Pediatrics Book

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Cerebral Palsy

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  1. Epidemiology
    1. Incidence: Up to 2.5 per 1000 U.S. born children
  2. Pathophysiology
    1. Brain injury occurring before age 2 years
  3. Causes
    1. Prenatal causes or risk factors: Up to 80% of cases
      1. Delivery complications (i.e. asphyxia): 6% of cases
      2. Preterm birth before 32 weeks or <2500 grams
      3. Intrauterine Growth Retardation
      4. Intracranial Hemorrhage
    2. Postnatal causes (<20%)
      1. CNS Infection
      2. Head Trauma
      3. Hyperbilirubinemia
  4. Signs
    1. Limb spasticity (80% of cases)
      1. Hypertonic muscle movement
      2. Hyperreflexia
      3. Scissors gait
      4. Toe-walking
    2. Diskinesia (10-20% of cases)
      1. Slow, writhing limb movements worse during stress
    3. Ataxic cerebral palsy (5-10% of cases)
      1. Wide-based gait
      2. Intention Tremor
  5. Associated findings
    1. Cognitive Impairment (66% of cases)
    2. Seizure disorder (50% of cases)
    3. Growth delay
    4. Hearing Impairment
    5. Vision Impairment
      1. Screen for Strabismus and hemianopia
    6. Gastrointestinal disorders
      1. Vomiting (delayed gastric emptying)
      2. Constipation (GI motility, dehydration, mobility)
    7. Swallowing difficulty
      1. Aspiration risk
      2. Drooling
      3. Inadequate oral intake
    8. Osteoporosis
    9. Urinary Incontinence
    10. Altered sensory perception (pain on light touch)
  6. Diagnosis
    1. Assessment Tools
      1. Gross Motor Function Classification System for CP
        1. Palisano (1997) Dev Med Child Neurol 39:214
    2. Findings suggestive of cerebral palsy
      1. Slow motor development
      2. Altered muscle tone and posture
      3. Moro reflex persists beyond 6 months of age
      4. Dominant hand preference established under 12 months
    3. Findings of alternative diagnosis (neurodegenerative)
      1. Loss of acquired skills
      2. Atypical body odor (as seen in metabolic disorders)
      3. Loss of Deep Tendon Reflexes
  7. Differential diagnosis
    1. Consider neurodegenerative disorders
    2. Examples
      1. Arginase deficiency
      2. Glutaric aciduria
      3. Niemann-Pick Disease
      4. Lesch-Nyhan Syndrome
      5. Rett Syndrome
  8. Management
    1. Global therapies with variable efficacy
      1. Neurodevelopmental treatment (Bobath method)
      2. Conductive education with rehabilitation program
    2. Physical therapy
      1. Balance benefit with stress of frequent visits
      2. Resistive Exercise is controversial
        1. Has been avoided due to increased spasticity risk
        2. Recent studies suggest strengthening is beneficial
          1. Dodd (2002) Arch Phys Med Rehabil 83:1157
    3. Medications: Spasticity
      1. Botulinum toxin (Botox) injections for leg spasticity
        1. Reddigough (2002) Dev Med Child Neurol 44:820
      2. Baclofen (Lioresal) intrathecally
        1. Campbell (2002) Dev Med Child Neurol 44:660
    4. Medications: Pain (especially Hip Pain)
      1. Assess pain and treat adequately
    5. Surgery
      1. Leg spasticity
        1. Selective dorsal rhizotomy
          1. Selective cutting of L1-S2 dorsal rootlets
      2. Muscle imbalance with hip subluxation, dislocation
        1. Abduction bracing
        2. Soft tissue release
        3. Femoral or pelvic osteotomy
      3. Implantable stimulator to superior-medial Cerebellum
        1. Davis (2000) Arch Med Res 31:290
      4. Gastrostomy for swallowing and eating difficulties
        1. Samson-Fang (2003) Dev Med Child Neurol 45:415
    6. Adjuncts
      1. Lower limb orthoses (variable evidence)
      2. Elastic body suits (difficult compliance)
    7. General measures
      1. Multidisciplinary approach (care team)
      2. Assistive Devices for Activities of Daily Living
      3. Enable mobility
      4. Address Mood Disorders
  9. Prevention of secondary conditions
    1. Observe for cancers of higher risk in cerebral palsy
      1. Brain cancer
      2. Breast Cancer
      3. Routine health maintenance
        1. Left lateral position more comfortable for pelvic
    2. Educate about injury risks
      1. Drowning risk
      2. Motor vehicle accidents
  10. References
    1. Krigger (2006) Am Fam Physician 73:91

Cerebral Palsy (C0007789)

Definition (MSH)A heterogeneous group of nonprogressive motor disorders caused by chronic brain injuries that originate in the prenatal period, perinatal period, or first few years of life. The four major subtypes are spastic, athetoid, ataxic, and mixed cerebral palsy, with spastic forms being the most common. The motor disorder may range from difficulties with fine motor control to severe spasticity (see MUSCLE SPASTICITY) in all limbs. Spastic diplegia (Little disease) is the most common subtype, and is characterized by spasticity that is more prominent in the legs than in the arms. Pathologically, this condition may be associated with LEUKOMALACIA, PERIVENTRICULAR. (From Dev Med Child Neurol 1998 Aug;40(8):520-7)
Definition (CSP)heterogeneous group of nonprogressive motor disorders caused by chronic brain injuries that originate in the prenatal period, perinatal period, or first few years of life; the four major subtypes are spastic, athetoid, ataxic, and mixed cerebral palsy, with spastic forms being the most common; the motor disorder may range from difficulties with fine motor control to severe spasticity in all limbs; spastic diplegia (Little disease) is the most common subtype, and is characterized by spasticity that is more prominent in the legs than in the arms.
ConceptsDisease or Syndrome (T047)
ICD9343.9
MSHD002547
EnglishCerebral palsied, CEREBRAL PALSY, CP - Cerebral palsy, PALSY CEREBRAL
Spanishparalisis cerebral
Parent ConceptsBrain Diseases (C0006111), Brain Damage, Chronic (C0006109), Neurodegenerative Disorders (C0524851), Ambiguous concept (C1274012)
SourcesCOSTAR, CSP, CST, DXP, LCH, LNC, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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