Abstract
BackgroundCerebral palsy (CP) has a multifactorial etiology, and placental vascular disease may be one major risk factor. The risk of placental vascular disease may be lower among some immigrant groups. We studied the association between immigrant status and the risk of CP.MethodsWe conducted a population-based retrospective cohort study of all singleton and twin livebirths in Ontario between 2002–2008, and who survived ≥28 days after birth. Each child was assessed for CP up to age 4 years, based on either a single inpatient or ≥2 outpatient pediatric diagnoses of CP. Relative to non-immigrants (n = 566,668), the risk of CP was assessed for all immigrants (n = 177,390), and further evaluated by World region of origin. Cox proportional hazard ratios (aHR) were adjusted for maternal age, income, diabetes mellitus, obesity, tobacco use, Caesarean delivery, year of delivery, physician visits, twin pregnancy, preterm delivery, as well as small- and large-for-gestational age birthweight.ResultsThere were 1346 cases of CP, with a lower rate among immigrants (1.45 per 1000) than non-immigrants (1.92 per 1000) (aHR 0.77, 95% confidence interval [CI] 0.67 to 0.88). Mothers from East Asia and the Pacific (aHR 0.54, 95% CI 0.39 to 0.77) and the Caribbean (aHR 0.58, 95% CI 0.37 to 0.93) were at a significantly lower risk of having a child with CP. Whether further adjusting for preeclampsia, gestational hypertension, placental abruption or placental infraction, or upon using a competing risk analysis that further accounted for stillbirth and neonatal death, these results did not change.ConclusionsImmigration and ethnicity appear to attenuate the risk of CP, and this effect is not fully explained by known risk factors.
Highlights
Cerebral palsy (CP) has a multifactorial etiology, and placental vascular disease may be one major risk factor
About 80% of cases are due to prenatal injury of the brain and only 10% are due to adverse events peripartum; most cases of CP occur in children with an apparently uncomplicated pregnancy [1,2,3]
We initially identified 805,215 newborns, of whom we further excluded 61,159 for the following reasons: invalid health card number (n = 2,015), duplicates (n = 642), nonOntario resident (n = 47,485), age,14 or .50 years (n = 129), triplet or higher order pregnancy (n = 1,449), stillbirth (n = 709), newborn gestational age,23 weeks at birth (n = 239), birthweight,500 grams (n = 100) or neonatal death,28 days (n = 2,719), or immigrant landing date or country of origin unknown (n = 5,672)
Summary
Cerebral palsy (CP) has a multifactorial etiology, and placental vascular disease may be one major risk factor. The most recognized risk factors for CP are both low and high weight-for-gestation age (seen as a Jcurve phenomenon) [4], as well as premature birth [5]; about half of all children who develop CP are born at term [5]. While the pathogenesis of CP may be elusive, placental vascular disease – a known cause of fetal growth restriction and prematurity [6,7,8] – appears to be a risk factor for CP and neurological impairment among low birthweight [9], term [10,11,12] and premature infants [13]. The ‘‘maternal placental syndromes’’– preeclampsia, gestational hypertension, placental abruption & placental infarction – are often attributed to placental vascular disease [14,15,16], and seen in conjunction with intrauterine fetal growth restriction and preterm birth [17]
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