my first paper presentation

1. A STUDY OF CLINCAL SPECTRUM AND RISK
FACTORS OF CEREBRAL PALSY IN CHILDREN
BY DR JAGAN MOHAN VARAKALA (PG)
GUIDE: DR. M.SREERAM REDDY MD ,DCH
PROFESSOR & HOD, PEDIATRICS,
PRATHIMA INSTITUE OF MEDICAL SCIENCES
COGUIDES : DR AMITH KUMAR CH
ASSOCIATE PROFESSOR
DR HARISH GV
ASSISTANT PROFESSOR

2. INTRODUCTION
1) Cerebral palsy (CP) is a diagnostic term used to describe a group of
permanent disorders of movement and posture, causing activity
limitation that are attributed to non-progressive disturbances that
occurred in the developing fetal or infant brain1.
2) Cerebral palsy is a common problem, the worldwide incidence being 1.5
to 2.5 per 1000 live births.
3) There is no source of data in India since mild cases are missed and lack
of enough studies on prevalence2. But approximately 1-2 per 1000 live
births is a reasonable estimate3.
4) CP is widely used as one outcome measure of both obstetric and
neonatal care; and particularly as an indicator of the hazards of preterm
birth. The fall in neonatal mortality in the last four decades has
accompanied disappointingly not been by a concomitant decrease in
CP.4

3. 1) Nearly 42,000 new cases of cerebral palsy are added every year to Indian
population according to Prabhakar K (1983). The frequency of cerebral
palsy has remained steady or has risen slightly.13
2) Advances in perinatology have led to increasing survival of preterms and a
change in the distribution of clinical types of CP.6
3) The clinical spectrum of CP in resource-poor, developing countries is
different from that in the developed countries.
4) There is a paucity of clinical data in resource-poor settings. This difference
between the developed and developing countries may reflect the etiologies
and clinical features of CP
5) World CP is celebrated on October every year.

4. AIMS AND OBJECTIVES
Hospital based observational study of 30 months duration.
1. To study the clinical spectrum of cerebral palsy in children.
2. To study the risk factors for cerebral palsy in children.
3.To compare the data with available national and
international studies.
PERIOD OF STUDY
The study is conducted from Jan 2013 to August 2015

5. PATIENTS AND METHODS
 STUDY DESIGN: Hospital based observational study.
 INCLUSION CRITERIA: 100 consecutive children
diagnosed as cerebral palsy attending the Paediatric
department at Prathima Institute of Medical Sciences,
Karimnagar, during the period from January 2013 to
August 2015 were enrolled in this study.
EXCLUSION CRITERIA:
Children having disabilities other than cerebral palsy
were excluded from the study

6.  METHODOLOGY
Paediatric department during the period from
January 2013 to August 2015 This was a hospital
based observational study carried out at Prathima
Institute of Medical Sciences, Karimnagar, in 100
consecutive children diagnosed as cerebral palsy
attending.

7. AGE OF THE PATIENTS AT PRESENTATION
Age at presentation Present study Pratibha Singhi 22,
2013, India
Less than 2yr 47% 51.8%
2-5yrs 38% 33.2%
>5yrs 15% 15%
Graph-1: Distribution by age
In the present study less than 5 years constitute about 85% of CP cases. Majority of the
patients (47%) in
present study
were below 2yrs
of age at the
time of diagnosis
which was
comparable with
Pratibha Singhi
study (51.8%).

8. Table-2: Distribution of patients by sex
Male patients were the majority of cases which constitute 61% of
total cases and Female were 39%, ratio M:F=1.56:1
Sex Male Female
Pratibha Singhi 22, 2013,
India
72.4% 27.6%
Areeb Sohail 24, 2014,
Pakistan
80% 20%
OA Nafi 33, 2011, South
Jordan
54% 46%
Srivatsava V K 32,1992 65.1% 34.9%
Present study 61% 39%

9. Distribution according to place of delivery
According to place of delivery
Place of delivery Institutional Home
Pratibha Singhi 22, 2013, India 81% 19%
Present study 79% 21%
The causes of CP in institutional
deliveries may be due to lack of timely
intervention in high risk pregnancies
and very sick new born infants. And it
may be due to lack of timely referral to
secondary and tertiary level institutions
for better care.
The increase in CP cases in
institutional deliveries may be due to
improved documentations of the CP
cases, whereas in home deliveries due
to lack of consultations for health
check-up such cases may not be
documented

10. Head circumference of the patients
Majority of the patients (62%) had
microcephaly which was
comparable to study by Pratibha
Singhi (64.27%). Microcephaly may
be the one of the co-morbidities of
cerebral palsy.According to Head circumference
Head circumference Normal Microcephal
y
Pratibha Singhi et al22,
2013, India
35.73% 64.27%
OA Nafi33, 2011, South
Jordan
60.7% 39.3%
Present study 38% 62%

11. Clinical type of cerebral palsy
Clinical type of cerebral palsy
Spastic cerebral palsy was the
commonest physiological type
of cerebral palsy (81%).
Atonic, dyskinetic and mixed
types formed the rest of 19 %
of cases.

12. CLINICAL TYPE OF CEREBRAL PALSY
Clinical type Spastic Dyskinetic Atonic/ Hypotonic Mixed
Pratibha Singhi 22,
2013, India
73% 7% 11.2% 8.8%
Areeb Sohail24 ,
2014, Pakistan
75% 10% - 15%
OA Nafi33, 2011,
South Jordan
82.7% 8.2% - 6.6%
Srivatsava V K
32,1992
91.4% 1.5% 7% 0.2%
Sahu Suvanand
25,1997
88% 3.2% 8.8% -
Present study 81% 6% 9% 4%

13. Topographical type of cerebral palsy
Among the spastic group quadriplegia was
the commonest topographical type (69.14%)
followed by diplegia (22.22%).
Topographical
type
Number of
patients
Percentage(n=81)
Quadriplegia 56 69.14
Diplegia 18 22.22
Hemiplegia 7 8.64
Total 81 100.00
0
10
20
30
40
50
60
70
Quadriplegia Diplegia Hemiplegia
Percentage 69.14 22.22 8.64
Topographical type of cerebral palsy

14. TOPOGRAPHIC TYPE OF SPASTIC CEREBRAL PALSY
Topographic type Quadriplegia Diplegia Hemiplegia Monoplegia
Pratibha Singhi 22,
2013, India
51.5% 34.5% 13.8% -
Areeb Sohail 24,
2014, Pakistan
40% 46.7% 13.3% -
OA Nafi33, 2011,
South Jordan
34.4% 22.1% 26.2% -
Srivatsava V K
32,1992
38.22% 23.94% 31.38% 1%
Sahu Suvanand
25,1997
86.4% 2.4% 9.6% 1.6%
Present study 69.14% 22.22% 8.64% -

15. 1) The distribution of topographical type of spastic CP cases have
discrepancies between developed and developing countries. Spastic
quadriplegia was the most commonest type of CP in developing countries
with rates between 36% and 71% whereas spastic diplegia was the
commonest in developed countries with rates between 5% and 47%.22
2) The present study shows spastic quadriplegia is the commonest
topographical type of CP which is comparable with other studies of
developing countries.
3) The higher rates of spastic quadriplegia in developing countries is due
to increased perinatal and post natal risk factors like asphyxia, meningitis
and septicaemia etc., whereas higher rates of spastic diplegia in
developed countries is due to better new born care services and higher
rates of premature survivors.
4) The proportion of spastic diplegia has increased from 22% to
34.5% in a study in North India by Pratibha Singhi, 22 which reflects
the improved neonatal care and premature care services in
developing countries like India which indirectly reflects the
increasing survival of infants with antenatal brain damage or with
post natal brain damage due to complications of prematurity.

16. ANTENATAL RISK FACTORS FOR CEREBRAL PALSY
Risk factors Numb
er of
patient
s
Percentage
among
antenatal
factors (n=21)
Percentage
among total
cases
(n=100)
PIH 8 38.09 8.00
Maternal
anaemia
7 33.33 7.00
Maternal
fever
5 23.80 5.00
APH 4 19.04 4.00
8
7
5
4
Pregnancy InducedHypertension Maternal anaemia
Maternal fever/Infection AntepartumHemorrhage
Antenatal risk factors
Antenatal risk factors were reported
in 21% (n=100) of mothers in
present study among them
pregnancy induced hypertension
was most common antenatal risk
factor seen in 8% of mothers in
present study which is comparable
to other studies by Sahu Suvanand
in 8.8% cases and Pratibha Singhi
in 30% cases

17. ANTENATAL RISK FACTORS FOR CEREBRAL PALSY
Risk factors Maternal anaemia PIH APH Maternal fever /
infections
Pratibha Singhi 22,
2013, India
- 30% 12% 18%
Areeb Sohail 24,
2014, Pakistan
5% - - 40%
Sahu Suvanand
25,1997
- 8.8% 4% -
Present study 7% 8% 4% 5%
In a European study (2006) of CP antenatal infection was strongly associated
with CP and 39.5% of mothers of children with CP reported having an infection
during the pregnancy, with 19% having evidence of a urinary tract infection and
11.5% reporting taking antibiotics.1

18. NATAL RISK FACTORS FOR CEREBRAL PALSY
Risk
factors
Num
ber of
patie
nts
Percentage
among natal
risk factors
(n=62)
Percentage
among
total cases
(n=100)
Birth
asphyxia
44 70.96 44.00
LBW 33 53.22 33.00
Preterm 19 30.64 19.00
Instrumen
t/CS
18 29.03 18.00
PROM 4 6.45 4.00
Prolonged
labour
2 3.22 2.00
Malpositio
n
2 3.22 2.00
Multiple
gestation
2 3.22 2.00
Natal risk factors

19. ANTENATAL RISK FACTORS FOR CEREBRAL
PALSY
Risk
factors
Pratibha
Singhi 22,
2013,
India
Areeb
Sohail 45,
2014,
Pakistan
Srivatsav
a V K 38,
1992
Sahu
Suvanan
d42,
1997
Present
study
Birth
asphyxia
51.98% 25% 24.5% 25.6% 44%
PROM - - - - 4%
Prolonge
d labor
13.6% - 3.3% 1.6% 8%
Preterm 24.3% 15% - - 19%
Low
birth
weight
37.87% 10% - - 33%
Caesarea
n section
20.5% 5% 4.3% 10.4% 18%
Malpositi
on
0.1% - 2.6% 2.4% 2%
Multiple
gestation
3.4% 5% 0.6% 0.8% 2%
Among natal risk factors birth
asphyxia is the most common natal
risk factor seen in 44% cases in
present study.
Many recent studies from
industrialized countries show a rise in
the childhood prevalence of cerebral
palsy, largely because of the
increasing contribution of children
with low and very low birth weight.
The only demographic determinant of
cerebral palsy prevalence that is
changing rapidly is survival of low
birth weight and very low birth weight
infants. Based on the magnitude of
change in the survival of low and very
low birth weight infants.

20. POSTNATAL RISK FACTORS FOR CEREBRAL PALSY
Risk factors Number
of
patients
Percentage
among postnatal
risk factors
(n=36)
Percentage
among total
cases
(n=100)
Neonatal
seizures
23 63.88 23
Neonatal
sepsis
16 44.44 16
Neonatal
jaundice
9 25.00 9
[]
23
[]
16
[]
9
Number of patients
Postnatal risk factors were reported in
36% of cases among them neonatal
seizures was the commonest postnatal
risk factor which was present in 23% of
the cases and accounted for 63.88% of
all the postnatal risk factors.

21. Risk factors Neonatal seizures Neonatal jaundice Neonatal
sepsis/Meningitis
Pratibha Singhi 22, 2013,
India
26.9% 35.14% 30.6%
Areeb Sohail 24, 2014,
Pakistan
50% 30% -
OA Nafi33, 2011, South
Jordan
- 29.6% -
Sahu Suvanand 25,1997 15.2% 16.8% 22.4%
Present study 23% 9% 16%

22. PRESENTING COMPLAINTS
Presenting complaints Pratibha Singhi 22, 2013,
India
Present study
Developmental delay 88% 86%
Seizures 34.7% 32%
Feeding difficulties - 14%
Abnormal tone/posture 22.8% 12%
Delayed milestones was the commonest presenting complaint seen in
86% of cases which was comparable to study by Pratibha Singhi seen in
88% cases, followed by seizure and feeding difficulties in 32% and 14%.

23. RECOMMENDATIONS
1) All pregnancies should be registered and should receive proper
antenatal care.
2) High risk pregnancies should be identified and managed
appropriately.
3) Timely referral of the high risk cases to tertiary care centres is the
key in preventing poor outcome both in mother and the baby.
4) Periodic follow up of cases born with the risk factors mentioned
(antenatal, natal and postnatal) for early identification and therapy of
cerebral palsy.
5) A detailed study on children with CP in a large population based
birth cohort is indicated which includes most of the children with CP
who had experienced classical birth asphyxia, and such a study
may make it possible to identify a combination of risk factors rather
than single factor operating alone.
6) Children with CP are more likely to have associated conditions like
speech and language disorders, mental retardations, eye and
hearing impairment screening for these conditions should be done
during initial assessment of CP.

24. LIMITATIONS
 The study included only patients coming to our
institution and does not include large
community.
 Limited study period.
 Only included sample size of 100 cases which
makes difficult to accurately derive the true
association between the clinical spectrum and
risk factors of cerebral palsy.

25. CONCLUSION
1) Out of the 100 cases of cerebral palsy studied male
patients were the majority (61%), with male to female
ratio was 1.54:1.
2) Most of the patients were less than 2years of age at the
time of presentation (47%).
3) Majority of the patients hailed from rural area (63%).
4) Consanguinity was observed in 52%.
5) Institutional deliveries were 79% and 21% were home
deliveries.
6) Most patients (61%) with cerebral palsy were first born
as found in this study.
7) 78% of the cases were malnourished.
8) Majority of the cases had microcephaly (62%).

26. 1) Spastic cerebral palsy was the commonest clinical type of cerebral
palsy accounting for 81% of the cases.
2) Quadriplegia and diplegia were the commonest topographical
types of spastic cerebral palsy accounting for 69.14% and 22.22%
of the cases respectively.
3) Delayed milestones in 86% cases and convulsions in 32% cases
were the commonest presenting complaints.
4) Speech delay seen in 62% of cases, subnormal intelligence seen
in 58% cases and convulsions seen in 34% of cases were the
commonest associated manifestations.
5) Natal risk factors were the commonest seen in 62% of the cases,
antenatal and postnatal risk factors were 21% and 36%
respectively.
6) Birth asphyxia seen in 44% cases, low birth weight seen in 33%
cases prematurity seen in 19% of cases and neonatal convulsions
seen in 23% cases were the commonest risk factors observed in
this study.

27. SUMMARY
1) Male patients formed the majority.
2) Most patients were below 2years of age at the time of
presentation.
3) Majority of the patients had microcephaly.
4) Delayed milestones and convulsions were the commonest
presenting complaints.
5) Spastic type of cerebral palsy was the commonest clinical type.
6) Quadriplegia was the commonest topographical type of spastic
cerebral palsy.
7) Natal risk factors were the most commonly found risk factors in
cases of cerebral palsy. Birth asphyxia, low birth weight, preterm
and neonatal convulsions were the commonest risk factors
observed in this study.
8) Speech delay, subnormal intelligence and convulsions were the
commonest associated manifestations in cases of cerebral palsy.

28. REFERENCES
1) Michael V. J. Cerebral palsy. In:Kliegman, Stanton, Geme.S.T, Schor,
Behrman (eds.) Nelson textbook of paediatrics. 19th ed. India: Reed
Elsevier; 2012. p2061-65.
2) Chitra Sankar, Nandini Mundkur, Cerebral palsy-definition, classification,
etiology and early diagnosis. Indian journal of Paediatrics 2005; 72(10):
865-868.
3) Vinod K paul, Aravind bagga, Cerebral palsy, Ghai Essential Pediatrics, 8th
ed. India: CBS Publishers; 2013. p581-83.
4) Dabydeen Lyvia. Cerebral palsy: A neonatal perspective. Annals of Indian
Academy of Neurology. 2007; 10 (5):33-43
5) Pharoah POD, Platt MJ, Cooke T, “The changing epidemiology of cerebral
palsy”, Arch Dis Child 1996; 75: 169-173.

29. 1) Pratibha D Singhi, Munni Ray, Gunmala Suri. Clinical spectrum of
cerebral palsy in North India- an analysis of 1000 cases. Tropical
journal of Pediatrics 2002 ;( 48):162-166.
2) Pratibha D Singhi, Munni Ray, Gunmala Suri. Clinical spectrum of
cerebral palsy in North India- an analysis of 1000 cases. Tropical
journal of Pediatrics 2002 ;( 48):162-166.
3) Vykuntaraju KN, Cerebral palsy and early stimulation, 1 ed. India:
Jayapee; 2014
1) Areeb S.B, Muhammad.Z.H, Rabia I, Nosheen Z. Risk factors and
types of cerebral palsy. Journal of Pakistan Medical Association.2014;
64(1): 103-07
2) Nafi OA (2011); Clinical Spectrum of Cerebral Palsy in South Jordan;
Analysis of 122 Cases. Pediatr Therapeut 2011; 1: 101
3) Srivastava VK, Laisram N, Srivastava RK. Cerebral palsy, Indian
Pediatrics 1992; 29(8): 993-6