AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 7, NUMBER 2 April 1990
CHANGING DIAGNOSIS OF CEREBRAL PALSY IN VERY LOW BIRTHWEIGHT CHILDREN Geoffrey W Ford, M.B., FR.A.C.R, William H. Kitchen, M.D., FR.A.C.R, Lex W. Doyle, M.B., FR.A.C.R, Anne L. Richards, M.A., M.A.P.S., and Elaine Kelly, M.A.
The stability of the diagnosis of cerebral palsy from 2 to 5 years of age was examined in 83 children of birthweight under 1000 gm, and 112 of birthweight 1000 to 1500 gm. In 20 2-year-old children with cerebral palsy, the diagnosis persisted in 11 (55%, 95% confidence intervals 35.1 to 76.9%); 2 of 175 children (1.1%) free of cerebral palsy at 2 years of age subsequently developed the condition. Severe or moderate cerebral palsy at 2 years persisted in all eight children (100%). In 9 of 12 children in whom cerebral palsy at 2 years had disappeared by 5 years, minor neurologic abnormalities and left-hand preference occurred frequently but mean psychologic test scores were similar to children always free of cerebral palsy. In this cohort, cerebral palsy at 2 years was not a static condition, but overestimated later prevalence.
Because techniques of neonatal intensive care are changing rapidly, it is important to identify in survivors serious sequelae, such as cerebral palsy, as soon as reliable outcome data are available. Of special contemporary interest is the relationship between neonatal cranial ultrasound abnormalities and the subsequent development of cerebral palsy; in some recent reports, the children are less than 2 years old.1>2 However, several authors have cautioned that ascertainment of cerebral palsy in young children may not be reliable.3~5 In a small cohort of infants of birthweight less than 1000 gm, we found that cerebral palsy often disappeared over time.6 This provoked us to examine the diagnosis of cerebral palsy in all children of birthweight less than 1501 gm, seen at both 2 and 5 years of age in The Growth and Development Clinic. The aims were to determine: (1) the predictive accuracy of a diagnosis of cerebral palsy at 2 years; (2) the groups of 2-year-old children in whom cerebral palsy persisted or disappeared; and (3) whether children recovering from cerebral palsy at 2 years had an excess of minor neurologic abnormalities or lower psychologic test scores.
PATIENTS AND METHODS
All children in the study were born in The Royal Women's Hospital, Melbourne, Australia, a tertiary perinatal center. The cohort comprised 85 consecutive survivors to at least 5 years of age who weighed less than 1000 gm at birth and who were born between January 1,1977, and March 31,1982, and 124 consecutive survivors to at least 5 years who weighed between 1000 and 1500 gm and who were born between October 1, 1980, and March 31, 1982. Of children of birthweight less than 1000 gm, 83 of 85 (97.6%) were assessed at both 2 and 5 years. Of children of birthweight 1000 to 1500 gm, 112 of 124 (90.3%) 5-year survivors were assessed at both 2 and 5 years. We performed all the psychologic and standardized neurodevelopmental assessments at 2 and 5 years. At both ages, the children were assessed and the findings were coded without knowledge of the child's perinatal history and, at 5 years, with no knowledge of the 2-year neurodevelopmental findings. Children considered neurodevelopmentally normal were seen by only one pediatrician, but ab-
Department of Obstetrics & Gynaecology and of Paediatrics, the University of Melbourne, and the Royal Women's Hospital, Carlton, Australia Supported by the National Health and Medical Research Council and Royal Women's Hospital—3AW Clinical Research Foundation, Carlton, Australia Address all correspondence to: Dr. Kitchen, Dept. of Obstetrics & Gynaecology, University of Melbourne, Parkville 3052, Australia
178
Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: National University of Singapore. Copyrighted material.
ABSTRACT
normal or equivocal neuromuscular findings were usually corroborated by a second pediatrician. The psychologic assessment at 5 years of age (corrected for prematurity) included the Wechsler Preschool and Primary Scales of Intelligence (WPPSI).7 All 2-year-old children with cerebral palsy had one of the spastic syndromes. Children with spastic cerebral palsy had increased active tone, increased deep tendon reflexes, and positive Babinski reflexes. The diagnosis of hemiplegia was supported by marked hand dominance on the normal side, toe walking on the affected side, and an asymmetric gait. Diplegia was diagnosed if the lower limbs were predominantly affected and quadriplegia if all limbs were equally affected. Cerebral palsy was graded according to the severity of the motor disability. Mild cerebral palsy was defined as a disability in ambulant children that interfered only slightly with normal daily functioning. Moderate cerebral palsy included those children who were attempting to walk at 2 years; severe cerebral palsy included those who were considered likely to remain permanently nonambulant. The same criteria for diagnosis and severity of cerebral palsy were used at the 5-year assessment; the one 5-year-old child with ataxic cerebral palsy showed intention tremor, past-pointing, walked on a wide base, and had increased deep tendon reflexes. Data were analyzed by computer, using SPSSX programs. Differences in distribution were analyzed using 2-tailed t tests, and differences in proportion using corrected chi-square tests; a p value on any test less than 0.05 was considered to be statistically significant.
RESULTS
The positive predictive value of a diagnosis of cerebral palsy at 2 years for a diagnosis of cerebral palsy at 5 years was 55% (95% confidence intervals (CI) 31.5 to 76.9%). If cerebral palsy was absent at 2 years, the chance of it being diagnosed at 5 years was 1.1% (95% CI 0.1 to 4.1%) (Table 1).
Table 1. Cerebral Palsy in Children Seen at Both 2 and 5 Years of Age Birth weight (n)
CHANGING DIAGNOSIS OF CEREBRAL PALSY IN VERY LOW BIRTHWEIGHT CHILDREN Geoffrey W Ford, M.B., FR.A.C.R, William H. Kitchen, M.D., FR.A.C.R, Lex W. Doyle, M.B., FR.A.C.R, Anne L. Richards, M.A., M.A.P.S., and Elaine Kelly, M.A.
The stability of the diagnosis of cerebral palsy from 2 to 5 years of age was examined in 83 children of birthweight under 1000 gm, and 112 of birthweight 1000 to 1500 gm. In 20 2-year-old children with cerebral palsy, the diagnosis persisted in 11 (55%, 95% confidence intervals 35.1 to 76.9%); 2 of 175 children (1.1%) free of cerebral palsy at 2 years of age subsequently developed the condition. Severe or moderate cerebral palsy at 2 years persisted in all eight children (100%). In 9 of 12 children in whom cerebral palsy at 2 years had disappeared by 5 years, minor neurologic abnormalities and left-hand preference occurred frequently but mean psychologic test scores were similar to children always free of cerebral palsy. In this cohort, cerebral palsy at 2 years was not a static condition, but overestimated later prevalence.
Because techniques of neonatal intensive care are changing rapidly, it is important to identify in survivors serious sequelae, such as cerebral palsy, as soon as reliable outcome data are available. Of special contemporary interest is the relationship between neonatal cranial ultrasound abnormalities and the subsequent development of cerebral palsy; in some recent reports, the children are less than 2 years old.1>2 However, several authors have cautioned that ascertainment of cerebral palsy in young children may not be reliable.3~5 In a small cohort of infants of birthweight less than 1000 gm, we found that cerebral palsy often disappeared over time.6 This provoked us to examine the diagnosis of cerebral palsy in all children of birthweight less than 1501 gm, seen at both 2 and 5 years of age in The Growth and Development Clinic. The aims were to determine: (1) the predictive accuracy of a diagnosis of cerebral palsy at 2 years; (2) the groups of 2-year-old children in whom cerebral palsy persisted or disappeared; and (3) whether children recovering from cerebral palsy at 2 years had an excess of minor neurologic abnormalities or lower psychologic test scores.
PATIENTS AND METHODS
All children in the study were born in The Royal Women's Hospital, Melbourne, Australia, a tertiary perinatal center. The cohort comprised 85 consecutive survivors to at least 5 years of age who weighed less than 1000 gm at birth and who were born between January 1,1977, and March 31,1982, and 124 consecutive survivors to at least 5 years who weighed between 1000 and 1500 gm and who were born between October 1, 1980, and March 31, 1982. Of children of birthweight less than 1000 gm, 83 of 85 (97.6%) were assessed at both 2 and 5 years. Of children of birthweight 1000 to 1500 gm, 112 of 124 (90.3%) 5-year survivors were assessed at both 2 and 5 years. We performed all the psychologic and standardized neurodevelopmental assessments at 2 and 5 years. At both ages, the children were assessed and the findings were coded without knowledge of the child's perinatal history and, at 5 years, with no knowledge of the 2-year neurodevelopmental findings. Children considered neurodevelopmentally normal were seen by only one pediatrician, but ab-
Department of Obstetrics & Gynaecology and of Paediatrics, the University of Melbourne, and the Royal Women's Hospital, Carlton, Australia Supported by the National Health and Medical Research Council and Royal Women's Hospital—3AW Clinical Research Foundation, Carlton, Australia Address all correspondence to: Dr. Kitchen, Dept. of Obstetrics & Gynaecology, University of Melbourne, Parkville 3052, Australia
178
Copyright © 1990 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: National University of Singapore. Copyrighted material.
ABSTRACT
normal or equivocal neuromuscular findings were usually corroborated by a second pediatrician. The psychologic assessment at 5 years of age (corrected for prematurity) included the Wechsler Preschool and Primary Scales of Intelligence (WPPSI).7 All 2-year-old children with cerebral palsy had one of the spastic syndromes. Children with spastic cerebral palsy had increased active tone, increased deep tendon reflexes, and positive Babinski reflexes. The diagnosis of hemiplegia was supported by marked hand dominance on the normal side, toe walking on the affected side, and an asymmetric gait. Diplegia was diagnosed if the lower limbs were predominantly affected and quadriplegia if all limbs were equally affected. Cerebral palsy was graded according to the severity of the motor disability. Mild cerebral palsy was defined as a disability in ambulant children that interfered only slightly with normal daily functioning. Moderate cerebral palsy included those children who were attempting to walk at 2 years; severe cerebral palsy included those who were considered likely to remain permanently nonambulant. The same criteria for diagnosis and severity of cerebral palsy were used at the 5-year assessment; the one 5-year-old child with ataxic cerebral palsy showed intention tremor, past-pointing, walked on a wide base, and had increased deep tendon reflexes. Data were analyzed by computer, using SPSSX programs. Differences in distribution were analyzed using 2-tailed t tests, and differences in proportion using corrected chi-square tests; a p value on any test less than 0.05 was considered to be statistically significant.
RESULTS
The positive predictive value of a diagnosis of cerebral palsy at 2 years for a diagnosis of cerebral palsy at 5 years was 55% (95% confidence intervals (CI) 31.5 to 76.9%). If cerebral palsy was absent at 2 years, the chance of it being diagnosed at 5 years was 1.1% (95% CI 0.1 to 4.1%) (Table 1).
Table 1. Cerebral Palsy in Children Seen at Both 2 and 5 Years of Age Birth weight (n)
