CEREBRAL PALSY KIDS APPROACH AND MANAGEMENT

cerebral palsy

1. CEREBRAL PALSY

2. A group of permanent disorders of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or immature brain.  prevalence1.5 to 3 per 1,000 live births Postneonatal CP results from an injury to the brain after neonatal period and before 5 years of age (traumatic brain injury, neardrowning , and meningitis)

3. Factors associated with a higher risk for CP Congenital brain malformations Genetic susceptibility Hypoxic-ischemic encephalopathy In utero or perinatal stroke In vitro fertilization Kernicterus Low birthweight Maternal disorders of clotting Maternal- fetal infections Multiple gestation Neonatal seizures Neonatal sepsis or meningitis Postneonatal meningitis Postneonatal traumatic brain injury Pre-pregnancy obesity Preterm birth

4. EARLY SIGNS OF CP 3-6 MONTHS 6-10 MONTHS > 10 MONTHS Head falls back when picked up while lying on back Feels stiff Feels floppy Seems to overextend back and neck when cradled in someone’s arms Legs get stiff and cross or scissor when picked up Doesn’t roll over in either direction Cannot bring hands together Has difficulty bringing hands to mouth Reaches out with only one hand while keeping the other fisted Crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg Scoots around on buttocks or hops on knees, but does not crawl on all fours

5. Comorbidities in CP Pain75% Intellectual disability50% Gait disorders33% Hip displacement33% Speech problems25% Epilepsy25% Incontinence85% Sleep disorders40% Hearing impairment9% Vision impairment10% Cognitive impairment77% Thyroid dysfunction3% G.I. disturbances2% Behavior disorders25%

6. MRI Brain – 90% abnormal When to suspect metabolic/genetic etiology ? Abnormal neuromotor development, Loss of motor skills, Unexplained hypoglycemia, Recurrent vomiting or seizures A family history of unexplained neurologic symptoms or infant deaths

7. MANAGEMENT OF CP

8. Modified Ashworth scoring system spasticity Grade 0 No increase in muscle tone Grade 1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension Grade 1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM Grade 3 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved Grade 3 Considerable increase in muscle tone, passive movement difficult Grade 4 Affected part(s) rigid in flexion or extension

9. Management of Spasticity PHARMACOLOGICAL Baclofen – dose 0.12–1 mg/kg/day Tizanidine – 0.3 mg–0.5 mg/kg/day D iazepam – 0.12–0.8 mg/kg/day C lonazepam – 0.01–005 mg/kg/day ) Dantrolene sodium: 3–12 mg/kg/day . IM botulinum toxin A NON PHARMACOLOGICAL Physiotherapy Occupational therapy Use of adaptive equipment and orthoses Orthopedic surgical procedures Selective dorsal rhizotomy

10. Management of Dystonia Trihexyphenidyl – Anticholinergic . Starting dose of 0.1–0.2 mg/kg/day, increase once in 3 days to the maximum dose of 1 mg/kg/day (total-max dose <10 kg–30 mg/day and more than 10 kg–60 mg/day. can be tried with monitoring adverse effects). The main side effects are dry eyes and mouth, gastrointestinal disturbances, urinary retention , and behavioral disturbances Tetrabenazine dose 0.5 mg–4 mg/kg/day. In 2 or 3 divided doses, increase once in 3 days. Side effects include drowsiness, parkinsonism, depression, insomnia, nervousness, anxiety, and akathisia Baclofen (in high doses 1 mg/kg /day reduces dystonia ) Levodopa ( Syndopa ) – start at 0.5 mg/kg/day up to 10– 20 mg/kg/day) Benzodiazepines (e.g., diazepam – 0.12–0.8 mg/kg/day and clonazepam – 0.01–005 mg/kg/day) Deep brain stimulation.

11. PROGNOSIS OF CP Poor prognostic factors: quadriplegic and dyskinetic CP, IQ <50, severe visual impairment, active epilepsy, absence of rolling over/sitting/crawling at 2 years of age, absence of functional hand use by 2 years, the persistence of primitive reflexes beyond 2 years of life, GMFCS class IV to V.

12. Prognosis based on MRI