Follow-up of children with cerebral palsy after selective posterior rhizotomy with intensive physiotherapy or physiotherapy alone.

In all 21 children with spastic cerebral palsy (CP) underwent surgery involving selective posterior rhizotomy (SPR), followed by six months intensive physiotherapy (PT). Neurological and physiotherapeutic assessments were made one, three and five years after the operation. The children undergoing surgery were compared to 21 comparison children who took part in a regular physiotherapy programme during the same time period. At the preoperative assessment, the children undergoing surgery were similar to the comparative children in terms of age, sex, type of CP, spasticity of the legs and mean functional scores. The children were selected for SPR on the basis of more than half a year's arrest of motor development, which was the only significant difference to the comparative group. Motor function was measured using two different methods, the Illinois-St Louis Scale and the Gross Motor Functional Classification System (GMFC). Both groups experienced steady development during the five-year follow-up period and no significant differences were observed in the mean functional scores between the groups. We conclude that this comparative study, like most controlled studies, failed to demonstrate any additional effect of SPR on motor development of children with spastic CP. Nevertheless, SPR may contribute to a resumption of motor development in children with arrested motor development despite vigorous conservative therapy. SPR is therefore justified as treatment in selected cases.

A national two year follow up study of extremely low birthweight infants born in 1996-1997.

OBJECTIVE: To study neurodevelopmental outcome in a two year cohort of extremely low birthweight (ELBW) infants at 18 months corrected age, to compare the development of the ELBW infant subcohort with that of control children, and to find risk factors associated with unfavourable outcome. STUDY DESIGN: All 211 surviving ELBW infants (birth weight < 1000 g) born in Finland in 1996-1997 were included in a national survey. The ELBW infants (n = 78) who were born and followed in Helsinki University Hospital belonged to a regional subcohort and were compared with a control group of 75 full term infants. A national follow up programme included neurological, speech, vision, and hearing assessments at 18 months of corrected age. Bayley infant scale assessment was performed on the subcohort and their controls at 24 months of age. Risk factors for unfavourable outcome were estimated using logistic and linear regression models. RESULTS: The prevalence of cerebral palsy was 11%, of all motor impairments 24%, of ophthalmic abnormalities 23%, and of speech delay 42%. No impairment was found in 42% of children, and 18% were classified as severely impaired. The prevalence of ophthalmic abnormalities decreased with increasing birth weight and gestational age, but the prevalence of other impairments did not. In the subcohort, a positive correlation was found between the date of birth and Bayley scores. CONCLUSION: Ophthalmic abnormalities decreased with increasing birth weight and gestational age, but no other outcome differences were found between birthweight groups or in surviving ELBW infants born at 22-26 weeks gestation. The prognosis in the regional subcohort seemed to improve during the short study period, but this needs to be confirmed.

Cognitive performance and attachment patterns at four years of age in extremely low birth weight infants after early intervention.

This study aims at assessing the effects of an early occupational therapy intervention on the cognitive development and the development of attachment patterns in ELBW infants. The intervention, given weekly at home from six months to 12 months, aimed at supporting parent-child interaction and enhancing motor control and coordination. The study population consisted of 100 ELBW infants matched in pairs in accordance to their pre-perinatal risk scores and allocated successively to intervention or non-intervention groups. Cognitive development was assessed with the Bayley Scales at age two and with the WPPSI at age four. Attachment to primary caregiver was assessed with the Preschool Assessment of Attachment (PAA). Cognitive performance was within age norms in both groups at both ages. Intervention did not show any effect on cognitive performance at the age of two years. At the age of four years, cognitive level was overall, and most notably for verbal performance, higher in the intervention group than in the control group. There was an over-representation of the so-called atypical attachment patterns (those not fitting the normative A, B, or C categories) in the control group. The results are discussed in terms of finding more global ways to support the development of at risk pre-term children.

Neurological development up to the age of four years of extremely low birthweight infants born in Southern Finland in 1991-94.

A total of 142 infants with birthweights of less than 1000 g were examined at the age of 4 y by a child neurologist, by a neuropsychologist and by an occupational therapist in order to establish the rate of neurological disorders. A total of 57 (40%) of the children had normal neurological development, 52 (37%) had minor neurological disorders, 27 (19%) were diagnosed with cerebral palsy, and 6 (4%) were mentally retarded (IQ <71) with no motor disability. The rate of cerebral palsy was identical with the figure at age 2 y, but the rate of minor neurological disorders increased from 25% to 37%. Compared with international rates, we found a higher rate of cerebral palsy, but the incidence of minor neurological disorders corresponded with figures published previously.

Predicting neurological disorders in infants with extremely low birth weight using the movement assessment of infants.

PURPOSE: The aim of the study was to investigate the predictive value of the Movement Assessment of Infants (MAI) in early detection of neurological disorders in infants with extremely low birth weight (ELBW; <1000 g). METHOD: Thirty-three infants were examined and predictions regarding neurologic status were made at the corrected age of four months using the MAI. Follow-up examinations took place at the corrected age of 12 and 24 months by a pediatric neurologist and a physiotherapist. A neuropsychological assessment using the Bayley Scales of Infant Development was completed at the corrected age of two years. RESULTS: For predicting cerebral palsy (CP), the sensitivity was 64%; specificity 91%, and the positive and negative predictive values were 78% and 84%, respectively. For minor neurological disorders (MND), the value of sensitivity was 44%, specificity 71%, the positive predictive value was 50%, and the negative predictive value was 67%. CONCLUSION: The MAI assessment administered at the corrected age of four months is highly specific in predicting CP in the infants with ELBW.

Does perinatal hypocarbia play a role in the pathogenesis of cerebral palsy?

This study aimed to evaluate the role of hypocarbia as a risk factor for mortality and for cerebral palsy in extremely low birthweight infants. The records for 215 extremely low birthweight children were analysed, grouping the infants into those who died (n = 72), those who had a confirmed diagnosis of cerebral palsy (n = 27) and those without major neurological symptoms at the age of 2 y (n = 116). The analysed risk factors were: birthweight, gestational age, maternal diseases and toxaemia, multiple pregnancy, male gender, respiratory distress syndrome, abnormal neonatal cerebral ultrasound, occurrence of septic infection, and/or at least one episode of systemic hypotension and/or at least two episodes of hypocarbia (<3 kPa) during the neonatal period. The mortality rate was 31% and the rate of cerebral palsy was 17% in the survivors. Hypocarbia was found in 33% of children with cerebral palsy, in 10% of infants who died and in 19% of the healthy controls; the differences were statistically insignificant. Birthweight and gestational age, episodes of systemic hypotension and abnormal ultrasound emerged as risk factors for mortality. Abnormal cerebral ultrasound was the only significant risk factor for cerebral palsy. The role of hypocarbia in the pathogenesis of CP remained indistinct but the distribution of risk factors was different in infants with a mortal outcome and in infants with cerebral palsy.

Temperament profiles and their role in neurodevelopmental assessed preterm children at two years of age.

The aim of this study was to determine whether preterms (n = 80, mean birth weight 1,205 g) differ from full-terms (n = 80) in temperament profile at 24 months of age and to explore the relationship between temperament, neurodevelopment, and behavior. Temperament was assessed using the Toddler Temperament Questionnaire, which defines nine temperament dimensions: activity, rhythmicity, approach/withdrawal, adaptability, mood, intensity, distractability, persistence, and sensory threshold. Neurodevelopment was assessed by the Bayley Scales of Infant Development and by neuropediatric examination. Behavior was assessed using the Infant Behavior Record, which is a part of the Bayley Scales. When temperament was considered, the preterms were significantly less active, more adaptive, more positive in mood, less intense, and lower in threshold to respond than the controls. The results on IBR showed that preterms were significantly less goal directed, less attentive, and lower in endurance than the controls. The preterms performed significantly less well than the controls on the Bayley test. Low Bayley scores correlated with temperament scores of high rhythmicity, positive mood, low persistence, and high threshold and with IBR scores of poor social orientation, negative emotional tone, poor co-operation, short attention span, and poor endurance.

Neurodevelopment until the adjusted age of 2 years in extremely low birth weight infants after early intervention--a case-control study.

A total of 104 infants with birth weights of less than 1000 grams were enrolled in this prospective case-control study in order to examine the effect of occupational therapy based on sensory integration (SI) and neurodevelopmental therapy (NDT) on neurological development. The children were grouped as matched pairs on the basis of a set of developmental risks assessed at the age of 3 months. The intervention children had a weekly session of 60 minutes of occupational therapy from the corrected age of 6 months up to 12 months. All the children were examined at the corrected age of 3, 6, 9, 12, 18 and 24 months. The neurodevelopment of the cases and the controls did not differ essentially and the only significant difference was found in the social development of the children at the age of 12 months to the advantage of the intervention group. It is concluded that this amount of occupational therapy in at-risk children does not have a relevant effect on neurological development.

Randomized study of the effect of antenatal dexamethasone on growth and development of premature children at the corrected age of 2 years.

The objective of the series was to study the effect of prenatal dexamethasone therapy on the growth and neurological development of preterm children until the age of 2 years. Eighty-two children with a mean gestational age of 30 (24-33) weeks and a mean weight of 1291 (530-2360) g at birth, treated antenatally with either dexamethasone (n = 50) or placebo (n = 32), were examined at the adjusted age of 24 months by a paediatric neurologist, a neuropsychologist and a speech therapist. Neurological development was defined as normal if all scores of neuropaediatric, neuropsychological and verbal tests were within the normal range. Normal neurological development was found in 52% of the dexamethasone-treated and in 34% of the placebo-treated children. The incidence of cerebral palsy was 10% in the dexamethasone group and 22% in the placebo group. Minor developmental delay was found in 42% of dexamethasone-treated and in 53% of placebo-treated children. Our follow-up results indicate that the beneficial effect of prenatal glucocorticoid treatment on cerebral complications (intraventricular haemorrhage or periventricular leucomalacia) demonstrated during the neonatal period may be followed by a lower incidence of cerebral palsy in surviving premature children.

Growth and development until 18 months of children exposed to tocolytics indomethacin or nylidrin.

Indomethacin, a prostaglandin synthesis inhibitor, is a more efficient tocolytic than the beta-sympathomimetic nylidrin, but causes more frequent unwanted effects in the neonatal period. In order to elucidate the effects on neurodevelopment, infants randomly exposed in utero to either compound were followed up to 18 months. A total of 93 children (40 exposed to nylidrin and 53 exposed to indomethacin) were examined at the age of 12 months. A detailed neurological examination was carried out in 44 of these infants at the age of 18 months. At the age of 12 months the children in the indomethacin group showed poor outcome (death or severe BPD and/or CP and/or severe ROP) in 23% and the children in the nylidrin group in 5% (p = 0.039, Fisher Exact Test). Concerning the children born during tocolysis the corresponding figures were 73% and 13% respectively (p = 0.002, Fisher Exact Test). The growth of the children did not differ significantly between the two treatment groups. Neurological assessment at the age of 18 months revealed more subnormally scoring children in the indomethacin group, but the differences were not significant. It was concluded that the higher incidence of poor outcome and a lest favourable neurological development in the indomethacin group do not support indomethacin's position as the drug of choice for tocolysis.

Monitoring of concentrations of clobazam and norclobazam in serum and saliva of children with epilepsy.

Clobazam was added to the previous antiepileptic drug therapy of 90 children suffering from drug resistant epilepsy. Ten patients became seizure free, although four of these later developed tolerance. Thirty-three patients experienced a decrease in seizure frequency, and 24 of these, too, developed tolerance. Forty-four patients showed no change in seizure frequency, and three experienced an increase. The best results were experienced by patients with myoclonic seizures, whereas patients with complex partial seizures usually developed tolerance. The concentrations of clobazam and its active metabolite norclobazam were measured in 251 serum and 57 saliva samples. The group of seizure-free patients had the lowest clobazam and norclobazam concentrations; tolerance was associated with the highest concentrations. Beneficial side effects were associated with low, and adverse effects with high, concentrations of norclobazam. The concentrations of clobazam and norclobazam in saliva correlated with concentrations in serum. Monitoring of serum and salivary concentrations of clobazam and norclobazam is of limited value only, and no therapeutic target range can be given.