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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 90-93

Comorbidities and their relationship to subtype of cerebral palsy in a tertiary care hospital in South India


1 Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
2 Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Web Publication12-Apr-2017

Correspondence Address:
Vykuntaraju K Gowda
Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-4264.204408

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  Abstract 


Introduction: Comorbid conditions such as intellectual disability (ID), visual disability, epilepsy, and hearing impairment are associated with cerebral palsy (CP). For many children with cerebral palsy, it is these cooccurring conditions that may often have the greatest impact on the child and family from varying perspective.
Aims: The aim of the current study was to provide data on the frequency and type of comorbidities in children with cerebral palsy and the burden of comorbidities among each motor subtypes of CP. In addition, we evaluated the causative agent of motor subtypes of CP.
Methods: Two hundred consecutive children with cerebral palsy attending the pediatric neurology outpatient department with an age group from 3 months to 18 years were enrolled in the study. Information on neurologic subtype classified according to the topographic distribution of the motor impairment on neurologic examination and the presence of comorbidities: ID, visual impairment, hearing impairment, and coexisting afebrile seizures, was obtained. Demographic factors were also noted.
Results: The mean age of the children was 55 months, with 120 boys and 80 girls. ID was seen in 91% (182/200) of children. Active afebrile seizure disorder was noted in 40% (80/200), severe auditory impairment was noted in 4% (8/200), and cortical visual impairment was noted in 19.5% (39/200) of children. Comorbidities were most frequent in children with spastic and dyskinetic cerebral palsy. The most common type of seizures was focal seizures in 47 individuals (23.5% of all the individuals), followed by generalized seizures in 23 individuals (11.5% of all the individuals) and myoclonic seizures in 11 individuals (5.5% of all the individuals).
Conclusion: ID and seizures are more frequently associated comorbidities with CP. Bilateral spastic and dyskinetic CP are more likely to be associated with comorbidities.

Keywords: Cerebral palsy, comorbidities, etiology of cerebral palsy, intellectual disability, seizures


How to cite this article:
Amoghimath R, Gowda VK, Benakappa A. Comorbidities and their relationship to subtype of cerebral palsy in a tertiary care hospital in South India. Indian J Cereb Palsy 2016;2:90-3

How to cite this URL:
Amoghimath R, Gowda VK, Benakappa A. Comorbidities and their relationship to subtype of cerebral palsy in a tertiary care hospital in South India. Indian J Cereb Palsy [serial online] 2016 [cited 2017 Aug 22];2:90-3. Available from: http://www.ijcpjournal.org/text.asp?2016/2/2/90/204408




  Introduction Top


Cerebral palsy (CP) is accompanied by various comorbidities and these comorbidities are the major drivers of outcome and quality of life which is amenable to intervention, which are best served by early detection.[1] Comorbidities reflect brain injury beyond the motor tracts.[2] CP is not a progressive disorder; however, new comorbidities may appear or become severe as the child grows.[2],[3] According to the Surveillance of CP in Europe (SCPE), the most common comorbidities are speech and language impairments, followed by severe intellectual impairment, epilepsy, and visual impairment.[4] In addition, hearing impairment which is a common complication can exacerbate language difficulties. Social difficulties and autism spectrum disorders are also commonly associated comorbidities.[5]

Objectives

The aim of the current study was to provide data on the frequency and type of comorbidities in children with cerebral palsy and the burden of comorbidities among each motor subtypes of CP. In addition, we evaluated the causative agent of motor subtypes of CP.


  Methods Top


Our study included 200 consecutive children presenting with clinical features suggestive of cerebral palsy to a tertiary care center. Detailed history and clinical examination were noted. CP was clinically classified both physiologically and topographically. Computerized tomography of the brain was done to find out the cause and severity of brain injury; if inconclusive, further magnetic resonance imaging was performed. Intelligent quotient was assessed by a clinical psychologist using Vineland Social Maturity Scale. Visual evaluation was done by a pediatric ophthalmologist and visual evoked potential was performed. Hearing assessment was done by an audiologist with brainstem auditory evoked potentials. Electroencephalogram was performed in individuals with epilepsy. Children with neurological examination consistent with CP and nonprogressive brain malfunction manifested early in life were included in the study while children with progressive neurological disorders were excluded from the study.


  Results Top


The mean age of the children was 55 months (range, 3–180 months) at the time of registration and the sex ratio male to female was 1.5. Subnormal intelligence was observed to be the most common comorbidities in our series (91% of all the individuals). Among the spastic children, subnormal intelligence was observed to be more common in bilateral spastic and spastic hemiplegic (90% combined) as compared to spastic diplegic (28.5%) children. All the individuals with dyskinetic cerebral palsy were mentally retarded [Table 1].
Table 1: Comorbidities in various types of cerebral palsy

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Convulsions were observed in 81 children (40.5%). The frequency of convulsions was 22 (56.4% of all individuals with epilepsy) in individuals with hemiplegic cerebral palsy, and majority had focal convulsions, whereas 58 (41.7% of all individuals with epilepsy) individuals of bilateral spastic cerebral palsy children had epilepsy. One child (6% of all individuals with epilepsy) with dyskinetic cerebral palsy and none of children with diplegic cerebral palsy had convulsion. Overall, the incidence of focal seizures was observed to be the highest (47 children, 23.5% of all the individuals), followed by generalized tonic–clonic seizures (23 individuals, 11.5% of all the individuals) and myoclonic seizures (11 individuals, 5.5% of all the individuals) [Table 1].

Visual problems were reported in 39 (19.5%) children with cerebral palsy and hearing deficits were noted in 8 individuals (4%), 6 of them were bilateral spastic cerebral palsy (BSCP), and rest 2 were dyskinetic cerebral palsy (DKCP) [Table 1].

History of perinatal asphyxia was found in 138 (69%) individuals making it the single most common predisposing factor [Table 2]. Of these, 98 (71%) individuals had bilateral spastic type, 30 (21%) children had spastic hemiplegic type, 6 (4%) had diplegic and the rest 4 (2.8%) children had dyskinetic type of CP. Other etiologies associated with CP seen in our study include hypoglycemia, TORCH infection in mother, prematurity, bilirubin encephalopathy, malformations, perinatal stroke, and neuro-infections. Details of each are described in [Table 2].
Table 2: Common predisposing factor in cerebral palsy

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  Discussion Top


The mean age observed in our study was 55 months (range, 3–180 months) at the time of registration. Sex distribution observed in our study was male to female ratio of 1.5. Our results were comparable to a multicenter study in Europe (2002), in which male to female ratio of 1.33.[4] No sex predisposition was seen in our study.

In the present study, 185 (92.5%) children were spastic CP and 15 (7.5%) were DKCP. Among spastic cerebral palsy children, BSCP, 139 (69.5%), was the most commonly encountered type of spastic CP, followed by spastic hemiplegic CP (HPCP), 39 (19.5%). Various Indian studies found that the spastic type of CP was the predominant form in preterm and term infants. Sharma et al. reported 77.9% of their individuals with spastic cerebral palsy and Gowda et al. mentioned 81% of their individuals with spastic cerebral palsy.[6],[7] According to a multicenter study done in Europe, 85.7% were considered to have spasticity [Table 3].[4]
Table 3: Comparison of types of cerebral palsy

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Mental retardation was found in most of the BSCP as compared to diplegia, thus confirming the general rule that more the upper limbs are affected, lower is the intelligence.[8] In our study, developmental delay was noted in around 90% of children whereas in Sharma et al., it was 75%, and in Gowda et al., it was 55%.[6],[7] In SCPE, 69% of individuals had intellectual delay. A high percent of developmental delay in our study can be because, we analyzed the cohort of children who were referred to the tertiary care center and milder individuals might have been missed or not referred to the institute.

Epilepsy in children with cerebral palsy was mainly noted in BSCP and HPCP, whereas convulsions were less common in diplegia and DKCP individuals. In a study by Gowda et al., seizures were observed in 46% of individuals. In SCPE, 39% of children had epilepsy. Lesser prevalence of seizures in spastic diplegia is probably because of the cortical sparing of the pathological events resulting in diplegia.

Other comorbidities observed were visual problems in 19.5% (strabismus, nystagmus, cataract, amblyopia, and cortical blindness) and hearing impairment in 4% of children (sensorineural hearing loss). In a study by Gowda et al., visual problems were observed in 26% and hearing impairment in 11% (35.8%), whereas in a study by Sharma et al., 35.8% had ocular defects with squint being most common (12% of the individuals) [Table 4].
Table 4: Comparison of associated comorbidities in cerebral palsy

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Birth asphyxia (hypoxic ischemic encephalopathy) was most common cause of CP with 69% and TORCH infections in 8.5% of individuals which were comparable with a previous study.[6] Prematurity was observed in 8% of individuals as compared to 25.4% seen in Sharma et al. and 15% in Gowda et al., which might be secondary to increased survival of morbid premature infants in their study [Table 5].
Table 5: Comparison of incidence of risk factors and etiologies of cerebral palsy

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  Conclusion Top


BSCP was the most common motor form of CP observed in our study. Intellectual disability and seizures are more frequently associated comorbidities and are mostly associated with BSCP and DKCP. Unilateral CP is less commonly associated with comorbid illness. Perinatal asphyxia is a major etiological factor in our study, which can be prevented by timely obstetrical intervention and immediate newborn care.

We suggest that comorbidities are the major drivers of outcome and quality of life in children with cerebral palsy; hence, appropriate screening and management of comorbidities, especially vision, hearing, speech, seizures, and nutrition, improve the overall prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shevell MI, Dagenais L, Hall N; REPACQ Consortium. Comorbidities in cerebral palsy and their relationship to neurologic subtype and GMFCS level. Neurology 2009;72:2090-6.  Back to cited text no. 1
    
2.
Gabis LV, Tsubary NM, Leon O, Ashkenasi A, Shefer S. Assessment of abilities and comorbidities in children with cerebral palsy. J Child Neurol 2015;30:1640-5.  Back to cited text no. 2
    
3.
Pruitt DW, Tsai T. Common medical comorbidities associated with cerebral palsy. Phys Med Rehabil Clin N Am 2009;20:453-67.  Back to cited text no. 3
    
4.
Johnson A. Prevalence and characteristics of children with cerebral palsy in Europe. Dev Med Child Neurol 2002;44:633-40.  Back to cited text no. 4
    
5.
Venter A, Schirm N, Joubert G, Fock J. Profile of children diagnosed with cerebral palsy at universitas hospital, Bloemfontein, 1991–2001. S Afr Fam Pract 2006;48:15. Available from: http://www.tandfonline.com/doi/abs/10.1080/20786204.2006.10873350.  Back to cited text no. 5
    
6.
Sharma P, Sharma U, Kabra A. Cerebral palsy-clinical profile and predisposing factors. Indian Pediatr 1999;36:1038-42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10745315. [Last cited on 2016 Dec 11].  Back to cited text no. 6
    
7.
Gowda VK, Kumar A, Shivappa SK, Srikanteswara PK, Shivananda S, Mahadeviah MS, Clinical profile, predisposing factors, and associated co-morbidities of children with cerebral palsy in South India. J Pediatr Neurosci 2015;10:108-13.  Back to cited text no. 7
    
8.
McIntosh N, editor. Cerebral palsy. In: Forfar & Arneil's of Pediatrics. 7th ed. Edinburgh: Elsevier; 2008. p. 888-97.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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