PAKISTAN PEDIATRIC JOURNAL

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1 Vol. 38(3) September, 2014 Print: ISSN Online: ISSN X PAKISTAN PEDIATRIC JOURNAL A JOURNAL OF PAKISTAN PEDIATRIC ASSOCIATION Indexed in EMBASE/Excerpta Medica & Index medicus WHO IMEMR

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3 ORIGINAL ARTICLE Association of Perinatal Adverse Events Withthe Type of Cerebral Palsy ERUM AFZAL, MUHAMMAD WAQAR RABBANI, TANVEER AHMAD, Imran Iqbal Pak Pediatr J 2014; 38(3): Author s affiliations Correspondence to: Erum Afzal, Department of Pediatrics, The Children s Hospital & The Institute of Child Health, Multan erumafzal@yahoo.com INTRODUCTION ABSTRACT Objective: To determine the relationship of different types of cerebral palsy (CP) with perinatal adverse events in CP patients presenting to the Children s Hospital &the Institute of Child Health Multan. Study Design: Cross-sectional study Cerebral palsy describes as a group of disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, cognition, communication, perception, behavior, and/or seizure disorders 1,2.It is one of the most Methodology: This study was conducted at Rehabilitation services unit, The Children s Hospital & the Institute of Child Health Multan from June 2010 to March 2012.Patients (1 to 12 years of age)with abnormalities of tone, movement and posture and diagnosed as cerebral palsy, were included in the study. Details of perinatal adverse events were recorded by detailed history and available perinatal record and type of cerebral palsy was ascertained in each case by clinical examination. All the information was recorded on a predesigned Performa for final analysis. Results: Out of 178 cerebral palsy patients, 39.9%(n=71) were spastic quadriplegic, 30.9%(n=55)spasticdiplegic,22.5% (n=40) spastic hemiplegic, 3.4%(n=6) chorioathetoid,1.7%(n=3) hypotonic and 1.7%(n=3)were mixed type. Spastic quadriplegic type was mainly associated with birth asphyxia whereas spastic diplegia with prematurity and low birth weight. Sepsis, meningitis and intracranial bleed were the main events responsible for spastic hemiplegia. Chorioethetoid type was related to kernicteris whereas hypotonic type to CNS bleed and malformations. In mixed type there was history of birth asphyxia in most of the patients. In 8.5%( n=15)patients no definite factor could be determined. Conclusion: Most common presentation of cerebral palsy is spastic quadriplegia, mainly caused by birth asphyxia. Key Words: Cerebral palsy, perinatal events, Birth asphyxia common causes of neurological impairment in childhood 3. The prevalence of cerebral palsy vary from 1-6 per ,5.The main developing causative factors include birth asphyxia, birth trauma, prematurity, kernicterus, intracranial bleed 6, CNS infections and malformations 6,7.. Improved and upgraded management plans during perinatal periods have changed the

4 180 Afzal E, Rabbani MW, Ahmad T spectrum of presentation and type of cerebral palsy; better obstetric techniques have reduced the birth trauma, more over early interventions in the management of jaundice neonatorum (JNN) have decreased the prevalence of spastic and chorioathetoid types 8,9. Prematurity, low birth weight and placental dysfunctions are becoming major factors of cerebral palsy in recent years due to the increased survival of these children in developed countries 10. The aim of this study is to see the proportions of different types of cerebral palsy, their associated factors and relationship between these factors and the type of cerebral palsy. This will help in estimating the disease burden and formulating the management plan for commonly prevalent types of cerebral palsy in this region. MATERIAL AND METHODS This study was conducted from June 2010 to March 2012 at Rehabilitation services unit, The Children s Hospital and the Institute of Child Health Multan. Patients (1 to 12 years of age) with abnormalities of tone, movement and posture; diagnosed as cerebral palsy, were included in the study. Patients diagnosed as storage disorders, metabolic disorders, degenerative brain diseases, myopathies, neuropathies and dysmorphic syndromes on the basis of history, clinical findings and relevant investigations were excluded. Parents/guardians were detailed about the study and prior written permission was taken. Study was approved by the institutional ethical committee. Complete neurological examination was done in all CP patients to determine the type. Developmental assessment of the patients was done by using PEEP (Portage early education programe) and functional severity of motor function was also assessed by using GMFM (Gross Motor Function Measure). Fundoscopy and/or hearing assessment were done in selective patients. The detail of adverse perinatal events was ascertained by detailed history and available perinatal record. For a child to be labeled as birth asphyxia, APGAR scores when available were considered. In the absence of these the following criteria were used (i) history of delayed cry >5 min after birth (ii) baby turning blue and requiring oxygen therapy and having difficulty in respiration, lethargy and/or seizures within 72 hours of birth 11. Birth weight and gestational age were asked and confirmed by available record. Babies having birth weight less than 2.5 kilogram and gestational age less than 37 weeks completed were labeled as low birth weight and premature respectively. Sepsis or meningitis was considered as an associated factor in patients having available record like; (raised CRP, positive blood and CSF culture reports). Kernicterus was labeled in patient having history of deep jaundice along with fits or posturing and managed by phototherapy or exchange transfusion. Intracranial bleed and structural malformations were considered as an associated factorin CP patients having available CT/MRI scan of brain. All the information was recorded on a predesigned Performa for final analysis. Data was analyzed by using SPSS software version 19. RESULTS Out of 178 patients 56% (n=100) were male with male to female ratio 1.3:1.Various presentations of CP are given in Table I. TABLE 1: Type of CP No of patient Valid Percent Spastic quadriplegic CP Spastic hemiplegic CP Spastic diplegic CP Chorioathetoid CP Hypotonic CP Mixed CP Major associated factor for cerebral palsy were found as birth asphyxia 33.9% (n=60), sepsis and meningitis 24.9% (n=44), prematurity and low birth weight 18% (n=32), kernicterus 3.4% 6, intracranial bleed 8.5% (n=15) and CNS malformations 4% (n=7). In 8.5% (n=15) cases no associations could be detected. Spastic quadriplegic CP was associated with birth asphyxia 52% (n=37), sepsis 28.2% (n=20), prematurity and low birth weight 7.1% (n=5), Intracranial bleed 4.2% (n=3) and CNS malformation 1.4 %(n=1). In spastic diplegia the major factors include prematurity and low birth weight 42.5% (n=23),

5 Association of Perinatal Adverse Events With the Type of Cerebral Palsy 181 sepsis 24.1% (n=13), birth asphyxia 22.2% (n=12) and kernicterus 1.9% (n=1). For hemiplegic type, sepsis 25% (n=10), intracranial bleed 22.5% (n=9), birth asphyxia 17.5% (n=7) and prematurity 10% (n=4) were the major contributory factors. Kernicterus 83.3% (n=5) and birth asphyxia 16.7% (n=1) were related factors for chorioathetoid type of CP. Birth asphyxia 33.3% (n=1), intracranial bleed 33.3% (n=1) and CNS malformation 33.3% (n=1) were involved in hypotonic type. Mixed type of CP was mostly associated with birth asphyxia 66.7% (n=2) and sepsis 33.3% (n=1). In15 patients no definite association could be ascertained which includes, spastic quadriplegic 7% (n=5), diplegic 9.3% (n=5) and hemiplegic 12.5% (n=5). (Table 2) TABLE 2: Relation of type and perinatal events causing cerebral palsy Perinatal Events Birth Asphyxia Prematurity& Low Birth Weight Spastic Spastic Spastic quadriplegia diplegia hemiplegia Chorioathetoid Hypotonic Mixed N % N % N % N % N % N % Kernicterus Sepsis & Meningitis CNS Bleed CNS Malformation Idiopathic Total DISCUSSION Cerebral palsy is a non-progressive disorder of movement and posture resulting from an insult to the growing brain, several risk factors are involved in the etiology 11,12. This study was conducted to determine the effect of different perinatal adverse events with different types of CP. We found that quadriplegic type of CP was mainly instigated by birth asphyxia and central nervous system infections, which is similar to the observation made in other studies done in developing countries 1,6,11-14, Birth asphyxia remains the leading contributory factor for cerebral palsy 15. Such morbidities can be reduced by improving awareness about these risk factors, early diagnosis, timely referral and better hospital management. In developed countries overall incidence of CP has decreased significantly over the past few decades but relative increase in diplegic type may be ascribed to better survival rates of extremely premature infants 15. The situation in third world countries remains the same because of lack of awareness and insufficient health facilities. Different studies have shown significant relationship between prematurity and diplegic CP, similar results have been seen in this study 16,17. Sepsis is mainly related to hemiplegic type similar to otherstudy 18 which can be reduced by proper sterilization techniques and better interventions. The proportion of chorioathetoid CP due to kernicterus in this study was 3.4%, almost similar observation has been made in studies done by Nazir B et al, Haque KN et al, Khan NZ et al 12,19,20. In developed countries chorioathetoid CP has disappeared 11, due to better intervention of kernicterus, we can also reduce by emphasizing early referral of patients, creating awareness regarding blood group incompatibilities, early diagnosis and aggressive management. Hypotonic and mixed types contribute little proportions, mainly caused by birth asphyxia and CNS malformations which is comparable with other international studies 7. In 15 patients no definite factor could be identified, which is at par with other studies 11,14,21,22.

6 182 Afzal E, Rabbani MW, Ahmad T The shortcomings of this study include; insufficient information because of recall bias, unavailable perinatal record and small sample size. Determining the perinatal adverse events and their association with the different types of CP may assist in defining the disease burden of various sub types of CP in this region. This will help in focusing the specific risk factors like; better obstetrical care, improved resuscitative techniques, measures for better outcome of premature and low birth weight babies, prompt management of postnatal CNS infections and kernicterus. CONCLUSION The main associated factors responsible for developing CP in this study include; birth asphyxia, prematurity, low birth weight, sepsis, kernicterus, CNS bleed and CNS malformations which determine the type of CP, most common being spastic type Author s affiliations Erum Afzal, Muhammad Waqar Rabbani, Tanveer Ahmad, Imran Iqbal Department of Pediatrics, The Children s Hospital & The Institute of Child Health, Multan REFERENCES 1. Moreno-De-Luca, Andres DH, Ledbetter, Christa LM. "Genetic insights into the causes and classification of the cerebral palsies." The Lancet Neurology. 2012;11(3): BaxM,Goldstem M, Leviton A, Paneth N, Dan B, Jacobsson B, Damino D. Proposed definition and classification of cerebral palsy.devmed child Neurol.2005; 47(8): Krageloh-Mann I, Hagberg G, Meinsner C, Schelp B, Haas G, Eeg-Olofsson KE, Selbmann HK, Hagberg B, Michaelis R. Bilateral spastic cerebral palsy-a comparative study between south west Germany and western Sweden. II: Epidemiology. 1994; 36(6): Koterazawa K, Nakano K, Nabetani M, Miyata H, Kodama S, Takada S, Nakamura H. Incidence of cerebral palsy in Himeji City in No ToHattatsu Jan; 39(1): Bottos M, Granato T, Allibrio G, Gioachin C, Puato ML. Prevalence of cerebral palsy in north-east Italy from 1965 to Dev Med Child Neurol. 1999; 41(1): Singhi-PD. Ray M, Suri G. Clinical spectrum of cerebral palsy in North India. An analysis of 1000 cases. J Trop Pediatr. 2002; 48(3): Laisran N, Srivastava VK, Srivastava RK. Cerebralpalsy: an etiological study. Indian J pediatr. 1992; 59(6): Lindostorm K, Blemberg S. Cerebral palsy epidemiology. Acta paediatr, 1997; 86(7): Yoon BH, Jun JK, Romero R, Park KH, Gomez R, Choi JH, Kim LO. Risk factors for cerebral palsy. Am J Obstet Gynecol, 1997; 177(1): Hegberg B, Hagberg G, Zelterstorm R. Decreasing perinatal mortality: increasing in cerebral palsy morbidity. Acta Pediatr Scand 1998; 78: Nazir B, Shamoon M, Bhutt MA, Sheikh S, Ayesha H, Bhatti MT. Relationship of type of cerebral palsy with the etiology. Professional Med J. 2006; 13(1): Nazir B, Bhatt MA, Shamoon M, Sheikh S, Malik A, Hashmat N. Etiology and types of cerebral palsy. Pak Paed J.2003; 27(4): Winter S, Autry A, Boyle C, Yeargin-Allsopp M. Trends in the prevalence of cerebral palsy in a population-based study. Pediatrics. 2000; 110(6): Okike CO, Onyire BN, Ezeonu CT, Agumadu HU, Adeniran KA, Manyike PC. Cerebral palsy among children seen in the neurology clinic of Federal Medical Centre (FMC), Asaba. J Community Health. 2013; 38(2): Miller SP, Hall N, Shevell M. The spectrum of abnormal neurologic outcomes subsequent to term intrapartum asphyxia. Pediatr Neurol Dec; 41(6):

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