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CLINICAL RESEARCH AND METHODSattributed more to the increasednumber of survivors as a result ofimproved care in itself(9,10). Theneed for resuscitation and presenceof congenital abnormalities were alsoidentified as risk factors for CP(11).More recent studies showed thatthe Apgar score equal or lower than3 in the 5th minute of birth in manyobserved infants did not lead toCP; but the study of Apgar scorein minutes 10th and 20th of birth isimportant(5). In another study it wasdefined that in more than 50% ofpatients, asphyxia was not the solereason of CP and a concomitantetiology also existed. It should bementioned that in considering theetiology of CP the percent of asphyxiais not absolute and it is in conjunctionwith other factors such as LBW,prematurity, respiratory distresssyndrome(RDS), NICU admission >3days and environmental stresses andprocedures(12).According to the WHO report 2006, in Iran “ perinatal factors “ are thefourth common cause of mortality inall ages, and cause 10 years of lifelost (YLL), which is the third mostcommon cause for lost years in thecountry (after ischemic heart diseaseand road traffic accidents)(13).According to the same report until2004, the under 5 - mortality rate inIran was 38 per 1000 live births, 63percent of which was due to neonatalmortality which in comparison to 43percent in the regional averageEastern Mediterranean countries, isa significant figure. The same sourcehas reported that among all etiologiesfor neonatal mortality in Iran, pretermbirth (31%, in comparison to 22%in the Eastern Mediterraneanarea), congenital anomalies (15%in comparison to 9% in the EasternMediterranean area with high childand adult mortality), birth asphyxia(22%), and severe infections (22%)are the most common(13).One can conclude that congenitalanomalies aside, the three othermost common etiologies of neonatalmortality in Iran are somehow relatedto the perinatal period, and thus under5 mortality, which as said before ismainly due to neonatal causes andoccurs mainly in the neonatal period,is also strongly related to perinatalfactors.When considering years of life lostin Iran, one can also presume thatchildhood long-term morbidities andhandicaps may be significantly relatedto the perinatal period as well(13).One report supporting thispresumption suggests that indeveloping countries, amongall etiologies of cerebral palsy,prematurity and intrauterine growthrate restriction (40 -50%) and birthasphyxia or birth trauma (25-30%)are the most common causes(14).In order to prevent neurodevelopmentaldisorders, one of themost effective strategies universally,is early intervention following earlydetection of the most subtle andearliest signs of neuro-developmentaldisorders. Thus the early signs andsymptoms for primary physiciansis very important for referral for thesecond level of assessment whichis performed by experts and withprofessional tests.On the other hand, cerebral palsyis a common cause of disability inIranian children. Because there hasnot been any research about themost frequent etiologies and kindsof CP and its associated disorders,this research has been done tospecify the most frequent causes forbetter management and preventionfor reducing incidence in Iran anddeveloping countries such as Iran.Since prevention is superior totreatment especially for disease suchas CP, the importance of this researchwill be noted.Materials and MethodThis study was carried out inthe years 2004-2006, on 112 oneto six-year old children, who werereferred from different health-carecenters in the northern and easterndistricts of Tehran to the child neurodevelopmentservice at the UniversityRehabilitation Clinic in the easternand northern Tehran provinces ofIran and were evaluated at 3-monthlyintervals for at least two years.The reason for choosing thenorthern and eastern districts waseasier geographical accessibility tothis center for the referred childrenand their families. The gender andsocio - economic status were thesame of Tehran province, the capitalcity of Iran, with 20 million inhabitants,(all coming from the same districts inTehran city).In order to detect etiology, aquestionnaire was completed for eachchild, including the prenatal, perinatal,neonatal and infantile medical history,with the aid of the mother and thechild’s medical and health records.At the initial assessment, informationon their demographic characteristics,clinical data including the durationof gestation and labor, place andmethod of delivery, number of fetusesand outcome, birth weight, maternalpast and current medical and socialhistories, complications duringpregnancy and labor was collected.In addition, information on stillbirths,abnormal children, ante partumhemorrhage, and exposure to drugs,exanthemata, and febrile illnesssevere enough to warrant admissionto the hospital in the mother duringthe current pregnancy, was alsoobtained.Baseline investigations includedcomplete blood count, serumelectrolytes, renal, thyroid and liverfunction tests. Organic acid screen,TORCH study, serum lactate andpyruvate, electroencephalography(EEG) and cranial computerized axialtomography (CT) or MRI, visual andhearing evaluation were obtainedon clinical suspicion and were notperformed in any of the children.Information on intrauterine growthand details of monitoring of fetalgrowth for any of the children wasalso not available.The questionnaire had beenpreviously evaluated for contentvalidity and pilot studies had beencarried out.The diagnosis of CP was reachedusing predefined criteria for thestudy. CP was defined as a chronicdisability characterized clinically bynon progressive aberrant control ofmovement that appears early in lifeand is not caused by a recognizedprogressive disease or identifiedetiology such as encephalitis orMIDDLE EAST JOURNAL OF FAMILY MEDICINE •VOLUME 6, ISSUE 6 25