Disability and Rehabilitation, February 2006; 28(4): 183 – 191

REVIEW

The epidemiology of cerebral palsy: Incidence, impairments

and risk factors

ELSE ODDING, MARIJ E. ROEBROECK, & HENDRIK J. STAM

Department of Rehabilitation Medicine, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
Disabil Rehabil Downloaded from informahealthcare.com by Serials Unit - Library on 08/16/13

Accepted April 2005.

Abstract
Purpose. Describing the epidemiology of cerebral palsy (CP), its impairments and risk factors.
Method. Literature review 1965 – 2004. Search terms: Cerebral palsy, incidence, prevalence, impairments, risk factors.
Results. In the last 40 years the prevalence of CP has risen to well above 2.0 per 1000 life births. In this time span the
proportion of low-birthweight infants rose, the proportion of diplegia decreased, while the proportion of hemiplegia
increased. CP is more prevalent in more deprived socio-economic populations. The majority of people with CP have the
spastic syndrome of which the diplegic group is the smallest. Dependent on the subgroup of CP, 25 – 80% have
For personal use only.

additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type
of CP and especially increases when epilepsy is present. Epilepsy is present in 20 – 40%; it is most common among the
hemi- and tetraplegics. Sensibility of the hands is impaired in about half. Chronic pain is reported by more than a
quarter of the adults. Up to 80% have at least some impairment of speech. Low visual acuity is reported in almost
three-quarters of all children. Half of all children have gastrointestinal and feeding problems. Stunted growth occurs in a
quarter, while under- or overweight problems are present in half of the children. Almost 70% of people with spastic CP
have abnormal brain CT findings; abnormal cranial ultrasounds is most strongly associated with hemiplegia, normal
cranial ultrasounds with diplegia. The most important risk factors for CP are low birthweight, intrauterine infections and
multiple gestation.

Keywords: Cerebral palsy, epidemiology, incidence, impairment, risk factors

introducing or reviewing measurement instruments,

Introduction
In The Netherlands as well as in many other western
countries children diagnosed with cerebral palsy
(CP) are referred for rehabilitation care. They are
the largest diagnostic group treated in pediatric
rehabilitation. Research on the subject of CP is,
however, predominantly published in journals other
than the 49 rehabilitation journals listed in PubMed.
In PubMed and Medline the search term CP was
found in 8566 articles, of which only 309 were in
rehabilitation journals. Of those 309 articles, 93 were
published before 1980, 66 between 1980 and 1990,
leaving 150 articles of more recent date. The
topics in the rehabilitation journals predominantly
are: (new) treatment policies, motion analysis,
and describing specific impairments.
Combining the search term cerebral palsy with
the terms epidemiology, and incidence and pre-
valence, respectively, revealed 757 manuscripts
published between 1990 and 2002. Of these, the
vast majority is published in pediatric (411),
obstetric (76), and neurological (70) journals. Only
13 manuscripts with the terms incidence and/or
prevalence were published in rehabilitation journals.
Of the 75 review articles about the epidemiology of
CP, published between 1990 and 2004, none were
published in the rehabilitation journals. It must be
concluded that an important aspect of the scientific
knowledge about CP is missing in the rehabilitation
literature.

Correspondence: M.E. Roebroeck, Department of Rehabilitation Medicine, Erasmus MC – University Medical Centre Rotterdam, P.O. Box 2040, 3000 CA
Rotterdam, The Netherlands. Tel: 31 10 463 4769. Fax: 31 10 463 3843. E-mail: m.roebroeck@erasmusmc.ul
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2006 Taylor & Francis
DOI: 10.1080/09638280500158422
 184 E. Odding et al.
The Department of Rehabilitation Medicine of the
Erasmus Medical Centre Rotterdam investigates, in
co-operation with the rehabilitation centers in the
southwest region of The Netherlands, the long-term
consequences of childhood disability. In order to
design proper studies, two issues have to be resolved,
the first being: which outcome measures and
potential determinants should be assessed. Or, to
put it differently, what is known about the epide-
miology of CP? The second issue involves the way in
which those outcome measures and determinants
should be assessed, or: do we have valid and reliable
measurement instruments?
This paper presents the results of a literature review
on the epidemiology of CP, and its impairments and
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risk factors. The second issue – about measurement
instruments – will be addressed in another paper.
Methods
The literature search was performed on the Medline
database for the period 1966 – 2002, complemented
with PubMed for the period 1965 – 2004. Search
terms were: cerebral palsy, epidemiology, preva-
lence, incidence, impairment, assessment, adoles-
For personal use only.
cents, hemiplegic, diplegic, tetraplegic, spasticity,
cognitive, behavior, speech, dysarthria, risk factors.
Prevalence and incidence
In 1998, fourteen centers in eight European countries
started a network called Surveillance of Cerebral
Palsy in Europe (SCPE). After reaching consensus
about the criteria to classify CP, they presented the
prevalence rates in six countries, and more detailed
prevalence estimates of 13 areas [1,2]. In Table I a
summary of the prevalence estimates of CP of the
SCPE, as well as from some other northwestern
Europe countries, is given. As can be concluded from
this table the prevalence and the trends in time of CP
are comparable in these countries. The prevalence of
CP rises in time from well below 2.0 per 1000 life
births in the 1970s to well above 2.0 in the 1990s [3 –
9]. Boys form a small majority (58%) [5].
It seems fair to assume that these European data
are not very different from findings in other parts of
the world. For example the prevalence of CP in
China is reported to be 1.6 per 1000 children under
age 7 [10]. In Mississippi (USA) 2.12 per 1000
inhabitants were diagnosed with CP with a higher
prevalence for males, and a, non-significant, higher
prevalence in black people [11]. The prevalence of
CP in Australia is 2.0 to 2.5 per 1000 live births [12].
The prevalence of CP among low-birthweight
children is higher than among normal birthweight
children [3 – 5,10]. From 1964 to 1993 the incidence
rose in low-birthweight children from 29.8 to 74.2 per
1000 neonatal survivors weighing less than 1500 g,
and from 3.9 to 11.5 for those weighing 1500 – 2499 g
[10]. More detailed study of the period between 1983
and 1995 revealed an increase for those weighing less
than 1000 g to 90 per 1000 in 1987 – 1989 and a
decrease to 57 in 1993 – 1995. Among infants weigh-
ing 1000 – 1500 g the rate rose to 77 in 1987 – 1989
and then fell to 40 in 1993 – 1995 [13,14]. The
proportion of low-birthweight infants among all
children with CP is rising: 32% of all cases in 1966
and 50% in 1989 [15]. Newborns weighing less than
2500 g now contribute half of all cases of CP and just
over half of the most severe cases, whereas in the 1960s
they contributed one-third of all cases, and only one-
sixth of the most severe [9].
There is a clear social class gradient in the
prevalence of CP as a whole, and in the subgroups
hemiplegia and diplegia. Among normal birthweight
cases there is a strong association with social class [16].
In the United Kingdom the prevalence of CP at birth is
3.33 per 1000 births in the most deprived quintile, and
2.08 in the most affluent quintile of the Carstairs area
deprivation index. This socio-economic gradient was
similar at age five [17]. There is also an association
between birthweight and socio-economic status.
Within the normal birthweight category the preva-
lence of CP is 2.42 per 1000 in the most deprived
quintile, and 1.29 in the most affluent quintile. A
greater proportion of CP births in the more deprived
quintiles is of low or very low birthweight.
The excess of summer births among children born
with CP might be explained by the effect of infectious
agents, many of which vary seasonally [18].
Impairments
Table II gives a summary of the data about the most
common impairments associated with CP. In the
first column crude prevalences are given. The second
presents the prevalence of impairments in various
subgroups. In the last columns the prevalence of the
various impairments within the diagnostic subgroups
of CP is given, in so far as they could be traced from
the literature. It must be noted that, because data are
derived from several publications, the totals of the
subgroups do not necessarily add up to 100.
Motor impairments
Motor impairment is obligatory for the diagnosis CP.
Table II shows the distribution of these motor
impairments. In summary: the majority is consti-
tuted of the spastic syndromes, of which the diplegic
group is the smallest [19 – 21]. With the rising
incidence of CP in time, the distribution over the
subtypes changed: fewer cases with diplegia and
more with hemiplegia [15]. The motor impairments
 The epidemiology of cerebral palsy 185

Table I. Prevalence of cerebral palsy in Northwest Europe.

Birthweight specific
per 1000 lifebirths
Prevalence
Birthyear per 1000 lifebirths 51000 1000 – 1499 1500 – 2499 42500

Northeast England 1964 – 1968 1.68 59.7 6.55 1.19

1969 – 1973 1.39 22.9 6.40 0.96
1974 – 1978 1.71 27.6 8.90 1.20
1979 – 1983 2.00 76.6 8.22 1.26
1984 – 1988 2.27 75.9 9.65 1.31
1989 – 1993 2.45 80.0 11.80 1.26
Scotland, England 1984 – 1989 2.10 78.1 65.7 10.20 1.10
Northern Ireland 1981 – 1993 2.24
Norway 1977 – 1981 1.91 88.9
1982 – 1986 1.98 28.8
1987 – 1991 2.05
Denmark 1979 – 1986 2.80
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1987 – 1990 2.40

Sweden 1979 – 1982 2.17
1990 – 1993 2.20
1991 – 1994 2.12
The Netherlands 1977 – 1979 0.77
1980 – 1982 1.00
1983 – 1985 1.84
1986 – 1988 2.44

of CP, in especially the spastic types, lead to other impairment [1,29]. The prevalence varies with the
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impairments of the musculoskeletal system; for
example, among tetraplegic children and adoles-
cents, 75% have hip luxations, 73% contractures,
and 72% scoliosis [22].
Children and adolescents with CP have a lower
physical fitness compared with their able-bodied peers
[23]. They also have subnormal values for peak
anaerobic power and muscular endurance of the
upper and lower limbs. They score between 2 and 4
standard deviations below the expected mean value for
power. Gait abnormalities increase submaximal walk-
ing energy expenditure almost 3-fold compared with
healthy children [24]. Diplegic children have a higher
fat percentage and are hypoactive compared with
healthy children [25]. Wheelchair-dependent adoles-
cents with CP are hypoactive, which is not the case for
ambulatory adolescents with CP [26]. Physical, but
not mental, fatigue is more common in adults with CP,
than in the general population. The strongest pre-
dictors for fatigue are bodily pain, deterioration of
functional skills, limitations in emotional and physical
role function and life satisfaction [27].
In people with hemiplegic CP the prevalence of
additional impairments is 42% [28]. Common addi-
tional impairments are cognitive impairments,
epilepsy, sensory, endocrine and urogenital impair-
ments.
Cognitive impairments
As can be seen in Table II, a large proportion of
people with CP have some kind of cognitive
type of CP and especially increases when epilepsy is
present. In severely disabled CP children, 97.7% are
profoundly mentally impaired [30]. But, since 1976
the prevalence of severe mental retardation has
decreased significantly [31].
About 40% of children with hemiplegic CP have
normal cognitive abilities, while children and ado-
lescents with tetraplegic CP are generally severely
intellectually impaired. [22,32]. There is no associa-
tion between IQ level and memory scores and
location of brain damage (left or right) [33]. Non-
verbal learning impairments, characterized by good
language abilities and week visual-spatial abilities
with fear of new situations and stepwise develop-
ment, are common [34].
Behavior problems are five times more likely in
children with CP (25.5%) compared with children
with no known health problem. The odds ratio for
behavior problems of children with CP without
mental retardation is 4.9. The attention deficit
hyperactivity disorder (ADHD) is more common
among children with CP [35]. Other specific behavior
problems in children with CP are dependency, being
headstrong, and hyperactivity in general [36].
Epilepsy
As can be seen in Table II, a large minority of
people with CP has epilepsy, and the prevalence
varies with the type of motor impairment [37]. It is
most common among the hemi- and tetraplegics.
Children with tetraplegic CP tend to have an earlier
 186 E. Odding et al.

Table II. Prevalence of impairments among people with cerebral palsy.

Impairment % Subgroups % CP-subgroups %

Motor 100 Spasticity 72 – 91 Hemiplegic 21 – 40

Diplegic 13 – 25
Tetraplegic 20 – 43
Other 9 – 28 Dyskinetic 12 – 14
Ataxic 4 – 13
Cognitive (*) 23 – 44 Hemiplegic 60
With epilepsy 59 – 77
Without epilepsy 18 – 50
Severe (IQ 5 50) 30 – 41 Tetraplegic 100
Sensibility 44 – 51 Hemiplegic 90
Speach 42 – 81 Hemiplegic 30
Diplegic 20
Tetraplegic 85
Dyskinetic 95
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Severe 24
Visual (**) 62 – 71 Strabismus 50
Hemianopsy 15 – 25
Moderate 16
Severe 10 Tetraplegic 47
Hearing (#) 25 Moderate 1
Severe 2
Epilepsy 22 – 40 Hemiplegic 28 – 35
Diplegic 14
Tetraplegic 19 – 36
Dyskinetic 8 – 13
Ataxic 13 – 16
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Feeding Choking 56
Long feeding time 28
Nonorally 80
Gastrointestinal Constipation 59
Vomiting 22
Growth 23
Weight 52 Undernourished 30
Overweight 14
Obesity 8
Urinary 23.5 Hemiplegic 20
incontinence Diplegic 20
Tetraplegic 46

*Cognitive impairment: IQ570.

**Visual impairment: moderate = 6/18–6/60 D, severe = 56/60 D.
#
Hearing impairment: moderate = 45–70 dB loss, severe = 70 dB loss.

onset than children with other types of CP [38].
Epilepsy is present in 79.5% of severely disabled
children. [30]. Of the severely mentally disabled
tetraplegics, 94% have epilepsy [22]. All types of
epilepsy occur; but generalized and partial epilepsy
are the predominant types [39]. Children with
tetraplegic CP are more likely to have generalized
epilepsy, and more than half of them require two or
more anti-epileptic drugs. In hemiplegic children
the predominant type is localization related epilepsy
(83%) [38,40]. The frequency of seizures often
decreases after age 16.
Impairments in sensibility and senses
Stereognosis and two-point discrimination of the
hands is impaired in 44 – 51% of all children with CP
(astereognosia in 20%). Term children tend to be
more severely affected [41]. Sensory impairments are
most common among hemiplegic CP people. Nine
out of 10 hemiplegic children have significant bilateral
sensory deficits. Stereognosis and proprioception are
the chief modalities affected bilaterally. The extent of
sensory loss does not mirror the severity of the motor
deficit [42]. Chronic pain is reported by 28% of the
adults with CP, versus 15% of the adults in the general
population. Back pain is the most common in all types
of CP, with the lowest prevalence in persons with
hemiplegia. Foot and ankle pain is most prevalent in
persons with diplegia, pain in the knee in tetraplegia,
and neck and shoulder pain and headache in persons
with dyskinesia. Poor physical role functioning, low
life satisfaction and deterioration of functional skills
are associated with chronic pain [43].

Impairment of speech is common (Table II) and
strongly associated with the type and severity of the
motor impairment (dyskinetic the most, tetraplegic
more than diplegic) [44]. The most common
impairment is dysarthria but aphasia occurs also.
As a rule mentally retarded tetraplegic people do not
speak [22].
Ophthalmic abnormalities are present in 62% of
CP children [5,21,45]. Low visual acuity is reported
in 71% of children with CP. Because ophthalmolo-
gical examination cannot explain the low visual
acuity of the vast majority, there is a high probability
of cerebral visual disturbance [46]. Among mentally
disabled tetraplegic children, 47% have severe visual
impairments [22]. In prematurely born children (less
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than 32 weeks) with CP there are significantly more
cases with cicatricial retinopathy, cortical visual
impairment and concomitant strabismus. In preterm
children the prevalence of refractive error without
other ocular abnormalities is similar for children with
and without CP [47].
Impairments in hearing do occur but less often
than the other impairments; however, data are very
scarce [4,45].
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Endocrine impairments
As can be seen in Table II, in children with CP
gastrointestinal as well as feeding problems are
common [48]. Sucking and swallowing problems in
the first 12 months of life are common: 57 and 38%,
respectively. Eighty percent have been fed non-orally
on at least one occasion. In 60% of the children,
severe feeding problems even precede the diagnosis
of CP [49]. Significant silent aspiration is found in
68.2% of those with severe spastic CP [50,51].
Almost a third of all children with CP have suffered
at least one pulmonary infection in the previous 6
months [48]. There is an increased prevalence of
malocclusion in children with CP; they are likely to
have a significant increased overjet [52]. Children
with CP who have permanent dentition have more
dental caries than healthy children with the same age
and socioeconomic background [53].
Linear growth in diplegic and hemiplegic CP
children is often significantly reduced. More than
half of children with CP have problems with their
weight, either under- or overweight, and almost a
quarter have stunted growth [54].
Bone-mineral density (BMD) in children and
adolescents with spastic CP varies greatly, but
averages nearly one standard deviation below the
age-matched normal means. Osteopenia of the femur
is present in three-quarters of all children with
moderate to severe CP and in almost all who are
unable to stand. Decrease in BMD of the lumbar
spine is less pronounced. The severity of disability,
The epidemiology of cerebral palsy 187
difficulty feeding the child, use of anticonvulsants
and lower triceps skinfold scores are all indepen-
dently associated with low BMD [55,56].
Urogenital impairments
Almost a quarter of children and adolescents with CP
have primary urinary incontinence. Tetraplegia and
low intellectual capacity are the most important
determinants. At age six, 54% of the tetraplegic,
and 80% of the hemiplegic and diplegic children gain
urinary continence spontaneously [57]. Among CP
children referred with daytime urinary incontinence
at age 10 years, 85% have abnormal videourodynamic
patterns. Treatment leads to improvement in all [58].
Radiological features
Sixty-eight percent of children with tetraplegic CP are
microcephalic [22]. Almost 70% of children with
spastic CP have abnormal brain CT findings; this
group has a greater possibility of having develop-
mental delay [59]. MRI brain abnormalities can be
classified into four groups: i.e. group 1: brain
malformations; group 2: cortical-subcortical lesions;
group 3: abnormalities of the periventricular white
matter; and group 4: postnatal brain-injuries. In
groups 1 and 2 the severity of hemiplegia is mainly
moderate, while it is mild in groups 3 and 4. The third
group presents a large involvement of the lower limb,
while the upper limb is more affected in the other
groups. Mental retardation occurs in one-third of
children in groups 1 and 4, less often in the other two.
Seizures occur in half of the children in groups 1 or 2,
while the incidence was lower in the other two [60].
In very low-birthweight children (500 – 1499 g)
periventricular leukomalacia, and secondly, intraven-
tricular hemorrhage are predictive of cerebral palsy
and of functional outcome [61 – 63]. Among all CP
categories, abnormal cranial ultrasound is most
strongly associated with hemiplegia, normal cranial
ultrasounds with diplegia [64].
In children with bilateral spastic CP hypoperfusion
in the thalamus or cerebellar hemispheres is found.
Mildly decreased perfusion is associated with mild
delays in gross motor development, while almost all
children with severe hypoperfusion show severe
developmental delay [65].
Risk factors
It has been long known that there is an association
with birthweight [66]. Table I gives some prevalence
data. The prevalence of CP among low-birthweight
children is higher than among normal birthweight
children [3 – 5]. Children of 32 – 42 weeks gestation
with a birthweight for gestational age below the 10th
 188 E. Odding et al.
percentile are 4 – 6 times more likely to have CP then
are children between the 25th and 75th percentile. In
children with a weight above the 97th percentile, the
increased risk is smaller (2–3), but still significant
[67].
Studies on possible risk factors for CP are
abundant. Most studies trying to investigate causes
of CP conclude that there are many pathways, many
of which cannot be identified yet. Each contributes
only a small proportion and many may be multi-
factorial. Risk factors can be categorized as
prenatally, perinatally and postnatally acquired.
Among congenital hemiplegics, 42% are classified
as prenatal, 16% as perinatal, 9% as combined pre-
and perinatal, and 34% as untraceable [28]. Of
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children with tetraplegic CP some 50 – 55% are
prenatally, around 30% perinatally and about 15 –
20% postnatally derived [21]. In preterm children,
12% have a prenatal etiology, 61% a peri/postnatal,
and 27% cannot be classified. In term children these
figures are 51, 36 and 14%, respectively [68].
Among the prenatal risk factors, intrauterine
infection (chorioamnionitis) is the best known. In
full-term infants the relative risk of intrauterine
infections for CP is 4.7 (95% CI 1.3 – 16.2) and in
For personal use only.
preterm infants 1.9 (1.4 – 2.5) [69 – 71]. It is the most
important prenatal factor in the pathogenesis of CP in
very low-birthweight infants. The relative risk of CP
increases approximately 4-fold in very low-birth-
weight infants with a neonatal history of sepsis [72].
Perinatal infection and other risk factors, such as
death of a co-twin, placental abruption, and cerebral
ischemia, are thought to trigger a cytokine cascade
resulting in damage to the developing brain [73].
Periventricular leukomalacia is one of the under-
lying disorders accounting for much of the CP
among children who were very preterm, and for
perhaps a fraction of CP in infants born at term [74].
The risk of periventricular leukomalacia is higher
with delivery at a very low gestational age, and
maternal or placental infection [75,76]. There is an
association between increased cytokine levels in
amniotic fluid or umbilical cord blood and risk of
preterm labor and periventricular leukomalacia
[77,78]. The cytokine interleukin-18 (IL-18) is
undetectable in the cord blood of normal full-term
infants, but is present in high levels in the cord blood
samples obtained from pre-term infants who neona-
tally developed periventricular leukomalacia followed
by CP [79].
Preeclampsia has been shown to be strongly
protective against CP in preterm infants [80,81].
The low frequency of intrauterine infections in
mothers with preeclampsia might explain the appar-
ent protective effect of this disorder.
Intrapartum initiation of the etiological pathway
is likely in only 9% of the cases [82]. Children with
obvious perinatally derived tetraplegic CP have a high
load of complications in the partum and postpartum
period [21]. Reported perinatal risk factors for CP are:
neonatal convulsions, birth asphyxia, instrument-
assisted delivery, neonatal jaundice, antepartum
hemorrhage, and neonatal infection [83]. The role
of asphyxia in the etiology of CP is somewhat
controversial. Some report that only a minority of
cases with asphyxia are associated with an increased
risk of CP, while others state that in almost one-third
of the term CP children birth asphyxia is the likely
cause [84]. Low Apgar scores at 5, 10 and 20 min are
strongly associated with CP [85 – 87]. In low-birth-
weight in nonvertex presentations only, active labor is
associated with CP [88]. The higher risk among term
breech presentation infants is more likely linked to a
higher rate of being small for gestational age in breech
infants than to the mode of delivery [89]. In children
with hemiplegic CP there is no association with
thrombophilia [90]. In very low-birthweight children
there is no association with multiple and complicated
pregnancy, caesarean section, severe asphyxia and
respiratory distress syndrome [91].
Multiple gestation is a risk factor for CP: the
prevalence of CP is 2.3 per 1000 in singletons, 12.6
in twins and 44.8 in triplets. Among infants weighing
2500 g or more, there is a significantly higher risk in
multiple than in singleton births; among those with
birthweight less than 2500 g there is no such
difference [92]. From 1971 to 1997, the incidence
of twin births increased with 53%, of triplets with
more than 400% and of quadruplets with more than
1100%. In the same period there was a vast increase
in the rate of CP per 1000 live births in triplets
compared with singletons (26.6 vs. 1.6) [93]. Apart
from the risk of CP by multiple gestation alone, the
live-birth co-twin of a fetus that died in utero is also at
an increased risk of CP. The CP prevalence is 95 per
1000 in same-sex life births and 29 per 1000 in
different-sex births [94]. In the surviving low-birth-
weight twin (1000 – 1999 g) whose co-twin has died
postnatally the prevalence of CP is much higher
in same sex twins (167 per 1000) than in those of
different sex (21 per 1000) [95].
Finally, term infants with encephalopathy with
other birth defects are three times more likely to have
CP than term infants with encephalopathy without
other birth defects [96].
Conclusion
Prevalence
The prevalence of CP has risen in time from about
1.5 per 1000 life births in the 1960s to about 2.5
in the 1990s. With the rising incidence of CP
there were fewer cases with diplegia and more with

hemiplegia. The proportion of low-birthweight
infants among all children with CP is rising.
Newborns weighing less than 2500 g now contribute
half of all cases of CP and just over half of the most
severe cases, whereas in the 1960 they contributed
one-third of all cases, and only one-sixth of the most
severe. There is a clear social class gradient in the
prevalence of CP.
Impairments
The majority of people with CP have the spastic
syndrome, of which the diplegic group is the
smallest. Dependent on the subgroup of CP, 25 –
80% of people with CP have additional impairments.
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A large proportion of people with CP have some kind
of cognitive impairment. The prevalence varies with
the type of CP and especially increases when epilepsy
is present. Twenty to 40% of people with CP have
epilepsy; it is most common among hemi- and
tetraplegics. Behavior problems are five times more
likely in children with CP.
Sensibility of the hands is impaired in about half of
people with CP. Chronic pain is reported by more
than a quarter of adults with CP. Up to 80% of
For personal use only.
people with CP have at least some impairment of
speech. Low visual acuity is reported in almost three-
quarters of all children.
Half of all children with CP have gastrointestinal
and feeding problems. Stunted growth occurs in a
quarter of children with CP, while under- or over-
weight problems are present in half of the children.
Primary urinary incontinence occurs in 23% of
children and adolescents with CP. Children and
adolescents with CP have lower physical fitness
compared with their able-bodied peers. Physical,
but not mental, fatigue is more common in adults
with CP.
Radiological features
Almost 70% of people with spastic CP have
abnormal brain CT findings. Among all CP cate-
gories, abnormal cranial ultrasound is most strongly
associated with hemiplegia, normal cranial ultra-
sound with diplegia.
Risk factors
The most important risk factors for CP are low-
birthweight, intrauterine infections and multiple
gestation. Children with a birthweight below the
10th percentile are 4 – 6 times more likely to have CP.
Intrauterine infections lead to a five times increased
risk of CP in full-term infants and a two times
increased risk in preterm infants. The prevalence of
CP in twins is five times and in triplets 19 times
The epidemiology of cerebral palsy 189
higher than in singletons. Given that low birthweight
and multiple gestation often coincide, and that
multiple births of more than two infants are
predominantly caused by in vitro fertilization pro-
cedures, we think that the Dutch policy to implant a
maximum of two embryos per procedure should be
promoted.
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