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A STUDY OF CLINCAL SPECTRUM AND RISK FACTORS OF CEREBRAL PALSY IN CHILDREN

BY DR JAGAN MOHAN VARAKALA (PG)

GUIDE: DR. M.SREERAM REDDY MD ,DCH PROFESSOR & HOD, PEDIATRICS, PRATHIMA INSTITUE OF MEDICAL SCIENCES

COGUIDES : DR AMITH KUMAR CH ASSOCIATE PROFESSOR

DR HARISH GV ASSISTANT PROFESSOR

INTRODUCTION

1) Cerebral palsy (CP) is a diagnostic term used to describe a group of permanent disorders of movement and posture, causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain1.

2) Cerebral palsy is a common problem, the worldwide incidence being 1.5 to 2.5 per 1000 live births.

3) There is no source of data in India since mild cases are missed and lack of enough studies on prevalence2. But approximately 1-2 per 1000 live births is a reasonable estimate3.

4) CP is widely used as one outcome measure of both obstetric and neonatal care; and particularly as an indicator of the hazards of preterm birth. The fall in neonatal mortality in the last four decades has accompanied disappointingly not been by a concomitant decrease in CP.4

1) Nearly 42,000 new cases of cerebral palsy are added every year to Indian population according to Prabhakar K (1983). The frequency of cerebral palsy has remained steady or has risen slightly.13

2) Advances in perinatology have led to increasing survival of preterms and a change in the distribution of clinical types of CP.6

3) The clinical spectrum of CP in resource-poor, developing countries is different from that in the developed countries.

4) There is a paucity of clinical data in resource-poor settings. This difference between the developed and developing countries may reflect the etiologies and clinical features of CP

5) World CP is celebrated on October every year.

AIMS AND OBJECTIVES Hospital based observational study of 30 months duration.

1. To study the clinical spectrum of cerebral palsy in children. 2. To study the risk factors for cerebral palsy in children. 3.To compare the data with available national and

international studies.

PERIOD OF STUDY The study is conducted from Jan 2013 to August 2015

PATIENTS AND METHODS

STUDY DESIGN: Hospital based observational study.

INCLUSION CRITERIA: 100 consecutive children diagnosed as cerebral palsy attending the Paediatric department at Prathima Institute of Medical Sciences, Karimnagar, during the period from January 2013 to August 2015 were enrolled in this study.

EXCLUSION CRITERIA: Children having disabilities other than cerebral palsy

were excluded from the study

METHODOLOGY Paediatric department during the period from

January 2013 to August 2015 This was a hospital based observational study carried out at Prathima Institute of Medical Sciences, Karimnagar, in 100 consecutive children diagnosed as cerebral palsy attending.

AGE OF THE PATIENTS AT PRESENTATIONAge at presentation

Present study Pratibha Singhi 22, 2013, India

Less than 2yr 47% 51.8%2-5yrs 38% 33.2%>5yrs 15% 15%

Graph-1: Distribution by age

In the present study less than 5 years constitute about 85% of CP cases. Majority of the patients (47%) in present study were below 2yrs of age at the time of diagnosis which was comparable with Pratibha Singhi study (51.8%).

Table-2: Distribution of patients by sex

Male patients were the majority of cases which constitute 61% of total cases and Female were 39%, ratio M:F=1.56:1

Sex Male Female

Pratibha Singhi 22, 2013,

India

72.4% 27.6%

Areeb Sohail 24, 2014,

Pakistan

80% 20%

OA Nafi 33, 2011, South

Jordan

54% 46%

Srivatsava V K 32,1992 65.1% 34.9%

Present study 61% 39%

Distribution according to place of delivery

According to place of delivery

Place of delivery Institutional Home

Pratibha Singhi 22, 2013, India 81% 19%


The causes of CP in institutional deliveries may be due to lack of timely intervention in high risk pregnancies and very sick new born infants. And it may be due to lack of timely referral to secondary and tertiary level institutions for better care.

The increase in CP cases in institutional deliveries may be due to improved documentations of the CP cases, whereas in home deliveries due to lack of consultations for health check-up such cases may not be documented

Head circumference of the patients

Majority of the patients (62%) had microcephaly which was comparable to study by Pratibha Singhi (64.27%). Microcephaly may be the one of the co-morbidities of cerebral palsy.

According to Head circumference

Head circumference Normal Microcepha

ly

Pratibha Singhi et al22,

2013, India

35.73% 64.27%

OA Nafi33, 2011, South

Jordan

60.7% 39.3%


Clinical type of cerebral palsy

Clinical type of cerebral palsy

Spastic cerebral palsy was the commonest physiological type of cerebral palsy (81%). Atonic, dyskinetic and mixed types formed the rest of 19 % of cases.

CLINICAL TYPE OF CEREBRAL PALSY

Clinical type Spastic Dyskinetic Atonic/ Hypotonic Mixed

Pratibha Singhi 22,

2013, India

73% 7% 11.2% 8.8%

Areeb Sohail24 ,

2014, Pakistan

75% 10% - 15%

OA Nafi33, 2011,

South Jordan

82.7% 8.2% - 6.6%

Srivatsava V K

32,1992

91.4% 1.5% 7% 0.2%

Sahu Suvanand

25,1997

88% 3.2% 8.8% -

Present study 81% 6% 9% 4%

Topographical type of cerebral palsy

Among the spastic group quadriplegia was the commonest topographical type (69.14%) followed by diplegia (22.22%).

Topographical type

Number of patients

Percentage(n=81)

Quadriplegia 56 69.14

Diplegia 18 22.22

Hemiplegia 7 8.64

Total 81 100.00

Quadriplegia Diplegia Hemiplegia0

10

20

30

40

50

60

70

Topographical type of cerebral palsy

TOPOGRAPHIC TYPE OF SPASTIC CEREBRAL PALSY

Topographic type Quadriplegia Diplegia Hemiplegia Monoplegia

Pratibha Singhi 22,

2013, India

51.5% 34.5% 13.8% -

Areeb Sohail 24,

2014, Pakistan

40% 46.7% 13.3% -

OA Nafi33, 2011,

South Jordan

34.4% 22.1% 26.2% -

Srivatsava V K

32,1992

38.22% 23.94% 31.38% 1%

Sahu Suvanand

25,1997

86.4% 2.4% 9.6% 1.6%

Present study 69.14% 22.22% 8.64% -

1) The distribution of topographical type of spastic CP cases have discrepancies between developed and developing countries. Spastic quadriplegia was the most commonest type of CP in developing countries with rates between 36% and 71% whereas spastic diplegia was the commonest in developed countries with rates between 5% and 47%.22

2) The present study shows spastic quadriplegia is the commonest topographical type of CP which is comparable with other studies of developing countries.

3) The higher rates of spastic quadriplegia in developing countries is due to increased perinatal and post natal risk factors like asphyxia, meningitis and septicaemia etc., whereas higher rates of spastic diplegia in developed countries is due to better new born care services and higher rates of premature survivors.

4) The proportion of spastic diplegia has increased from 22% to 34.5% in a study in North India by Pratibha Singhi, 22 which reflects the improved neonatal care and premature care services in developing countries like India which indirectly reflects the increasing survival of infants with antenatal brain damage or with post natal brain damage due to complications of prematurity.

ANTENATAL RISK FACTORS FOR CEREBRAL PALSY

Risk factors

Number of patients

Percentage among antenatal factors (n=21)

Percentage among total cases (n=100)

PIH 8 38.09 8.00Maternal anaemia

7 33.33 7.00

Maternal fever

5 23.80 5.00

APH 4 19.04 4.00

8

7

5

4

Pregnancy Induced Hypertension Maternal anaemia

Maternal fever/Infection Antepartum Hemorrhage

Antenatal risk factors

Antenatal risk factors were reported in 21% (n=100) of mothers in present study among them pregnancy induced hypertension was most common antenatal risk factor seen in 8% of mothers in present study which is comparable to other studies by Sahu Suvanand in 8.8% cases and Pratibha Singhi in 30% cases


Risk factors Maternal anaemia PIH APH Maternal fever /

infections

Pratibha Singhi 22,

2013, India

- 30% 12% 18%

Areeb Sohail 24,

2014, Pakistan

5% - - 40%

Sahu Suvanand

25,1997

- 8.8% 4% -

Present study 7% 8% 4% 5%

In a European study (2006) of CP antenatal infection was strongly associated with CP and 39.5% of mothers of children with CP reported having an infection during the pregnancy, with 19% having evidence of a urinary tract infection and 11.5% reporting taking antibiotics.1

NATAL RISK FACTORS FOR CEREBRAL PALSY

Risk factors

Number of patients

Percentage among natal risk factors (n=62)


Birth asphyxia

44 70.96 44.00

LBW 33 53.22 33.00Preterm 19 30.64 19.00Instrument/CS

18 29.03 18.00

PROM 4 6.45 4.00Prolonged labour

2 3.22 2.00

Malposition

2 3.22 2.00

Multiple gestation

2 3.22 2.00

Natal risk factors


Risk factors

Pratibha Singhi 22, 2013, India

Areeb Sohail 45, 2014, Pakistan

Srivatsava V K 38,1992

Sahu Suvanand42,1997

Present study

Birth asphyxia

51.98% 25% 24.5% 25.6% 44%

PROM - - - - 4%Prolonged labor

13.6% - 3.3% 1.6% 8%

Preterm 24.3% 15% - - 19%Low birth weight

37.87% 10% - - 33%

Caesarean section

20.5% 5% 4.3% 10.4% 18%

Malposition

0.1% - 2.6% 2.4% 2%

Multiple gestation

3.4% 5% 0.6% 0.8% 2%

Among natal risk factors birth asphyxia is the most common natal risk factor seen in 44% cases in present study.Many recent studies from industrialized countries show a rise in the childhood prevalence of cerebral palsy, largely because of the increasing contribution of children with low and very low birth weight. The only demographic determinant of cerebral palsy prevalence that is changing rapidly is survival of low birth weight and very low birth weight infants. Based on the magnitude of change in the survival of low and very low birth weight infants.

POSTNATAL RISK FACTORS FOR CEREBRAL PALSY

Risk factors Number of patients

Percentage among postnatal risk factors (n=36)


Neonatal seizures

23 63.88 23

Neonatal sepsis

16 44.44 16

Neonatal jaundice

9 25.00 9 [] 23

[]16

[] 9

Number of patients

Postnatal risk factors were reported in 36% of cases among them neonatal seizures was the commonest postnatal risk factor which was present in 23% of the cases and accounted for 63.88% of all the postnatal risk factors.

Risk factors Neonatal seizures Neonatal jaundice Neonatal

sepsis/Meningitis

Pratibha Singhi 22, 2013,

India

26.9% 35.14% 30.6%

Areeb Sohail 24, 2014,

Pakistan

50% 30% -

OA Nafi33, 2011, South

Jordan

- 29.6% -

Sahu Suvanand 25,1997 15.2% 16.8% 22.4%

Present study 23% 9% 16%

PRESENTING COMPLAINTS

Presenting complaints Pratibha Singhi 22, 2013, India

Present study

Developmental delay 88% 86%

Seizures 34.7% 32%

Feeding difficulties - 14%

Abnormal tone/posture 22.8% 12%

Delayed milestones was the commonest presenting complaint seen in 86% of cases which was comparable to study by Pratibha Singhi seen in 88% cases, followed by seizure and feeding difficulties in 32% and 14%.

RECOMMENDATIONS

1) All pregnancies should be registered and should receive proper antenatal care.

2) High risk pregnancies should be identified and managed appropriately.3) Timely referral of the high risk cases to tertiary care centres is the key

in preventing poor outcome both in mother and the baby.4) Periodic follow up of cases born with the risk factors mentioned

(antenatal, natal and postnatal) for early identification and therapy of cerebral palsy.

5) A detailed study on children with CP in a large population based birth cohort is indicated which includes most of the children with CP who had experienced classical birth asphyxia, and such a study may make it possible to identify a combination of risk factors rather than single factor operating alone.

6) Children with CP are more likely to have associated conditions like speech and language disorders, mental retardations, eye and hearing impairment screening for these conditions should be done during initial assessment of CP.

LIMITATIONS

The study included only patients coming to our institution and does not include large community.

Limited study period. Only included sample size of 100 cases

which makes difficult to accurately derive the true association between the clinical spectrum and risk factors of cerebral palsy.

CONCLUSION

1) Out of the 100 cases of cerebral palsy studied male patients were the majority (61%), with male to female ratio was 1.54:1.

2) Most of the patients were less than 2years of age at the time of presentation (47%).

3) Majority of the patients hailed from rural area (63%).4) Consanguinity was observed in 52%. 5) Institutional deliveries were 79% and 21% were home

deliveries. 6) Most patients (61%) with cerebral palsy were first born

as found in this study.7) 78% of the cases were malnourished. 8) Majority of the cases had microcephaly (62%).

1) Spastic cerebral palsy was the commonest clinical type of cerebral palsy accounting for 81% of the cases.

2) Quadriplegia and diplegia were the commonest topographical types of spastic cerebral palsy accounting for 69.14% and 22.22% of the cases respectively.

3) Delayed milestones in 86% cases and convulsions in 32% cases were the commonest presenting complaints.

4) Speech delay seen in 62% of cases, subnormal intelligence seen in 58% cases and convulsions seen in 34% of cases were the commonest associated manifestations.

5) Natal risk factors were the commonest seen in 62% of the cases, antenatal and postnatal risk factors were 21% and 36% respectively.

6) Birth asphyxia seen in 44% cases, low birth weight seen in 33% cases prematurity seen in 19% of cases and neonatal convulsions seen in 23% cases were the commonest risk factors observed in this study.

SUMMARY

1) Male patients formed the majority.2) Most patients were below 2years of age at the time of

presentation. 3) Majority of the patients had microcephaly.4) Delayed milestones and convulsions were the commonest

presenting complaints.5) Spastic type of cerebral palsy was the commonest clinical type.6) Quadriplegia was the commonest topographical type of spastic

cerebral palsy.7) Natal risk factors were the most commonly found risk factors in

cases of cerebral palsy. Birth asphyxia, low birth weight, preterm and neonatal convulsions were the commonest risk factors observed in this study.

8) Speech delay, subnormal intelligence and convulsions were the commonest associated manifestations in cases of cerebral palsy.

REFERENCES

1) Michael V. J. Cerebral palsy. In:Kliegman, Stanton, Geme.S.T, Schor, Behrman (eds.) Nelson textbook of paediatrics. 19th ed. India: Reed Elsevier; 2012. p2061-65.

2) Chitra Sankar, Nandini Mundkur, Cerebral palsy-definition, classification, etiology and early diagnosis. Indian journal of Paediatrics 2005; 72(10): 865-868.

3) Vinod K paul, Aravind bagga, Cerebral palsy, Ghai Essential Pediatrics, 8th ed. India: CBS Publishers; 2013. p581-83.

4) Dabydeen Lyvia. Cerebral palsy: A neonatal perspective. Annals of Indian Academy of Neurology. 2007; 10 (5):33-43

5) Pharoah POD, Platt MJ, Cooke T, “The changing epidemiology of cerebral palsy”, Arch Dis Child 1996; 75: 169-173.

1) Pratibha D Singhi, Munni Ray, Gunmala Suri. Clinical spectrum of cerebral palsy in North India- an analysis of 1000 cases. Tropical journal of Pediatrics 2002 ;( 48):162-166.

2) Pratibha D Singhi, Munni Ray, Gunmala Suri. Clinical spectrum of cerebral palsy in North India- an analysis of 1000 cases. Tropical journal of Pediatrics 2002 ;( 48):162-166.

3) Vykuntaraju KN, Cerebral palsy and early stimulation, 1 ed. India: Jayapee; 2014

4) Areeb S.B, Muhammad.Z.H, Rabia I, Nosheen Z. Risk factors and types of cerebral palsy. Journal of Pakistan Medical Association.2014; 64(1): 103-07

5) Nafi OA (2011); Clinical Spectrum of Cerebral Palsy in South Jordan; Analysis of 122 Cases. Pediatr Therapeut 2011; 1: 101

6) Srivastava VK, Laisram N, Srivastava RK. Cerebral palsy, Indian Pediatrics 1992; 29(8): 993-6

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