DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY REVIEW

An update on the prevalence of cerebral palsy: a systematic

review and meta-analysis
MARYAM OSKOUI 1 | FRANZINA COUTINHO 2 | JONATHAN DYKEMAN 3 | NATHALIE JETT E3 |
TAMARA PRINGSHEIM 4

1 Departments of Pediatrics and Neurology, McGill University, Montreal, Quebec; 2 School of Physical and Occupational Therapy, McGill University, Montreal, Quebec;
3 Department of Clinical Neurosciences and Hotchkiss Brain Institute, Department of Community Health Sciences and Institute of Public Health, University of Calgary,
Calgary, Alberta; 4 Departments of Clinical Neurosciences and Pediatrics, University of Calgary, Calgary, Alberta, Canada.
Correspondence to Dr Maryam Oskoui, Departments of Pediatrics and Neurology, McGill University, Montreal Children’s Hospital, 2300 Tupper Street, A-512, Montreal, Quebec,
Canada H3H 1P3. E-mail: maryam.oskoui@mcgill.ca

PUBLICATION DATA
Accepted for publication 22nd October 2012.
Published online 24th January 2013.
AIMS The aim of this study was to provide a comprehensive update on (1) the overall
prevalence of cerebral palsy (CP); (2) the prevalence of CP in relation to birthweight; and (3)
the prevalence of CP in relation to gestational age.
METHOD A systematic review and meta-analysis was conducted and reported, based on the
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement.
Population-based studies on the prevalence of CP in children born in 1985 or after were
selected. Statistical analysis was carried out using computer package R, version 2.14.
RESULTS A total of 49 studies were selected for this review. The pooled overall prevalence of
CP was 2.11 per 1000 live births (95% confidence interval [CI] 1.98–2.25). The prevalence of
CP stratified by gestational age group showed the highest pooled prevalence to be in
children weighing 1000 to 1499g at birth (59.18 per 1000 live births; 95% CI 53.06–66.01),
although there was no significant difference on pairwise meta-regression with children
weighing less than 1000g. The prevalence of CP expressed by gestational age was highest in
children born before 28 weeks’ gestation (111.80 per 1000 live births; 95% CI 69.53–179.78;
p<0.0327).
INTERPRETATION The overall prevalence of CP has remained constant in recent years despite
increased survival of at-risk preterm infants.

Cerebral palsy (CP) encompasses a heterogeneous group of
early-onset, non-progressive, neuromotor disorders that
affect the developing fetal or infant brain.1 CP is one of the
most common causes of childhood physical disability, with
an estimated lifetime cost, for persons born in the United
States in 2000, of 11.5 billion dollars.2 Accurate prevalence
estimates are needed to guide operational health policies
and to aid with appropriate resource allocation.
In the past decade, two limited reviews on the
prevalence of CP have been published.3,4 The first, pub-
lished in 2007, looked at both the overall prevalence of CP
and the prevalence reported by birthweight in preterm
infants. The overall median prevalence estimate reported
was 2.4 per 1000 live births.3 For preterm infants, a med-
ian prevalence of 11.2 per 1000 live births was reported
among children weighing between 1500g and 2499g at
birth, and 63.5 per 1000 live births among children weigh-
ing less than 1500g. This review did not follow the PRIS-
MA (Preferred Reporting Items for Systematic Reviews
and Meta-analyses) statement and had several methodolog-
ical limitations. Only English-language articles were
included, published between 1 January 1990 and 31 Janu-
ary 2005, searching a single bibliographic database (Pub-
Med). A meta-analysis was not performed; rather, the
overall prevalence estimates of selected studies were com-
bined equally to provide a median estimate. Studies report-
ing prevalence estimates with different denominators (live
births, neonatal survivors, children at a certain age) were
combined, and studies including participants born before
1985 were included.
A second systematic review, published in 2008, examined
the prevalence of CP only in relation to gestational age and
demonstrated a significant decrease in the prevalence of CP
with increasing gestational age.4 The prevalence ranged
from 146 (95% confidence interval [CI] 125–170) per 1000
children born at 22 to 27 weeks of gestation, steadily declin-
ing thereafter to an estimated 62 (95% CI 49–78) per 1000
children born at 28 to 31 weeks, 7 (95% CI 6–9) per 1000 at
32 to 36 weeks’ gestation, and 1.13 (95% CI 0.93–0.14) per
1000 in term-born infants. This systematic review used rig-
orous methodology, searching four bibliographic databases
(MEDLINE, CINAHL, Cochrane library, and Science

© The Authors. Developmental Medicine & Child Neurology © 2013 Mac Keith Press DOI: 10.1111/dmcn.12080 509
Direct) with a clearly stated search strategy, including stud-
ies published from 1985 to 2006 and excluding those with
participants born prior to 1985. A meta-analysis was per-
formed, when possible, to provide pooled estimates of prev-
alence; however, the studies used various denominators,
such as live births and neonatal survivors assessed at various
ages, limiting the possibility of such pooling.
A rigorous systematic review of the overall prevalence of
CP is lacking in the literature. Furthermore, more pub-
lished data have become available in recent years on CP
prevalence, both overall and in at-risk populations. The
goal of this study was to provide a comprehensive update
on the prevalence of CP and to systematically review (1)
the overall prevalence of CP; (2) the prevalence of CP in
relation to birthweight; and (3) the prevalence of CP in
relation to gestational age.
METHOD
Search strategy
Two bibliographic databases (MEDLINE and EMBASE)
were searched on 8 February 2011 to identify all potential
citations related to the prevalence of CP published
between 1985 and February 2011. Only studies presenting
data on children born during 1985 or later were included,
owing to considerable changes in perinatal care, and also
because a more uniform definition of CP and routine use
of imaging began in 1985.5 The search strategy was devel-
oped with the help of a health sciences librarian and
adapted for MEDLINE and EMBASE (Appendix SI, sup-
porting information published online).
References from MEDLINE and EMBASE were
combined and downloaded into a reference manager
(Endnote X2). Abstracts of all references were screened
independently by two reviewers (MO and FC) to select
population-based studies on the prevalence of CP report-
ing cohorts of all live-born children, all preterm survivors,
or expressed by gestational age or birthweight. Studies
published in both French or English were included. When
cohorts ranging before and after 1985 were reported, we
included studies that allowed for a subgroup analysis of
cohorts born after 1985. Studies reporting on a single
subtype of CP (such as spastic diplegia only), conference
proceedings, interventional studies, review articles, and
case–control studies not including full cohorts as cases
were excluded. When multiple articles reporting data from
the same study population were encountered, the most
comprehensive study was selected. References of the two
available systematic reviews were manually searched to
identify further potential references. Two reviewers
assessed study quality using a qualitative tool adapted from
previously published scales (Appendix SII, supporting
information published online). Studies with a quality score
below 5 (range 1–4) were excluded (Table SI, supporting
information published online); for articles included in the
study, the mean score was 6. Disagreement pertaining to
inclusion of articles was resolved by consensus between the
two reviewers.
510 Developmental Medicine & Child Neurology 2013, 55: 509–519
What this paper adds
• This is the first worldwide CP prevalence estimate provided by
meta-analysis.
• The overall prevalence of CP worldwide is 2.11 per 1000 live births.
• The prevalence of CP has remained constant in recent years, despite
improved survival of at-risk preterm infants.
Data extraction
Two reviewers independently abstracted the following
information on the methods and results from each article
meeting all eligibility criteria: reference, year of publica-
tion, geographical location of the study, birth cohorts
included, data sources, assessment of diagnosis and diag-
nostic criteria used, age at diagnosis, as well as the overall
number of cases, population surveyed and denominator
used (live births, neonatal survivors, children at a specified
age). Data sources were also classified as population-based
data (e.g. data from patient registries) or administrative
data (e.g. data from physician billing diagnostic codes or
hospital discharge summaries). Subgroup information for
number of cases and numbers surveyed based on gesta-
tional age and birthweight was also collected.
Data analyses
It was decided a priori that a random effects model would
be used to calculate the pooled prevalence of CP and 95%
CIs for all predetermined groups. To assess for significant
between-study heterogeneity, the Cochran’s Q statistic was
calculated and I2 was used to quantify between-study
heterogeneity; however, both measures of heterogeneity
were used only descriptively and not in decision-making
regarding model selection.6 The following prevalence esti-
mates were calculated: (1) the overall prevalence of CP in
children at certain ages and in all live births; (2) the preva-
lence of CP in relation to four birthweight categories for
live births (<1000g, 1000–1499g, 1500–2499g, and >2500g)
and using three birthweight categories for neonatal survi-
vors (<1500g, 1500–2499g, and >2500g); and (3) the preva-
lence of CP in extremely preterm newborn infants in
relation to five gestational weeks (23wks, 24wks, 25wks,
26wks, and 27wks) and the prevalence of CP in relation to
four gestational age categories (<28wks, 28–31wks, 32–
36wks, and >36wks).
Pairwise meta-regression analysis was performed to
assess whether CP prevalence was significantly different
between groups. Furthermore, to investigate whether the
prevalence of CP had changed over time, meta-regressions
were performed including terms for the start and end
years of data collection for each study. These were chosen
as surrogates for year-by-year prevalence estimates, which
were often not provided by the studies. To address the
decision to combine studies that included postneonatal
cases with those that did not, a stratified analysis was
completed to see whether these groups of studies were
different from each other. A cumulative meta-analysis was
conducted on the overall prevalence of CP per 1000 live
births to assess the impact of studies published since the
last review on the overall estimate. Publication bias was
assessed using the Egger regression test, Begg and
Mazumdar correlation test, and a visual inspection of fun-
nel plots. A sensitivity analysis was also carried out to
assess the effect of the methodological quality on the
results.
For all tests, p<0.05 was deemed to be significant. Statis-
tical analyses were carried out in R version 2.14.7 The
meta package (version 2.1–0, 2012 was used to produce
the pooled estimates and forest plots. In accordance with
the random effects model, the studies were weighted
according to the inverse of their variance along with the
between-study heterogeneity (tau-squared) arrived at with
a DerSimonian–Laird estimator. The metafor package
(installed in R) was used to conduct the meta-regression
using restricted maximum likelihood estimation.8
RESULTS
Selected studies
A total of 1521 references from MEDLINE and EMBASE
were initially identified. A manual search of the references
cited in two available systematic reviews of CP prevalence
yielded an additional 16 abstracts. Duplicates were
removed (323) and the remaining 1214 abstracts were
screened, with 91 being selected for full-text review. Of
these, 35 were excluded: two did not provide data on CP
prevalence, one was a letter to the editor, seven did not
provide data for sub-analysis of infants born in or after
1985, 13 had a quality score of 4 or less, and 12 were in
languages other than English or French. The 13 studies
excluded based on quality assessment are described in
Table SI. Of the remaining 56 studies, seven were excluded
because they presented data from the same study popula-
tion, leaving a total of 49 studies included for the meta-
analysis. The meta-analysis included 29 studies on overall
CP prevalence and 20 on CP prevalence in preterm survi-
vors (Table I). The selection process details are outlined in
Figure 1.
Overall prevalence of cerebral palsy
The study by Sinha et al.29 was excluded from analysis
because it focused on a small ethnic community with a
high rate of consanguinity that did not represent a true
population-based estimate in the study region. Pooling 19
studies that reported estimates using live births as the
denominator, the overall prevalence of CP was 2.11 per
1000 live births (95% CI 1.98–2.25; Fig. 2a). The cumu-
lative meta-analysis demonstrates that the overall preva-
lence of CP has remained stable with the addition of new
studies over the past 10 years (Fig. 2b). There was no
significant difference in overall prevalence per 1000 live
births between studies using population-based data (1.93;
95% CI 1.69–2.21) and studies using administrative data
(2.19; 95% CI 2.02–2.37). A meta-regression sorting the
studies by start year of each cohort and end year of
cohort was also conducted, and showed no significant dif-
ference by either start (p=0.34) or end year (p = 0.54).
When assessing the importance of including postneonatal
cases, the overall estimates of the two groups of studies
were almost identical. Studies including these cases had a
prevalence of 2.10 (1.93–2.30) and those excluding the
cases had a prevalence of 2.11 (2.03–2.19). The overall
prevalence appeared higher using studies reporting chil-
dren at a specific age (range 18mo–8y) as the denominator
(Fig. S1, supporting information published online), with a
pooled prevalence of 2.91 per 1000 children (95% CI
2.16–3.93).
Prevalence of cerebral palsy by birthweight
The pooled prevalence of CP in children per 1000 live
births was calculated by birthweight category (Fig. 3). The
prevalence was highest in children weighing 1000 to 1499g
(59.18 per 1000 live births; 95% CI 43.38–73.95), and low-
est in children weighing over 2500g (1.33 per 1000 live
births; 95% CI 1.19–1.49). The prevalence among children
weighing under 1000g was not significantly different from
the prevalence among those weighing 1000 to 1499g
(p=0.8159), but in both cases was significantly higher than
among children weighing 1500 to 2499g (p<0.001). The
prevalence among children weighing over 2500g was sig-
nificantly lower than in all other birthweight groups
(p<0.001).
Three studies reported the prevalence of CP in relation
to birthweight per 1000 neonatal survivors: 60.04 (95%
CI 45.21–81.23) in children under 1500g, 8.33 (95% CI
5.33–13.03) in children weighing between 1500g and
2499g, and 1.16 (95% CI 1.04–1.29) in children weighing
over 2500g. The prevalence of CP is significantly lower
among children weighing between 1500g and 2499g than
in those weighing under 1500g (p<0.001). Among children
with a birthweight over 2500g the prevalence of CP was
significantly lower than in all other groups (p<0.001).
Prevalence of cerebral palsy in relation to gestational
age
The pooled prevalence per 1000 live births was calculated
for each gestational age group (Fig. 4). The prevalence was
highest, at 111.80 (95% CI 69.53–179.78), among children
born before 28 weeks of gestation and lowest, at 1.35
(95% CI 1.15–1.59), for children born after 36 weeks.
Pairwise meta-regression showed that the prevalence of CP
was significantly lower among children born between 28
and 31 weeks’ gestation than in children born before
28 weeks’ gestation (p=0.0327). Prevalence was significantly
lower among children born between 32 and 36 weeks’ ges-
tation than among those born more preterm (p<0.001), and
was significantly lower among children born after
36 weeks’ gestation than in all other groups (p<0.001).
There were fewer studies reporting the prevalence of CP
in neonatal survivors in relation to gestational age group.
The prevalence was 111.80 (95% CI 69.53–179.78) per
1000 neonatal survivors born before 28 weeks and 144.72
(95% CI 63.71–328.71) per 1000 neonatal survivors born
between 28 weeks and 31 weeks; the number of studies
Review 511
 Table I: Selected studies. (a) Selected studies on overall cerebral palsy (CP) prevalence. (b) Selected studies on cerebral palsy prevalence in infants born preterm

Data/source Number Number Prevalence Quality

Reference Location Birth cohort methodology Agea with CP surveyed per 1000 Denominator scores

(a)
Rice et al.9 Australia 1993–1998 Administrative database 5 333 151 286 2.2 Live births 6
Robertson et al.10 Canada 1985–1988 Administrative database 3 248 96 359 2.57 Children at 8y 7
Smith et al.11 Canada 1991–1995 Administrative database 3 497 185 746 2.7 Live births 7
Liu et al.12 China 1990–1997 Health care records 0–7 622 388 192 1.6 Children <7y 7
Ravn et al.13 Denmark 1987–1998 Administrative database 1–5 880 408 077 2.2 Live births 6
Sigurdardottir et al.14 Iceland 1990–2003 Administrative database and 4–8 139 60 808 2.3 Live births 6
other sources
Mongan et al.15 Ireland 1990–1999 Administrative database and 5 85 45 321 1.88 Neonatal survivors 7
other sources
16
Dolk et al. Northern Ireland, 1987–1997 Multiple sources: agencies, >5 547 252 185 2.2 Live births 7
UK parents, MD
17
Wichers et al. Netherlands 1986–1988 Administrative database and Any 52 43 645 1.19 Children at 10y 7
other sources
Andersen et al.18 Norway 1996–1998 Administrative database 4 374 178 095 2.1 Live births 6
Lie et al.19 Norway 1986–1995 Administrative database 1–5 988 543 064 1.8 Live births 6
Hagberg et al.20 Sweden 1991–1994 Administrative database >4 241 113 724 2.12 Live births 6
Hagberg et al.21 Sweden 1987–1990 Administrative database >4 216 91 542 2.36 Live births 6

512 Developmental Medicine & Child Neurology 2013, 55: 509–519

Himmelmann et al.22 Sweden 1995–1998 Hospital clinical chart review 4–8 170 88 371 1.92 Live births 6
and other
Himmelmann et al.23 Sweden 1999–2002 Hospital clinical chart review 4–8 186 85 737 2.18 Live births 6
and rehabilitation reports
Hjern and Thorngren-Jerneck24 Sweden 1987–1993 Administrative database >1 1437 804 543 1.78 Live births 5
Nordmark et al.25 Sweden 1990–1993 Hospital/chart review NA 145 65 514 2.2 Live births 6
Westbom et al.26 Sweden 1990–1997 Administrative database 4–7 343 125 564 2.7 Live births 7
and other sources
Ozturk et al.27 Turkey 1990–2004 Multiple sources, confirmed >1 102 91 000 1.1 Live births 5
by two MDs
28
Colver et al. UK 1989–1993 Administrative database 4 117 47 691 2.45 Neonatal survivors 6
and other
Sinha et al.29 UK 1985–1987 Administrative database 5 75 17 564 3.9 Live births 5
Surman et al.30 UK 1987–1995 Administrative database and >1 652 318 951 2 Live births 7
other sources
Pharoah et al.31 Scotland, 1985–1999 Hospital clinical chart review 5 1383 658 221 2.1 Live births 7
UK and other
Arneson et al.32 USA 1999 Administrative database and 5 227 68 272 3.3 Children at 5y 7
other sources
33
Bhasin et al. USA 1996, 2000 Hospital clinical chart review 8 268 80 342 3.34 Children at 8y 6
and other
Petrini et al.34 USA 2000–2004 Administrative database 0–5 357 141 321 2.5 Live births 6
Winter et al.35 USA 1986–1991 Administrative database and >3 443 221 500 2 Live births 5
other sources
Yeargin-Allsopp et al.36 USA 1994 Multiple sources 8 416 114 897 3.6 Children at 8y 8
a
Reference Location Birth cohort Age Number with CP Number surveyed Prevalence per 1000 Denominator per 1000 Quality score

(b)
Doyle et al.38 Australia 2005 2 16 163 98.2 <28wks GA survivors at 2y 6
Doyle et al.39 Australia 1985–1987 2 12 95 126.31 24–26wks GA survivors at 5y 6
Roberts et al.40 Australia 1997 8 16 144 113.5 22–27wks GA survivors at 8y 6
 Quality score

Age: age at ascertainment (years). The study by Serdaroglu et al.37 was excluded from analysis. This study was based in Turkey on a parental questionnaire for children born in 1996. Out
was too small to calculate a pooled prevalence in older
gestational age groups.

6 Prevalence of cerebral palsy per gestational week in

6
7
5
5
5
5
6
6
7
5
6
5
5
6
6
6
extremely preterm infants

22–27wks GA, BW 500–999g survivors at 2y

The pooled prevalence per 1000 neonatal survivors at a
predetermined age was calculated per gestational week
from 23 to 27 weeks (see Fig. S2, supporting material
23–26wks GA survivors at 18–24mo published online). The pooled prevalence was highest in
23–27wks GA survivors at 12mo

23–29wks GA survivors at 18mo

22–32wks GA survivors at 18mo

BW 1000–1500g survivors at 2y
<26wks GA survivors at 12mo

children born at 23 weeks’ gestation (261.42; 95% CI

24–27wks GA survivors at 2y

22–32wks GA survivors at 5y
30–34wks GA survivors at 5y
32–35wks GA survivors at 2y
<28wks GA survivors at 6y

<26wks GA survivors at 6y
140.52–486.34) and lowest in children born at 27 weeks’
20–27wks GA live births
24–30wks GA live births

gestation (102.70; 95% CI 66.44–158.77). Pairwise meta-

Denominator per 1000

ELBW survivors at 4y
ELBW survivors at 2y

of 41 861 children surveyed, 186 were identified with CP, yielding a prevalence of 4.4 per 1000 children aged 2–16y. MD, physicians; NA, not available.
regression showed that the prevalence among children
born at 27 weeks’ gestation was significantly lower than
that among children born at 23 weeks’ gestation
(p=0.0063).

Evaluation of potential bias

For the overall prevalence estimate of CP per 1000 live
Prevalence per 1000

births, no significant publication bias was detected on

visual inspection of funnel plots of the standard error by
the logit of the prevalence rate and supported by statisti-
cal testing. For the Begg and Mazumdar rank correlation
102.4
172.1
137.8

170.5
153.3

110.6

149.1

132.8
160.1
65.3
98.2

190

87.7
52.4
1.32

117
69.7

test, Kendall’s tau-b is 0.15584 (p-value 0.15502). Egger’s

regression test showed an intercept of 2.49981 (95% CI
–0.92154 to 5.92115), with t=1.52411, df=20 (p-value
Number surveyed

0.07157). For the prevalence estimate of CP in preterm

survivors, no significant publication bias was detected on
visual inspection of funnel plots of the standard error by
the logit of the prevalence rate and supported by statisti-
1515

1812
1461

3785
293
244
248

672
217
274
142
208

167
149
120
373
241

cal testing. For the Begg and Mazumdar rank correlation

test, Kendall’s tau-b is –0.19883 (p-value 0.11712). Eg-
ger’s test showed an intercept of –1.02719 (95% CI
Number with CP

–4.01953 to 1.96515), with t=0.72424, df=17 (p-value

0.23938).
GA, gestational age; ELBW, extremely low birthweight; BW, birthweight.

In our selection process, 12 studies were excluded based

on language: three were written in Spanish, five in Chi-
30
42
70
65
66
37
42
27
23

76
22
17
14
26
32
159

606

nese, one in Polish, two in Japanese, and one in German.

Of these, two presented data on live births, five presented
1.5–2
Agea

2
1
1
2
2

5
5
2
6
2
2
6
1.5

1.5

1.5

data on children at a particular age, of which three

reported on the same population, and four presented data
Not provided

on preterm survivors.
Birth cohort

1989–1996
1992–1993
1999–2001
1986–2003
1993–2003
1987–1992
1990–1994
1991–1994
1996–1997

1990–1992
1992–1997

1999–2000

1993–1998

DISCUSSION
1997
1997

1995

Main findings
This study, through a systematic review and meta-analysis
UK and Ireland

of the available literature, provides an updated estimate of

the overall prevalence of CP, as well as its relationship
Australia
Australia
Location

Norway
Canada
Canada
Canada
Canada
Finland
Finland
Austria

with gestational age and birthweight. The most commonly

France
France
France
France
Kenya

USA

reported denominators were live births, neonatal survivors,

and survivors at a predetermined age. Overall prevalence
estimates were similar using live births or neonatal survi-
Were and Bwibo54
Tommiska et al.49
Robertson et al.44
Table I: Continued

Salokorpi et al.48

Leversen et al.55
Lefebvre et al.46

vors; however, in the preterm subgroup the estimates are

Burguet et al.52

Marlow et al.56
Jacobs et al.47

Valleur et al.53
Beaino et al.50
Sutton et al.42

Marret et al.51
Weber et al.43

Vincer et al.45

Vohr et al.57
Gray et al.41

expected to differ as perinatal mortality is higher among

Reference

preterm infants have in term-born newborn infants. There

were fewer studies reporting the prevalence of CP per neo-
natal survivors in relation to gestational age group. The
a

Review 513
 Records identified through database Additional records identified
searching through other sources

Identification
(n =1521) (n =16)

Records after duplicates removed

(n=1214)
Screening

Records excluded
(n=1137)

Full-text articles excluded,

with reasons (n=35)
Full-text articles assessed
for eligibility 2: No data on cerebral palsy
(n=91) prevalence
Eligibility

1: Letter

7: Articles Eligible studies meeting 7: Sub analysis for children

excluded as data inclusion criteria born after 1985 not
on same study (n=56) possible
populations
13: Quality score 4 or less

12: Studies in other

languages
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n=49)

Figure 1: Flow chart of study selection.

pooled estimate for children born at gestational age 28 to
31 weeks is unexpectedly higher than children born at a
gestational age of less than 28 weeks; however, there were
fewer studies reporting the former group and the pooled
estimate shows a larger confidence interval, and this
difference was not significant in a pairwise meta-regression
analysis. Most studies reporting estimates on preterm sur-
vivors were based on population-based registries following
groups of infants born preterm. For overall prevalence,
sources of case ascertainment varied considerably between
studies. Most European studies used population-based
patient registries with multiple sources of case ascertain-
ment and uniformly applied diagnostic inclusion criteria.
In North America, several states reported data from popu-
lation-based registries; however, both Canadian studies
used administrative databases with ICD-9 codes as
diagnostic criteria. Prospective population-based patient
registries are favoured as more validated data sources, but
they are associated with higher operational costs than large
pre-existing administrative databases. It is encouraging,
however, that estimates from population-based studies and
administrative data did not differ significantly in our analy-
sis. Although prevalence estimates were comparable across
geographic sites and cultural groups, one study that was
excluded from analysis reported prevalence estimates that
were much higher.29 This study focused on a British ethnic
community (Bradford District Health Authority) with a
high rate of consanguinity, highlighting the potential
genetic aetiology in this population.
The overall prevalence of CP estimate in our review is
2.11 per 1000 live births, consistent with the prevalence
reported by an earlier review without meta-analysis.3 This
prevalence was also shown to have remained constant in
recent years with the addition of new published studies. A
number of factors may contribute to an increased preva-
lence of CP, such as a improved survival in preterm infants
and higher numbers of multiple births, which often result
in preterm births. There are also a number of factors that
may contribute to a decreased prevalence of CP, such as
the use of antenatal corticosteroids, cooling for term-born

514 Developmental Medicine & Child Neurology 2013, 55: 509–519

 (a) (b)
Study Prevalence 95% CI Study Prevalence 95% CI

Hagberg, 1996 2.36 [2.06; 2.70] Adding Hagberg, 1996 (k = 1) 2.36 [2.07; 2.70]
Pharoah, 1998 2.10 [1.99; 2.21] Adding Pharoah, 1998 (k = 2) 2.19 [1.96; 2.44]
Hagberg, 2001 2.12 [1.86; 2.40] Adding Hagberg, 2001 (k = 3) 2.15 [2.02; 2.28]
Nordmark, 2001 2.21 [1.87; 2.60] Adding Nordmark, 2001 (k = 4) 2.14 [2.05; 2.23]
Winter, 2002 2.00 [1.82; 2.19] Adding Winter, 2002 (k = 5) 2.11 [2.03; 2.21]
Surman, 2003 2.04 [1.89; 2.21] Adding Surman, 2003 (k = 6) 2.10 [2.02; 2.17]
Himmelmann, 2005 1.92 [1.65; 2.24] Adding Himmelmann, 2005 (k = 7) 2.09 [2.02; 2.16]
Dolk, 2006 2.17 [1.99; 2.36] Adding Dolk, 2006 (k = 8) 2.10 [2.03; 2.17]
Westbom, 2007 2.73 [2.45; 3.04] Adding Westbom, 2007 (k = 9) 2.17 [2.04; 2.31]
Ozturk, 2007 1.12 [0.91; 1.36] Adding Ozturk, 2007 (k = 10) 2.06 [1.89; 2.26]
Smith, 2008 2.68 [2.45; 2.92] Adding Smith, 2008 (k = 11) 2.11 [1.93; 2.32]
Andersen, 2008 2.10 [1.89; 2.32] Adding Andersen, 2008 (k = 12) 2.11 [1.94; 2.30]
Hjern, 2008 1.79 [1.70; 1.88] Adding Hjern, 2008 (k = 13) 2.08 [1.91; 2.27]
Rice, 2009 2.20 [1.97; 2.45] Adding Rice, 2009 (k = 14) 2.09 [1.93; 2.27]
Sigurdardottir, 2009 2.29 [1.92; 2.70] Adding Sigurdardottir, 2009 (k = 15) 2.10 [1.94; 2.27]
Petrini, 2009 2.53 [2.27; 2.80] Adding Petrini, 2009 (k = 16) 2.13 [1.97; 2.29]
Ravn, 2010 2.16 [2.02; 2.30] Adding Ravn, 2010 (k = 17) 2.13 [1.99; 2.28]
Lie, 2010 1.82 [1.71; 1.94] Adding Lie, 2010 (k = 18) 2.11 [1.97; 2.26]
Himmelmann, 2010 2.17 [1.87; 2.50] Adding Himmelmann, 2010 (k = 19) 2.11 [1.98; 2.25]

Pooled totals 2.11 [1.98; 2.25] Pooled totals 2.11 [1.98; 2.25]
I–squared = 89.5%, Q = 171.8, df = 18, p < 0.0001

Figure 2: Overall prevalence of cerebral palsy per 1000 live births.

asphyxiated infants, and the use of magnesium sulphate.
Contributing genetic aetiologies may either be increasing
or decreasing. The analysis of CP based on birthweight
showed, as expected, that the prevalence decreases signifi-
cantly among children born with a birthweight above
1500g. This prevalence estimate was similar irrespective of
the denominator used in the calculation, that is per 1000
live births or per 1000 neonatal survivors. One of the rea-
sons for this similarity in prevalence estimates could be the
small number of high-quality studies included that report
prevalence of CP using neonatal survivors as the denomi-
nator and inclusion of term-born low-birthweight infants,
among whom mortality may be lower. As reported in an
earlier meta-analysis, the prevalence of CP shows an
inverse relationship to gestational age.4 The prevalence
estimate for preterm births varied significantly based on
the denominator, though a decline in CP prevalence was
observed with increased gestational age.3,4 When reported
as a proportion of neonatal survivors, the prevalence esti-
mates were, as expected, larger than the corresponding
estimates reported as a proportion of live births, although
these proportions revealed a similar declining trend with
increasing gestational age.
Strengths and limitations
This review is based on rigorous methods and quality
assessment of the selected studies. Efforts were made to
report the meta-analysis based on the PRISMA state-
ment.58 Additionally, analysis using the random effects
model aimed to account for heterogeneity between studies.
In comparison with previous reviews, our meta-analysis
analysed a greater number of studies, used only data from
study cohorts born in or after 1985 to account for changes
in clinical practice, and computed pooled prevalence esti-
mates based on comparable common denominators. All
efforts were made to adjust for potential bias.
Though many studies used administrative data, the diag-
nosis of CP based on ICD-9 coding has not, to our know-
ledge, been validated in these databases. Administrative
databases are susceptible to limitations such as inaccuracy in
diagnostic code entry, resulting in possible misclassification
bias, multiple entries from varying sources, a lack of univer-
sal case definitions, and financial incentives in coding in
some countries.59 North American studies are also
restricted to a few provinces or states, with questionable
generalizability of the available data to the rest of the coun-
try, where demographic and social variables may differ.
There was significant heterogeneity across studies, and
an attempt was made to adjust for this by using a random
effects model and by pooling only studies with similar
denominators. There were several factors contributing to
potential selection bias in our review. First, there is a poten-
tial ascertainment bias by individual studies using different
definitions and age at diagnosis of CP without reference to
functional severity. Mortality in the first years of life would
lead to exclusion of more severe cases, while a late age of
diagnosis or ascertainment only through rehabilitation facil-
ities may exclude milder cases. This may have had an impact

Review 515
 (a) (b)
Study Prevalence 95% CI Study Prevalence 95% CI

Hagberg, 2001 80.97 [58.48; 108.63]

Hagberg, 2001 48.51 [26.08; 81.52] Hagberg, 1996 68.24 [46.17; 96.53]
Hagberg, 1996 56.60 [29.59; 96.79] Himmelmann, 2005 54.46 [34.44; 81.29]
Himmelmann, 2005 82.05 [47.63; 129.83] Himmelmann, 2010 43.96 [25.33; 70.40]
Himmelmann, 2010 58.30 [31.40; 97.62] Lie, 2010 67.89 [57.15; 79.95]
Lie, 2010 89.55 [69.03; 113.77] Nordmark, 2001 40.61 [23.39; 65.11]
Nordmark, 2001 50.00 [23.12; 92.79] Pharoah, 1998 57.20 [50.16; 64.90]
Pharoah, 1998 41.82 [33.35; 51.71] Smith, 2008 53.08 [38.83; 70.60]
Surman, 2003 42.88 [31.33; 57.15] Surman, 2003 54.89 [45.16; 66.01]

Pooled totals 56.64 [43.38; 73.95] Pooled totals 59.18 [53.06; 66.01]
I–squared = 75%, Q = 28, df = 7, p = 0.0002 I–squared = 38.7%, Q = 13.1, df = 8, p = 0.1099

0 20 40 60 80100120140 0 20 40 60 80 100120140
CP per 1000 live births CP per 1000 live births
Birthweight <1000g Birthweight 1000–1499g

(c) (d)
Study Prevalence 95% CI Study Prevalence 95% CI

Dolk, 2006 1.23 [1.12; 1.35]

Dolk, 2006 11.28 [9.82; 12.89] Hagberg, 2001 1.25 [1.05; 1.48]
Hagberg, 2001 11.40 [8.33; 15.23] Hagberg, 1996 1.37 [1.14; 1.64]
Hagberg, 1996 13.90 [10.16; 18.56] Himmelmann, 2005 1.21 [0.98; 1.47]
Himmelmann, 2005 6.73 [4.22; 10.17] Himmelmann, 2010 1.44 [1.19; 1.72]
Himmelmann, 2010 9.79 [6.62; 13.95] Lie, 2010 1.15 [1.06; 1.25]
Lie, 2010 12.44 [10.74; 14.32] Nordmark, 2001 1.40 [1.12; 1.73]
Nordmark, 2001 7.40 [4.46; 11.53] Petrini, 2009 2.10 [1.86; 2.36]
Pharoah, 1998 10.31 [9.30; 11.40] Pharoah, 1998 1.14 [1.06; 1.23]
Sigurdardottir, 2009 16.15 [10.84; 23.11] Sigurdardottir, 2009 1.28 [1.01; 1.61]
Smith, 2008 10.02 [7.93; 12.49] Smith, 2008 1.79 [1.59; 1.99]
Surman, 2003 9.58 [8.19; 11.15] Surman, 2003 1.16 [1.04; 1.29]
Winter, 2001 6.10 [4.89; 7.52] Winter, 2001 1.10 [0.96; 1.26]

Pooled totals 10.17 [8.94; 11.58] Pooled totals 1.33 [1.19; 1.49]
I–squared = 78.1%, Q = 50.2, df = 11, p < 0.0001 I–squared = 90.9%, Q = 132, df = 12, p < 0.0001

0 5 10 15 20 25 0 1 2 3 4 5
CP per 1000 live births CP per 1000 live births
Birthweight 1500–2499g Birthweight >2500g

Figure 3: Prevalence of cerebral palsy (CP) in relation to birthweight. (a) Birthweight less than 1000g; (b) birthweight between 1000g and 1499g; (c)
birthweight between 1500g and 2500g; (d) birthweight over 2500g.

on the numerator, though the extent of impact cannot be
established. Furthermore, estimating the impact on health
care costs and planning of services would need to take into
consideration the severity of dysfunction in affected chil-
dren, which is not provided in most studies. A second poten-
tial source of selection bias is referral filter bias, as some
studies reported cases from academic institutions, which
may impose a bias in access to care. In this meta-analysis,
data from 8 of the 48 studies were hospital based. These
hospital-based studies were included as the institutes were
considered to be centres of excellence and representative of
the population they served.
A third potential source of selection bias is publication
bias. Although efforts were made to make the search strat-
egy as comprehensive as possible, the search did not
include unpublished material or data from the ‘grey litera-
ture’. However, based on inspection of funnel plots and
supported by statistical testing, we did not find significant
evidence of publication bias for either the overall preva-
lence estimate or the estimate in premature survivors.
The fourth potential source of selection bias in this
review is language bias, as only studies published in Eng-
lish and French were selected. The impact of excluding
studies published in languages other than English has been

516 Developmental Medicine & Child Neurology 2013, 55: 509–519

 (a) (b)
Study Prevalence 95% CI Study Prevalence 95% CI

Hagberg, 2001 85.50 [54.97; 125.53]

Hagberg, 1996 80.32 [49.75; 121.32] Hagberg, 2001 60.43 [43.90; 80.81]
Himmelmann, 2005 76.56 [44.39; 121.34] Hagberg, 1996 53.51 [36.89; 74.71]
Himmelmann, 2010 55.56 [29.03; 95.03] Himmelmann, 2005 40.42 [25.79; 60.04]
Hjern, 2008 59.51 [49.02; 71.46] Himmelmann, 2010 43.74 [27.61; 65.47]
Nordmark, 2001 72.29 [37.91; 122.87] Hjern, 2008 28.50 [24.57; 32.85]
Sigurdardottir, 2009 75.68 [41.99; 123.71] Marret, 2007 52.58 [39.39; 68.55]
Weber, 2005 197.74 [157.52; 243.10] Nordmark, 2001 32.19 [18.13; 52.54]

Pooled totals 82.25 [54.49; 124.17] Pooled totals 43.15 [32.70; 56.94]
I–squared = 91.1%, Q = 78.3, df = 7, p < 0.0001 I–squared = 83.3%, Q = 35.9, df = 6, p < 0.0001

0 50 100 150 200 250 0 20 40 60 80

CP per 1000 live births CP per 1000 live births
Gestational age <28 weeks Gestational age 28–31 weeks

(c) (d)
Study Prevalence 95% CI Study Prevalence 95% CI

Hagberg, 2001 1.26 [1.06; 1.49]

Hagberg, 2001 6.18 [4.28; 8.63] Hagberg, 1996 1.35 [1.12; 1.62]
Hagberg, 1996 7.79 [5.52; 10.68] Himmelmann, 2005 1.11 [0.89; 1.36]
Himmelmann, 2005 6.66 [4.53; 9.44] Himmelmann, 2010 1.43 [1.18; 1.72]
Himmelmann, 2010 6.09 [4.05; 8.79] Hjern, 2008 1.08 [1.01; 1.16]
Hjern, 2008 3.34 [2.80; 3.95] Nordmark, 2001 1.40 [1.12; 1.73]
Marret, 2007 20.64 [13.40; 30.32] Petrini, 2009 2.00 [1.76; 2.26]
Nordmark, 2001 4.60 [2.63; 7.46] Sigurdardottir, 2009 1.23 [0.96; 1.55]
Petrini, 2009 7.31 [5.60; 9.38] Topp, 2001 1.50 [1.28; 1.74]

Pooled totals 6.75 [4.59; 9.94] Pooled totals 1.35 [1.15; 1.59]
I–squared = 92.2%, Q = 90.1, df = 7, p < 0.0001 I–squared = 90.5%, Q = 84.2, df = 8, p < 0.0001

0 5 10 15 20 25 30 35 0 1 2 3 4 5
CP per 1000 live births CP per 1000 live births
Gestational age 32–36 weeks Gestational age >36 weeks

Figure 4: Prevalence of cerebral palsy (CP) in relation to gestational age per 1000 live births. (a) Gestational age less than 28 weeks; (b) gestational
age between 28 weeks and 31 weeks; (c) gestational age between 32 weeks and 36 weeks; (d) gestational age over 36 weeks.

shown to have generally little effect on summary treatment
effect estimates.60 In our selection process, 12 studies were
excluded based on language. A language bias cannot be
excluded.
CONCLUSIONS
This meta-analysis provides updated prevalence estimates
of CP across different populations, showing a constant
overall estimate per live births in recent years despite the
addition of new data and increased survival of at-risk pre-
term infants. Although the prevalence of disease is
unchanged, future studies are needed to evaluate a change
over time in the phenotypic spectrum of CP. Studies on
the prevalence of CP in adolescence and adulthood would
also be important future goals as the majority of children
with CP are expected to survive into adulthood. Further
studies are also needed in North America and Canada, as
the available data are restricted to a few regions, princi-
pally regions in Canada. Direct comparison of case ascer-
tainment from patient registries and administrative
databases is needed to establish the validity of the diagnosis
of CP in the latter, as administrative databases are increas-
ingly used for surveillance because of their larger sampling
frame, lower operational cost, and availability of longitudi-
nal data. Accurate and updated prevalence estimates are
imperative in estimating the burden of illness and planning
appropriate health resource allocation for this vulnerable
patient population.
A CK N O W L E D G E M E N T S
This study was funded by an operational grant from the Public
Health Agency of Canada (PHAC) in conjunction with the Neu-

Review 517
rological Health charities of Canada (NHCC).The PHAC and SUPPORTING INFORMATION
the NHCC did not participate in the design and conduct of the Additional supporting information may be found in the online
study; in the collection, analysis, and interpretation of the data; or version of this article:
in the preparation, review, or approval of the manuscript. Appendix SI: Description of the search strategy.
Appendix SII: Quality assessment tool.
D I SC L O S U R E S Table SI: Description of excluded studies based on quality
N Jette is an Alberta Innovates Health Solutions Population assessment.
Health Investigator and holds a Canada Research Chair Tier 2 in Figure S1: Overall prevalence of CP per children at a specified
Neurological Health Services Research. T Pringsheim receives age.
salary/research support from Alberta Health and Wellness, the Figure S2: Prevalence per 1000 neonatal survivors in extremely
Canadian Institute of Health Research, and the Public Health premature infants.
Agency of Canada.

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