Cerebral palsy in children
Children with cerebral palsy may have abnormal muscle tone. Muscles may be very stiff (spastic) or unusually relaxed and “floppy.” Limbs may be held in unusual or awkward positions.
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For example, spasticity of the leg muscles may cause legs to cross in a scissor-like position. They may also have abnormal movements which may be jerky or abrupt, or slow and writhing. These abnormal movements may appear uncontrolled and purposeless.
People who have cerebral palsy on only one side may have shortening of the limbs, particularly the leg on the affected side. This can cause tilting of the pelvic bones and scoliosis (curvature of the spine).
Another presentation may be in the form of joint contractures, especially those with spastic type of CP may develop severe stiffening of the joints because of unequal pressures on the joints exerted by muscles of differing tone or strength.
Some patients with CP may have mental retardation. The first indication of this may be severe teeth grinding and generally, the more severe the retardation, the more severe the overall disability. About one third of people with cerebral palsy have seizures. Seizures may appear early in life or years after the brain damage that causes cerebral palsy. Seizure may be masked by the abnormal movements seen in cerebral palsy patients.
Speech is partly controlled by movements of muscles of the tongue, mouth and throat. Some individuals with cerebral palsy are unable to control these muscles and thus cannot speak normally.
Furthermore, swallowing is a very complex function that requires precise interaction of many groups of muscles. People with CP who are unable to control these muscles will have problems sucking, eating, drinking and controlling their saliva. They may drool. An even greater risk is aspiration, the inhalation into the lungs of food or fluids from the mouth or nose. This can cause recurrent lung infections or even death through suffocation.
Partial or even total hearing loss is not unusual in people with cerebral palsy. The child may not respond to sounds or may have delayed speech. Three quarters of people with cerebral palsy have squint, the turning in or out of one eye due to weakness of the muscles that control eye movement. They also have dental problems such as cavities and caries a result of both defects in tooth enamel and difficulties in brushing the teeth. Also due to lack of muscle sphincter control, CP patients may have bladder and bowel incontinence.
There is no medical test that confirms the diagnosis of cerebral palsy. The diagnosis is made from the history and physical examination and some specialised laboratory investigation. Relevant information in the history includes medical histories of both the mother’s and father’s families, the mother’s medical problems before and during pregnancy, and a detailed account of the pregnancy, labour, delivery and the newborn period.
Relevant physical examination include observation of posture, gait, head measurement, eye movements, complete systemic examination including the heart and lung fields, muscle tone, reflexes, etc.
Various blood and urine tests may be requested if there is suspicion that the child’s difficulties are due to chemical, hormonal, or metabolic problems. Chromosomal studies, including Karyotyping and specific DNA analysis, may be done for syndromic babies.
Imaging studies provide a picture of structures inside the body. These tests are not always necessary, but in many cases, they may help identify the cause or extent of the cerebral palsy. They should be done as early as possible so that appropriate treatment, if indicated, can be instituted. Many individuals with mild cerebral palsy have no visible brain abnormalities. These include Ultrasound of the brain which uses harmless sound waves to detect certain types of structural and anatomic abnormalities. It can show bleeding in the brain or damage caused by lack of oxygen to the brain. Ultrasound is often used on newborns whose fontanelles are still patent.
CT scan of the brain gives a three-dimensional image which helps identify malformations, bleeding and certain other abnormalities in infants more clearly than ultrasound.
MRI of the brain: This is the preferred test, since it defines brain structures and abnormalities more clearly than any other method. Children who are unable to remain still for at least 45 minutes may require medicines to make them sleep to undergo this test.
MRI of the spinal cord: This may be necessary in children with spasticity of the legs and worsening of bowel and bladder function, which suggest an abnormality of the spinal cord. Such abnormalities may or may not be related to cerebral palsy.
Under certain circumstances, your child may have to do other tests such as Electroencephalogram (EEG), which is important in the diagnosis of seizure disorder. A high index of suspicion is needed in order to detect non-convulsive or minimally convulsive seizures.
Electromyogram (EMG) and nerve conduction studies (NCS) may be helpful in distinguishing CP from other muscle or nerve disorders.
Will conclude with treatment and my verdict on your interactions with health professionals next week.
A member of Paediatric Society of Ghana
