Raktima Chakrabarti, PDham, SP Goel
Departments of Pediatrics, LLRM Medical College, Meerut, UP, India,

Address for Correspondence: Dr. Raktima Chakrabarti, Departments of Pediatrics, LLRM Medical College, Meerut, UP- 250004, India. Email: dr_raktima@yahoo.com

There has been an explosive growth in the developmental neurosciences in recent years. As an increasing number of extremely preterm, seriously ill infants are surviving with better medical care; the burden of neurologically disabled children is increasing. Since the knowledge about various complex interactions during pregnancy, labor and neonatal period can prevent the development of neurological abnormalities it is of utmost importance to find out these factors to decrease this burden.

The present study was carried out in the neonatal unit of the Department of Pediatrics at SVBP Hospital attached to LLRM Medical College, Meerut on 240 term neonates admitted for at least 3 days after delivery. Only term infants (gestational age = 37 weeks) were included in the study. Hospital stay of at least 3 days after delivery was required for inclusion criteria, Infants with gross congenital anomaly were excluded at the outset.

Detailed information about mothers personal history, obstetric history of all three trimesters, labor, and neonatal factors were collected and recorded on a pre structured Performa.

The maternal data included, information about maternal age, weight, height, educational status, socioeconomic status, parity, past adverse pregnancy outcome, antenatal course in present pregnancy, with special emphasis on anemia, pregnancy induced hypertension, ante partum hemorrhage, gestational diabetes mellitus and premature rupture of membrane. Detailed information was also collected about the intra partum course, presence of fetal distress and mode of delivery.

Among neonatal factors emphasis was given on birth weight, Apgar score at 1 and 5 minute, gestational age, hyperbilirubinemia, hypoglycemia, anemia, thrombocytopenia, respiratory distress and septicemia.

A detailed neurological examination, based on the method described by Prachtl was done on all neonates in the behavioral state 3 - eyes open, some isolated spontaneous movements, no crying in addition to routine examination. The neurological examination was done only after 48 hours of delivery, as the behavioral state and many responses are not stable until after the first two days of life. Neonatal neurological examination included behavioral state, muscle tone, posture, movement, deep tendon reflexes, neonatal reflexes, presence of abnormal twitching, convulsions and tremors. These newborns were also examined in prone position, ventral suspension, upright position, pulled- to-sit position depending on general condition. Cry of the infants, anterior fontanel, size of the pupil, reaction to light, doll's eye phenomena, habituation to auditory and visual stimulus were also observed. Abnormal examination findings were supported by hematological, biochemical and radiological investigations and were followed up for at least one month for further neurological evaluation.

Obtained data were compiled and statistically analyzed by Chi Square test.

Results: The overall incidence of neonatal neurological abnormalities in the present study was 16.67% (40/240). It was found that maternal education has statistically significant correlation with the neonatal neurological abnormality (p< 0.05). (Table 1).

Educational status	Number with CNS abnormality (n=40) (%)	Number Without CNS abnormality (n=200) (%)	P Value
Illiterate	19 (47.5)	59 (29.5)	< 0.05
Up to 5th class	6 (15)	23 (11.5)
More than 5 th but less than high school	7 (17.5)	26 (13)
26 (13)	7 (17.5)	58 (29)
Intermediate	1 (2.5)	21 (10.5)
Graduate	0 (0)	13 (6.5)

Among the maternal anthropometric factors: maternal weight, quetlet index (weight/height2) were found to be significantly correlated with neonatal neurological status (p< 0.05). Relationship with maternal age, height and parity was not statistically significant (Table 2).

Maternal	With CNS abnormality (Mean)	Without CNS abnormalities	P value
anthropometry		(Mean)
Age (years )	25.21	25.68	> 0.05
Weight (kg )	48.34	50.13	< 0.05
Height (cm)	152.58	153..19	> 0.05
Quetlet index	2.107	2.154	< 0.05
Parity	2.46	2.18	> 0.05

A significant correlation was also found between antenatal care and neonate's neurological status (p < 0.05). 52.5% mother with abnormal neonates had no antenatal check up, 12.5% had < 3 and 35% had 3 or more antenatal check up. Among normal neonates, 53% mothers had 3 or more number of check ups, 17% had <3 and 30 % had no check up.

The presence of pregnancy induced hypertension (PIH), ante partum hemorrhage (APH), premature rupture of membrane (PROM), gestational diabetes mellitus (GDM) had a highly significant correlation with neurological abnormalities (p<0.001) (Table 3).

Pregnancy complications	With CNS abnormalities	Without CNS abnormalities	P value
PIH	20%	7%	<0.001
PROM	32.5%	9.5%	<0.001
APH	15%	5%	<0.001
GDM	2.5%	1.5%	<0.001
Fetal distress
Heart rate irregularities	60%	24.5%	<0.001
Meconium stained liquor	45%	5.5%	<0.001

Out of 17 neonates delivered at home by trained birth attendants 10 (58.82%) had neurological morbidities. Neonatal factors associated with neurological abnormalities are depicted in Table 4.

Parameters	With CNS morbidities	Without CNS morbidities	P value
Gestational age Small for gestational age Appropriate for gestation Large for gestation	25% 72.5% 2.5%	18.5% 79% 2.5%	<0.05
Gender Male baby Female baby	70% 30%	51% 49%	<0.05
Apgar score At 1minute (mean ) At 5 minute (mean)	3.65 5.30	6.78 8.49	<0.001
Respiratory distress	70%	4.5%	<0.001
Early onset sepsis	30%	4.5%	<0.001
Metabolic problems	2.5%	1.5%	>0.05
Hematological problems	30%	6.5%	<0.001
Hyperbilirubinemia	7.5%	7.5%	>0.05
Acute renal failure	17.5%	0%	<0.001

Among the 40 neonates with neurological abnormalities, cranial ultrasonography was done in 34 cases within 7 days of birth. 22 (64.71%) neonates had no abnormality on USG, increased echogenicity was present in 5 (14.71%) cases, 5 (14.71%) had ventricular dilatation and intra ventricular hemorrhage was present in 2 (5.88%) cases. Of these 40 neonates with neurological abnormalities, 7 expired, 11 left untreated and 22 improved. On follow up among these 22 patients, 12 (54.55%) were normal, 4 (18.18%) had suspected neurological abnormalities, 6 (27.27%) were abnormal. On the other hand, 59 normal neonates were followed up and none of them had neurological abnormalities.

This hospital based study revealed that neonatal neurological abnormality is significantly influenced by various maternal and neonatal factors. The adverse maternal factors observed here were illiteracy and low maternal weight. A strong association was found between the number of antenatal visits and neonatal neurological abnormality. This points towards the need to improve the availability of proper antenatal care so that high risk cases would be identified and proper management could be done in time.

The presence of one or more of the pregnancy complications was found to be significantly associated with neonatal neurological abnormality. Of these complications pregnancy induced hypertension and premature rupture of membrane had more significant correlation. We found a highly significant correlation between fetal distress, in the form of fetal heart rate irregularity and meconium stained amniotic fluid and neurological abnormality. Poor Apgar score at 1 and 5 minute also had impact on the same. Small for gestational age neonates were found to be at greater risk for neurological abnormality in the present study. A positive correlation also found between male gender and neurological abnormality. In the present study, we found a significant correlation between neonatal neurological abnormality and neonatal problems like respiratory distress, early onset sepsis, anemia, thrombocytopenia, acute renal failure. Respiratory problems may be attributed to meconium aspiration, sepsis, asphyxia and may overlap other predictors of neurological abnormality. Sepsis may cause hypoxemia, acidosis and can mimic many features of neonatal encephalopathy or may be a cause for it. Acute renal failure may be attributed to the neonatal encephalopathy.

Thus, the present study has shown a better prediction of neurological morbidity among neonates who are clinically at risk. Many of the risk factors are preventable and universal availability of proper antenatal and perinatal services would go a long way in reducing the neurological morbidity.

We acknowledge Department of Pediatrics & Neonatology along with Department of Gynecology & Obstetrics for valuable support and also the cooperation of the study subjects.

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Last Updated: 1st October 2008 Volume 5 Issue 10 Art # 42

Advance Access: 1st November 2007

Chakrabarti R, Dham P, Goel SP. A Study of Neurological Abnormalities of Term Neonates and its Relationship to Adverse Obstetric and Neonatal Factors. Pediatric Oncall [serial online] 2008 [cited 2008 October 1]. Art # 42. Available from: