Risk for cerebral palsy in infants with total serum bilirubin levels at or above the exchange transfusion threshold: a population-based study.

IMPORTANCE: Exchange transfusion is recommended for newborns with total serum bilirubin (TSB) levels thought to place them at risk for cerebral palsy (CP). However, the excess risk for CP among these infants is unknown. OBJECTIVE: To quantify the risks for CP and CP consistent with kernicterus that are associated with high TSB levels based on the 2004 American Academy of Pediatrics exchange transfusion threshold (ETT) guidelines. DESIGN, SETTING, AND PARTICIPANTS: We enrolled 2 cohorts from a population of 525,409 infants in the Late Impact of Getting Hyperbilirubinemia or Phototherapy (LIGHT) birth cohort. Eligible infants were born at a gestational age of at least 35 weeks at 15 hospitals within the Kaiser Permanente Northern California integrated medical care delivery system from January 1, 1995, through December 31, 2011. EXPOSURES: The exposed cohort included all 1833 infants with at least 1 TSB measurement at or above the ETT based on age at testing, gestational age, and results of direct antiglobulin testing. The unexposed cohort was a 20% random sample of 104 716 infants with TSB levels below the ETT. MAIN OUTCOMES AND MEASURES: A pediatric neurologist blinded to the TSB levels reviewed medical records to determine the presence of CP, defined as a nonprogressive congenital motor dysfunction with hypertonia or dyskinesia. Cerebral palsy was judged to be consistent with kernicterus if magnetic resonance imaging of the brain revealed bilateral globus pallidus injury in the setting of dyskinetic CP. RESULTS: We identified CP in 7 of 1833 exposed (0.4%) vs 86 of 104 716 unexposed (0.1%) infants (relative risk, 4.7 [95% CI, 2.2-10.0]). Absolute risk differences were 0.2% (95% CI, 0%-0.5%) for a TSB level 0 to 4.9 mg/dL above the ETT (n = 1705), 0.9% (95% CI, 0.1%-5.3%) for a TSB level 5.0 to 9.9 mg/dL above the ETT (n = 102), and 7.6% (95% CI, 2.1%-24.1%) for a TSB level 10 mg/dL or more above the ETT (n = 26). Cerebral palsy consistent with kernicterus occurred in 3 infants (incidence, 0.57 per 100,000 births); all 3 had TSB levels of more than 5.0 mg/dL above the ETT and at least 2 risk factors for neurotoxicity, such as prematurity, glucose-6-phosphate dehydrogenase deficiency, or hypoxia-ischemia. CONCLUSIONS AND RELEVANCE: Cerebral palsy consistent with kernicterus occurred only in infants with 2 or more risk factors for neurotoxicity and TSB levels of more than 5 mg/dL above the ETT. Among infants with lower degrees of TSB level elevation, the excess risk for CP is minimal.

Comparison of micronutrient levels in children with cerebral palsy and neurologically normal controls.

OBJECTIVE: To measure levels of micronutrients in children with cerebral palsy and compare them with neurologically normal children of similar nutritional status. METHODS: Fifty children with cerebral palsy (2-12 y) and 50 age and sex matched controls of similar nutritional status were enrolled. Detailed dietary history was recorded and nutritional status assessed. Venous blood (3 ml) was drawn for analysis. Micronutrient levels were measured as per standard technique. RESULTS: Serum iron was 12.6 ± 5.9 and 20.9 ± 3.3 µmol/L in CP and controls respectively (P < 0.001). Mean copper levels were 106.2 ± 38.3 µg/dl in CP and 128.8 ± 20.2 µg/dl in controls (P < 0.001); magnesium levels were 1.97 ± 0.4 and 2.2 ± 0.3 mg/dl (P = 0.003). Zinc levels were similar in CP and controls (P = 0.979). The mean energy intake was significantly less in CP (P = 0.016). Mean protein intake did not vary significantly (P = 0.847). No correlation was found between energy intake and serum levels of micronutrients (P > 0.05). There was no difference in micronutrient levels with respect to gross motor functional classification system (GMFCS) grades and limb involvement (P > 0.05). CONCLUSIONS: The serum levels of iron, copper and magnesium are significantly less in children with cerebral palsy, hence the need for supplementation.

Effect of acupuncture on inflammatory cytokines expression of spastic cerebral palsy rats.

OBJECTIVE: To To investigate the effect of acupuncture on the tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP), nitric oxide synthase (NOS) content and muscular tension of spasticity cerebral palsy rat model. METHODS: The rats with spastic cerebral palsy were randomly divided into the control group, model group and acupuncture group. After successful modeling, the muscular tension and the content of TNF-α, IL-6, CRP, NOS were measured. RESULTS: The serum TNF-α, IL-6, CRP, NOS content were significantly decreased in the acupuncture group (P<0.05). The low and high shear viscosity of whole blood of the acupuncture group were significantly lower than the control group and the model group (P<0.05). The erythrocyte electrophoresis indexes in the acupuncture group were significantly lower than that in the model group and the control group (P<0.05). Acupuncture significantly reduced the muscular tension of spastic cerebral palsy rat and increased the active extent in the paralytic extremity (P<0.05), but it could not be restored to normal level. Compared with the control group, the difference had significant (P<0.05). CONCLUSIONS: Acupuncture treatment can inhibit the release of inflammatory cells after brain injury, then reduce immune injury, relieve muscle spasms and reduce muscular tension.

Reduced platelet aggregation in a boy with scurvy.

Pediatric scurvy is a rare condition characterized by perifollicular petechiae and bruising, hemorrhagic gingivitis and musculoskeletal symptoms, all assumed to be predominantly related to abnormal collagen structure. We report on a 9-year-old autistic boy with vitamin C deficiency due to a highly limited food range presenting with multiple petechiae, gum bleeding and debilitating bone pain, in whom platelet aggregometry revealed a distinctly reduced thrombocyte aggregation, normalizing after vitamin C supplementation. This observation indicates that platelet dysfunction may additionally contribute to the hemorrhagic diathesis in scurvy, and demonstrates that ascorbic acid deficiency should be considered in children with an otherwise unexplained acquired thrombocytopathy.

[Evaluation of serum total carnitine values in persons with severe motor and intellectual disabilities with enteral (tube) feeding].

OBJECTIVE: The nutritive evaluation and the serum carnitine values were measured for persons with severe motor and intellectual disabilities with enteral (tube) feeding. METHODS: In Shimada Rehabilitation Center, twenty one people who had serum albumin levels of 3.4 g/dl or less, and were taking nutrition with enteral (tube) feeding, were tested. Body weight, blood samples, and serum carnitine levels were measured. RESULTS: The total carnitine value was less than the standard value in 19 patients. The total carnitine value decreased in the group taking valporate sodium (VPA), compared to the values from the group non-taking VPA. CONCLUSIONS: From our evaluation, we think that daily carnitine supplements is essential for persons with sever motor and intellectual disabilities taking VPA to maintain carnitine levels in the blood, and regular urine test should be done for earlier detection secondary lack complications from the secondary lack of carnitine.

Insufficient energy and nutrient intake in children with motor disability.

AIM: Children with motor disabilities are at increased risk of compromised bone health due to impaired weight bearing. Poor nutritional status may be an additional risk factor. The aim of this study was to evaluate energy and nutrient intakes in children with motor disability. PATIENTS AND METHODS: Fifty-four children with motor disability (cerebral palsy in 59%) were included. Three-day food diaries were collected and analysed. The results were compared with recommended dietary allowances for age and sex. RESULTS: The median age was 10.9 years. The median energy intake was 76% of the recommendation and <80% in 57% of children. Of the total energy, 17% was from protein, 32% from fat and 50% from carbohydrates. The medians were for calcium intake 142% and for vitamin D intake 76% of the recommendation; serum 25-hydroxy-vitamin D concentrations were low (median 46 nmol/L). Children with low energy intake were shorter and lighter and had more severe motor disability than children with sufficient energy intake. CONCLUSION: Insufficient energy and nutrient intake is common in children with motor disability. This may have adverse health effects especially when associated with low vitamin D intake. Energy and vitamin D supplements should be considered.

Increased incidence of iron deficiency anemia secondary to inadequate iron intake in institutionalized, young patients with cerebral palsy.

We observed high incidence of anemia in patients with cerebral palsy sheltered in a specialized institution in Thessaloniki, Greece. Therefore, we decided to investigate its cause. We studied 108 patients, and assessed complete blood cell count, peripheral blood smear, serum iron, ferritin, folate, B12 and the presence of hemoglobin or parasites in the stools. In all cases, anemia was hypochromic and microcytic. Approximately 33% of patients suffered from hypochromic anemia, whereas 38% were iron deficient. There was no statistical difference in the incidence of iron deficiency between different age groups. All tests for fecal occult blood or intestinal parasites were negative. Folic acid and B12 levels were within normal range in all cases. We also found that 87 and 95.6% of patients on liquid diet were anemic and iron deficient, respectively, compared to only 18.8 and 22.3% of patients on normal diet. The high incidence of anemia was attributed to iron deficiency which was secondary to inadequate iron intake and decreased iron absorption. Thus, it would not be irrational to consider iron supplementation as the first measure in such patients and postpone endoscopic procedures for a later stage, unless there are clinical or laboratory findings (such as fecal occult blood) suggestive of gastrointestinal blood loss.

Micronutrient status in children with cerebral palsy.

AIM: To investigate micronutrient status in a group of children with cerebral palsy (CP). METHODS: Thirty-six children with CP, aged 1.5-17 years, completed a 4-day food diary, underwent anthropometric measurements and delivered blood for analysis of micronutrient concentrations. RESULTS: Low intake of iron, folate, niacin, calcium, vitamin E and vitamin D was common, even among those who were receiving nutritional supplements. Laboratory tests revealed low serum concentration of folate in eight children, alpha-tocopherol in six children, ferritin in five children and pyridoxal-5-phosphate in three children. Two participants were low in zinc and one was low in selenium. Severely disabled children received nutrition supplements more frequently than those with less severe disability (71% vs.16%, p = 0.01). Tube feeding and use of nutrition supplements was reflected in higher concentrations of micronutrients in blood and serum. CONCLUSION: Low intake of micronutrients as well as low micronutrient concentrations was common in this heterogenic group of children with CP. Children with neurological disabilities should have their nutritional status evaluated in order to ascertain sufficient intake of micronutrients.

Vitamin D levels in noninstitutionalized children with cerebral palsy.

Calcitriol (1,25-dihydroxy vitamin D) is an important hormone in calcium and phosphate metabolism. Levels of calcitriol and its precursor, 25-hydroxy vitamin D (calcidiol), were measured in a heterogeneous group of 125 noninstitutionalized children and adolescents with spastic cerebral palsy. Levels of each were correlated with: (1) clinical factors including mobility, prior fracture, and use of anticonvulsants; (2) nutrition and growth parameters including skinfolds, body mass index, and use of vitamin supplements; and (3) other serum analyses including osteocalcin as a marker of bone formation, calcium, and alkaline phosphatase. Levels of calcidiol and calcitriol did not correlate with any of the various clinical, nutritional, or growth parameters examined. The prevalence of low (< 10 ng/mL) levels of calcidiol was significant (19%), and dependent on the season of the year in which the level was measured. In contrast, less than 2% of the patients were found to have a low (< 20 pg/mL) level of calcitriol and the mean was comparable to normal pediatric subjects. Levels of calcitriol are maintained in noninstitutionalized children with cerebral palsy despite anticonvulsants, poor nutrition, and calcidiol levels that vary greatly with the seasons.

[A neuromorphological analysis of the motor area of the cerebral cortex in rat pups subjected to prenatal exposure to normal and pathological blood serum]. / Neiromorfologicheskii analiz motornoi oblasti kory mozga krysiat, podvergshikhsia prenatal'nomu vozdeistviiu normal'noi i patologicheskoi syvorotki krovi.

Morphological quantitative and qualitative analysis of the pyramidal neurones in the motor cortex of rat puppies after administration of the blood serum from human donors with central motor disorders reveals the dependence of the quality and quantity of neurones from the effect of corresponding blood sera. Pathologic blood serum decreases the number and induces degradation of dendritic organization of the pyramidal neurones. The effect of the blood sera on quantitative and qualitative properties of the pyramidal neurones in rat puppies depends on the age of donor infants with central motor disorders. Blood serum from newborn babies with motor dysfunctions significantly decreases the number of labeled pyramidal neurones and results in degradation of dendritic organization, whereas sera from 11-13-year infants only insignificantly affect these characteristics.

[Zinc sulfate in the complex treatment of children with cerebral palsy]. / Sul'fat tsinka v kompleksnom lechenii detei s tserebral'nymi paralichami.

Ninety-six children aged 3 to 14 years with cerebral paralysis in the form of spastic diplegia of medium and grave intensity were examined. The majority of the children showed disorders of zinc metabolism and of other types of metabolism. To correct metabolic abnormalities, 20 children received zinc sulfate in biological doses per os in addition to the main complex of treatment measures. 38 children suffering from cerebral paralysis made up the control group and were given a complex of routine rehabilitation treatment measures. It has been established that introduction of the biotic doses of zinc sulfate into the complex of therapeutic measures for children with cerebral paralysis in the form of spastic diplegia favoured the improvement of metabolic processes, the clinical health status of the children, and enhancement of the body defence properties.