From the Journals

Cerebral palsy rate down in children born very or moderately preterm



A French study of very and moderately preterm infants showed a statistically important decrease in the rate of cerebral palsy – but the developmental delay risk was high, even in children who were born moderately preterm.

The researchers gathered data for cerebral palsy from the medical questionnaire, including information on head control, sitting, standing, walking, and quality of gait; trunk and limb tone; and any abnormal neurologic signs. Development was assessed using the second version of the 24-month Ages and Stages Questionnaire (ASQ), which is completed by parents.

Of 4,199 neonates born between 22 and 34 weeks’ gestation in 2011 enrolled in the EPIPAGE-2 study who lived until a median of 24.2 months corrected age, the rate of cerebral palsy dropped from 7% to 4% in those born between 24-26 and 27-31 weeks’ gestation, reported Véronique Pierrat, MD, PhD, of the Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, INSERM, in Paris, and her associates. At 32-34 weeks’ gestation, the cerebral palsy rate was 1%. Only one child born at 22-23 weeks’ gestation lived beyond the neonatal period. Fewer than 1% of the children overall had severe auditory or visual impairment.

A premature baby in an incubator Fuse/Thinkstock
“The rate of survivors with no or minor neuromotor or sensory disabilities increased from 94% at 24-26 weeks’ gestation to 97% at 27-31 weeks’ gestation and 99% at 32-34 weeks’ gestation,” Dr. Pierrat and her associates said (BMJ 2017;358:j3448).

ASQ analysis was considered for 2,506 children, after excluding children with cerebral palsy, deafness or blindness, or severe congenital brain malformations. ASQ scores were below threshold in 50%, 41%, and 36% of children born at 24-26, 27-31, and 32-34 weeks’ gestation, respectively. “The domains most frequently scoring below threshold were communication and personal-social in all gestational age groups. Proportions of children scoring below the threshold in either of these domains decreased with increasing gestational age but still were 18% and 13%, respectively, at 32-34 weeks’ gestation,” the investigators said.

Only 1% or fewer of the children in this cohort had severe gastrointestinal or respiratory disabilities.

In a comparison of 1997 data and this 2011 data after adjustment for baseline characteristics in children born at 22-31 weeks’ gestation, survival increased by a mean 6% , and survival without neuromotor or sensory impairment by 7%; in children born at 24-31 weeks’ gestation, cerebral palsy decreased by a mean 3%. No statistically significant changes were found between the two periods for survival, survival without neuromotor or sensory disabilities, and rates of cerebral palsy in children born at 24 weeks’ gestation, but “noticeable improvements were seen at 25-26 weeks and, to a lesser extent, at 27-31 weeks,” Dr. Pierrat and her associates said. At 32-34 weeks’ gestation, the cerebral palsy rate dropped by 3%, but survival and survival without severe neuromotor or sensory impairment were similar between the two time periods.

In regard to the 2011 data, “the proportion of infants at risk of developmental delay was high, even for those born at 32-34 weeks’ gestation. Our results invite questioning perinatal strategies in France, and in countries with similar recommendations. However, improving outcomes at extremely low gestational age requires a complex change in philosophy of care and close cooperation not only between obstetricians and neonatologists, but also developmental specialists, parent associations, and policy makers,” Dr. Pierrat and her associates concluded.

The investigators said they had no relevant financial disclosures. The study was funded by the French Institute of Public Health Research/Institute of Public Health and several of its partners, the PREMUP Foundation, Fondation de France, and Fondation pour la Recherche Médicale.

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