Associated problems in CP
Seizures
Visual impairments
Intellectual impairment
Learning disabilities
Hearing problems
Communication problems and dysarthria
Oromotor dysfunction
Gastrointestinal problems and nutrition
Teeth problems
Respiratory dysfunction
Bladder and bowel problems
Social and emotional disturbances

Cortical blindness, sensory loss, deafness, mental retardation and epilepsy are primary impairments because of the neurological lesion. Disabilities that are secondary to motor deficits are weakness of external eye muscles causing strabismus or difficulties in normal swallowing leading to alnutrition. Malnutrition is an important cause of retarded brain growth and myelination. Lastly, deprivation handicaps occur. The child who cannot move is deprived of peer interaction and stimulation through play. Psychosocial problems develop as a result. Check for the presence of associated problems and get appropriate referral for treatment. Correct these problems as much and as early as possible to prevent the development of deprivation handicaps.

Intellectual impairment

Cognition refers to specific aspects of higher cortical function; namely, attention, memory, problem solving and language. Cognitive disturbance leads to mental retardation and learning disability. The prevalence of moderate, severe and profound mental retardation is 30 to 65% in all cases of CP. It is most common in spastic quadriplegia. Visual and hearing impairments prevent the physician from accurately assessing the degree of
intellectual impairment. Children with intellectual impairment need special education and resources to stimulate the senses for optimal mental function.

Epileptic seizures

Seizures affect about 30 to 50% of patients. They are most common in the total body involved and hemiplegics, in patients with mental retardation and in postnatally acquired CP. Seizures most resistant to drug therapy occur in hemiplegics. Seizure frequency increases in the preschool period. Electroencephalograms are necessary for the diagnosis of seizure disorder.

Vision problems

Approximately 40 % of all patients have some abnormality of vision or oculomotor control. If there is damage to the visual cortex, the child will be functionally blind because he will be unable to interpret impulses from the retinas. In severe cases, the optic nerves may also be damaged. Loss of coordination of the muscles controlling eye movements is very common. The child cannot fix his gaze on an object. In half of the cases, binocular vision does not develop. Myopia is a concomitant problem. Screen for visual deficits because some are preventable and they contribute to the movement problem.

Hearing

Sensorineural hearing loss is seen in 10 % of children. Children born prematurely are at high risk for hearing loss. It is generally not diagnosed early because of other handicaps. Test all babies for hearing loss because appropriate hearing devices prevent many future problems resulting from loss of hearing ability.

Communication problems and dysarthria

Dysarthria refers to speech problems. The child has difficulty producing sound and articulating words. Dysarthria occurs in 40% of patients. The causes are respiratory diffi culties due to respiratory muscle involvement, phonation diffi culties due to laryngeal involvement, and articulation diffi culty due to oromotor dysfunction. Spasticity or athetosis of the muscles of the tongue, mouth and larynx cause dysarthria. It is important that every child is provided with an alternative means of communication as early as
possible to avoid further disability .

Oromotor dysfunction

Sucking, swallowing, and chewing mechanisms are impaired. Drooling, dysarthria and inability to eat result in failure to thrive, delayed growth and nutrition, poor hygiene and impaired socialization.This condition bring teeth problems

teeth problems

Dentin Primary or hyperbilirubinemia
Malocclusion Spasticity
Tooth decay Feeding, swallowing problems
Gingival hyperplasia Antiepileptic drug use

Gastrointestinal problems and nutrition

There is a general deficiency of growth and development. Children with dyskinesia and spastic quadriplegia fail to thrive.  This is related to inadequate intake of food, recurrent vomiting with aspiration secondary to gastroesophageal refl ux and pseudobulbar palsy. Difficulties in swallowing (dysphagia), hyperactive gag reflex, spasticity or loss of fine motor control impair feeding. Gastroesophageal reflux and impaired swallowing cause aspiration pneumonia. Many children with CP have high basal metabolic rates. Increase in basal metabolic rate coupled with feeding difficulties cause malnutrition. Malnutrition may be severe enough to affect brain growth and myelination in the fi rst 3 years of life. There is immune system suppression and increased risk of infection.

Respiratory problems

Aspiration in small quantities leads to pneumonia in children who have difficulty swallowing. Premature babies have bronchopulmonary dysplasia. This leads to frequent upper respiratory tract infections. Respiratory muscle spasticity contributes to the pulmonary problems.

Bladder and bowel dysfunction

Loss of coordination of bowel and bladder sphincters results in constipation and/or incontinence. Enuresis, frequency, urgency, urinary tract infections and incontinence are common problems. The causes are poor cognition, decreased mobility, poor communication and neurogenic dysfunction. Urodynamic assessment has demonstrated bladder hyperreflexia, detrusor
sphincter dyssynergia, hypertonic bladders with incomplete leakage and periodic relaxation of the distal sphincter during filling. Constipation is a common but overlooked phenomenon. It causes distress in the child, increases spasticity and results in poor appetite. It is a result of many factors, including poor diet and decreased mobility. Establishing a routine for bowel training and encouraging upright posture help reduce constipation.

Psychosocial problems

A diagnosis of CP is extremely stressful for the family and the child when he grows up. This causes various reactions ranging from denial to anger, guilt and depression. Coping with the emotional burden of disability is easier if the family has strong relationships, financial security, and supportive members of the community. The child and the family need to find ways to
connect to each other. A healthy relationship between the mother and the child forms the basis of future happiness. Prevention or appropriate treatment of associated problems improves the quality of life of the child and the family. The severely involved mixed quadriplegic child.

Risk factors associated with CP are grouped into prenatal, perinatal, and postnatal factors. Prematurity and low birth weight are the two most important risk factors in developed countries with high standards of obstetrical care. Postnatal risk factors additionally play a major role in other countries. A clear association exists between premature delivery and spastic diplegia. Low birth weight increases the risk. Rubella, herpes simplex, toxoplasma, and cytomegaloviruses cross the placenta to infect the fetus and have severe effects on the developing CNS. Eclampsia or other severe maternal illness hypothermia, hypoglycemia of the neonate cause a reduction in the levels of oxygen and nutrients available to the fetus or an increase in the levels of toxins or waste products, adversely affecting the developing CNS. Multiple pregnancies or breech presentation also can increase the risk. Excess of bilirubin resulting from the haemolytic disease of the newborn is clearly associated with CP. Babies who carry these risk factors should be under close supervision by a pediatric neurologist for signs suggestive of neuromotor developmental delay.

Epidemiology
CP is the most common cause of childhood disability in Western societies. The incidence is 2-2.5/1000 live births. Some affected children do not survive and the prevalence varies between 1-5/1000 babies in different countries. It was previously thought that improvements in perinatal and

obstetric care would decrease the incidence of CP. However, the incidence has not declined and the overall prevalence increased during the 1980s and 1990s. This is explained by increased survival of premature and very-low-birth-weight infants and by a rise in the number of multiple births. Even at centers where optimal conditions exist for perinatal care and birth asphyxia is relatively uncommon, the incidence of CP in term babies has remained the same. This has led researchers to consider unknown prenatal causative factors.

Etiology
The etiology can be identified only in 50% of the cases. Certain factors in the history of the child increase the risk of CP. The incidence of CP among babies who have one or more of these risk factors is higher than among the normal
population. The clinician should therefore be alerted to the possibility of the presence of CP in a patient with these factors.

Cerebral Palsy (CP) is a disorder of movement and posture that appears during infancy or early childhood. It is caused by nonprogressive damage to the brain before, during, or shortly after birth. CP is not a single disease but a name given to a wide variety of static neuromotor impairment syndromes
occurring secondary to a lesion in the developing brain. The damage to the brain is permanent and cannot be cured but the consequences can be minimized. Progressive musculoskeletal pathology occurs in most affected children. The lesion in the brain may occur during the prenatal, perinatal, or postnatal periods. Any nonprogressive central nervous system (CNS) injury occurring during the first 2 years of life is considered to be CP. In addition to movement and balance disorders, patients might experience other manifestations of cerebral dysfunction. CP was first described by the English physician Sir Francis William Little in 1861 and was known as Little’s disease

for a long time. Little thought that this condition was caused by neonatal asphyxia. Later, Sigmund Freud and other scientists challenged Little’s idea and proposed that a variety of insults during pregnancy could damage the developing brain. Today, it is accepted that only approximately 10% of cases of CP can be attributed to neonatal asphyxia. The majority occur during the prenatal period, and in most of the cases, a specific cause cannot be identified.