 1983. The association between febrile seizures and cognitive function, measured with the Boerge Prien validated group intelligence test, was examined overall and by age of seizure, adjusted for potential confounders. The analysis was restricted to men without a known history of epilepsy (n = 18 276).

RESULTS

Of the 18 276 eligible conscripts, 507 (2.8%) had a record of hospitalization with febrile seizures. Compared with conscripts with no such record, the adjusted prevalence ratio for having a Boerge Prien score in the bottom quartile was 1.08 (95% CI, 0.94-1.25). The adjusted prevalence ratios were 1.38 (95% CI, 1.07-1.79) for febrile seizures with an onset age of 3 months to <1 year, 0.98 (95% CI, 0.80-1.18) for febrile seizures with an onset age of 1 to 2 years, and 1.14 (95% CI, 0.79-1.66) for an onset age of 3 to 5 years.

CONCLUSIONS

Overall, there was little association between febrile seizures and cognitive function.

Association of Apgar scores with death and neurologic disability

Apgar score was devised with the aim to standardize the assessment of newborns. It has been used worldwide to evaluate infants’ condition immediately after birth, to determine their need for resuscitation, and to evaluate the effectiveness of resuscitation. Apgar score was never intended for prediction of outcome beyond the immediate postnatal period; however, since low scores correlate with prenatal and perinatal adversities, multiple studies have examined the relation between the value of Apgar score and duration of low (<7) Apgar score and subsequent death or neurologic disability. This article reviews such studies. The author concludes that the overall evidence shows consistent association of low Apgar scores with increased risks of neonatal and infant death and with neurologic disability, including cerebral palsy, epilepsy, and cognitive impairment. Dose-response patterns have been shown for the value of Apgar score and duration of low score and the outcomes of mortality and neurologic disability. The association of Apgar score <7 at five minutes with increased risks of neurologic disability seems to persist many years postnatally. Some corresponding relative risk estimates are large (eg, four to seven for epilepsy or more than 20 for cerebral palsy), while others are modest (eg, 1.33 for impaired cognitive function). The absolute risks, however, are low (<5% in for most neurologic conditions), and majority of surviving babies with low Apgar scores grow up without disability. The low magnitude of absolute risks makes Apgar score a poor clinical predictor of long-term outcome. Nevertheless, the observed associations point to the importance of fetal and perinatal periods for neurodevelopment.

Association of Apgar score at five minutes with long-term neurologic disability and cognitive function in a prevalence study of Danish conscripts

BACKGROUND

Apgar score is used for rapid assessment of newborns. Low five-minute Apgar score has been associated with increased risk of severe neurologic outcome, but data on milder outcomes, particularly in the long term, are limited. We aimed to examine the association of five-minute Apgar score with prevalence of neurologic disability and with cognitive function in early adulthood.

METHODS

We conducted a prevalence study among draft-liable men born in Denmark in 1978-1983 and presenting for the mandatory army evaluation in a northern Danish conscription district. We linked records of this evaluation, which includes medical exam and intelligence testing, with the conscripts' records in the Medical Birth Registry, containing perinatal data. We examined prevalence of neurologic disability and of low cognitive function according to five-minute Apgar score.

RESULTS

Less than 1% (136/19,559) of the conscripts had 5-minute Apgar scores <7. Prevalence of neurologic disability was 2.2% (435/19,559) overall; among conscripts with Apgar scores <7, 7-9, and 10 (reference), it was 8.8%, 2.5%, and 2.2% respectively. The corresponding prevalences of low cognitive function (intelligence test score in the bottom quartile) were 34.9%, 27.2%, and 25.0%. The outcomes were more prevalent if Apgar score <7 was accompanied by certain fetal or obstetric adversities. After accounting for perinatal characteristics, 5-minute Apgar score <7 was associated with prevalence ratios of 4.02 (95% confidence interval: 2.24; 7.24) for neurologic disability and 1.33 (0.94; 1.88) for low cognitive function.

CONCLUSION

A five-minute Apgar score <7 has a consistent association with prevalence of neurologic disability and with low cognitive function in early adulthood.

Gestational age, birth weight, intrauterine growth, and the risk of epilepsy

The authors evaluated the association between gestational age, birth weight, intrauterine growth, and epilepsy in a population-based cohort of 1.4 million singletons born in Denmark (1979-2002). A total of 14,334 inpatients (1979-2002) and outpatients (1995-2002) with epilepsy were registered in the Danish National Hospital Register. Children who were potentially growth restricted were identified through two methods: 1) sex-, birth-order-, and gestational-age-specific z score of birth weight; and 2) deviation from the expected birth weight estimated based on the birth weight of an older sibling. The incidence rates of epilepsy increased consistently with decreasing gestational age and birth weight. The incidence rate ratios of epilepsy in the first year of life were more than fivefold among children born at 22-32 weeks compared with 39-41 weeks and among children whose birth weight was <2,000 g compared with 3,000-3,999 g. The association was modified by age but remained into early adulthood. Incidence rate ratios of epilepsy were increased among children identified as growth restricted according to either of the two methods. In conclusion, short gestational age, low birth weight, and intrauterine growth restriction are associated with an increased risk of epilepsy.

Validation of epilepsy diagnoses in the Danish National Hospital Register

PURPOSE

To validate the diagnosis of epilepsy in the Danish National Hospital Register.

METHODS

We randomly selected 200 patients registered with epilepsy in the Danish National Hospital Register between 1977 and 2002 and validated the diagnosis according to the guidelines developed by the International League Against Epilepsy.

RESULTS

We reviewed the medical records of 188 (94%) persons from 57 departments at 41 hospitals. The epilepsy diagnoses were confirmed in 153 patients, providing a positive predictive value for epilepsy of 81% (95% confidence interval (95% CI): 75-87%). Among the 35 patients who did not fulfill the criteria for epilepsy, 14 were admitted after a single, unprovoked seizure. Among patients registered with epilepsy the positive predictive value of seizure disorder was 89% (95% CI: 83-93%). Among patients classified with epilepsy syndromes, the positive predictive value for syndrome classification was 60% (95% CI: 44-74%) for epilepsy with complex focal seizures and 35% (95% CI: 22-51%) for primary generalized epilepsy.

CONCLUSION

The validity of the epilepsy diagnoses in the Danish National Hospital Register has a moderate to high positive predictive value for epilepsy, but a relatively low predictive value for epilepsy syndromes.

Postterm delivery and risk for epilepsy in childhood

OBJECTIVE

Postterm delivery is a risk factor for perinatal complications, some of which increase risk for neurologic morbidity. We aimed to examine the association between postterm delivery and risk for epilepsy in childhood.

METHODS

We conducted a cohort study of singleton children who were born in 3 Danish counties from 1980 to 2001. Birth registry data were linked with hospital records to identify cases of epilepsy in the first 12 years of life. We included children who were born at > or = 39 gestational weeks and computed crude, age-specific, and birth weight standardized incidence rates of epilepsy. We estimated adjusted incidence rate ratios according to mode of delivery by Poisson regression.

RESULTS

Among the 277,435 nonpreterm births, 32,557 were at > or = 42 weeks, including 3396 at > or = 43 weeks. Nearly one fourth of the 2805 epilepsy cases occurred in the first year of life. In that period, birth weight standardized incidence rate ratios for epilepsy were 1.3 for birth at 42 weeks and 2.0 for birth at > or = 43 weeks, compared with birth at 39 to 41 weeks. Among children who were delivered by cesarean section, incidence rate ratios adjusted for birth weight, presentation, malformations, and county were 1.4 for birth at 42 completed weeks and 4.9 for birth at > or = 43 weeks, compared with term vaginal births. There was a similar tendency among children who were delivered with the assistance of instruments. We found no evidence for the association between postterm delivery and risk for epilepsy beyond the first year of life.

CONCLUSIONS

Prolonged gestation is a risk factor for early epilepsy; the added increase in risk for instrument-assisted and cesarean deliveries could be attributable to factors that are related to both birth complications and epilepsy.