Study of Generalized Movements for Early Prediction of Cerebral Palsy

Cerebral palsy (CP) is considered a clinical syndrome caused by a preceding brain injury
early in brain development that results in static neurological deficits. These deficits
usually involve the somatomotor system manifesting as hemi-, di- or quadriplegia. Cerebral
palsy can also manifest as hypertonicity and contractures, sensory deficits, hearing and
visual difficulties, feeding problems and global developmental delay and almost always
coincides with chronic lung disease. The most common causes of cerebral palsy are
hypoxic-ischemic brain injury, periventricular leukomalacia or intraventricular and/or
parenchymal hemorrhage that occurs in the first year of life. Hypoxic brain injury as a
result of poor oxygen delivery often occurs in the perinatal period but can also be caused
by pulmonary dysfunction. Thus, pulmonary diseases such as bronchopulmonary dysplasia,
pneumonia, meconium aspiration syndrome, congenital diaphragmatic hernia and respiratory
distress syndrome can lead to hypoxic brain injury and consequent CP. Less common etiologies
are genetic disorders, infections and intrapartum injuries. Current treatments of CP are
targeted to maintaining function, relieving contractures, improving nutrition and providing
developmental supportive care, but to date there is no cure or preventive guideline.
Moreover, supportive measures and family counseling is delayed since CP can be diagnosed
only at the age of 18-24 months. As a result, interventions that may aid in limiting CP
effects are delayed due to the lack of a predictive diagnostic assessment during the first
six months of life. Head ultrasound, EEG and functional MRI have been tested for their
predictive value before the actual diagnosis of cerebral palsy. The low sensitivity of these
studies shows that they are not useful as screening tools. Heinz Prechtl, an Austrian
neurologist, developed a clinical assessment method to study the spontaneous movements of
preterm and term infants. Monitoring of cramped synchronized generalized movements and
fidgety movements has resulted in 100% sensitivity and 95% specificity in predicting
cerebral palsy in many studies. A meta-analysis of predictive tools for cerebral palsy
identified Prechtl's method as superior to head ultrasound or MRI. These studies have not
been repeated in the USA. Our aim is to assess the predictive value of Prechtl's method in
Hawaii, in preterm and term infants with and without lung disease, who are at risk for
development of cerebral palsy. We will compare the incidence of pulmonary diseases and
cerebral palsy and observe any relationship between the development of lung disease and
brain injury. We will identify at risk infants and observe their generalized movements
according to Prechtl's assessment. We will conduct a 2-year longitudinal follow up of our
patients and interpret the predictive value of our assessment based on the diagnosis of
cerebral palsy. We will compare the sensitivity and positive predictive value of head
ultrasound and the assessment of generalized movements. It is hoped that this assessment
will allow us to start supportive measures at an earlier stage of life, thus improving the
outcome of children with cerebral palsy.

Inclusion Criteria:

- Term newborns with pulmonary diseases (meconium aspiration, congenital diaphragmatic
hernia, bronchopulmonary dysplasia, pneumonia, lobar emphysema and respiratory
distress syndrome)

- Preterm infants less than 30 weeks of gestational age or less than 1500g weight

- Preterm or term infants with intrauterine growth retardation

- Infants with the diagnosis of IVH larger than grade II

- Infants diagnosed with periventricular leukomalacia

- Any preterm and term infant who experienced hypoxic-ischemic injury, defined as
having a 5 minute Apgar score less than 4 or requiring resuscitation >10 minutes.

Exclusion Criteria:

- Congenital anomalies

- Congenital heart disease

- Any genetic anomalies