|Year : 2015 | Volume
| Issue : 2 | Page : 75-79
Perinatal risk factors in cerebral palsy: A rehab center based study
Varidmala Jain1, Jitendra Kumar Jain2, Gyanendra Singh3, Amit pandey4
1 Department of Public Health, Sam Higginbottom Institute of Agriculture Technology and Sciences, Allahabad, Uttar Pradesh, India
2 Department of Pediatric Orthopedics, MLN Medical College, Allahabad, Uttar Pradesh, India
3 Department of Community Medicine, MLN Medical College, Allahabad, Uttar Pradesh, India
4 Department of Physiotherapy, Samvedna Trust, MLN Medical College, Allahabad, Uttar Pradesh, India
|Date of Web Publication||7-Jan-2016|
182C/350A Tagore Town Allahabad, Allahabad
Source of Support: None, Conflict of Interest: None
Introduction: The etiology of cerebral palsy (CP) is very diverse and multifactorial including prenatal, natal, and postnatal factors.
Objective: This study is an attempt to describe the distribution of risk factors among children with cerebral palsy.
Materials and Methods: This study was conducted to explore perinatal risk factors among 307 children having cerebral palsy.
Results: Major risk factors found in this study were history of spontaneous abortions in 33 (10.7%), anemia during pregnancy in 53 (17.3%), hypertension in 26 (8.5%), and history of infection in 22 (6.2%) mothers. In total, 141 (45%) children were born preterm and 28 (9.1%) were born in multiple births. Further, it was also found that 12 (3.9%) deliveries were forceps delivery. Out of the total 307 respondents, 208 (67.8%) reported a history of delayed crying of their child at birth. Out of the available record of 278 children, 108 (38.8%) had birth weights of <1.5 kg. The most frequent risk factors in the postnatal period were high fever in 82 (26.7%), convulsion in 81 (26.4%), and jaundice in 99 (32.2%).
Conclusions: In this study, factors related to poor antenatal care as well as other unavoidable risk factors were found; therefore, there is a need to prevent avoidable causes that lead to CP through strict standard practices, mass awareness programs, etc.
Keywords: Cerebral palsy, perinatal period, risk factors
|How to cite this article:|
Jain V, Jain JK, Singh G, pandey A. Perinatal risk factors in cerebral palsy: A rehab center based study. Indian J Cereb Palsy 2015;1:75-9
| Introduction|| |
The etiology of cerebral palsy (CP) is very diverse and multifactorial. The injury to the developing brain may be prenatal, natal, or postnatal. According to a study, approximately 75-80% of the reported cases are due to prenatal insult, and only 10% are due to significant birth trauma or asphyxia.  One more study states that prenatal risk factors include intrauterine infections, placental complications, multiple births, teratogenic exposures, and hyperthyroidism. The incidence of CP is higher among twins and triplets than singletons. Perinatal risk factors are infections, intracranial hemorrhage, seizures, hypoglycemia, hyperbilirubinemia, and significant birth asphyxia. Postnatal causes include meningitis, encephalitis, and head injury. However in a large number of cases, the cause of CP remains unknown.  Although ample researches are done in the developed world, but there is a scarcity of literature in Indian subcontinent, so there is a need to find the prevalence of these factors in Indian aspect. This study is an attempt to describe the distribution of risk factors among children with CP coming to Samvedna Trust, Allahabad, dealing with this problem and catering to the children from many states of Northern India.
| Materials and methods|| |
Approval was taken from Institutional Ethics Committee of Sam Higginbottom Institute of Agriculture Technology and Sciences (Deemed University), Allahabad, India prior to the study and informed consent was taken from respondents. Confidentiality was maintained.
This was a descriptive study.
The study was conducted at Samvedna Trust. This trust is located at Allahabad, Uttar Pradesh, India and working in the field of childhood disability mainly CP and catering to many children from various states of India.
Optimum sample was calculated by using the formula with approximation for large population which came out as 304. Ultimately data were collected for 307 children (out of 426 children who were registered for treatment to the trust during last year) who were regular visitors, and also gave consent to participate in the study.
The respondents who did not give consent or had adopted children were excluded from the study, since perinatal details were not available for them.
The study was conducted to explore the conditions encountered during the perinatal period by mother and child, which possibly led to the development of CP. Data were collected by face-to-face interview by the respondents on predesigned interview schedule. Parents or attending guardians were the respondents. Records of children were also referred for data including birth weights and microcephaly. For classifying families' socio-economic status, Kuppuswamy classification modified for the year 2012 was used.  Descriptive analysis was done using the Statistical Package for Social Sciences (SPSS).
| Result|| |
Health of the mother during the prepregnancy period has a very important impact on upcoming offspring. In the present study, it was found that 16 (5.2%) mothers were hypertensive whereas 25 (8.1%) were anemic even before pregnancy [Figure 1]. This problem was aggravated during pregnancy, and we found anemia in 53 (17.3%) and hypertension in 26 (8.5%) mothers during pregnancy. Out of the total, 22 (7.2%) gave a history of bleeding and 25 (8.2%) had a history of either oligo-hydroamnios or leakage of liquor amnii during pregnancy. In the present study 33 (10.7%) mothers gave a history of spontaneous abortion. Totally 19 (6.2%) mothers also gave a history of infections or fever during pregnancy [Figure 2].
The increased risk of both mortality and CP in multiple births has been known for many years.  In this study, it was found that 27 (8.8%) children had twin sibling and one child was one of the triplets [Table 1]. It was also found that 77 (24.9%) deliveries were not conducted by doctors, out of them 16 (5.2%) deliveries were even conducted by dais (traditional birth attendants) and 4 (1.3%) by neighbors. It was also found that 12 (3.9%) deliveries were forceps deliveries [Table 1]. Preterm birth is considered to be one of the most important risk factors for CP. In the present study, out of total 307,141 (45.9%), children were born preterm (<37 weeks).
Effect of gestational age at birth was found on the type of CP. It was found that out of preterm infants 112 (79.4%) were spastic as compared to term infants amongst whom 89 (56.7%) were spastic. It shows that the incidence of spastic CP is more common in preterm infants, whereas other varieties were more common in term infants. This was found statistically significant (P = 0.000) [Figure 3]. Nine postterm born cases were excluded because their number was too small for correct estimation.
History of delayed cry at birth was found in 208 (67.8%) children, indicating a hypoxic condition. Out of total 217 (70.7%) children had a history of admission to Neonatal Intensive Care Unit (NICU) at the time of birth. Birth weight record was available only in 278 cases, out of whom 108 (38.8%) were having birth weights <1.5 kg. Total 33 (10.7%) cases had been diagnosed as having microcephaly [Table 2].
The most frequent problems which could cause damage to the brain in postnatal period were high fever 82 (26.7%), convulsion 81 (26.4%) and severe jaundice 99 (32.2%) [Figure 4].
| Discussion|| |
In spite of advance antenatal care, the incidence of CP remains stable in developed countries. This is because of some possible genetic factors, along with more survival of premature newborn. In developing countries, there is a large variation in obstetric care from ultra-sophisticated urban hospitals to primary health care or to home deliveries. Therefore in these countries both factors are contributing, including poor antenatal care in rural areas to more survival of premature infants in advanced ICUs.
As per the definition "CP describes a group of disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain.  Hence, it is very important to have a comprehensive look at the risk factors throughout the perinatal period and up to 3 years of age while the brain of the child is still immature. Apart from these, the health of the mother during the prepregnancy period is also important in determining the birth of high-risk child. In the present study, large numbers of mothers were suffering from conditions like hypertension and anemia during the prepregnancy period, and their condition aggravated during pregnancy.
Maternal infections have been described to be associated risk factor of CP.  In this study, 6.2% respondents reported an episode of infections or a high fever during the antenatal period. Antepartum hemorrhage has also been found to increase the risk of CP associated with preterm birth.  In this study 22 (7.2%) respondents gave histories of antepartum hemorrhage.
Home delivery is still being practiced in many parts of our country that puts the health of mother and child both at risk. In our study, we found that 8.5% children were born at home, and maximum deliveries were attended by traditional birth attendant and neighbor. Even in hospital few deliveries were performed by forceps that put a child at risk for getting an injury to the brain. There is need of total restructuring and strengthening of our antenatal and natal care system to prevent these avoidable risk practices. Low birth weight is also a known risk factor for CP. It was also suggested in a study that both antenatal and postnatal complications, increase the incidence of CP in low birth weight infants.  Now-a-days with good pediatric care a large number of premature children are being saved, and many of them are prone to develop CP because of the immaturity of the brain and respiratory system. The risk of CP increases with decreasing fetal age at delivery.  Incidence of CP is much higher when newborn baby is very preterm (<32 weeks) and very low birth weight (<1.5 kg). An apparently unavoidable side effect of the increasing success of newborn intensive care is a moderate rise in the childhood prevalence of CP.  In our study, it was found that 70% children were admitted to NICU.
Periventricular leukomalacia, known to be strongly correlated with spastic diplegic CP in preterm children, predominantly occurs in the 24 th to 32-34 th week of gestation, whereas cortical/subcortical insults occur after that time.  In the present study occurrence of approximately 80% spastic CP in preterm infants indicates toward high chances of periventricular leukomalacia in causing CP in these cases.
In this study, 10% mothers gave a history of spontaneous abortions. This can hint toward possible genetic factor or intrauterine infection of CP in these children; this fact has also been mentioned by Moreno De Luca et al.  Out of 27, 12 siblings born in twin pregnancy did not survive. According to Pharaoh and Cooke  the death of one twin may impair the neurological development of the survivor throughout gestation. Microcephaly is also commonly found and is a well-known risk factor associated with Neuro-developmental delay, especially CP. According to Rankin et al.  the most frequent cerebral anomalies in children with CP were primary microcephaly (26.5%).
In the present study, most of the families belonged to middle and upper socio-economic class [Figure 5], which shows that people from better socio-economic background sought a proper remedy. However, it does not mean that CP is more commonly occurring amongst the good socio-economic background. Since this study was an urban center based study, only those parents approached for treatment who were aware and had access to it. However around 80% population live in the rural areas with very poor Maternal and Child Health services available to them. As such the number of cases seems to be the tip of an iceberg of the problem as a whole.
| Conclusions|| |
In the present study factors related to both poor antenatal care as well as other unavoidable risk factors like spontaneous abortions, multiple pregnancies are found. For the prevalence of CP in India, we are largely dependent on generalizations of other countries, whereas considering the above conditions and also increased survival of high-risk infants there is need to find out the actual amount of problem in our Indian society specifying to different community setups. Also, there is need to prevent avoidable causes leading to CP through strict practices, mass awareness programs, etc., which is always better and shall cause less burden on society than required to deal with this lifelong condition.
We acknowledge the support of Samvedna Trust and its Physiotherapists. We also acknowledge the support provided by Faculty of Health Sciences, SHIATS, Allahabad, for providing opportunity for this study. We are also thankful to Dr. Dinesh Kumar Government Medical College, Chandigarh for helping in methodology part.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
MacLennan A. A template for defining a causal relation between acute intrapartum events and cerebral palsy: International consensus statement. BMJ 1999;319:1054-9.
Sankar C, Mundkur N. Cerebral palsy-definition, classification, etiology and early diagnosis. Indian J Pediatr 2005;72:865-8.
Kumar N, Gupta N, Kishore J. Kuppuswamy's socioeconomic scale: Updating income ranges for the year 2012. Indian J Public Health 2012;56:103-4.
Reddihough DS, Collins KJ. The epidemiology and causes of cerebral palsy. Aust J Physiother 2003;49:7-12.
Rosenbaum P, Dan B, Fabiola R, Leviton A, Paneth N, Jacobsson B, et al
. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol 2005;47:571-6.
Murphy DJ, Sellers S, MacKenzie IZ, Yudkin PL, Johnson AM. Case-control study of antenatal and intrapartum risk factors for cerebral palsy in very preterm singleton babies. Lancet 1995;346:1449-54.
Stanley FJ, Blair E, Alberman E. Cerebral palsies, epidemiology and causal pathways. Clinics in Developmental Medicine No 151. London: Mac Keith Press; 2000.
Stanley FJ. Survival and cerebral palsy in low birth weight infants: Implications for perinatal care. Paediatr Perinat Epidemiol 1992;6:298-310.
Bhushan V, Paneth N, Kiely JL. Impact of improved survival of very low birth weight infants on recent secular trends in the prevalence of cerebral palsy. Pediatrics 1993;91:1094-100.
Hagberg B, Hagberg G, Beckung E, Uvebrant P. Changing panorama of cerebral palsy in Sweden. VIII. Prevalence and origin in the birth year period 1991-94. Acta Paediatr 2001;90:271-7.
Moreno-De-Luca A, Ledbetter DH, Martin CL. Genetic [corrected] insights into the causes and classification of [corrected] cerebral palsies. Lancet Neurol 2012;11:283-92.
Pharoah PO, Cooke RW. A hypothesis for the aetiology of spastic cerebral palsy - The vanishing twin. Dev Med Child Neurol 1997;39:292-6.
Rankin J, Cans C, Garne E, Colver A, Dolk H, Uldall P, et al
. Congenital anomalies in children with cerebral palsy: A population-based record linkage study. Dev Med Child Neurol 2010;52:345-51.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]