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Causes and Risk Factors of Cerebral Palsy

Cerebral palsy (CP) is caused by abnormal development of the brain or damage to the developing brain that affects a child’s ability to control his or her muscles. There are several possible causes of the abnormal development or damage. People used to think that CP was mainly caused by lack of oxygen during the birth process. Now, scientists think that this causes only a small number of CP cases.

The abnormal development of the brain or damage that leads to CP can happen before birth, during birth, within a month after birth, or during the first years of a child’s life, while the brain is still developing.

Congenital CP

CP related to abnormal development of the brain or damage that happened before or during birth is called congenital CP. The majority of CP (85%–90%) is congenital. In many cases, the specific cause is not known.

Risk Factors for Congenital CP

Some things increase the chance that a child will have CP. These are called risk factors. It is important to remember that having a risk factor does not mean that a child will have CP. Some of the risk factors for congenital CP are:

• Low birthweight―Children who weigh less than 5 1/2 pounds (2,500 grams) at birth, and especially those who weigh less than 3 pounds, 5 ounces (1,500 grams) have a greater chance of having CP. Read articleexternal icon
• Premature birth―Children who were born before the 37th week of pregnancy, especially if they were born before the 32nd week of pregnancy, have a greater chance of having CP. Intensive care for premature infants has improved a lot over the past several decades. Babies born very early are more likely to live now, but many have medical problems that can put them at risk for CP. Read articleexternal icon
• Multiple births―Twins, triplets, and other multiple births have a higher risk for CP, especially if a baby’s twin or triplet dies before birth or shortly after birth. Some, but not all of this increased risk is due to the fact that children born from multiple pregnancies often are born early or with low birthweight, or both. Read summaryexternal icon
• Assisted reproductive technology (ART) infertility treatments―Children born from pregnancies resulting from the use of some infertility treatments have a greater chance of having CP. Most of the increased risk is explained by preterm delivery or multiple births, or both; both preterm delivery and multiple births are increased among children conceived with ART infertility treatments. Read articleexternal icon, Read summaryexternal icon
• Infections during pregnancy―Infections can lead to increases in certain proteins called cytokines that circulate in the brain and blood of the baby during pregnancy. Cytokines cause inflammation, which can lead to brain damage in the baby. Fever in the mother during pregnancy or delivery also can cause this problem. Some types of infection that have been linked with CP include viruses such as chickenpox, rubella (german measles), and cytomegalovirus (CMV), and bacterial infections such as infections of the placenta or fetal membranes, or maternal pelvic infections. Read summaryexternal icon, Read articleexternal icon
• Jaundice and kernicterus― Jaundice is the yellow color seen in the skin of many newborns. Jaundice happens when a chemical called bilirubin builds up in the baby’s blood. When too much bilirubin builds up in a new baby’s body, the skin and whites of the eyes might look yellow. This yellow coloring is called jaundice. When severe jaundice goes untreated for too long, it can cause a condition called kernicterus. This can cause CP and other conditions. Sometimes, kernicterus results from ABO or Rh blood type difference between the mother and baby. This causes the red blood cells in the baby to break down too fast, resulting in severe jaundice.
• Medical conditions of the mother―Mothers with thyroid problems, intellectual disability, or seizures have a slightly higher risk of having a child with CP. Read summaryexternal icon
• Birth complications―Detachment of the placenta, uterine rupture, or problems with the umbilical cord during birth can disrupt oxygen supply to the baby and result in CP. Read summaryexternal icon

Preventing CP

In many cases, the cause or causes of congenital CP aren’t fully known, which means that currently little can be done to prevent it. CP related to genetics is not preventable. However, there are actions people can take before and during pregnancy, as well as after birth that might help reduce the risk of developmental problems, including CP.

Taking steps to help ensure a healthy pregnancy can help prevent developmental problems, including CP. Acquired CP often is related to an infection or injury, and some of these cases can be prevented.

Before Pregnancy

• Be as healthy as possible before pregnancy. Make sure that any infections in the mother are treated and health conditions are in control, ideally before pregnancy occurs.
• Get vaccinated for certain diseases (such as chickenpox and rubella) that could harm a developing baby. It is important to have many of these vaccinations before becoming pregnant.
• If assistive reproductive technology (ART) infertility treatments are used to get pregnant, consider ways to reduce the chance of a multiple pregnancy (twins, triplets, or more), such as transferring only one embryo at a time.

During Pregnancy

• Learn how to have a healthy pregnancy.
• Get early and regular prenatal care, both for your health and for that of your developing baby.
• Wash your hands often with soap and water to help reduce the risk of infections that might harm your developing baby.
• Contact your health care provider if you get sick, have a fever, or have other signs of infection during pregnancy.
• A flu shot is your best protection against serious illness from the flu. A flu shot can protect pregnant women and their unborn babies, both before and after birth. Flu shots have not been shown to cause harm to pregnant women or their babies.
• If there is a difference in the blood type or Rh incompatibility between mother and baby it can cause Jaundice and kernicterus. Women should know their blood type and talk to their doctor about ways to prevent problems. Doctors can treat the mother with Rh immune globulin (“Rhogam”) when she is 28 weeks pregnant and again shortly after giving birth to prevent kernicterus from occurring.
• Talk to your doctor about ways to prevent problems if you are at risk for preterm delivery. Research has shown that taking magnesium sulfate before anticipated early preterm birth reduces the risk of CP among surviving infants. ^(1,2,3,4)

After the Baby is Born

• Learn how to help keep your baby healthy and safe after birth.
• Any baby can get jaundice. Severe jaundice that is not treated can cause brain damage, called kernicterus. Kernicterus is a cause of CP that potentially can be prevented. Your baby should be checked for jaundice in the hospital and again within 48 hours after leaving the hospital. Ask your doctor or nurse about a jaundice bilirubin test. In addition, steps can be taken to prevent kernicterus that is caused by Rh blood type incompatibility between the mother and baby.
• Make sure your child is vaccinated against infections that can cause meningitis and encephalitis, including Haemophilus influenzae type B (HiB vaccine) and Streptococcus pneumoniae (pneumococcal vaccine).
• Take steps to prevent injuries:
  • Buckle your child in the car using an infant or child car seat, booster seat, or seat belt (according to the child’s height, weight, and age).
  • Make living areas safer for children by using window guards to keep young children from falling out of open windows and using safety gates at the top and bottom of stairs.
  • Make sure the surface on your child’s playground is made of a shock-absorbing material, such as hardwood mulch or sand.
  • Carefully watch young children at all times around bathtubs, swimming or wading pools, and natural bodies of water. Adults watching kids near water should avoid distracting activities like using a computer or handheld device, reading, or talking on the phone.
  • Make sure your child wears a helmet for activities like riding a bike.
  • Never hit, throw, shake, or hurt a child.

For More Information

• American Academy of Pediatrics Healthy Children / Cerebral Palsyexternal icon
• National Institute of Neurological Disorders and Stroke (NINDS) Cerebral Palsy Informationexternal icon

References

1. Doyle LW, Crowther CA, Middleton P, Marret S. Antenatal magnesium sulfate and neurologic outcome in preterm infants: a systematic review. Obstet Gynecol. 2009 Jun;113(6):1327-33.
2. Magnesium sulfate before anticipated preterm birth for neuroprotection. Committee Opinion No. 455. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;115:669–71.
3. Crowther CA, Middleton PF, Voysey M, et al (2017). Assessing the neuroprotective benefits for babies of antenatal magnesium sulphate: An individual participant meta-analysis. PLoS Med, 14(10):e1002398.
4. Magnesium sulfate use in obstetrics. Committee Opinion No. 652. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127(1):e52-3.

Infantile cerebral palsy in the "fetters" of intrauterine infection.

In the last ten years, there has been an increase in the frequency of congenital infections, predominantly of viral etiology. High infant mortality, as well as childhood disability as a result of infectious pathology, are a serious demographic problem. Infection of the fetus and the infectious process can begin in the prenatal period, during childbirth, or postnatally. These are the so-called perinatal or intrauterine infections (IUI). The most common IUIs are referred to as the TORCH syndrome. nine0004

The abbreviation TORCH is used to refer to a range of diseases, including toxoplasmosis (Toxoplasmosis), syphilis (Other), rubella (Rubella), cytomegalovirus infection (Cytomegalovirus) and herpes infection (Herpes simplex virus).

In many countries this abbreviation has been changed to STARCH to include human immunodeficiency virus (AIDS) infection. The danger of TORCH syndrome and other viral infections lies in the fact that they cause 80% of congenital malformations in children. Among them, the leading place is occupied by damage to the central nervous system, congenital heart and kidney defects. It has been established that infection of the fetus in the first trimester of pregnancy leads to the development of micro-, hydrocephalus, heart defects, gastrointestinal tract, genitourinary system, skeleton, cataracts, and deafness. nine0004

Infection in the II and III trimesters causes hepatosplenomegaly, anemia, jaundice, malnutrition, pneumonia, meningocephalitis, and sepsis in the fetus.

In the Medical Center C0RTEX in 2008-2013 and the first half of 2014, 1009 children were examined and treated with cerebral palsy, mental retardation, with delays in the psychoverbal and motor areas of unspecified genesis. The age of the children ranged from 9 months to 20 years. All children underwent: CEEG, EP, MRI, (PET performed according to indications) of the brain, ultrasound of internal organs, clinical blood and urine tests according to generally accepted methods, testing for TORCH-complex infection by polymerase chain reaction and enzyme immunoassay with the determination of immunoglobulins G and M. nine0004

All children had pre- and perinatal anamnesis: the threat of abortion was noted in 69% of mothers, and in half of them in the 1st and 2nd semesters, severe toxicosis -41%, immunoconflict -23%, chronic intrauterine hypoxia fetus - 73%, 31% of mothers had an exacerbation of genital herpes, 15% of mothers were treated for infertility, more than 30% of mothers had acute respiratory viral infections and 5% of toxoplasmosis during pregnancy. Signs of placental insufficiency were observed in 65% of mothers, and exacerbation of chronic ureoplasmosis, chlamydia, mycoplasmosis was observed in 40% of mothers. nine0004

Most often, in the examined patients (more than 45%), chronically persistent cytomegalovirus and herpetic infection with symptoms of sluggish leukoencephalitis were verified, in -21% - neuroinfection caused by listeriosis, ureaplasmosis, chlamydia. In 18% of cases, children suffered intrauterine toxoplasmosis, candidiasis, mycoplasmosis, complicated by urosepsis, pneumonia with pulmonary edema, gastric and intestinal bleeding, as well as meningitis and meningoencephalitis. Post-vaccination lesions of the brain were detected in 6% of patients. 5% were diagnosed with acute meningoencephalitis and 3% with acute radiculoanglioneuritis caused by the association of herpetic viruses (HSV, Varicella-Zoster, Epstein-Barr). nine0004

A third of children were diagnosed with intrauterine pneumonia, malnutrition, 40% with neonatal jaundice, hepato-splenomegaly, thymomegaly and subclinical thyroid dysfunction, heart and connective tissue defects were found in 10% of patients, 6% had malformations of the genitourinary system, 30 % pathology of the organs of vision (glaucoma, microphthalmia, coloboma, atrophy of the optic nerves), etc. .

According to neuroimaging data, 56% of the examined patients were found to have subcortical cysts and cysts in the parechima of the brain, 42% — subatrophy of the cerebral cortex, ventriculomegaly — 46%, foci of gliosis and periventricular leukomaalacia — 52%, thinning of the corpus callosum — 27%, congenital anomalies of the brain -11%, intraventricular hemorrhage 65% and occlusion of the CSF tract - 2%. nine0004

In the majority of children with IUI, the formation of a gross neurological defect was observed - up to 77% of the total number of patients, in the form of: tetraparesis, paraparesis, hemiparesis, spastic diplegia, hemiplegia, statomotor and sensitive ataxia. Intellectual and behavioral disorders were observed in 45%, episyndrome - in 55%. With a "lighter" outcome of IUI, in 33% of cases, MMD syndrome (minimal brain dysfunctions) was detected in the form of hyperactivity with attention deficit. These violations were distinguished by the persistence of manifestations and resistance to drug treatment, as well as in 15% turning into "wrong behavior". So IUI have the highest percentage in the etiology of cerebral palsy, mental retardation and epilepsy in children . Therefore, it is very important to carry out diagnostics to identify IUI in pregnant women and newborns.

But what is really happening?

At birth, in maternity hospitals, 70% of children take blood for TORCH syndrome. Then the children are discharged home without results, but with a diagnosis: either IUI or a consequence of IUI if the child is severe. The results of studies on TORCH syndrome are made within 5 to 14 days, plus the time for delivery to the children's clinic at the place of birth of the child. In addition, being the “gold standard”, the virological method is not available to most medical institutions, since cultivation using cell cultures is a labor-intensive, expensive process that requires highly qualified personnel. The reliability and sensitivity of the method depends on: the time elapsed from the moment of material sampling to sowing; quality of material sampling and transportation conditions; the quality of the media and reagents used. nine0004

Unfortunately, not all medical institutions comply with these rules and requirements, which affects the accuracy of the results.

So, the results are delivered and attached to the card, but only 10% are evaluated by pediatricians or pediatric neurologists! The situation regarding “childhood” in the country is as follows: if there are no acute clinical manifestations of IUI, then they simply forget about it. And in the case of an IUI diagnosis made in the maternity hospital, most often it is not taken into account, with the further appearance of epileptic seizures and other neurological symptoms in the child, another diagnosis is already made (cerebral palsy, epilepsy, mental retardation, etc.) nine0004

Another variant of . If the child initially had a serious condition at birth, and then he develops poorly and malformations of other organs are detected, then a diagnosis is made; a consequence of the transferred IUI, and the children are offered to be taken to a special boarding school, as unpromising.

As with the first and second options, the "standard" treatment of children with vascular, antiepileptic, nootropic, etc. drugs is ineffective! nine0013