A clinical study of children with cerebral palsyin a
tertiary care in Assam
Devi
D1, Gedam DS2, Verma M3
1Dr
Dipti Devi,Ex.Associate Professor of Pediatrics, Tezpur Medical College,Assam,
India, 2Dr D Sharad Gedam, Associate Professor, Department of Pediatrics,
Government Autonomous Medical college, Vidisha, MP, India, 3Ms Mamta
Verma, Associate Professor, AIIMS College of Nursing, Bhopal, MP, India
Address
for Correspondence: Dr D Sharad Gedam, Associate Professor,
Department of Pediatrics, Government Autonomous Medical college, Vidisha, MP,
India, Email: sharad.gedam@gmail.com
Abstract
Introduction:Cerebral
Palsy is not a disease but a condition affecting health and well being of a
child. Reports claim a rising incidence of cerebral palsy. Fifty children with
cerebral palsy were studied to find out the etiological factors and the
clinical findings. Method: A
retrospective, cohort, observational study was done in 50 children with
cerebral palsy attending the department of Pediatric,Tezpur Medical College,
Assam from Feb 2016 to Nov 2017.Results:Male
to female ratio was 7:3. Prenatal, natal and postnatal factors were found in
16%, 30% and 38% of cases respectively. In 8% of cases, cause was unknown.Birth
Asphyxia was the commonest cause and spasticity was the commonest clinical
type. Epilepsy and speech defect were the commonest problems associated with
cerebral palsy. In 86% of cases the cause of 1stconsultation was
after 3 years with complain of not able to walk. Of all the cases 6% were
diagnosed at High Risk Clinic at around 6 months of age. Conclusions: This study suggestsimprovement of maternal and child
health care and follow up of high riskchildren from birth onwards.
Key
words: Cerebral palsy, Etiology, High risk clinic
Author Corrected: 26th July 2018 Accepted for Publication: 30th July 2018
Introduction
Cerebral Palsy is not a disease but
a condition affecting health and wellbeing of the child and the members of his
family.It is reported as 2 per 1000live birth [1]. Reports from developed
countries claimed rising incidences because of better intensive care [2,3]. CP
is a non-progressive impairment in movement or posture caused by injury or anomaly
of the developing brain[4].Various reports have been published till now
regarding etiology. But the exact etiology is not clear till today. In our day
to day practice, we often getsuch children. In this study an attempt was made
to find the etiological factors and clinical presentation of children with
cerebral palsy.
Perinatal factors include low birth
weight, hypoxic ischemic injury, hyperbilirubinemia, metabolic abnormalities hypoglycaemia
[5]. The families of the CP children are affected psychologically, financially
and socially [4]. It also imposes a huge burden on the national health system.
In India, neonatal care services are facing a challenging situation especially
in the rural and remote areas in the south of the country [4]. These factors
have all contributed to the increased percentage of children born with many
health disorders in India. However, shortages in studies exploring the actual
numbers and prevalence of these health problems have not helped those under
privileged population get the proper attention they need [5,6].
Recent improvements in neonatal care have not resulted in a decline in the overall prevalence of CP and, in fact, greater numbers of very preterm, very low birth weight infants are surviving with CP and other developmental problems. Therefore, the emphasis would mainly be on the availability of a functional and efficient antenatal care and on the availability of a well-equipped neonatal care units and services to avoid the problem of having babies with CP. This study aims at highlighting the need for more emphasis on antenatal and neonatal care services in prevention of CP.
Materials and Methods
A retrospective, observational,
cohort study was done in 50 children with cerebral palsy attending the department
of Pediatrics, Tezpur Medical college Hospital, Assamfrom Feb 2016 to Nov 2017.
Cerebral palsy was diagnosed as per definition of American Academy for cerebral
palsy [7] and by AmielTison method in high risk infants [8]. A thorough history
was taken.Term, birth weight more than 2.5 kg included in study.Children suspected
of degenerative diseases were excluded from the study.Etiological Factors were
classified as prenatal, natal, postnatal, mixed and unknown. Prenatal factors
were present during antenatal period, natal factors during delivery and post
natal factors after birth to 5 yrs of age. More than one factor was regarded as
mixed. In the absence of any factor, it was labeled as unknown. A thorough
clinical examination was done. Diagnosis was clinical. Classification was done
according to Mitchell [7]. Vision and hearing were examined by Stycar&
Sheridan’s and Sheridan’s method respectively [9,10]. Mental retardation is
very difficult to diagnose in a case with cerebral palsy. So cases were divided
as mentally normal or subnormal [11].Electroencephalography (EEG) was done in
symptomatic epilepsy.
Results
In the total 50 cases, case
distribution according to gender, birth order and socio- economic status is
shown in table 1
Table-1: Showing
demographic distribution
Total |
No
of children |
% |
Male |
35 |
70% |
Female |
15 |
30% |
1st
born |
22 |
44% |
2nd
born |
12 |
24% |
3rd
born |
11 |
22% |
4th
born |
3 |
6% |
5th
born |
2 |
4% |
High
socio-economic status |
6 |
12% |
Middle
socio-economic status |
17 |
34% |
Low
socio-economic status |
27 |
54% |
Out
of total 50 children, 35(70%) were male and 15(30%) were female, 22(44%) were 1st
born and 27(54%) were from low socio economic status.
The etiological factors may result
in injury to the developing brain from the date of conception to 5 years of
chronological age. Family history of cerebral palsy was present in 4 cases.
They were 2 siblings with congenital Toxoplasmosis, one paternal uncle and one
nephew. There can be varied number of insults during antenatal, natal or
postnatal periods.
Antenatal-Congenital
infection, IUGR, Vaginal bleeding, Hypertension, Chronic disease
|
|
Natal-
Birth asphyxia, Fetal distress, birth trauma
Postnatal-
Sepsis,
meningitis, marked jaundice, pneumonia, convulsion, respiratory distress
Table-2:
Aetiologicalfactors
Factor |
No
of cases |
% |
Antenatal |
8 |
16% |
Natal |
15 |
30% |
Postnatal |
19 |
38% |
Mixed |
4 |
8% |
Unknown |
4 |
8% |
Highest
numbers of factors were seen in natal (15=30%) and postnatal periods (19=38%).
The clinical types and associated
problems are shown in table 3.
Table-3:
Clinicaltypes and associated problems
Type |
No
of cases |
% |
Spastic
diplegia |
24 |
48% |
Spastic
hemiplegia(lt) |
5 |
10% |
Spastic
hemiplegia(rt) |
4 |
9% |
Spastic
triplegia |
2 |
4% |
Athetosis |
14 |
28% |
Hypotonic |
1 |
2% |
Spastic
double hemiplegia |
0 |
0% |
Associated
problems |
|
|
Epilepsy |
25 |
50% |
Mentally
subnormal |
25 |
50% |
Vision
defect |
5 |
10% |
Hearing
defect |
6 |
12% |
Speech
defect |
25 |
50% |
Malnutrition |
8 |
16% |
Dental
caries |
10 |
20% |
Squint |
5 |
10% |
Spastic
diplegia was found in highest number (24=48%). Epilepsy and speech defect were
the commonest associated problems.
Figure-1: Shows the
presenting problems for consultation
Out
of 50 children, more than 80% presented after 3 yrs of age for not able to
walk. On the otherhand, 6 % of children were picked up for early intervention
at the age of 6 months; all of them were attending HRC regularly.
Table-4:
Age at diagnosis
Beyond
infancy |
No
of cases |
% |
Not
attending high risk clinic(HRC) |
47 |
94% |
Attending
HRC |
3 |
6% |
Out of all cases, 94% were diagnosed beyond
infancy. All of them were not on follow up at high risk clinic.
Table-5: Studies
reporting etiological factors
Studies |
Antenatal |
Natal |
Postnatal |
Mixed |
Unknown |
Peristein,
USA |
30% |
60% |
10% |
- |
- |
Hagberg,Sweden |
21% |
48% |
10% |
- |
21% |
Elliot,Missouri |
39% |
46% |
15% |
- |
- |
Maureem,Nigeria |
- |
55% |
45% |
- |
- |
Makewabe,
Tanzania |
- |
24% |
72% |
- |
4% |
Laisram,
Delhi |
7% |
44% |
26% |
15% |
8% |
Present
study |
16% |
30% |
38% |
8% |
8% |
Our
study shows highest natal and postnatal factors like in Nigeria, Tanzania and
Delhi.
Discussion
According to World
Health Organization (WHO) estimation, 10% of the global population has some
form of disability due to different causes; in India, it is 3.8% of the
population. Nearly 15-20% of the total physically handicapped children suffer
from Cerebral Palsy (CP)[12].
It is found that
10% of the global population has some form of disability from different causes;
in India, it is 3.8% of the population. Nearly 15-20% of physically disabled
children are affected by Cerebral Palsy. In India, the estimated incidence is
around 3/1000 live births [13,14].
There are about 25
lakh CP children in India as per the last statistical information [15]. It is a
symptom complex or syndrome condition rather than a single disease. It is an
umbrella term encompassing a group of non-progressive, non-contagious condition
that causes motor impairment syndrome characterized by abnormalities in
movement, posture, and tone.[16]
Cerebral palsy
(CP), the most common motor disability in childhood resulting from a lesion
caused by early insults to the developing brain, is a syndrome that has a
serious impact on the life qualities of the affected children and their families.
The prevalence of CP is approximately 1.8–3.5 per 1000 live births in developed
countries [16,17].
There are several
antenatal factors, including preterm delivery, low birth weight,
infection/inflammation, multiple gestations, and other pregnancy complications,
that have been associated with CP in both the preterm and term infant, with
birth asphyxia playing a minor role. Due to the increasing survival of the very
preterm and very low birth weight infant secondary to improvements in neonatal
and obstetric care, the incidence of CP may be increasing [16].
In our study, Out of total 50
children, 35(70%) were male and 15(30%) were female similar to study done by
leisram et al they found [18]
Five hundred and forty four cases of cerebral palsy were studied to find the
etiology. Male to female ratio was 1.9∶1. Prenatal, natal and postnatal
factors were found in 42 (7.72%), 238 (43.75%) and 142 (26.1%) cases
respectively.Our study shows a male preponderance as according to
other workers [18, 19,20]. It may reflect the Indian culture of interest and
care of male siblings. The birth order was seen to be decreasing from 1st
to 5th born. A small family is better planned and taken care now.
Cases were increasing from high to low socio-economic statusindicating level of
care. Postnatal factors were the commonest followed by natal factors in our
study. Studies from developing country like Nigeria [21] and Tanzania [22]
reported same way.Developed countries like USA [23,24] and Sweden [25] reported
low postnatal factors. It may be because of better medical care in developed
countries. Current knowledge highlights on last trimester, perinatal and
postnatal adverse events as etiology of cerebral palsy [6].Late fetal, early
neonatal and postnatal hypoperfusion and dysmetabolic cellular derangement play
major role. Metabolic abnormalities during reperfusion injury contribute
substantially to the nature and extent of neuronal destruction of the
developing brain. Such major abnormalities are loss of cellular ATP, oxygen
free radical formation, cellular acid base disturbances, imbalance between
excitatory and inhibitory neurotransmitter activity and deranged calcium
homeostasis. For term infant, such damage occurs during last trimester, at
delivery or at postnatal period. In preterm infants the most vulnerable and
decisive period for brain development is 26-36 gestational weeks i.e. the most
problematic period of extra-uterine existence [19].
In the present study, most common
type of CP was spastic (24-48%) whereas it was 80% in a study done by Das et
al[26],and 77% in a study done by Mustafa et al done in Libya[27].
Severe asphyxia is the leading
perinatal cause of CP in this study which was observed in 33% of the cases,
whereas it was much higher 57% in study by Das et al [26].
Because of neuronal plasticity
during early years of life, early intervention claims optimization of
developmental potential of the child [28]. The parents are involved early
resulting in better care and adjustment with a special child. But, in a
developing country like India, the real scenario is far from optimal. Often
such children reach the appropriate caring facility quite late. Parmelee and
Humes defined a high risk infant as “any newborn or young infant who has a high
probability of manifesting in childhood a sensory or otordeficit /or mental
handicap” [28]. Ideally every graduate of NICU is a high risk baby.He needs
intense follow up to diagnose and intervene early. NationalNeonatology Forum(
NNF) recommended long back that there should be a high risk clinic at all
hospitals offering level 2 care for newborn and one neurodevelopment clinic for
a population of 5 lakhs [29].
Soumya V et al [30] studied Socioeconomic
status of the subjects according to updated BG Prasad Classification. It shows
that most of the study subjects belong to lower middle class 34 (38%) followed
by upper middle 26 (29%), upper lower 24 (26.5%) and upper class 6 (6.5%).None
of the study subjects belong to lower class, similar to our study in which 54%
of cases belongs to lower socioeconomic status.
Severe asphyxia is the leading
perinatal cause of CP in the study done by soumya et al[30] which was observed
in 33% of the cases, whereas it was much higher 57% in study by Das et al[26].
4Birth asphyxia (hypoxic ischemic encephalopathy) was observed in 43% of cases
in Gowda et al study [31].Our study findings correlate with that of the
findings of study done by sharma et al [32] which shows that birth asphyxia as
an important risk factors for CP among children.
Improved as the
perinatal and neonatal intensive cares are, the prevalence of CP remains
relatively stable over the last several decades in developed countries[33] It
is suggested that perinatal disorders may not be the main cause of CP.
Increasing evidence has demonstrated CP as a heterogeneous disease resulting
from genetic factors, intrauterine triggers, and perinatal and neonatal
diseases or their interaction effects[34], such as maternal infection[35,36],
gestational age[37], small for gestational age[38]
It is a term to describe a neuro
developmental disorder because of injury to the developing brain. Though it is
a static encephalopathy, it affects the health and wellbeing of the whole
family. Numerous therapeutic interventions are being used by professionals to
improve the functional capabilities of these children [39]. Early intervention
provides a range of stimulation and remedial training activities to the child at
the earliest possible time [28].
Conclusion
In this study, spasticity was the
commonest type followed by athetosis. Among the associated problems epilepsy
and speech defect were high. Developmental delay was the commonest presenting
complaint. Most of the cases were diagnosed late because of unawareness of
parent. However, the cases attending HRC were diagnosed and intervened early.
Our study suggests better maternal and child care at every possible contact and
follow up of high risk babies at least till 1 year of age for early diagnosis
and early intervention.
Follow up of high risk babies is very important for early
diagnosis and early intervention of children with cerebral palsy. More research
is needed to understand the risk factors of CP and specifically how they relate
to causal pathways of cerebral palsy.
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