Generality
Infantile cerebral palsy is a neurological disorder, which mainly affects motor skills and muscle tone.
The symptoms of infantile cerebral palsy are very varied and each patient is a case in itself; this variability depends on the extent of brain damage, which is measurable only by radiological examinations (CT and nuclear magnetic resonance).
Although there is no possibility of recovery, therapeutic countermeasures can be put into practice that can improve patients' symptoms and standard of living.
What is infantile cerebral palsy?
Cerebral cerebral palsy is a persistent, non-progressive neurological disorder that alters movement coordination, posture, tonicity and mastery of skeletal muscles, perception of space and a child's communication skills.
Epidemiology
According to some English statistics, every 400 newborns are born with child cerebral palsy.
As will also be seen in the chapter dedicated to causes, the subjects most affected are those born prematurely (40-50% of cases) and those who have an extremely low birth weight (6% of cases).
70-90% of children, with infantile cerebral palsy, developed the disorder before birth.
Causes
Infant cerebral palsy arises after an insult to the brain - suffered by the patient before, during or after birth - has blocked its normal development and damaged part of its nervous structure.
But what exactly does this damage cause?
At one time, it was believed that infantile cerebral palsy was solely linked to an episode of asphyxiation in the child during childbirth. Since the 1980s, however, numerous scientific studies conducted on this subject have shown the existence of other risk factors, which occur more frequently before the birth of the child.
Here is a list and brief description of potentially dangerous situations:
- A genetic mutation affecting one or more genes involved in brain development.
- A mother's health problem during pregnancy; disorder that can be represented by a viral or bacterial infection that is transmitted to the fetus, from a thyroid problem, from contact with toxic material, etc.
- A fetal stroke, which consists of an interruption of blood flow to the child's brain (both before and after birth).
- A lack of oxygen in the brain compartment (asphyxia), which occurs due to labor or a problematic birth.
- A fetal infection, which affects the brain of the child after birth, or a condition of jaundice, or jaundice, severe (always after birth).
- Brain trauma to the child. Examples of traumas are those caused by a fall from the bed or the bike seat.
- Premature birth : it is considered as such when it occurs before the 37th week of gestation. According to a statistical survey, all those born before the 32nd week are at high risk.
- Low birth weight : high risk children are those who weigh between 1 and 1.5 kilograms.
- Breech birth, that is when the child, at birth, appears with the feet, rather than with the head.
In the following, some aspects related to the health problems of the mother and child will be studied in depth.
Figure: attention, when pregnant, to viral or bacterial infections: some may have effects on the fetus.
MATERIAL HEALTH DISORDERS
Maternal infections associated with infantile cerebral palsy are:
- Rubella . Caused by a virus, there is an effective vaccine.
- Chickenpox . It is a viral infection that can be prevented with a vaccine.
- Cytomegalovirus . This viral infection causes symptoms similar to those of influenza, but unlike the latter it can cause serious problems to the fetus (not only the infantile cerebral palsy).
- Toxoplasmosis . It is caused by a parasite that is usually found in contaminated food or in the faeces of infected cats.
- Syphilis . It is a bacterial infection, transmitted sexually.
Furthermore, they are situations favoring exposure to methylmercury, thyroid problems, arterial hypertension and recurrent epilepsy attacks.
INFECTIONS AND OTHER DISORDERS IN THE CHILD
The newborn is at risk of cerebral palsy if he takes one of the following conditions: bacterial meningitis, viral encephalitis or severe (or untreated) jaundice.
Bacterial meningitis is an inflammation of the meninges, or the membranes that surround the brain and spinal cord.
Viral encephalitis is an inflammation of the brain and spinal cord.
Finally, severe jaundice is a pathological condition, in which bilirubin accumulates in the tissues due to its non-disposal; the classic sign of jaundice is the yellow color of the patient.
Symptoms and Complications
To learn more: Symptoms of Cerebral Childhood Paralysis
Each patient, suffering from infantile cerebral palsy, represents a case in itself, as the symptoms and signs depend on the severity and extent of the cerebral insult. In other words, the greater the damage to the brain, the greater the number of impaired brain functions.
The lack of coordination in the movements and the altered mastery of the skeletal muscles are, in absolute terms, the most characteristic manifestations of the disease; moreover, the symptom picture can be complicated with many other disorders, from those of learning and communicative faculties to those of sight and food intake.
Below is a full account of the symptoms that can characterize infantile cerebral palsy:
- Reduced muscle tone. Muscle mass weakens ( muscular hypotonia ) and takes on a soft appearance.
- Muscular spasticity, characterized by exaggerated tendon reflexes.
- Muscle stiffness .
- Lack of motor coordination ( ataxia ).
- Hand tremors or involuntary movements (for example, strange facial gestures).
- Slow twitching movements ( atetosis ).
- Delay or difficulty in learning to hold objects, to stand up without aid and to crawl.
- Difficult walking: the typical gait is on the tips, also known as scissor gait .
- Excessive drooling, difficulty in chewing and swallowing ( dysphagia ), language problems and in speaking clearly ( dysarthria ). All these disorders are due to the lack of control and hypotonia of the mouth and tongue muscles.
- Posture problems and column malformations, mainly due to poor muscle tone.
- Hearing and sight impairment; altered perception of depth.
- Epilepsy.
- Mental disorders and poor learning.
- Urinary incontinence.
Some frequently asked questions
- When do symptoms appear?
Symptoms generally appear within the first three years of life.
- Are the symptoms only one side of the body or both?
It depends on the extent of the damage the brain has suffered. If the insults are extended to both cerebral hemispheres, then the symptoms appear on both sides of the body. On the contrary, if the insult is limited to one of the hemispheres, the signs of infantile cerebral palsy appear on one side only.
- Is it a progressive disease?
Infantile cerebral palsy is a persistent but not progressive neurological disorder; therefore, it does not deteriorate over time. This does not exclude, however, that complications may arise due to poor muscle tone and lack of motor coordination.
COMPLICATIONS
They are mainly due to poor muscle tone, spasticity and lack of motor coordination.
The most important complications are muscle contractures : these, in the long run, hinder normal bone growth, deform the joints and cause arthrosis .
Afterwards, there are: malnutrition, especially when the difficulties of chewing and swallowing are considerable, and scoliosis, caused by a musculature of the trunk inadequate to weak.
Diagnosis
If the conditions exist for a child to be affected by infantile cerebral palsy, the first diagnostic check to be made is a thorough physical examination.
After that, the situation is definitively clarified by a series of specific checks on the brain (radiological examinations and electroencephalogram) and by laboratory tests.
EXAMINATION OBJECTIVE
During the physical examination, the doctor thoroughly analyzes the entire symptomatology and, together with the mother, investigates the clinical history of the small patient, from before birth to the moment of birth, to the immediately following days. For example, for what has been said about the risk factors, for diagnostic purposes it can be fundamental to know if the birth was premature, if the child weighed very little at birth, if there was a viral or bacterial infection to the detriment of the mother etc. This information is very often more important than all the various radiological and laboratory tests.
RADIOLOGICAL TESTS
Radiological images show the health conditions in which the brain is exposed and which areas of the organ are actually damaged. Furthermore, they are very important for the purposes of differential diagnosis, that is, in the exclusion of pathologies similar to the suspected one.
The exams consist of:
- Nuclear magnetic resonance ( NMR ): it is an examination not harmful to the health of the child, which takes place in an hour and shows the locations of the various brain anomalies.
- Computerized axial tomography ( TAC ): takes place in about 20 minutes and is able to show cerebral insults. It uses low doses of harmful ionizing radiation.
- Brain ultrasound : of the three, it is the least reliable. It takes place due to its speed and non-invasiveness.
EEG (EEG)
The EEG measures brain electrical activity, using electrodes applied to the patient's head. Often, this examination is used when the patient, with suspected infantile cerebral palsy, shows epilepsy attacks.
LABORATORY EXAMINATIONS
Blood tests (from the classic ones to genetic tests) are necessary, to the doctor, to exclude or not the possibility that the disorders are due to pathologies of blood coagulation or to congenital genetic diseases.
OTHER CHECKS
Based on the symptoms expressed by the patient, it is possible to carry out a long series of additional investigations, which concern sight, hearing, language skills, intellectual faculties, motor coordination, etc. The purpose is to assess the extent of the problem in order to plan the right treatment.
Treatment
Since the insult to the brain cannot be repaired, infantile cerebral palsy is not curable.
However, therapeutic countermeasures are available, able to improve the symptoms (consequently also the standard of living) and slow down the onset of complications. These treatments are mainly based on pharmacology and physiotherapy, although surgery (in the most severe cases), occupational therapy and speech therapy should not be excluded.
Once the pathology has been diagnosed, the parents of patients are advised to entrust their children to a team of doctors and experts in the field, to guarantee the best care (from infant to adult age).
PHARMACOLOGICAL TREATMENT
The pharmacological treatment aims to improve the disorders related to muscle spasticity and stiffness.
Botox side effects:
- Redness, itching and pain at the injection site
- Headache
- Muscle weakness
- Breathing difficulties
The choice of the most appropriate drugs depends on which and how many muscles are involved.
If spasticity is isolated to a group of muscles, the doctor will prescribe injections of Botox ( botulinum toxin ) directly into the affected area. If, on the other hand, spasticity is generalized (ie it includes more parts of the body), the doctor will subject the patient to oral administration of:
- Diazepam . Its prolonged use is not recommended, because it could cause dependence. The side effects are drowsiness and a sense of tiredness.
- Dantrolene . May cause the following side effects: nausea, diarrhea and drowsiness.
- Baclofen. Its side effects are drowsiness, confusion and nausea.
Other drugs used:
- Scopolamine
- glycopyrrolate
- trihexyphenidyl
Figure: some supports for the walking of children
PHYSIOTHERAPY
The purpose of physiotherapy is to improve muscle strength and elasticity, joint mobility and the patient's motor coordination.
Furthermore, the physiotherapist must take care to teach parents which movements and which exercises should be performed at home; in fact, the physiotherapy sessions alone are not enough.
If the conditions of the patient require it, it is useful to resort to guardians and walking aids (crutches, wheelchairs, etc.).
OCCUPATIONAL THERAPY
Occupational therapy has two main objectives:
- To favor the insertion of the patient in the social context (school, family, etc.), when this begins to relate to the world.
- Making the patient as independent as possible from others, teaching them to take care of themselves, to use walking aids adequately, to adapt to an environment unsuitable for their motor skills, etc.
All this requires a prepared therapist.
SPEECH THERAPY
The speech pathologist offers the patient functional rehabilitation exercises, aimed at improving compromised communication skills and broken language.
In the most serious cases, it can instruct the patient to use technological aids, such as a computer or tablet.
SURGERY
Surgery is used only when muscle spasticity causes such painful contractures that no other treatment can alleviate them.
Possible interventions are of two types.
The first corrects joint deformities, in such a way as to improve mobility ( orthopedic surgery ).
The second consists of the section (intended as a cut) of the nerves, which control the contracted skeletal muscles. This approach, called rhizotomy (because nerve roots are cut), is somewhat invasive and, although it greatly reduces the pain suffered by the patient, causes a constant sense of muscle numbness.
Prognosis and prevention
The prognosis, for a patient with infantile cerebral palsy, can never be positive, since the disease, despite not progressively worsening, is persistent and incurable.
Moreover, the extent of brain damage must also be considered: when the insult was noticeable, the therapies are of little success and the prognosis is, inevitably, poor; vice versa, in cases where the lesion has been limited, the effects of the treatments are discrete and the prognosis, compared to the previous cases, is better.
PREVENTION
Infant cerebral palsy cannot be prevented; however, risk situations can be reduced. In this perspective, the mother, or a woman who wants to have a child, should:
- Get vaccinated against infections whenever possible
- Take care of your health and live in a healthy environment, away from infectious sources or toxic substances
- When you are pregnant, undergo regular medical checks. In particular, if there have already been experiences of premature births or those characterized by low birth weight.
- Use all the available precautionary measures (seat belts, bed with protections, helmets for the bike, etc.), to safeguard the health of your child, especially in the first years of life, in which the risk of developing infantile cerebral palsy is very high high.
