MANAGING CHILDREN WITH CEREBRAL PALSY

Master O.K is an 11 months old infant who was brought to the clinic because the mother noticed the child cannot crawl or made attempt to stand. 

The infant’s history was taken, the examination was done and the infant’s condition was said to be fair.

She was asked to bring the husband the following day for full explanation of the child’s condition.

The following day i explained to the parents that the child was likely to have suffered some brain damage during child birth, a condition called Birth Asphyxia. 

The Infant now has Cerebral Palsy (CP). This means this child developmental milestones will be delayed that is, she will not be able to walk, talk, stand and probably hear on time.

Cerebral palsy (CP) is not a disease; it is not hereditary or contagious, it is a disability.
The disorder can be managed with proper therapies and medication, with the use of assistive technology that can maximise independence, reduce barriers and enhance quality life.

Parents of children with this special condition need adequate orientation and education so that they would know the health status of their children.

The first thing a family whose child was diagnosed with CP needs is counselling, information and education; without this, the family will be left groping in the dark.
Management of CP is not only intensive, it is expensive. CP is said to be one of  the most expensive congenital disorder to manage. It is difficult for a family to keep up.

I have approached Dr Gbemisola Boyede a Consultant Neurodevelopmental Paediatrician at the department of Paediatrics, Lagos University Teaching Hospital (LUTH) to give us a specialist overview to the subject.

Here is Dr Gbemisola,s overview: Cerebral palsy often abbreviated as CP is a group of disorders that affect a person’s ability to move and maintain balance and posture.

“Cerebral” means having to do with the brain. “Palsy” means weakness or problems with using the muscles.

The problem in CP is actually caused by abnormal brain development or damage to the developing brain (early childhood) that affects a person’s ability to control his or her muscles. The 7th October is World Cerebral Palsy Day. This is a day set aside to create awareness and support for the 17million people worldwide who live with cerebral palsy.

CP is the most common motor disability in childhood. The prevalence of CP is 2–3 per 1000 live births. It is especially much more common (100 per 1000 live births) in children who were born extremely premature.

CLINICAL FEATURES

Although the abnormality in the brain remains unchanged (non-progressive), the clinical picture of CP may change or be modified with age.

All people with CP have problems with movement and posture.  However, these are not the only problems with CP.

Many also have other conditions such as intellectual disability; seizures; problems with vision, hearing, or speech; changes in the spine (such as scoliosis); or joint problems (such as contractures).

The associated problems may even be more limiting to lifestyles than the posture or movement problems which primarily defined CP. 

The symptoms of CP vary from person to person. A person with severe CP might need to use special equipment to be able to walk, or might not be able to walk at all and might need lifelong care.

A person with mild CP, on the other hand, might walk a little awkwardly, but might not need any special help. CP does not get worse over time, though the exact symptoms can change over a person's lifetime.

CAUSES

Most of the time the cause of a child’s CP is not known, because it is difficult to tell exactly when the damage to the brain happened.

However common causes of CP in our own environment are delayed cry at birth (perinatal asphyxia) due to anything going wrong before and during delivery, prematurity (especially below 32 weeks and weight less than 1.5kg)

Other causes are severe neonatal jaundice (often requiring exchanged blood transfusions), infections in the brain (meningitis), bleeding in the brain, severe convulsions after birth and head injuries in very young children. 

Last week, a concise and brief explanation on cerebral palsy was made by a female colleague, Dr. Gbemisola Boyede.

She described cerebral palsy, often abbreviated as CP, as a group of disorders that affect a person’s ability to move and maintain balance and posture.
Boyede also said that the common causes of CP in our own environment are delayed cry at birth (asphyxia) due to anything going wrong before and during delivery, prematurity and jaundice in the new born.

SIGNS
The signs of CP vary greatly because there are many different types and levels of disability. The main sign that a child might have CP is a delay reaching motor or movement milestones (such as rolling over, sitting, standing, or walking).

Other early signs of possible CP in children younger than six months include head lag, stiffness of the body (sometimes the baby feels floppy) and overextension of the back and neck. Also, at times, the child’s legs get stiff and they cross or form a scissor.

In children older than six months, features suggestive of CP include: the child doesn’t roll over in either direction, he/she cannot bring her hands together.
He/she has difficulty bringing her hands to her mouth and he/she reaches out with only one hand while keeping the other fisted.

In infants older than 10 months, the child may crawl in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg. At times, most children with CP are not diagnosed until they are two years old when parents seek help because they are not walking.

Treatment
There is no cure for CP, but treatment can improve the lives of those who have the condition. It is important to begin a treatment programme as early as possible.
After a CP diagnosis is made, a team of health professionals works with the child and family to develop a plan to help the child reach his or her full potential.
Common treatments include medicines, surgery, braces, and physical, occupational, and speech therapies.
No single treatment is the best one for all children with CP. Most children get a combination of therapies.

Prevention
Prevention of CP is a major challenge because we do not always know why a child has it. Some strategies that can prevent some causes of CP include good and prompt antenatal care. This may help to reduce chances of preterm delivery by recognition and proper management of high risk pregnancies.
Supervised delivery by skilled healthcare workers and prompt management of complicated deliveries is another useful strategy.

Childhood Immunisation may prevent meningitis and CP due to brain infections.
Early detection and treatment of neonatal jaundice will also prevent CP due to brain damage from severe jaundice.
It is also important to avoid head injury in children by using car seats.
Where primary prevention is impossible early diagnosis and treatment will help to prevent more complications and allow the children to maximise their potential and live a good quality life.

Conclusion

In conclusion, CP is life-long. A child will always have CP and it will not go away. The earlier the diagnosis is made and therapies commenced, the better the outcome for the child.
If you observe any of the early signs mentioned in your child, please go to the hospital and see a paediatrician who is trained in managing children with developmental problems or a paediatric neurologist.
Although we cannot cure CP, all children have the potential to change
.
Dr Gbemisola Boyede is a consultant neurodevelopmental paediatrician at the Lagos University Teaching Hospital (LUTH). She can be reached via gbemmydevpaed@yahoo.com.

Proper management can help children to outgrow asthma

Asthma occurs when there is an obstruction of the airways that carry air to and from the lungs, or when there is a swelling or an inflammation of the airways and hyper-responsiveness.

Most of the time, it is noticed in very early childhood. Asthma is not just one particular disease condition; it is a range of conditions. Cases of asthma in children between ages two and six is commonest, while the least percentage one finds is between 12 and 16 years, when the majority of them would have outgrown it.

Those who still have asthma at that teenage age are likely to have it into adulthood. About 60 per cent of children with asthma are less than six years; the remaining 40 per cent will be in children between seven years and 16 years of age.

The child should be taken to the hospital for regular check up every three to six months. That would help to ensure that the child does not suffer many of the problems resulting from the disease.

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Asthma could affect the psychology and even growth of the child if not properly managed. But if managed and treated properly, the child could outgrow it. Again, the parents should comply with the prescription that accompanies drugs given by the doctor.

They should not wait until the child has the symptoms before they give the medications.

Causes

Hereditary factor is also important to know if a child is susceptible to asthma. For example, if there is a family history of it, that is, if someone in that family is asthmatic or has reactive conditions, such as particular allergies, it could lead to asthma or what is also called hyper-reactive airway disease.

The majority of children outgrow asthma later in their teenage years.

Industrial/air pollution triggers asthma. Also, the more developed a place is, the more likely they would have a higher rate of asthma cases. Cities like Lagos would be expected to have a high rate of asthma cases.

Effluents from cars and industries have also been associated with asthma. It also depends on other factors, including hereditary and the person’s predisposition to allergies and certain conditions.

Fumes from generators used in residential areas, or smoke from firewood have all been implicated as trigger factors.

Some people can actually have it without any hereditary link, but they are in the minority.

I will use the experience of one of my patients to narrate the shortage of asthma facilities in Nigeria.

Mrs. A.Y brought her six-year-old with symptoms and signs suggestive of asthma. She had been to two other hospitals where she was told that her son had asthma.

After I took her son’s medical history, family history of asthma and the complaints (symptoms) similar to asthma, I proceeded to examine the young boy.

He was very cooperative, I ordered some blood test for infections, blood count and allergy. They all came out negative, even the chest X-ray was normal.

I explained to her that her son would have a provisional diagnosis of childhood asthma. She requested a confirmation. I explained to her that the definite diagnosis of asthma would be on the result of a lung function test from a spirometer or a simple peak flow meter.

She was not pleased as she insisted on having the lung function test done. Unfortunately, after visiting other hospitals for the spirometry, she came back telling me that she was disappointed with the health care system in the country.

According to her, none of the five specialist hospitals, two children hospitals and one public teaching hospital she visited had a functioning spirometer.

A spirometer is an apparatus for measuring the volume of air inspired and expired by the lungs. A spirometer measures ventilation, the movement of air into and out of the lungs. It is used in diagnosing different types of abnormal ventilation patterns.

The test is very simple and it involves asking the patient to take in a big breath and then blow as hard and long as he or she can into a machine with a meter that reads the lung volumes.

Lack of this equipment has compromised the definite diagnosis of asthma in the nation’s hospitals. Government must look into it.

Back to Asthma.

Signs and symptoms

The child has difficulty in breathing or shortness of breath, cough, which is worse at night. It also depends on the degree of severity of the asthma. But the first signs are breathlessness and cough, pigeon chest – the chest may look bloated like that of a pigeon because of air congestion, the child is breathing air but cannot breathe it out.

Diagnosis

Most people who are said to be asthmatic are not. A diagnosis, which includes the lung function test, as well as spirometry, where the child is asked to take in a big breath and then blow as hard and long as he or she can into a machine, is used in making definitive diagnosis. It is especially in use for young children.

There is also the peak flow metre, used to measure how well air moves out.

There is also the six-minute walk test.

• To be continued