Cerebral Palsy: Early Markers of Clinical Phenotype and Functional Outcome.

The Prechtl General Movement Assessment (GMA) has become a cornerstone assessment in early identification of cerebral palsy (CP), particularly during the fidgety movement period at 3-5 months of age. Additionally, assessment of motor repertoire, such as antigravity movements and postural patterns, which form the Motor Optimality Score (MOS), may provide insight into an infant's later motor function. This study aimed to identify early specific markers for ambulation, gross motor function (using the Gross Motor Function Classification System, GMFCS), topography (unilateral, bilateral), and type (spastic, dyskinetic, ataxic, and hypotonic) of CP in a large worldwide cohort of 468 infants. We found that 95% of children with CP did not have fidgety movements, with 100% having non-optimal MOS. GMFCS level was strongly correlated to MOS. An MOS > 14 was most likely associated with GMFCS outcomes I or II, whereas GMFCS outcomes IV or V were hardly ever associated with an MOS > 8. A number of different movement patterns were associated with more severe functional impairment (GMFCS III-V), including atypical arching and persistent cramped-synchronized movements. Asymmetrical segmental movements were strongly associated with unilateral CP. Circular arm movements were associated with dyskinetic CP. This study demonstrated that use of the MOS contributes to understanding later CP prognosis, including early markers for type and severity.

Therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy had favourable outcomes at a referral hospital in a middle-income country.

AIM: This South African study documented the survival and neurodevelopmental outcomes of infants with hypoxic-ischaemic encephalopathy (HIE) after introducing cooling to a neonatal intensive care unit and identified early markers for neurodevelopmental outcome. METHODS: We retrospectively reviewed infants that received cooling according to the Total Body Hypothermia trial protocol from 2008 to 2011. Infants were screened with the Bayley Scales of Infant and Toddler Development, Third Edition, at one year of age and underwent neurological and hearing assessments. RESULTS: Data on 99 infants with HIE showed that 45% of cases were moderate, 23% severe and 32% mild. An abnormal amplitude integrated electro-encephalogram (aEEG) background was documented in 45 cases within 24 hours. Magnetic resonance imaging (MRI) scans were consistent with HIE in all but one case. We reviewed 50 traceable survivors at one year. Development was significantly impaired in nine and 41 were normal or mildly impaired. A severely abnormal aEEG background, severe HIE and an abnormal MRI were associated with death and severe impairment. A good suck, mild HIE, primiparity and normal MRI were associated with good outcomes. CONCLUSION: Most infants with HIE survived without major impairment. Previously described predictors of neurodevelopmental outcome were good surrogate markers in this population.

Management of therapeutic hypothermia for neonatal hypoxic ischaemic encephalopathy in a tertiary centre in South Africa.

AIM: Therapeutic hypothermia (TH), shown in developed countries to improve outcome in infants with hypoxic-ischaemic encephalopathy (HIE), was introduced into standard care at Tygerberg Children's Hospital in 2008. We aimed to describe the management and characteristics of infants treated with TH at this tertiary centre as well as the logistical challenges encountered. METHODS: Infants admitted for TH between 2008 and 2011 were included. They fulfilled TOBY study entry criteria and were cooled using a whole-body cooling system. A retrospective analysis of the cooling process and clinical findings was made using data collected during treatment. RESULTS: 100 infants with mild (32%), moderate (45%) and severe (23%) HIE were treated over 3 years. Mean time to admission was 4.87 (±1.63) hours, median time from delivery to target temperature was 7.5 h (range 2.5-15.5 h). Mean temperature on admission was 35.5°C (±1.5°C). Overall, rectal temperature was within target temperature for 82.8% of the time. Complications noted were clinically suspected/proven infection (45%), abnormal coagulation tests (48%), thrombocytopenia (34%), need for inotropic support (17%), hypoglycaemia (4%) and hyperglycaemia (10%). Rate of follow-up at 1 year among survivors was 57%. Infants not attending 1-year follow-up were more likely to have HIV-infected mothers, but there were no other demographic or clinical differences when compared with those who attended follow-up. CONCLUSIONS: Cooling is feasible in a resource-limited setting, within a strict protocol. With close monitoring, the known and common complications occur as frequently as in less resource-limited settings. Surrogate markers of later outcome need to be explored where follow-up is problematic.