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motor impairment are associated with comorbidities, which may have a greater effect on quality of life,
e moents int can ve most
weeks of gestation) have a different trajectory of motor develop-
lower proportion of fast-twitch bres), along with further alter-ations in brain maturation [3,5,6]. In addition, environmental
movements [2,8]. A meta-analysis of motor outcomes for childrentional age) or veryg) reported that,W children scoreddifference: 0.88;the psychomotor
during infancy (6eldren born VPT orers on two of thent, the Movement
95% CI: 0.69 to0.55) and the BruininkseOseretsky Test of MotorPerformance (BOTMP) (mean difference: 0.53; 95% CI: 0.60to 0.46) [1].
Research on long-term motor outcomes is limited by inconsis-tency in classication of motor impairments, selection of pop-ulations of infants (by birthweight and/or gestational age) and toolsused to determine impairment, making the ndings difcult toreadily synthesize [7,9,10]. Whereas it is evident that many children
* Corresponding author. Address: VIBeS, Murdoch Childrens Research Institute,Flemington Road, Parkville, Victoria 3052, Australia. Tel.: 61 3 8345 3778; fax: 613 93454836.
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Seminars in Fetal & Neonatal Medicine 19 (2014) 84e89E-mail address: [email protected] (A.J. Spittle).height, and head circumference) and smaller muscle size (with a Assessment Battery of Children (MABC) (mean difference: 0.62;ment compared with those children born at full term [3]. Earlyexposure to the extrauterine environment results in alteredmovement (e.g. gravity) and sensory (e.g. light and sound) expe-riences on the developing musculoskeletal and central nervoussystems [2,4]. Further, the birth of an infant in the late second orearly in the third trimester during periods of rapid brain develop-ment is thought to disrupt the genetically programmed pattern ofbrain genesis [5]. Postnatally, biological factors that may inuencemotor development include insufcient growth (reduced weight,
very preterm (VPT dened as
l &born preterm have variations in their motor developmentcompared with peers born at term, it is not always clear whetherthese variations result in long-term motor impairments [3,11]. It isessential to understand and distinguish the range of motor im-pairments experienced by children born preterm including mildmotor impairment and developmental coordination disorder (DCD)from CP, so that the most appropriate interventions can be imple-mented early and caregivers have an understanding of long-termmotor function [12].
2. Cerebral palsy
Cerebral palsy is primarily a motor disorder and is an um-brella term to describe a group of disorders of the developmentof movement and posture, causing activity limitations, which areattributed to non-progressive disturbances that occurred in thedeveloping fetal or infant brain [13]. The prevalence of CP in thegeneral population varies slightly between countries and is about0.1e0.2% of live births [10,14]. A recent review of CP registries inAustralia from 1970 to 2004 reported that the prevalence of CPincreased in the 1970s and 1980s due to the increasing survivalof extremely preterm (EP: dened as
l &Magnesium sulphate given to mothers when preterm labour isimminent has been shown to have a neuroprotective role and re-duces the risk of CP in their child [relative risk (RR): 0.68; 95% CI:0.54e0.87] and a reduction in the rate of substantial gross motordysfunction (0.61; 0.44e0.85) [47]. Caffeine for the treatment ofapnoea of prematurity has also been found to reduce the incidenceof CP (adjusted OR: 0.58; 95% CI: 0.39e0.87), and at 5 years relatedto improvement in GMFCS classication and MABC scores [48,49].These two neuroprotective interventions, along with the reducedusage of postnatal corticosteroids to treat bronchopulmonarydysplasia, may explain the diminishing rates of CP reported bysome studies in the 2000s [21].
7. Recommendations for follow-up
The American Academy of Pediatrics has published recom-mendations for follow-up of VLBW infants, which include astructured age-appropriate neuromotor examination at leastonce during the rst 6 months of life, followed by an examina-tion once during the second 6 months, at the ages of 1e2, 2e3,3e4 and 4e5 years [50]. Some of the motor impairments expe-rienced in children born preterm are apparent very early indevelopment, although follow-up throughout childhood isnecessary to accurately diagnose DCD and the milder forms of CP.Prediction of CP in the early months is now more reliable withthe use of assessment tools such as the general movements(GMs) and MRI which have high sensitivity and specicity[12,44,51]. Both abnormal GMs and MRI ndings have beenassociated with milder motor impairments, but the association isnot as strong as that with CP [52,53]. Whereas neither of thesetools should be used for diagnosis of CP in the newborn period,care-givers can be counselled about risk factors, the importanceof ongoing assessment and the infant enrolled in early inter-vention [12,33].
The age at which the diagnosis of CP is made is variable, withmisdiagnosis common prior to the age of 18 months [51]. At 2years the GMFCS can provide accurate prognostic information onfuture independent function for children with CP [12]. The diag-nosis of DCD is best made from the age of 5 years for a number ofreasons according to the European Academy for ChildhoodDisability (EACD) consensus for denition and diagnosis of DCDincluding the catch-up that younger children make in the earlyyears and the reliability of assessment tools for both motor anddaily living skills [24]. The EACD recommend using a score 15thpercentile on the MABC (or equivalent assessment) to classifychildren as DCD, whereas previous guidelines published in 2006recommended using a score
l &Conict of interest
None declared.
Funding sources
None.
References
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Research directions
Consistent classification of motor impairment is neededin the reporting of long-term outcomes of children bornpreterm.
Further understanding of the causal pathways and pre-dicting those children most at risk of motor impairmentare needed to inform interventions.
Practice points
Motor impairment is common in children born pretermand can range in severity from mild to severe, includingDCD and CP.
MRI and GMs assessments in the newborn period arepredictive of later motor impairment, including DCD andCP.
DCD is highly prevalent in children born preterm andtherefore follow-up needs to continue to at least 5 years ofage.
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A.J. Spittle, J. Orton / Seminars in Fetal & Neonatal Medicine 19 (2014) 84e89 89
Cerebral palsy and developmental coordination disorder in children born preterm1 Introduction2 Cerebral palsy3 Motor impairments in children without CP4 Comorbidities associated with motor impairment5 Neural mechanisms6 Perinatal risk factors7 Recommendations for follow-up8 Interventions to improve motor outcomes9 Future directions10 ConclusionsConflict of interestFunding sourcesReferences
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