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A prospective cohort study of auditory and visual comorbidities in children with cerebral palsy

1 Department of Pediatrics, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of Pediatrics, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Neonatology, Manipal Hospitals, Bengaluru, India

Date of Submission09-Apr-2022
Date of Decision15-May-2022
Date of Acceptance11-Jun-2022
Date of Web Publication02-Dec-2022

Correspondence Address:
Manas Ranjan Mishra,
Department of Pediatrics, INHS Kalyani, Gandhigram Post, Visakhapatnam - 530 005, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_58_22


Introduction: Cerebral palsy (CP) is a group of disorders involving movement, posture, and motor function with the uniqueness of being an outcome of a static insult and ever-changing clinical course. Early identification and rehabilitation of associated morbidities are the keys to comprehensive management. Materials and Methods: This was a prospective observational study conducted in a tertiary care teaching hospital in western India, from January 2016 to June 2017, to determine the prevalence of ocular and hearing morbidity in children with CP. All children presenting with developmental delay and diagnosed as a case of CP were serially recruited in the study. Data were collected by using a predesigned pro forma. Results: The study included 80 children with CP. Male-to-female sex ratio of 2.08:1 was observed. The prevalence of visual morbidity was 67.5%, with the most common morbidity being squint followed by refractive error and nystagmus. Auditory morbidity was present in 22.5% of cases with the predominant type being sensorineural hearing loss. Conclusions: This study emphasizes the importance of prompt identification of auditory and visual morbidities in these children, as early intervention is the key to management and is vital for optimal speech, vision, developmental, and neurocognitive outcomes in these cases.

Keywords: Auditory, cerebral palsy, hearing, morbidity, visual

How to cite this URL:
Mishra MR, Adhikari K M, Panigrahi NK. A prospective cohort study of auditory and visual comorbidities in children with cerebral palsy. J Mar Med Soc [Epub ahead of print] [cited 2023 Feb 6]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=362605

  Introduction Top

Cerebral palsy (CP) describes a heterogeneous group of nonprogressive disorders of posture or movement, causing activity limitation, due to an insult to the developing fetal or neonatal brain. These disorders are frequently accompanied by disorders of sensation, perception, cognition, communication, behavior disorders, epilepsy, and secondary musculoskeletal problems.[1],[2] In addition, anxiety and stress of caregivers are important concerns and a part of comprehensive care for the treating team. Minimizing the caregiver burden by early and timely interventions can lead to improved physical and mental health outcomes for both the child and the parents.[3]

The difficulty in identifying and making a specific diagnosis of CP is challenging, and therefore, a lot of variations are seen in the reported prevalence, viz., 2.4 per 1000 in Sweden and Malta, 2.5 per 1000 in Finland, and 1.6 per 1000 in China.[4],[5],[6],[7] A systematic review of the prevalence of CP in Indian children reported an overall pooled prevalence of 2.95 (95% confidence interval [CI] 2.03–3.88) per 1000 children.[8]

Timely identification of visual and hearing morbidity provides an early window of opportunity to capitalize on neuronal plasticity by the initiation of remedial measures. There are not enough data on the prevalence of these comorbidities in western India. The aim of this study was to ascertain the prevalence of ocular and hearing morbidity among children in western Maharashtra and their goal-directed rehabilitation along with the sensitization of parents in the early identification of symptoms.

  Materials and Methods Top

This prospective cross-sectional observational study was conducted in a tertiary care teaching hospital in western Maharashtra from January 2016 to June 2017. Due ethical clearance was obtained from the institutional ethical committee. All cases of CP from outpatient and inpatient were included in the study after obtaining parental consent. Children with noncentral causes of motor deficit, viz., metabolic, degenerative, genetic causes, hypotonic syndromes, peripheral motor neuron diseases, and progressive neurological disorders, were excluded. Detailed neurological examination was carried out on each child by the attending pediatrician, and the diagnosis of CP was confirmed by the pediatric neurologist. Data were recorded using a predesigned pro forma to obtain the clinical subtype, associated risk factors, hearing and ocular morbidities, and parental perception of symptoms.

Visual evaluation was done by a pediatric ophthalmologist for early detection of ocular morbidities. These included clinical refraction testing after 3 days of application of atropine ointment 1% using Manual Streak Retinoscopy and Kay Picture Chart for children below 5 years age and Snellen Chart and computerized testing using Grand Seiko GR-2100 Auto-Refractometer for children above 5 years after homatropine/tropicamide cycloplegia. Assessment for nystagmus, squint, and visual field was done by clinical examination, Hirschberg test, and confrontation method, respectively. Fundus examination was done through direct and indirect ophthalmoscopy.

Hearing evaluation was done based on the clinical assessment and suspicion of hearing morbidity on oto acoustic emissions (OAEs), participants were referred for brainstem evoked response audiometry (BERA), and further assessment was done by an otorhinolaryngologist.

Magnetic resonance imaging (MRI) of the brain was done in all cases as a part of detailed evaluation and for prognostication. Available MRI/computed tomography (CT) scans were also included in the analysis. Electroencephalogram was done in children with a history of seizures. Gross Motor Function Classification System (GMFCS) was used for the assessment of functional status of the children. GMFCS formed the basis for planning a broad management plan including the administration of medications and other therapeutic modalities.

Statistical methods

The entire data were entered and coded in MS Excel before statistical analysis. In the entire study, P < 0.05 was considered statistically significant. The intergroup statistical significance of difference of categorical variables was tested using Chi-square test or Fisher's exact probability test. Statistical Package for the Social Sciences (SPSS version 21.0, IBM Corporation, USA) for MS Windows was used for the analysis.

  Results Top

The study group comprised 80 cases. Fifty-four (67.5%) cases were male and 26 (32.5%) cases were female. Majority of children were in the age group of 2–5 years (n = 41, 51.3%) followed by 6–10 years (n = 24, 30%) and seven children were below 2 years [Table 1]. Among the clinical subtypes, spastic quadriplegic CP dominated (58.8%) followed by spastic diplegic CP (26.3%) [Table 2].
Table 1: Age and sex distribution of cases studied

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Table 2: Distribution of clinical type of cerebral palsy

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In this study, 54 (67.5%) children had visual abnormality, with the most common being squint (39 cases, 48.7%), followed by refractive error (31 cases, 38.7%) and nystagmus (8 cases, 10%). Abnormal fundoscopic findings were documented in 12.5% of cases, the most common being optic atrophy [Table 3]. Prolonged P100 latency on visual evoked potential was found in two cases.
Table 3: Distribution of prevalence of visual morbidity

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Among the children with refractive error, myopia was present in 45% (n = 14) of cases, hypermetropia in 54.8% (n = 17), and astigmatism in 64.5% (n = 20) [Figure 1]. Similarly, among the children with strabismus, esodeviation was present in 32.2% (n = 10), exodeviation present in 48% (n = 15), and alternating esodeviation and exodeviation present in 19.3% of cases (n = 6) [Figure 2]. Ten percent of patients had associated nystagmus; five patients had associated ptosis. Among the children with refractive errors, Abnormal fundoscopic findings were found in 12.5% (n=10) patients. Major fundoscopic anomaly being optic atrophy, which was present in 10% (n=8) patients. Other findings were temporal disc pallor (n=2), myopic fundus (n=4), and choroiditis (n=3). Spastic quadriparetic patients had greater incidence of visual abnormality compared to other clinical subtypes as shown in [Table 4].
Figure 1: Distribution of refractive error

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Figure 2: Distribution of strabismus

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Table 4: Distribution of prevalence of visual and auditory morbidity according to type of cerebral palsy

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Auditory morbidity was present in 18 children (22.5%). Seven (38.9%) had unilateral whereas 11 (61.1%) had bilateral hearing impairment. Five children had abnormal OAE at initial follow-up and all 18 had hearing deficits confirmed by BERA [Table 5]. Majority (14 cases, 17.5%) had sensorineural hearing loss (SNHL), while four children were under follow-up for repeated otitis media and had documented conductive hearing loss. One child had associated facial palsy and malformed ear, while others had preauricular tags. Spastic quadriparetic children had a greater incidence of auditory abnormality.

The distribution of prevalence of auditory as well as visual comorbidities did not differ significantly among preterm and term (P-value>0.05) [Table 6]. At the same time it was also noted that, with increasing sibling order, parents were able to pick up the abnormal developmental cues early in child's life. When the affected child was first born, the mean identification of symptoms was at 7.62 months, and for third-order baby, it was 6.5 months. The range of first identification of symptoms stretched from 3 months in children under neurodevelopmental follow-up for perinatal issues to 2 years in children who had less frequent medical attendance [Table 7] and [Table 8].
Table 5: Distribution of prevalence of auditory morbidity according to sex

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Table 6: Distribution of prevalence of visual and auditory morbidity according to gestational age

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Table 7: Distribution of mean age at which first parental perception of symptoms at various sibling orders in study group (n=80)

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Table 8: Parental perception of hearing and visual abnormalities in their children in study group

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Of the total 54 children who had visual morbidity, only 29 parents had perceived the visual subnormality, whereas 25 parents were not aware of the visual deficit in their children till it was pointed out after evaluation. Similarly, among the 18 children with auditory morbidity, only 11 parents had perceived morbidity on their own.

  Discussion Top

Various international studies and similar studies done in India have reported a varied incidence of auditory and visual comorbidities in children with CP ranging from 7% to 37% auditory morbidity and 9% to 54% visual morbidity.[9] This study was undertaken to evaluate the prevalence of the morbidities in western Indian population and follow-up the evaluation to analyze the gap in the intended services. The aim was to establish a registry after a thorough workup to enable further establishment of a dedicated early intervention center (EIC) for provision of holistic care to such children.

In this study, visual deficits were found in 67.5% of cases, with strabismus being the most common problem in 48.7% of cases. Similar results of occurrence of strabismus were found in a study done by Sabita Katoch et al.,[10] Pigassou-Albouy and Fleming,[11] and Kaur et al.,[12] with 39%, 50%, and 59.2% of cases, respectively. Estropia was more common than exotropia, with a ratio of 1.5:1.[13] The high incidence of strabismus in the CP population is probably related to lesions in the subcortical oculomotor centers or cerebellar lesions which disrupt binocular vision. Literature supports the medical treatment of strabismus in patients with CP. Strabismus surgery also results in comparable results among neurologically normal and children with CP.

Refractive errors were seen 36.7% of CP children with hypermetropia and myopia constituting 26.5% and 6.1%, respectively, by Kaur et al.[12] Hypermetropia predominated over myopia in most of the studies done as shown by Katoch et al. (20% vs. 13.5%) and Kaur et al.; this study's results also represented similar trends. However, a study done by Shrestha et al.[14] showed greater percentage of myopia cases with astigmatism (29% vs. 21%). Other causes of visual disability included optic atrophy, which was found in 10% of cases, a similar figure of 16.6% being reported by Katoch et al.[10] Neuroimaging in this group of children often showed periventricular leukomalacia (PVL). PVL affecting the visual radiation is thought to be the end result of hypoxic–ischemic insult to the developing brain. In more severe insults likely in premature babies where corticovisual impairment was present, it worsened the functional outcome in patients with CP. Other correctable causes of visual impairment such as cataract, ptosis, or coloboma, if diagnosed early, can result in definitive vision correction.

Hearing loss in CP is predominantly of sensorineural type, with a predisposition to be bilateral. The degree of motor and neurologic disability correlated well with the severity of hearing loss. In this study, 17.5% of SNHL and 5% of conductive hearing loss were found which was mostly among spastic quadriplegic children. Multiple Indian studies by Gowda et al.,[1] Sankar and Mundkur,[15] and Aggarwal et al.[16] have shown SNHL to be 11%, 12%, and 16.9%, respectively. It is of utmost importance to look for auditory morbidity in these children as early correction is vital for optimal speech and cognitive outcomes.

On assessing parental perception of symptoms, it was found that less than 50% of parents had perceived the visual or auditory morbidity of their children on their own, and it was only after a visit to doctor and a formal assessment that such deficit was identified. It is important to train parents during ambulatory pediatric and well-baby clinics to identify clues, suggestive of visual and hearing deficit.

Most visual morbidities such as refractive errors, amblyopia, strabismus, and auditory defects such as conductive hearing loss are easily treatable. This signifies the need for universal neonatal vision and hearing screening during earliest outpatient encounters, to pick up these deficits and start definitive therapy. Emphasis should be given for timely screening in high-risk infants who had a stormy neonatal course viz. severe hypoxic–ischemic insults, persistent or recurrent neonatal hypoglycaemia, severe neonatal jaundice and meningitis etc.

In this study, ten children with CP, after being diagnosed with refractive errors, were prescribed corrective glasses. Two children underwent surgery for squint. Among children with moderate-to-severe hearing loss, three children were provided hearing aids and two were listed for cochlear implant. About 50 children are undergoing physiotherapy and are being followed up on a regular basis. It is planned to keep all these children under regular follow-up by the establishment of dedicated EICs with holistic care in the form of physiotherapy, occupational therapy, speech therapy, and psycho-behavioral therapy under one roof and for planning subsequent specific interventions from time to time. Active efforts are being made to ensure smooth transition of care through the adolescent to adult stage to ensure maximum emphasis on functional outcome and societal integration to the best possible extent.

  Conclusions Top

Visual and auditory defects constitute some of the treatable comorbidities among the many problems faced by CP children. It is of utmost importance to diagnose and treat them early for a better neurocognitive outcome and holistic management in children with CP. Early intervention will help in the child's physical, social, academic, and visual development. As more numbers of children with CP are surviving to adulthood, these steps are most vital to ensure that some societal integration is possible for them as they step into productive years of adult age.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gowda VK, Kumar A, Shivappa SK, Srikanteswara PK, Shivananda, Mahadeviah MS, et al. Clinical profile, predisposing factors, and associated co-morbidities of children with cerebral palsy in South India. J Pediatr Neurosci 2015;10:108-13. doi: 10.4103/1817-1745.159191. PMID: 26167210; PMCID: PMC4489050.  Back to cited text no. 1
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Bhanuprakash CN, Reddy C. Spectrum of clinical profile, co-morbidities and parental burden of cerebral palsy children in a tertiary care centre. Int J Contemp Pediatr 2017;4:1364-8.  Back to cited text no. 3
Sciberras C, Spencer N. Cerebral palsy in Malta 1981 to 1990. Dev Med Child Neurol 1999;41:508-11.  Back to cited text no. 4
Riikonen R, Raumavirta S, Sinivuori E, Seppälä T. Changing pattern of cerebral palsy in the southwest region of Finland. Acta Paediatr Scand 1989;78:581-7.  Back to cited text no. 5
Liu JM, Li S, Lin Q, Li Z. Prevalence of cerebral palsy in China. Int J Epidemiol 1999;28:949-54.  Back to cited text no. 6
Hagberg B, Hagberg G, Olow I. The changing panorama of cerebral palsy in Sweden. VI. Prevalence and origin during the birth year period 1983-1986. Acta Paediatr 1993;82:387-93.  Back to cited text no. 7
Chauhan A, Singh M, Jaiswal N, Agarwal A, Sahu JK, Singh M. Prevalence of cerebral palsy in Indian children: A systematic review and meta-analysis. Indian J Pediatr 2019;86:1124-30.  Back to cited text no. 8
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Katoch S, Devi A, Kulkarni P. Ocular defects in cerebral palsy. Indian J Ophthalmol 2007;55:154-6.  Back to cited text no. 10
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Pigassou-Albouy R, Fleming A. Amblyopia and strabismus in patients with cerebral palsy. Ann Ophthalmol 1975;7:382-4, 386-7.  Back to cited text no. 11
Kaur G, Thomas S, Jindal M, Bhatti SM. Visual function and ocular status in children with disabilities in special schools of Northern India. J Clin Diagn Res 2016;10:C01-4.  Back to cited text no. 12
Collins ML. Strabismus in cerebral palsy: When and why to operate. Am Orthop J 2014;64:17-20.  Back to cited text no. 13
Shrestha S, Shrestha SM, Manoranjan A, Sharma R, Rajbhandari R. Ocular morbidity in children with cerebral palsy. PMJN 2012;12:16-9.  Back to cited text no. 14
Sankar C, Mundkur N. Cerebral palsy-definition, classification, etiology and early diagnosis. Indian J Pediatr 2005;72:865-8.  Back to cited text no. 15
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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