Development of a Bedside Tool to Predict the Diagnosis of Cerebral Palsy in Term-Born Neonates

Abstract

ImportanceCerebral palsy (CP) is the most common abnormality of motor development and causes lifelong impairment. Early diagnosis and therapy can improve outcomes, but early identification of infants at risk remains challenging.ObjectiveTo develop a CP prognostic tool that can be applied to all term neonates to identify those at increased risk of developing CP.Design, Setting, and ParticipantsThis case-control study used data from the Canadian Cerebral Palsy Registry (data collected from January 2003 to December 2019) for children with CP and the Alberta Pregnancy Outcomes and Nutrition study (mothers enrolled from May 2009 to September 2012; data extracted in 2020) for controls. There were 2771 children with CP and 2131 controls evaluated; 941 and 144, respectively, were removed for gestational age less than 37 weeks at birth, 565 with CP removed for incomplete data, and 2 controls removed for a diagnosis of CP. Data were analyzed from April to August 2022.ExposuresPotential risk factors were selected a priori based on the literature, including maternal, intrapartum, and infant characteristics.Main Outcomes and MeasuresDiagnosis of CP, defined as a disorder of motor function due to a nonprogressive brain abnormality before age 1 year and classified by Gross Motor Function Classification System levels I to V.ResultsOf 3250 included individuals, 1752 (53.9%) were male, and the median (IQR) gestational age at birth was 39 (38-40) weeks. Encephalopathy was present in 335 of 1184 infants with CP (28%) and 0 controls. The final prediction model included 12 variables and correctly classified 75% of infants, with a sensitivity of 56% (95% CI, 52-60) and specificity of 82% (95% CI, 81-84). The C statistic was 0.74 (95% CI, 71-76). Risk factors were found to be additive. A proposed threshold for screening is probability greater than 0.3, with a sensitivity of 65% (95% CI, 61-68) and specificity of 71% (95% CI, 69-73). The prognostic tool identified 2.4-fold more children with CP than would have presented with encephalopathy (odds ratio, 13.8; 95% CI, 8.87-22.65; P < .001).Conclusions and RelevanceIn this case-control study, a prognostic model using 12 clinical variables improved the prediction of CP compared with clinical presentation with encephalopathy. This tool can be applied to all term newborns to help select infants for closer surveillance or further diagnostic tests, which could improve outcomes through early intervention.

Apgar Score and Neurodevelopmental Outcomes at Age 5 Years in Infants Born Extremely Preterm

“…Nonetheless, the Apgar score remains the most commonly used assessment tool, and low Apgar scores at 5 minutes after birth are uniformly associated with an increased risk of mortality, acute morbidities, impaired neurodevelopmental outcomes, and educational support services in infants born at term. [2][3][4][5][6][7][8][9][10][11] A similar association of low 5-minute Apgar scores after birth and increased risks of mortality and cerebral palsy (CP) was observed in infants born preterm, although the strength of the association decreased at lower gestational ages. 5,[12][13][14] A 2022 study 12 by a multinational collaboration did not reveal an association between low Apgar scores and severe neurologic injury, defined as grade 3 or 4 intraventricular hemorrhage (IVH) or cystic periventricular leukomalacia (CPVL), in infants born extremely preterm (EPT; ie, those born at less than 28 weeks' gestation).…”

“…After the Apgar score’s original description, advances in medical care have dramatically improved neonatal outcomes. Nonetheless, the Apgar score remains the most commonly used assessment tool, and low Apgar scores at 5 minutes after birth are uniformly associated with an increased risk of mortality, acute morbidities, impaired neurodevelopmental outcomes, and educational support services in infants born at term …”

New Screening Tool for Term-Born Infants Enables Update to the Clinical Practice Guideline for Early Diagnosis of Cerebral Palsy

“…Indeed, firearm injury has surpassed motor vehicle crash to become the leading cause of death among children. 1 In this issue, Wilson et al 2 analyze longitudinal national data to provide compelling insights into the character-istics and circumstances of homicides of children that emphasize important avenues for prevention.…”

“…Rouabhi et al 1 present a novel prognostic tool for identifying the risk of cerebral palsy (CP) in a "low-risk" term newborn, using a large sample of population register data from Canadian infants. Selected clinical variables based on published risk factors were used to build and test a model.…”

Commentary on “Predictors of Risk for Cerebral Palsy: A Review”

“…We believe that parents want to know “what is my child's risk of CP?”, as well as “how likely is it that this will be the outcome for my child?” Understanding a child's risk of a neurodevelopmental disorder like CP is important in providing them with the best opportunity to thrive by starting intervention as early as possible. Proposed screening tools to predict CP, which include potentially modifiable risk factors, are emerging 2. Screening tools that help to answer the question of likelihood of diagnosis, while encouraging close surveillance, further diagnostic tests, and early intervention are what is needed.…”