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Cerebral palsy and socioeconomic status: a

retrospective cohort study
R Sundrum, S Logan, A Wallace and N Spencer

Arch. Dis. Child. 2005;90;15-18

doi:10.1136/adc.2002.018937

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15

ORIGINAL ARTICLE

Cerebral palsy and socioeconomic status: a retrospective

cohort study
R Sundrum, S Logan, A Wallace, N Spencer
...............................................................................................................................
Arch Dis Child 2005;90:15–18. doi: 10.1136/adc.2002.018937

Aims: To study the relation between risk of cerebral palsy and socioeconomic status.
Methods: A total of 293 children with a diagnosis of cerebral palsy out of 105 760 live births between
1 January 1982 and 31 December 1997 were identified from the special conditions sub-file of the West
See end of article for Sussex Computerised Child Health System.
authors’ affiliations Results: There was a linear association between risk of cerebral palsy and socioeconomic status (SES)
....................... measured by the Registrar General’s social class (RGSC) and enumeration district (ED) ranked into
Correspondence to: quintiles by the Townsend Deprivation Index derived from 1991 census data. Fifty one per cent and 30% of
Dr R Sundrum, Specialist cases of cerebral palsy were statistically ‘‘attributable’’ to inequality in SES using the RGSC and ED quintile
Children’s Services, respectively. A linear association was also noted for singleton live births. The association between risk of
Thelma Golding Centre,
92 Bath Road, Hounslow cerebral palsy and ED quintile persisted in a logistic regression model that included birth weight and
TW3 3EL, UK; gestational age, although that between RGSC and cerebral palsy no longer reached conventional levels of
ratna.Sundrum@ statistical significance after adjustment.
ealingpct.nhs.uk
Conclusions: A strong association was observed between socioeconomic status and the risk of cerebral
Accepted 3 February 2004 palsy, which was only partly accounted for by the known social gradients in birth weight and gestational
....................... age.

T
he negative impact of socioeconomic deprivation has 1 January 1982 and 31 December 1997. A Child Health
been shown for many aspects of child mortality and Record was routinely generated using information recorded
morbidity.1–3 The relation between socioeconomic status concurrently by midwives and in the birth registration. Birth
(SES) and the risk of cerebral palsy is not clear. An observed weight, gestation, plurality, Registrar General’s social class at
association between SES and cerebral palsy might suggest birth (based on father’s occupation), and current postcode
aetiological factors and pathways to prevention as well as were entered onto a study database. Current postcodes were
being important in the planning of services and the allocation converted to enumeration districts (100–150 households)
of resources. using the Office of National Statistics 1991 Enumeration
Low birth weight and prematurity are the strongest risk District/Postcode Directory9 and ranked in quintiles on the
factors for cerebral palsy.4 Given the observed association basis of Townsend Deprivation Indices (TDI) calculated using
between these factors and SES,5–7 an increased prevalence of 1991 Census data.10
cerebral palsy with low SES is expected. However, studies Children with cerebral palsy were identified from the
have produced conflicting results. Table 1 summarises the Special Conditions sub-file.11 Index children were those who
results of studies conducted in developed countries. In were recorded as having a diagnosis of cerebral palsy
developing countries, there is a higher proportion of children confirmed at 2 years of age or older or who had died under
with postnatally acquired cerebral palsy with a more clearly the age of 2 and who were recorded as having a prior
established socioeconomic gradient. diagnosis of cerebral palsy, irrespective of whether the
West Sussex has a population of 750 000 with roughly cerebral palsy was judged to have been acquired pre- or
8000 births per year. Compared with national figures, fewer postnatally. All children diagnosed as having cerebral palsy
belong to ethnic minority groups and there is a lower rate of had been seen by paediatricians in the Community Child
unemployment. However, there is a wide variation in SES Health Service who routinely recorded the type and severity
with areas of deprivation.8 of cerebral palsy. The Special Conditions sub-file is updated
In the present study, population based, routinely collected after each contact between the child and the family. The
data from West Sussex are used to: diagnosis of cerebral palsy and the recording of type
(classified as hemiplegia, diplegia, quadriplegia, and other)
N Examine the relation between the prevalence of cerebral
palsy and SES and between SES and the type and severity
and severity (mild, moderate, and severe, based on the degree
of functional impairment at last visit) was made on clinical
of cerebral palsy grounds and not on the basis of standardised criteria.
N Examine the degree to which any relation between SES
and the prevalence of cerebral palsy is mediated by Analysis
socioeconomic differences in birth weight and gestation.
The prevalence of cerebral palsy was calculated for all live
births, separately for singleton and multiple births and for
birth weight (,1500, 1500–2500, .2500 g) and gestational
METHODS age (,37, 37–40, .40 weeks) groups according to RGSC and
Case ascertainment and data collection
The study was undertaken using the computerised Child Abbreviations: ED, enumeration district; RGSC, Registrar General’s
Health System in West Sussex. The study sample comprised social class; SES, socioeconomic status; TDI, Townsend Deprivation
all live births to mothers resident in West Sussex between Indices

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16 Sundrum, Logan, Wallace, et al

Table 1 Cerebral palsy and socioeconomic status literature

Study Type Comparison SES measure Results

Dowding Retrospective population based CP v live births RGSC Increased risk among
Ireland study disadvantaged
13
1976–81
Stanley Retrospective population based CP v total population Father’s occupation Increased risk among
Australia study disadvantaged
14
1966–75
Nelson Prospective cohort study CP v non CP Score based on occupation No association
USA and income
15
1959–66
Emond Prospective study of 2 cohorts— CP v matched controls RGSC No association
UK nested case-control
16
1958 and 1970
Lagergren Retrospective population based CP v total Swedish Social group Highest prevalence in highest social
Sweden study population group
17
1969–70
Dolk Retrospective population based CP v births Electoral ward quintiles No association
N. Ireland study using TDI
1977–8918
Dolk Retrospective population based CP v births Electoral ward quintiles Increased risk in disadvantaged
UK study CP at age 5 v 1–7 year olds using Carstairs Index
1984–9019

ED quintile using SPSS for Windows.12 The prevalence of births greater than 2500 g to 12.7 in those with birth weight
each type and grade of severity was also recorded. A x2 test 1500–2500 g and 64.8 in those with birth weight less than
for linear trend was used to examine the association between 1500 g. Forty four per cent of children with cerebral palsy
prevalence of cerebral palsy and SES. Odds ratios were were reported to have hemiplegia, 17% quadriplegia, and 33%
determined for each RGSC and ED quintile using the least diplegia.
deprived social class and quintile as references. Separate Registrar General’s social class was recorded for 238
logistic regression analyses were performed among singleton (81.2%) children with cerebral palsy and 101 106 (95.9%)
births including birth weight, gestational age, and either without cerebral palsy. Table 2 shows the prevalence of
RGSC or ED quintile as independent variables. cerebral palsy in singleton births for each social class.
The proportion of cerebral palsy statistically ‘‘attributable’’ Compared with children in social class 1, the odds of having
to social inequality was estimated by comparing the overall a child with cerebral palsy in social class 5 is 2.57 (95% CI
population risk of cerebral palsy with the risk that would 1.27 to 5.21) and in the unclassified group is 2.77 (95% CI
have been found if the risk in the least disadvantaged groups 1.41 to 5.44). The increased odds ratios were observed not
(for both RGSC and ED quintile) applied to the whole only in the most deprived groups but in all groups when
population. compared with the least deprived group.
Only children of families resident in West Sussex at the Postcodes relating to EDs with census data were available
time of the child’s birth were included in the study. Of these for 280 (95.6%) children with cerebral palsy and 100 990
children, those born out of the county were a high risk group (95.8%) live births who did not develop cerebral palsy. Table 3
(25% low birth weight, 26% preterm, 7% multiple births) shows the prevalence of cerebral palsy in singleton births for
with a prevalence of cerebral palsy of 13 per 1000 live births. each ED quintile. The odds of having a child with cerebral
RGSC, taken from birth registration details, was not available palsy in the most deprived quintile is 1.65 (95% CI 1.14 to
for the majority of these children as their births were 2.39) compared with the odds in the least deprived quintile.
registered outside West Sussex and therefore these children A statistically significant linear association was observed
were omitted from the social class analyses. They were, between risk of cerebral palsy and SES for total live births
however, included in the ED quintile analysis. All children measured by RGSC (x2 for linear trend = 5.32, p = 0.021) and
born in West Sussex had RGSC recorded. An RGSC was ED quintile (x2 for linear trend = 5.41, p = 0.020). When only
recorded as unclassified for many of the most deprived singleton births were included the linear trend persisted for
families, including families with single mothers or un- both RGSC (x2 for linear trend = 5.92, p = 0.015) and ED
employed parents, and therefore this group was included in quintile (x2 for linear trend = 7.57, p = 0.006). In infants
the analysis. Children were excluded from further analysis born at term, those with birth weight greater than 2500 g,
using birth weight and gestation if this additional data was and those with quadriplegia, a statistically significant
missing. relation was seen for RGSC but not for ED quintile. A linear
gradient was observed for the prevalence of hemiplegia,
RESULTS diplegia, and ‘‘mild’’ cerebral palsy with ED quintile but
A total of 293 children were identified as having cerebral not RGSC. No gradient was noted in the low birth weight
palsy out of 105 760 live births in West Sussex between group.
1 January 1982 and 31 December 1997, an overall prevalence After adjustment for known risk factors of birth weight
of cerebral palsy of 2.77 per 1000 live births. Data on birth and gestation in the logistic regression analyses, the relation
weight were missing for 58 (0.05%) births and on gestation between the risk of cerebral palsy and RGSC no longer
for 148 (0.14%) births. Three per cent of live births were reached conventional levels of statistical significance
multiple births, 6.1% low birth weight (,2500 g), and 5.9% (p = 0.160). However, the association between the risk of
preterm. The prevalence of cerebral palsy in singleton births cerebral palsy and SES measured by ED quintile remained
was 2.5/1000 and 12.1/1000 in multiple births. The prevalence statistically significant (p = 0.046). The adjusted odds ratios
of cerebral palsy per 1000 live births increased from 1.7 in for each class and ED quintile are given in tables 2 and 3.

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Cerebral palsy and socioeconomic status 17

Table 2 Prevalence and odds ratios of cerebral palsy in RGSC groups (singleton births)
% of total Children Prevalence/ OR (95% CI) OR adjusted for BW and
singleton births with CP Total children 1000 (RGSC 1 as reference) gestation (95% CI)

RGSC 1 14.6 16 15018 1.1 1.00 1.00

RGSC 2 20.4 48 20974 2.3 2.15 (1.22 to 3.78) 2.09 (1.19 to 3.69)
RGSC 3NM 13.6 35 13915 2.5 2.36 (1.31 to 4.26) 2.25 (1.24 to 4.06)
RGSC 3M 29.9 68 30649 2.2 2.08 (1.21 to 3.59) 1.89 (1.09 to 3.26)
RGSC 4 6.2 13 6382 2.0 1.91 (0.92 to 3.98) 1.71 (0.82 to 3.56)
RGSC 5 5.3 15 5478 2.7 2.57 (1.27 to 5.21) 2.11 (1.04 to 4.30)
Unclassified 6.0 18 6112 2.9 2.77 (1.41 to 5.44) 2.15 (1.08 to 4.27)
RGSC missing 4.0 42 4081
x2 for linear trend 5.9 (p = 0.02)
4.2 (p = 0.04) if unclassified
group excluded

Overall 51% and 30% of cases of cerebral palsy were and colleagues18 19 is derived from ward of residence rather
statistically ‘‘attributable’’ to inequality in SES using RGSC than enumeration district. Wards are relatively large, socially
and ED quintile respectively. heterogeneous areas, which leads to a risk of non-differential
misclassification of SES and hence a bias towards the null. A
DISCUSSION significant gradient was shown in the Oxford, UK study19 but
These results show a substantial, statistically significant not in the Northern Ireland study.18
gradient in the prevalence of cerebral palsy by SES measured The aetiological mechanisms through which the relation
using either the RGSC classification or an area based between SES and the risk of cerebral palsy are mediated are
measure. They suggest that, even in this relatively affluent complex.4 The well documented relations between SES and
area, 30–51% of cases of cerebral palsy are statistically low birth weight and prematurity are likely to be at least
‘‘attributable’’ to socioeconomic inequality. These proportions partly responsible. However, in this study the association
are not directly comparable given the omission of a between SES measured by ED quintile and the risk of
substantial group of children with cerebral palsy from the cerebral palsy remained statistically significant even after
analyses of RGSC due to missing data on children born out of adjustment for birth weight and gestation. The association
the area. The same strong relation is found when the analysis between RGSC and the risk of cerebral palsy failed to reach
is restricted to singleton births. Whichever measure of SES is conventional levels of statistical significance after adjust-
employed, the prevalence of cerebral palsy is higher in all ment. However, apart from social class IV, the confidence
groups compared to the most advantaged, not merely in the intervals of adjusted odds ratios for each class compared to
poorest groups. social class 1 excluded 1 (table 2). This suggests that
Previous studies using measures of SES based on parental pathways other than that mediated via prematurity and
occupation13–17 or an area based measure of SES18 19 have low birth weight are also implicated.
produced conflicting results (table 1). In some studies the A major strength of this study is that it is based on
apparent lack of an association with lower SES may be prospectively collected, population based data. A comparison
related to study methodology. Emond and colleagues16 of the Child Health Computing system and the Cerebral Palsy
reported a case-control study nested in two population cohort Register in Northern Ireland found that neither identified all
studies (the UK 1958 and 1970 birth cohorts). Children in the children with cerebral palsy but that the register using
control group used to examine for SES effects were matched multiple sources for case ascertainment and a standardised
for birth weight. As at least part of the relation between SES assessment was more complete.20 The computerised health
and cerebral palsy is likely to be mediated through birth system in West Sussex utilises active case ascertainment
weight, this control group would inevitably underestimate through the community paediatric service. Although assess-
any association. Lagergren17 compared the percentage of ment of children is not carried out according to a formalised
children with cerebral palsy in the Malmöhus area of Sweden system, paediatricians regularly examine all children identi-
by social group with the percentage of the whole population fied as having cerebral palsy and the diagnoses are updated
in Sweden in these groups, and reported an increased risk in each year. The reported prevalence is high compared to other
the most advantaged group. This comparison may have studies4 and may reflect some variability in diagnostic
caused bias as the relation between the distribution of social boundaries. However, as the comparisons are internal
groups in Malmöhus and the rest of Sweden is not clear. The (between SES groups with a common method of diagnosis)
area based measure of SES employed in the studies by Dolk bias should not have occurred.

Table 3 Prevalence and odds ratios of cerebral palsy in ED quintiles (singleton births)
% of total Children Prevalence/ OR (95% CI) OR adjusted for BW and
singleton births with CP Total children 1000 (quintile 1 as reference) gestation (95% CI)

Quintile 1 19.2 34 19691 1.7 1.00 1.00

Quintile 2 17.1 41 17563 2.3 1.25 (0.82 to 1.91) 1.39 (0.91 to 2.14)
Quintile 3 17.0 45 17428 2.6 1.38 (0.91 to 2.09) 1.55 (1.02 to 2.35)
Qunitile 4 18.8 49 19330 2.5 1.35 (0.90 to 2.03) 1.39 (0.92 to 2.10)
Quintile 5 23.6 75 24255 3.1 1.65 (1.14 to 2.39) 1.55 (1.06 to 2.25)
Quintile missing 4.2 11 4342
x2 for linear trend 7.57 (p = 0.006)

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18 Sundrum, Logan, Wallace, et al

A diagnosis of cerebral palsy cannot be made reliably N Spencer, School of Postgraduate Medical Education and School of
before the age of 2 years.21 In the current study, therefore, a Health and Social Studies, University of Warwick, Coventry CV4 7AL,
diagnosis of cerebral palsy retained after the age of 2 was UK
accepted. The study does not include children who may have
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PO19 4YT, UK relation of these to cerebral palsy. JAMA 1985;254:1473–9.

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