The Influence of Gestational Age on Severity of Impairment in Spastic Cerebral Palsy

doi:10.1016/j.jpeds.2008.02.041

The Journal of Pediatrics

Volume 153, Issue 2, August 2008, Pages 203-208.e4

https://doi.org/10.1016/j.jpeds.2008.02.041 Get rights and content

Objective

To investigate the association between severity of impairment and gestational age in unilateral and bilateral spastic cerebral palsy, and to determine whether the influence of gestational age is independent of deviations from optimal birth weight.

Study design

The study group was a United Kingdom cohort of 4772 cases of spastic cerebral palsy born between 1960 and 1997, with information on birth demographics and severity of impairment. Generalized additive models were used to determine the proportions of cases severely impaired, by gestational age, and to determine whether gestational age or deviations from optimal birth weight better predicts severity of impairment.

Results

For unilateral spastic cerebral palsy, the proportions of severe impairments did not vary with gestational age. In contrast, for bilateral spastic cerebral palsy, the proportions of severe motor or cognitive impairments increased with increasing gestational age (e.g., from 20% to 50% between weeks 30 and 40 for cognitive impairment). For spastic cerebral palsy, gestational age is at least as good as deviation from optimal birth weight in predicting severity.

Conclusions

The severity of impairment increases with increasing gestational age in bilateral spastic cerebral palsy. This suggests differing etiologies in term and preterm infants and supports the theory that the developing brain is better able to compensate after a cerebral insult.

Section snippets

Methods

We compiled data on birth characteristics and impairments for subjects with unilateral and bilateral spastic cerebral palsy, for multiple and singleton births, from 5 well-established UK cerebral palsy registers. Combining data from within 1 country with some uniformity of registers minimizes the data biases that can arise when combining data from heterogeneous sources. This is of particular importance when evaluating influences of birth weight for gestational age, because both birth weight and

Results

A total of 5456 cases of cerebral palsy born between 1960 and 1997 were identified within the defined geographical area. These included 4772 cases of spastic cerebral palsy (87%), 514 cases of nonspastic cerebral palsy (9%), and 161 cases of unknown type (3%). Of the spastic cerebral palsy cases, 2939 were bilateral (62%), 1806 were unilateral (36%), and 27 were of unspecified type (1%) (Table I). The distribution of spastic, nonspastic, and unknown types was similar for multiple and singleton

Discussion

We have found that in spastic bilateral cerebral palsy, the proportion of cases with a severe manual, ambulatory, and cognitive impairment increases with increasing gestational age at delivery. The proportion with a severe hearing impairment does not change with gestational age, and the proportion with a severe visual impairment increases between 30 and 40 weeks of gestational age in singletons. Infants born preterm are known to be at an increased risk for cerebral palsy compared with those

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WISC-V motor-free cognitive profile and predictive factors in adolescents with cerebral palsy
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The relationship between gestational age at birth and cognitive outcomes in CP remains unclear, with inconsistent findings in the literature. Hemming et al. (2008) examined a UK CP register of over 4000 cases and found that gestational age was not associated with cognitive impairment in unilateral spastic CP, except for in extremely preterm cases born before 28 weeks gestation. However, infants born at term with bilateral CP were more likely to have severe intellectual impairment (IQ < 50) than those born preterm (Hemming et al., 2008).
The most commonly used intelligence tests – the Wechsler Scales – do not provide standardised procedures for assessing children with motor impairment, and as a result, may underestimate the intelligence quotient (IQ) of young people with CP.
To characterise a motor-free cognitive profile of adolescents with CP using the Wechsler Intelligence Scale for Children – Fifth edition (WISC-V) and explore the influence of clinical factors on cognitive abilities.
The WISC-V was used to assess cognitive abilities in 70 adolescents (M = 14 years 6 months, SD = 10 months). Sixty-six adolescents (Gross Motor Function Classification System (GMFCS) Level I, n = 26 ; II, n = 23; III, n = 15; IV, n = 1; V, n = 1) obtained either a Motor-free IQ or index score using the motor-free method.
MFIQ and index scores fell below the normative data and rates of borderline and impaired cognitive abilities were significantly higher in the CP group. Scores showed an uneven cognitive profile with a relative strength in verbal abilities. Severity of motor impairment and small for gestational age (SGA) were associated with lower IQ scores. A history of seizures was related to lower verbal abilities.
Cognitive abilities of adolescents with CP are significantly below expectation compared to normative data. Severity of motor impairment, SGA, and seizures need to be recognised by health professionals as risk factors for cognitive impairment. A substantial proportion of adolescents showed borderline cognitive abilities, constituting a group with CP which are relatively neglected in the literature.
Early prediction of cerebral palsy after neonatal intensive care using motor development trajectories in infancy
2013, Early Human Development
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In particular, preterm infants often have CP with higher levels of functionality, as 38% have a GMFCS < 2. This supports studies on outcomes of prematurity [55] and especially periventricular hemorrhagic infarction [11]. Predictive functionality curves have been established for the GMFCS and help providers understand the potential for rehabilitation [56].
Neonatal intensive care unit (NICU) patients are at high risk for developmental disabilities such as cerebral palsy (CP). Early identification of CP is essential to effective rehabilitation, but diagnosis is often delayed, especially in preterm infants. We hypothesized that through the longitudinal evaluation of motor trajectories in the NICU follow-up clinic, we could distinguish infants who develop CP by 3 years of age.
This was a retrospective study of 606 patients in the NICU Follow-up Clinic at Vanderbilt University with birth weight < 1500 g or a diagnosis of hypoxic ischemic encephalopathy.
Assessments included neurologic exams, the Developmental Assessment of Young Children (DAYC), the Bayley Scales of Infant Development (BSID) and the Gross Motor Function Classification Scale.
A decrease in DAYC scores between 6 and 12 months was present in preterm and term infants later diagnosed with CP, but not in children without CP (− 23 vs. + 1.5, p < 0.001). DAYC score decreases in infancy were highly predictive of later CP (p < 0.001). BSID scores quantified severe motor delays but did not add to prediction of CP diagnosis.
Standardized assessments of motor milestones quantitatively predict the risk of CP in former NICU patients by 12 months, allowing for timely diagnosis, counseling and therapy in high-risk infants.
Risk factors for cerebral palsy in term birth infants
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Maternal age was comparable in CP and controls. In previous studies [15,16], maternal age, maternal disease, pre-eclampsia and placenta previa had not been associated with CP. Our results partially confirm these findings.
The aim of this study was to identify the antenatal, intrapartum and neonatal risk factors in term birth infants for cerebral palsy (CP) among babies in a hospital-based study.
The medical records of children with cerebral palsy referred to our Pediatric Rehabilitation Department in Bialystok were reviewed. Antenatal, intrapartum, and neonatal events were compared among 213 children with CP and 280 controls in a retrospective study. We studied live births >36 weeks gestation born between January 1, 1990, and December 31, 2005.
Fifty-seven percent of the infants with CP were male. Spastic tetraplegia 78 (36.61%) and spastic hemiplegia 65 (30.51%) were the dominant types of CP. Factors associated with an increased risk of CP identified as antenatal and intrapartum risk factors were pre-eclampsia, abruptio placenta, and placenta previa. Birth asphyxia occurred significantly more often (p<0.001) in children with CP compared to controls. In the neonatal period, respiratory distress syndrome, meningitis and neonatal seizures were associated with an increased incidence of CP.
Our findings confirm that several antenatal, intrapartum and neonatal risk factors for CP in term birth infants contribute to the etiology of CP.
New developments in spastic unilateral cerebral palsy
2010, Revue Neurologique
Avec une prévalence de 0,6/1000 naissances, l’hémiplégie cérébrale infantile est la principale forme d’infirmité motrice cérébrale chez l’enfant né à terme. C’est aussi la deuxième en fréquence chez l’ancien prématuré après la diplégie spastique.
La symptomatologie, cliniquement caractéristique, est la conséquence d’une grande variété d’atteintes cérébrales dont la survenue précoce et le caractère unilatéral (ou très asymétrique) sont les deux spécificités principales. L’infarctus cérébral artériel est la première cause chez l’enfant né à terme tandis que les lésions cérébrales dues à la prématurité prédominent chez l’ancien prématuré. Les autres causes sont les malformations cérébrales, les thromboses veineuses, les hémorragies parenchymateuses par troubles de l’hémostase et les formes familiales de porencéphalie d’identification plus récente. L’imagerie par résonance magnétique est l’examen le plus approprié à déterminer cette cause et à établir un pronostic précoce.
En complément des soins habituels de la médecine physique et de réadaptation (kinésithérapie, ergothérapie, injection de toxine botulique…), des techniques prometteuses comme la thérapie par contrainte induite et le rétrocontrôle virtuel par effet miroir sont en développement.
Hemiplegic (or spastic unilateral) cerebral palsy accounts for about 30% of all cases of cerebral palsy. With a population prevalence of 0.6 per 1000 live births, it is the most common type of cerebral palsy among term-born children and the second most common type after diplegia among preterm infants.
Many types of prenatal and perinatal brain injury can lead to congenital hemiplegia and brain MRI is the most useful tool to classify them with accuracy and to provide early prognostic information. Perinatal arterial ischemic stroke thus appears as the leading cause in term infants, whereas encephalopathy of prematurity is the most common cause in premature babies. Other causes include brain malformations, neonatal sinovenous thrombosis, parenchymal hemorrhage (for example due to coagulopathy or alloimmune thrombocytopenia) and the more recently described familial forms of porencephaly associated with mutations in the COL4A1 gene.
In adjunction with pharmacologic treatment (botulinium neurotoxin injection), new evidence-based rehabilitational interventions, such as constraint-induced movement therapy and mirror therapy, are increasingly being used.
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: Sources of funding available at www.jpeds.com.

: Information on conflicts of interest available at www.jpeds.com.

: Karla Hemming was employed as a research assistant to Jane Hutton and Peter Pharoah under Medical Research grant G9900630, “Life expectancy in children and young adults with cerebral palsy: A UK collaboration.” The merging and cleaning of the database also was funded by this grant. Jennifer Kurinczuk was partially funded by National Public Health Career Scientist award PHCS022 from the National Coordinating Centre for Research Capacity Development. The Merseyside and Cheshire register is currently funded by the National Health Service. The North of England Collaborative Cerebral Palsy Survey receives grants from the Directors of Public Health of the Northern and Yorkshire Region and Primary Health Care Trusts. The 4Child - Four Counties Database of Cerebral Palsy, Vision Loss and Hearing Loss in Children is currently funded by the Department of Health under the Research Active Disease Registers Initiative and is based at the National Perinatal Epidemiology Unit, which is funded by the Department of Health. The Scottish Register of Children with Motor Deficit of Central Origin was originally set up at Glasgow University and funded by a grant from the Chief Scientist of the Scottish Office. The register was subsequently transferred to the care of the Information Services Division of the National Health Service, National Services Scotland. The Northern Ireland Cerebral Palsy Register is funded by the Department of Health, Social Services and Public Safety.

: Jane Hutton and Peter Pharoah have acted as expert witnesses on life expectancy, for both plaintiffs and defendants, in medicolegal cases. The various funding sources had no involvement in the design, collection, analysis or interpretation of data, or the decision to submit for publication. The views expressed in this article are those of the authors and not necessarily those of the funding bodies. No author received any payment to produce the manuscript.

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Original articleThe Influence of Gestational Age on Severity of Impairment in Spastic Cerebral Palsy

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Lancet

Clin Perinatol

Am J Obstet Gynecol

Early Hum Dev

Early Hum Dev

Neuropsychologia

Intrauterine growth and cerebral palsy in twins: a European multicenter study

Twin Res Hum Genet

Case sex and severity in cerebral palsy varies with intrauterine growth

Arch Dis Child

Intrauterine growth in children with cerebral palsy

Acta Paediatr

Intrauterine growth and survival in cerebral palsy

Arch Dis Child Fetal Neonatal Ed

Multiple birth and cerebral palsy in Europe: a multicenter study

Acta Obstet Gynecol Scand

ABC of preterm birth: epidemiology of preterm birth

BMJ

Gross and fine motor function and accompanying impairments in cerebral palsy

Dev Med Child Neurol

Original article
The Influence of Gestational Age on Severity of Impairment in Spastic Cerebral Palsy