Acta Padiatr Scand 78:581-587, 1989

Changing Pattern of Cerebral Palsy in the Southwest Region of Finland

R. RIIKONEN, S. RAUMAVIRTA, E. SINIVUORI and T. SEPPALA

From the Department of Pediatrics, University Central Hospital of Turku, Turku, Finland

ABSTRACT. Wonen, R., Raumavirta, S., Sivuori, E and Seppiila, T. (Department of

Pediatrics, University Central Hospital of Turku, Turku, Finland). Changing pattern of
cerebral palsy in the southwest region of Finland. Acta Paediatr Scand 7 8 581, 1989.
The prevalence of cerebral palsy (CP) increased siflcantly from 1968-72 to 1 9 7 H 2 in the
region of the University Central Hospital of Turku, Finland, from 1.6/1OOO live births during
the Blrst five-year period to 2 3 1 OOO live births during the second. The increase was due to an
increase of CP in low birthweight children (P=O.OOOZ). The distribution of CP patterns did
not change significantly. During the second period the diagnosis was made earlier in all
groups (except that of spastic tetraplegia), though it reached statisticalsignificance only in the
hemi- and diplegic groups. W e the perinatal mortality rate declined greatly during this
period (especially in low birthweight groups), the increase in CP prevalence was due to
increased survival rather than to a real change in prevalence. As a net gain, the decline
resulted in increased absolute figure in non-CP children, in spite of the rising prevalence of
the disease. Kcy wrdr: cerebral palsy, epidemiology.

In Finland the pennatal mortality (PNM) is low. During the 15-year period 1%8-1982
including our study period PNM for the country as a whole has declined from 19.9 in 1968
to 7.4 in 1982; this figure is for a cutoff weight of 1 OOO g. In the University Central Hospital
of Turku (UCHT), the decline in PNM during this period was 61 %; from 17.9 in 1968 to 7.0
in 1982 (1). It has been suggested that this improvement may have taken place only at the
cost of an increase in the prevalence of cerebral palsy (CP) and other disabilities.
The purpose of this paper is to report changes in CP rates and pattern during this period.

MATERIALS
Our study included all children born in the UCHT area during two five-year periods, 1%8-72 and
1978-82, who had a subsequent diagnosis of CP. Half of all deliveries in the UCHT region took place
at UCHT and the other half at eight small hospitals with 200-900 deliveries annually. During 1978-82,
forty-nine out of seventy children with later CP (70%) were born at UCHT, compared to twenty out
of forty-two children (48%) in 1%8-72. Practically all cases with suspected CP in this region are
examined by a pediatrician or a child neurologist at this hospital and the study can be assumed to have
included all UCHT cases with this diagnosis during this period. The study population of the present
paper thus consists of a regional birth and CP cohort.
The categonsation of type of cerebral palsy was made on the basis of information in the clinical
records of each child. As the diagnosis of CP type often changed for the same child over the years, the
last diagnosis was chosen for classification. Children with a doubtful diagnosis were often also re-
examined by the first author (R. R.). When a child had a mixed CP syndrome, the classification was
based on the predominant CP type (e.g. mainly athetotic, mainly dystonic). All the children were
followed for at least 5 years.
The children were grouped in four categories according to the suggested pathogenetic factors;
prenatal, perinatal, postnatal and untraceable. Our criteria for the classification of pathogenesis were
the same as those of Hagberg et al. (1, 2), with minor modifications.
Prenatal group
- Clear prenatal CNS malformation
- Small for gestational age (S2 SD)
or head growth retardation
- Identical CP syndrome in sibling
- Obvious abnormalities during pregnancy I normal pen- and
postnatal history
582 R . Riikonen et al. Acta Paediatr Scand 78

Perinatal group
- Obvious complication during delivery andor first week of life
- Birthweight <2500 g. Appropriate for gestational age and normal pre- and postnatal history
Postnatal group
- Lkfmed causes (8 days to 3 years of age)
Untraceable group
- Birthweight >2500 g, appropriate for gestational age and normal pre-, pen- and postnatal history
(children with slight hyperbilirubinerniaor slight infections were also included in this group).

In 1%8-72 there were 1180 live births with birthweight <2500 g and in 1978-82 1110.
The number of preterm children (<37 completed gestational weeks) during the former
period is unknown.
The University Central Hospital of Turku is situated in the Southwest of Finland with a
population of 450000 (nearly 10% of the Finnish population). About half of all deliveries in
the region throughout the 15-year period (approx. 5500 deliveries a year or 9% of the
Finnish annual births) took place at UCHT. The UCHT acts as a referral center for
mothers and neonates in need of special care. The Department of Obstetrics of UCHT also
serves low-risk patients. Although the centralization of the care of high-risk mothers has
been recommended throughout the 15-year period (1968-82), the principle was not fully
accepted until the latter third of this period. The centralization of obstetric and neonatal
services for risk cases, the introduction of modem obstetric and neonatal management
(neonatal intensive care unit from 1980), and the continuing training of personnel at every
level of maternity and neonatal care have contributed to the decline in PNM (3). Total
infant mortality declined from 15.8 per 1OOO live births in 1968 to 5.0 in 1982. This decline
was accounted for by neonatal mortality, as postneonatal mortality remained at the same
level throughout the study period. The ‘postponement’ of deaths from the early to the late
neonatal category occurred in the low birthweight category, but in this category too total
infant mortality declined dramatically (60%) (4).
Statistical significances were calculated using test for proportions and Student’s t-test.

RESULTS
Prevalence. During the ten-year period there were a total of 112 children with a diagnosis
of CP. During the first five-year period, 1968-72,42 children were given a diagnosis of CP
(Group A), giving a prevalence of 42/26 118 live births or 1.6/1OOO live births. During the
second five-year period 1978-1982 there were 70 children with CP (Group B) per 27643
live births, giving an prevalence of 2 3 1 OOO live births. This is a significant increase in the
prevalence rate (p=0.009).
Type of cerebral palsy. The distribution of type of motor impairment did not change
significantly over the 10-year period (Table 1).
Pathogenetic classification. There were no major changes in the distribution of different
pathogenetic categories in the two groups (Table 2). Perinatal factors still dominated in
Group B, in spite of improved perinatal care. However, if the numbers in the prenatal and
untraceable groups (the latter probably including unknown prenatal mechanisms) were
combined the resulting group was of the same size, accounting for 43% of the CP cases
during the earlier and 48% during the later period. Perinatal events dominated in the
diplegic (28/43 children or 65%) and dystonic groups (9/15 children or 60%). In the
hemiplegic group on the other hand, perinatal damaging events were more seldom record-
ed, i.e. in 11/36 children, (30%). All the preterm infants had some perinatal risk factors,
even the infants with prenatal lesion.
Acta Paediatr Scand 78 Cerebral palsy in Finland 583

Gestational age and birthweight

In the second period, there was an increase of CP prevalence in low birthweight (<2 500 g)
children with CP (Table 3) (p=0.0002). This increase was due to the increase in the number
of diplegic low weight children (8 children in Group A and 21 children in Group B) and to
the increase of hemiplegic low weight children (none in Group A, 6 in Group B). However,
the change of distribution of the type of CP was significant neither in preterm nor in low
birthweight children. There were six very low weight children ( e l 2 5 0 g), all from Group B
and all with spastic diplegia. Hemiplegic childrerl.usually had a normal birthweight (83 %).
The birthweights of all children with CP are shown in Fig. 1. Only 10/112 children (9%)
were small for gestational age.
The increase in CP in the low birthweight group was from 1.0/100 (Group A) to 3. W100
(Group B) live births, or 3-fold. The increase in spastic diplegia was also 3-fold (from
0.67/100 live births to 1.89/100 live births).

Apgar scores
Asphyxia (Apgar scores <7 at one min) was found in 11/42 children (26%) in Group A and
in 22/70 children (31 %) in Group B; five preterm children in the former and 18 in the latter
group (NS).The increase was again due to the increased number of low weight children
with asphyxia and later diplegia (318 children, or 38%, in Group A and 13/21 children, or

Table 1. Children with CP in a region of Finland (UCHT) during two periods (children
born 1968-72= Group A , 1978-82= Group B )
Group A Group B

Whole Whole
group Preterm group Preterm

Spastic hemiplegia 16 2 20 6
Spastic diplegia 12 7 31 22
Spastic tetraplegia 3 1 2 1
Tetraplegic dystonia 6 2 9 5
Athetosis 2 - - -
Ataxia 3 1 8 2
Total 42 13 70 36

Table 2. Pathogenetic classification of cerebral palsy in the UCHT region, Finland, in

children born 1968-72 (Group A ) and 1978-82 (Group B)
Group A Group B

Whole Whole
group Preterm group Preterm

Prenatal 15 5 18 7
Perinatal 18 8 36 28
Postnatal 6 - 1 -
Untraceable 3 - 15 1
Total 42 13 70 36
584 R . Riikonen et al. Acta Paediatr Scand 78

Birth weight. g
r
10%

'5%

iO%
!5%
0%

Fig. 1. Birthweights and gestational ages of 112

children with CP. 0, born in 1%8-72 (42 chil-
dren); 0, born in 1978-82 (70 children).
26 28 30 32 3L 36 38 LO L2
Gestational age. weeks

62%, in Group B (NS),reflecting the more aggressive neonatal care of these children
during the latter period.
Associated impairments. There was no signifcant change in associated impairments in
Group B compared to Group A (Table 4).
A total of 42 children had visual disturbances; strabismus in 31, optic atrophy in 4,

Table 3. Gestational age and birth weight in children with CP

Group A Group B

Gestational age
<37 completed weeks 13 36
Birth weight < 2500 g"
Total CP group 126 356
Diplegic group 8' 2IC
Hemiplegic group - 6

In 1968-72 1 180 live births with birth weight <2 500 g, in 1978-82 1 110 live births with birth weight
<2 500 g.
p=0.0002.
= p=o.005.

Table 4. Associated impairments in children with CP

Group A Group B

Whole Whole
group &term group Preterm

Mental subnormality
(mild to severe),
IQ<70 14 3 18 8
Epilepsy IS 1 20 7
Visual impairment 13 3 29 16
Acta Paediatr Scand 78 Cerebral palsy in Finland 585

amaurosis in 1, severe myopia in 1, hyperopia in 2, homonymic hemianopia in 2 and

congenital nystagmus in 1. A severe hearing loss was found only in two children (one from
Group A and one from Group B). As audiometric examinations were not always made,
mild hearing disturbances may have been missed.
Age at early andfinal diagnosis of CP. Table 5 shows the age of the child when CP was
suspected (usually also at the beginning of physiotherapy) and when the final diagnosis
was made. Cerebral palsy was suspected and diagnosed earlier in the hemiplegic group
(P=O.Ol and 0.002, respectively), and diagnosed earlier in the diplegic group (p=O.O6) in
Group B than in Group A. In the severe types’ of CP; dystonic tetraplegia and spastic
tetraplegia, and in the small group ataxia the time of suspicion and of diagnosis did not
differ significantly.

DISCUSSION
It has been suggested that increases and decreases of CP numbers could be used as
indicators of the gains and hazards of perinatal care (2). However, the value of this has
also been questioned (5).
There are no modem figures concerning the prevalence of CP in Finland. The children
of earlier studies (6, 7, 8) were born between 1947 and 1966. In these studies the CP
prevalence varied from 2.0 to 5.6/1000 live births. The incidence of CP in some other
countries has been estimated at 2.0/1 OOO live births for 1975-78 in Sweden (9), 1.51/1OOO
for 1966-77 in England (lo), and 1.64/1 OOO for 1968-75 in another English study (11). The
most recent study from Sweden (9) shows a rise in the prevalence of CP since the 1960s

Table 5. Age at early andfinal diagnosis of CP

Group A Group B

Suspicion Suspicion
age, mean Diagnosis age, mean Diagnosis
Yr Yr Yr Yr

Spastic hemiplegia 2.25“ 3.81’ 0.64“ 1 .36’

Spastic diplegia 1.80 5.09’ 0.73 1.53‘
Spastic tetraplegia 0.22 1.35 0.78 1.33
Tetraplegic dystonia 0.78 3.16 0.32 1.90
Athetosis 1.37 1.44
Ataxia 0.03 3.9 1.37 2.20

p=O.Ol. p=0.002. ‘p=0.06.

Table 6. “Gains” in saved lives (decrease in infant mortality minus the increase in
prevalence of cerebral palsied childredl OOO live births) in low birthweight infants without
cerebral palsy (C2 500 g ) in 1968-72 and 1978-82 in UCHT region, Finland
1968-72 1978-82 Difference

Infant mortality 18.8 7.6 11.2

Cerebral palsy 1 .o 3.1 2.1
“Gains” in saved
lives without CP 9.1”

When converted into absolute figures = 101 non-CP children (from 1 110 live births).
586 R . Riikonen et al. Acta Paediatr Scand 78

among infants of all weights. In England an upward trend was also found in the overall CP
rate and in that for the normal birthweight group in one study (1 l), but no discernible trend
in overall prevalence although a highly significant upward trend in low birthweight infants
in another (10).
We found a significant rise in CP in the UCHT area in Finland. There is a surprising
similarity in the figures for the change of prevalence in Finland and in Sweden, in Sweden
from 1.4 in 1968 to 2.0 in 1978, and in Finland from 1.6 in 1968 to 2.5 in 1978. In Finland the
rise occurred in all birthweight groups, but was significant only in the low birthweight
group. Further analysis showed that the increase was mainly referrable to increase of
prevalence of spastic diplegia in this group (p=0.005). At the same time, total infant and
perinatal mortality declined greatly. The greatest decline was in the low birthweight group.
The rate of children with low birthweight (<2500 g) in the UCHT region was 4.5% in 1968
and 3.8% in 1981-82 (l), and cannot explain the decline in perinatal mortality. Postneona-
tal mortality remained at the same level throughout the study period.
The significant increase in CP from 1968-72 to 1978-82 may well reflect the improved
facilities for exact diagnosis. A potentially serious source of error, in our study as in
others, is the difficulty of ensuring coverage. A substantial number of children are not
diagnosed as having CP until they are aged 3 to 4 years or more (12), and some mild cases
(30%) may not come to the notice of conventional clinical surveys at all (13). However, all
the children in our study were more than 5 years old, and we cannot see any great change
in diagnostic facilities during the study period. Furthermore, migration from this region of
Finland, which might affect the figures, has remained low. We therefore conclude that the
increased CP prevalence reflects the increased survival of low birthweight infants, often
with perinatal problems. The net gain in the number of surviving non-CP children,
expressed as the decrease in infant mortality minus the increase in CP prevalence,
compared with the preceding period, was, when converted into absolute figures, 101
children out of 1 110 live births with birthweight <2500 g (Table 6).
In the early fifties some 75% of the CP cases were of perinatal origin (4, 14). Today the
corresponding figure for Sweden is 45% (14), that for the USA more than 50% (15) and
that found in the present study 51 %. Perinatal damaging events did not decrease during
the latter study period despite improved neonatal care, probably reflecting the increased
survival rate of low birthweight infants with perinatal problems. Nelson & Ellenberg 1986
(5) in their multivariant analysis of risks, found that only 9% lacked prenatal factors (major
congenital malformations and other intrinsic defects), indicating that a large proportion of
CP cases remain unexplained and casting doubt on the role of perinatal damage in the
pathogenesis of CP. However, the interplay between pre- and perinatal events may be
complex.
In spite of the increase in CP incidence, there were some positive findings in our study;
the earlier diagnosis and habilitation, mainly due to the education of medical personnel,
but also to greater knowledge on the part of the parents. Further, as a sign of successful
centralization of the care of risk mothers only 30% of the children during the latter study
period were “surprise” CP children (born in small hospitals, not at UCHT) compared to
52% during the earlier period. Finally, as a net gain, the decline in PNM resulted in an
increased absolute figure for non-CP children, in spite of the rising prevalence of the
disease.

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Submitted May 31, 1988. Accepted Nov. 11, 1988

(R. R.) Department of Pediatrics

University of Turku
SF-20520 Turku
Finland