Cerebral palsy

Submitted by: Prerna Sharma

M.Sc Nursing,
4th Semester

Introduction
Cerebral palsy (CP) is defined as a non
progressive neuro-motor disorder of
cerebral origin.
Cerebral palsy (CP) is a broad term used
to describe a group of chronic "palsies
disorders that impair control of
movement due to damage to the
developing brain.

CP usually develops by age 2 or 3 and is a

non-progressive brain disorder, meaning
the brain damage does not continue to
worsen throughout life.

However, the symptoms due to the

brain damage often change over time
sometimes getting better and sometimes
getting worse.
CP is one of the most common causes of
chronic childhood disability.
It includes heterogeneous clinical states
of variable etiology and severity ranging
from minor incapacitation to total
handicap.

Most of the cases have multiple

neurological deficits and variable mental
handicap.
The term does not include progressive,
degenerative or metabolic disorders of
the nervous system.
It is difficult to estimate the precise
magnitude of the problem since mild
cases are likely to be missed.

FIG:1 Magnetic resonance image (MRI) of a 16-month-old boy who was born
at term but had an anoxic event at delivery. Examination findings were
consistent with a spastic quadriplegic cerebral palsy with asymmetry (more
prominent right-sided deficits).

Definition

Cerebral palsy is defined as "a group of

permanent disorders of the development
of movement and posture, causing
activity limitations, which are attributed
to non-progressive disturbances that
occurred in the developing fetal or infant
brain."

Cont..

Cerebral palsy is considered a

neurological disorder caused by a nonprogressive brain injury or malformation
that occurs while the childs brain is
under development. Cerebral palsy
primarily affects body movement and
muscle coordination.

What Causes Cerebral Palsy?

Infection
Genetics
Severe jaundice
Rh incompatibility between mother and infant.
The physical and metabolic trauma of being born
Severe oxygen deprivation to the brain or
significant trauma to the head during labor and
delivery.

Fig-2 causes of cerebral palsy

Risk factors
Breech births (with the feet, knees, or
buttocks coming out first).
Vascular or respiratory problems in the
infant during birth.
Physical birth defects such as faulty spinal
bone formation, groin hernias, or an
abnormally small jaw bone.

Receiving a low Apgar score 10 to 20 minutes

after delivery.
A low birth weight (less than 2,500 grams, or 5
lbs. 7.5 oz.) and premature birth (born less than
37 weeks into pregnancy).
Being a twin or part of a multiple birth.
A congenital nervous system malformation, suc
as an abnormally small head (microcephaly).

Seizures shortly after birth.

Mothers who had bleeding or
severe proteinuria(excess protein in the
urine) late in their pregnancy have a higher
chance of having a baby with CP.
Mothers who have hyperthyroidism or
hypothyroidism mental retardation, or
seizures.

Etiopathogenesis

Factors may operate prenatally, during delivery or in

the post natal period.
Cerebral malformations, prothombotic factors, acid
base imbalance, indirect hyperbilirubinemia, metabolic
disturbances and intrauterine or acquired infections
may operate.
Most infants have multiple risk factors like; Prematurity
is an important risk factor for spastic diplegia while
term weight babies get quadriparesis or hemiparesis.

Contd..

The mechanism of CP in a large proportion of

cases remains unclear and primary
neurological aberrations may be unfolded in
future.
A variety of pathological lesions such as
cerebral atrophy, porencephaly, periventricular
leukomalacia, basal ganglia thalamic and
cerebrallar lesions may be observed.

Signs and Symptoms

History
Physical examination

History

Contd..
The child with cerebral palsy can present
after failing to meet expected
developmental milestones or failing to
suppress obligatory primitive reflexes.
Ophthalmologic and hearing impairments
Speech and language disorders
Oromotor dysfunction

a) Prenatal history
The prenatal history should include information
on the mother's pregnancy, such as prenatal
exposure to illicit drugs, toxins, or infections;
maternal diabetes; acute maternal illness; trauma;
radiation exposure; prenatal care; and fetal
movements.
A history of early frequent spontaneous
abortions, parental consanguinity, and a family
history of neurologic disease

b) Perinatal history
The perinatal history should include the child's
gestational age at birth,
Presentation of the child and delivery type, birth
weight, Apgar score, and
Complications in the neonatal period (e.g.,
intubation time, presence of intracranial
hemorrhage on neonatal ultrasonogram, feeding
difficulties, apnea, bradycardia, infection, and
hyperbilirubinemia).

c) Developmental history

Gross motor milestones

Current social skills
Standardized cognitive and educational
testing

Gross motor skill

Head control at age 2 months,
Rolling at age 4 months, sitting at age 6
months, and walking at age 1 year.
Infants with cerebral palsy may have
significantly delayed gross motor milestones
or show an early hand preference when
younger than 1.5 years, suggesting the
relative weakness of one side

Current social skills

Academic performance,
participation in an early intervention
program (if < 3 year) or school support
(if >3 year) should be reviewed,
Including resource room assistance;
physical, occupational, and speech and
language therapy; and adaptive physical
education.

Standardized cognitive and

educational testing

A current individualized education plan can

be used to determine whether speech
therapy, occupational therapy, and physical
therapy are in place or whether referrals for
these are needed.

B) Physical Examination
Physical indicators of cerebral palsy include
joint contractures secondary to spastic muscles,
hypotonic to spastic tone, growth delay, and
persistent primitive reflexes.
The initial presentation of cerebral palsy
includes early hypotonia, followed by spasticity.
Generally, spasticity does not manifest until at
least 6 months to 1 year of life.

Contd..

The diagnosis begins with a history of gross motor

developmental delay in the first year of life.
Cerebral palsy frequently manifests as early hypotonia
for the first 6 months to 1 year of life, followed by
spasticity.
Abnormal muscle tone is the most frequently observed
symptom.
The child may present as either hypotonic or, more
commonly, hypertonic with either decreased or increased
resistance to passive movements, respectively.

Contd..
Definite hand preference before age 1
year is a red flag for possible hemiplegia.
Asymmetric crawling or failure to crawl
may also suggest cerebral palsy.
The general medical history should include
a review of systems to evaluate for the
multiple complications that can occur with
cerebral palsy.

Contd..

Before the formal physical examination,

observation may reveal abnormal neck or
truncal tone (decreased or increased,
depending on age and type of cerebral
palsy); asymmetric posture, strength, or
gait; or abnormal coordination.

Contd..
Patients with cerebral palsy may show increased
reflexes, indicating the presence of an upper
motor neuron lesion.
This condition may also present as the
persistence of primitive reflexes, such as the
Moro (startle reflex) and asymmetric tonic neck
reflexes (ie, fencing posture with neck turned in
same direction when one arm is extended and the
other is flexed).

Fig-5 symptoms of cerebral palsy

Gait abnormalities :
Hip Excessive flexion, adduction, and femoral
anteversion make up the predominant motor
pattern. Scissoring of the legs is common in spastic
cerebral palsy.
Knee Flexion and extension with valgus or varus
stress occur.
Foot Equinus, or toe walking, and varus or
valgus of the hindfoot is common in cerebral palsy.

Type of cerebral palsy

Fig-5 Types of Cerebral Palsy

A) Spastic cerebral palsy

This commonest form (65%) and is

topographically classified into spastic
quadriparesis, diplegia or hemiparesis.

Early diagnostic features of

neural damage include
Abnormally persistent neonatal reflexes,
Feeding difficulties,
Persistent cortical thumb after 3 month age and
a firm grasp, on a vertical suspension, t
The infant goes into scissoring due to adductor
spasm with an extensor posture and does not
flex his knees or thigh.
The stretch tendon reflexes are always brisk.

Contd..
They have variable degrees of mental and visual
handicaps, seizure and behavior problems.
Patients have signs of upper motor neuron
involvement, including hyperreflexia, clonus,
extensor Babinski response, persistent primitive
reflexes, and overflow reflexes (crossed adductor).
This may be observed by the child's tendency to
keep the elbow in a flexed position or the hips
flexed and adducted with the knees flexed.

a) Spastic quadriparesis:

It is more common in term babies and

exhibit signs including opisthotonic
posture, pseudobulbar palsy, feeding
difficulties, restricted voluntary
movements and motor deficits.

Cognitive impairment and demonstrate

the following classic physical
presentations:

All limbs affected, either full-body hypertonia or

truncal hypotonia with extremity hypertonia
Oromotor dysfunction
Increased risk of cognitive difficulties
Multiple medical complications
Seizures
Legs generally affected equally or more than arms
Categorized as double hemiplegic if arms more
involved than legs

b) Spastic

diplegia:

It is common in pre term babies and is associated

with peri-ventricular leukomalacia.
The lower limbs are more severly affected with
extension and adduction posturing, brisk tendon
jerks and contractures.
Patients with spastic diplegia often have a period of
hypotonia followed by extensor spasticity in the
lower extremities, with little or no functional
limitation of the upper extremities.

Contd ..
Patients have a delay in developing gross
motor skills.
Spastic muscle imbalance often causes
persistence of infantile coxa valga and
femoral anteversion.
Cognitive impairment is present in
approximately 30% of spastic diplegic
patients.

Spastic diplegic cerebral palsy includes the

following classic physical presentations:
Upper motor neuron findings in the legs
more than the arms
Scissoring gait pattern with hips flexed
and adducted, knees flexed with valgus,
and ankles in equinus, resulting in toe
walking
Learning disabilities and seizures less
commonly than in spastic hemiplegia

c) Spastic hemiplegia:It is usually recognized after 4-6 months age.

Early hand preference, abnormal persistent fisting,
abnormal posture or gait disturbance may be
presenting complaint.
Vascular insults, porencephaly or cerebral
anomalies may be associated.
Hemiplegia is characterized by weak hip flexion
and ankle dorsiflexion, an overactive posterior
tibialis muscle,

Contd..
Hip hiking/circumduction, supinated foot instance,
upper extremity posturing (
One-sided upper motor neuron deficit
Arm generally affected more than leg; possible early
hand preference or relative weakness on one side;
gait possibly characterized by circumduction of
lower extremity on the affected side
Specific learning disabilities

Contd..

Oromotor dysfunction
Possible unilateral sensory deficits
Visual-field deficits (eg, homonymous hemianopsia)
and strabismus
Seizures
Forearm pronated, wrist flexed, hand clenched in a fis
with the thumb in the palm),
Impaired sensation, impaired 2-point discrimination,
and/or impaired position sense.

B)Hypotonic
(Atonic ) cerebral plasy:B)
Despite pyramidal involvement, these patients are
atonic or hypotonic.
Tendon reflexes are normal or brisk and babinski
response is positive.
They are often severally mentally retarded.
In cerebellar involvement, hypotonia is not
associated with exaggerated reflexes.
Muscle may show fiber disproportion and delayed
CNS maturation is common.

C)

Extrapyramidal CP:-

Abnormal movement patterns may increase with stress

or purposeful activity.
Muscle tone is usually normal during sleep. Intelligence
is normal in 78% of patients with athetoid cerebral
palsy.
A high incidence of sensorineural hearing loss is
reported.
Patients often have pseudobulbar involvement, with
dysarthria, swallowing difficulties, drooling, oromotor
difficulties, and abnormal speech patterns.

The clinical manifestations

Athetosis,
Choreiform movements,
Dystonia,
Tremors and rigidity.
Arms,leg,neck and trunk may be involved.
Mental retardation and hearing deficits may be present.
High tone audiometry should be performed.
cerebral damage following bilirubin ence-phalopathy is
one of the causes.

Contd..
Oromotor dysfunction
Gait difficulties
Truncal instability
Risk of deafness in those affected by
kernicterus

D) Cerebellar involvement
This form is seen in less than 5% of the
patients.
There is hypotonia and hyporeflexia.
Ataxia and intention tremors appear by the age
of 2 year.
Nystagmus is unusual;
Mental status may be near normal in some of
these patients.

E)

Mixed type:-

A proportion of the patients have features

of diffuse neurological involvement of
the mixed type.

Severity of lesion
Mild cases of cerebral palsy are ambulatory;
these account for only 20% of patients.
Moderately involved patients achieve
ambulation by help, may be treated at
outpatient level and include 50% of the
patients.
Severely affected children and those with
multiple deficits account for the remainder.

Evaluation
EyesNearly half of the patients have strabismus,
paralysis of gaze, cataracts, coloboma,
retrolental fibroplasis, perceptual and refractive
errors.
EarsPartial or complete loss of hearing is usual in
kernictures. Brain damage due to rubella may be
followed by receptive auditory aphasia.

Contd..
SpeechAphasia,dysarthria and dyslalia are common among
dyskinetic individuals.
Sensory defectsAstereognosis and spatial disorientation are seen in one
third of the patients.
Seizures
Spastic patients usually have generalized or focal tonic
seizures.Electroencephalograms show gross
abnormalities.

Contd..
Intelligence
About a quarter of the children may have
borderline intelligence (IQ; 80-100); and about
half of them are severely mentally retarded.
MiscellaneousInadequate thermoregulation and problems of
social and emotional adjustment are present in
many cases.

Diagnostic evaluation
Lab investigation
Imaging
others

Lab investigation
Thyroid function studies: Abnormal thyroid
function may be related to abnormalities in
muscle tone or deep tendon reflexes or to
movement disorders
Lactate and pyruvate levels: Abnormalities
may indicate an abnormality of energy
metabolism
Ammonia levels: Elevated ammonia levels
may indicate liver dysfunction or urea cycle
defect

Contd..
Organic and amino acids: Serum quantitative amino
acid and urine quantitative organic acid values may
reveal inherited metabolic disorders
Chromosomal analysis: Chromosomal analysis,
including karyotype analysis and specific DNA
testing
Cerebrospinal protein: levels may assist in
determining asphyxia in the neonatal period; protein
levels can be elevated, as can the lactate-to-pyruvate
ratio

Imaging studies
Cranial imaging studies to help evaluate
brain damage and identify persons who are at
risk for cerebral palsy include the following:
Cranial ultrasonography: Can be performed
in the early neonatal period to delineate clearcut structural abnormalities and show
evidence of hemorrhage or hypoxic-ischemic
injury

Contd..
Computed tomography scanning of the brain: In
infants, helps to identify congenital malformations,
intracranial hemorrhage, and periventricular
leukomalacia or early craniosynostosis.
Magnetic resonance imaging of the brain: The
diagnostic neuroimaging study of choice because
this modality defines cortical and white matter
structures and abnormalities more clearly than does
any other method.

Others
Electroencephalography
Electromyography and nerve conduction
studies; Electromyography (EMG) and nerve
conduction studies are helpful when a muscle
or nerve disorder is suspected
Evoked potentials are used to evaluate the
anatomic pathways of the auditory and visual
systems.

Differential diagnosis:Neurodegenerative disorders:Progressively increasing symptoms,familial pattern of

disease, consanguinity, specific constellation of
symptoms and signs are usual clues for neurometabolic
disorders.
Failure to thrive,vomiting,seizure are significant
symptoms.
Hydrocephalus and subdural effusionHead size is large, fontanel may bulge and sutures may
separate.

Contd..
Brain tumor or space occupying lesions Extradural tumors - Arise outside the spinal cord
and the meninges and the epidural tissue
Intradural-extramedullary tumors - Arise inside
the dural sac, from the leptomeninges or the nerve
root, outside the substance of the spinal cord
parenchyma
Intramedullary tumors - Arise within the
substance of the spinal cord

Contd..
Metabolic neuropathyThe term metabolic neuropathy includes a
wide spectrum of peripheral nerve
disorders associated with systemic
diseases of metabolic origin.

Contd..
Muscle disordersCongenital myopathies and muscular dystrophies
can mimic cerebral palsy. Distribution of muscle
weakness and other features is
characteristic,hypotonia is associated with
diminished reflexes.
Ataxia telangiectasiaAtaxia may appear before the ocular telangiectasi
are evident.

Prevention
Prevention of maternal infection, fetal or
perinatal insults, and good maternal and
neonatal care reduces prevalence.
Early diagnosis, prompt adequate
management plans can reduce the residual
neurological and psychosocial emotional
handicaps for the child and his family.

Management
The management plan should be holistic,
involve the family and be directed to
severity, type of neurological deficits and
associated problem.
Stress on improving posture, reducing
tone, preventing contractures and early
stimulation is necessary.

A) Pharmacotherapy

Tranquilizers are administered for behavior disturbance

and muscle relaxants may be used for muscle function
improvement.
Baclofen and tizanidine helps to reduce spasticity.
Diazepam may ameliorate spasticity and athetosis.
Dantrolene sodium helps in relaxation of skeletal
muscle.
Dynamic contractures can be managed with botulinum
toxin injection or alternatively nerve block with phenol.

Contd..
Plastic orthoses may help to prevent contractures,
surgical procedures for spasticity and contractures
may be required in selected patients.
Tizanidine is an imidazoline derivative and a central
alpha2 noradrenergic agonist. The antispasticity
effects are the probable result H-reflex inhibition.
Tizanidine is a centrally acting muscle relaxant that
is metabolized in the liver and excreted in the urine
and feces.

Contd..

Dopamine does not the cross blood-brain

barrier, but levodopa (L-dopa). L-dopa is
decarboxylated to dopamine in the brain
and in the periphery. When administered
alone, levodopa induces a high incidence of
nausea and vomiting.

B) Neurosurgery and Orthopedic

Surgery
Intrathecal baclofen pump insertion
Selective dorsal rhizotomy
Stereotactic basal ganglia
Orthopedic surgical intervention
Intrathecal baclofen pump insertion

Intrathecal insertion of a baclofen pump to

treat spasticity and/or dystonia

It is useful in the patient with diffuse

spasticity or dystonia ; the baclofen pump is
most useful in helping to decrease spasticity
in the lower extremities and trunk, but it can
also reduce spasticity in the upper
extremities and improve speech

Contd..

The pump is placed in the anterior abdominal wall and

connects to a catheter inserted in the subarachnoid space
overlying the conus of the spinal cord.
Intrathecal baclofen can allow more local presynaptic
inhibition of I-a sensory afferents and has fewer adverse
effects than oral baclofen.
The degree of improvement in the upper extremities is
increased with higher placement of the pump catheter.
The dose can be adjusted by the physician with an
external handheld programmer, with different doses
administered during the day and evening, depending on
the patient's needs.

b) Selective dorsal rhizotomy

Another neurosurgical treatment is that of

selective dorsal rhizotomy, which may be
beneficial in both the short term and long term to
treat velocity-dependent spasticity.
This procedure includes a laminectomy and then
surgical ablation of 70-90% of the dorsal or
sensory nerve roots.
By cutting I-a sensory fibers, selective dorsal
rhizotomy decreases spasticity by decreasing
reflexive motoneuron activation, which is
thought to result from the lack of descending
fiber input.

Contd..

Patients must be selected carefully for this

procedure, because the weakness produced may
decrease the level of functional independence.
Underlying weakness is uncovered with the
decrease in spasticity.
This surgery has come to be performed less
frequently since the advent of the baclofen
pump. Because of the laminectomies, some of
the earlier surgeries had complications of more
severe lumbar lordosis several years after
surgery.

c) Stereotactic basal ganglia

Although data are limited in this

population, stereotactic basal ganglia
surgery may improve rigidity,
choreoathetosis, and tremor.

d) Orthopedic surgical intervention

Scoliosis and hip dislocation are the most
common conditions requiring surgery.
Tendon lengthening or transfer can
decrease spastic muscle imbalance and
deforming forces, and osteotomy can
realign limbs, including the femoral neck,
tibia, and calcaneus.

Contd..

Additionally, reconstructive surgery to the upper

extremities can restore muscle balance, release
contractures, and stabilize joints to improve
placement of the hand in space, as well as voluntary
grasp, release, and pinch functions.
Combined use of a continuous-infusion device and
oral analgesics has been shown to be more effective
than oral medications alone in reducing pain
intensity in children with cerebral palsy undergoing
lower extremity orthopedic procedures.

Occupational therapy
Simple movements of self help in feeding and
dressing with progressive development of more
intricate activities like typing.
A family-centered philosophy is used with
children who have CP.
CP commonly causes hemiplegia. Those with
hemiplegia have limited use of the limbs on one
side of the body, and have normal use of the limbs
on the other side.

Contd..
Hemiplegics often adapt by ignoring the limited limbs,
and performing nearly all activities with the unaffected
limbs, which can lead to increased problems with
muscle tone, motor control and range of motion.
An emerging technique called constraint-induced
movement therapy (CIMT) is designed to address this.
In CIMT, the unaffected limbs are constrained, forcing
the individual to learn to use the affected limbs.

E) EducationalThe defect of vision, perception, speech and learning are

managed by adequate special education experiences.
F) Orthopedic supportTendon, muscle and bony surgeries may be required. Light
weight splints may be required for tight tendo-achilles and
cortical thumb.
G) Social
The family should be given social and emotional support to
help it to live with childs handicap.

H) Rehabilitation and vocational guidance

Parents should help the child to adjust in the society and if

possible to become independent by proper vocational guidance
and rehabilitation.
Sever handicapped children may need to be institutionalized.
Speech therapy helps control the muscles of the mouth and jaw,
and helps improve communication.
Just as CP can affect the way a person moves their arms and legs,
it can also affect the way they move their mouth, face and head.
This can make it hard for the person to breathe; talk clearly; and
bite, chew and swallow food.
Speech therapy often starts before a child begins school and
continues throughout the school years.

H) CONDUCTIVE EDUCATION(CE)

It is a unified system of rehabilitation for

people with neurological disorders including
cerebral palsy, Parkinson's disease and multiple
sclerosis, amongst other conditions.
It is theorized to improve mobility, self-esteem,
stamina and independence as well as daily
living skills and social skills.
The conductor is the professional who delivers
CE in partnership with parents and children.

Biofeedback
It is a therapy in which people learn how to control
their affected muscles. Biofeedback therapy has
been found to significantly improve gait in children
with cerebral palsy.
J) Massage therapy
It is designed to help relax tense muscles, strengthen
muscles, and keep joints flexible. More research is
needed to determine the health benefits of these
therapies for people with CP.
I)

Nursing Diagnosis for Cerebral Palsy

a)
b)
c)

d)
e)

f)

g)

Risk for injury r/t spasms, uncontrolled movements and seizures

Impaired Physical mobility r/t spasms and muscle weakness.
Altered health maintenance R/T deviations from normal growth
and development.
Impaired verbal communicationr/t difficulty in articulation.
Risk for aspiration r/t neuromuscular disorders
Changes in thought processes r/th cerebral injury, learning
disabilities.
Self-care Deficit r/t muscle spasms, increased activity, cognitive
changes.
Deficient Knowledge r/t home care and therapeutic needs.

Goal:
1.
2.
3.

4.
5.
6.
7.
8.

9.

Children will always be safe and free from injury.

Children will have maximum movement ability and not have contractures.
Children will explore how to learn and participate with other children in doing
some activities.
Children will express their needs and develop a body weight within normal limits.
Children do not have aspirations.
The child will demonstrate an appropriate level of learning ability.
Daily needs of the child tetpenuhi.
Parents / family demonstrate understanding of the needs of child care that is
characterized by taking an active role in child care.
Children do not show a marked impairment of skin integrity with intact skin.

Nursing Interventions

The increasing need for security and prevent

injury

1.

Avoid children from harmful objects, for example can

be dropped.
Watch the children during activity.
Give the kids a break when tired.
Use safety equipment when necessary.
When a seizure; install a safety device in the mouth so
that the tongue is not bitten.
Do suction.
The provision of anti-seizure in the event of a seizure.

2.
3.
4.
5.

6.
7.

Improve the physical mobility

1) Examine the movement of the joints and muscle tone.

2) Do physical therapy.
3) Do repositioning every 2 hours.
4) Evaluation of the needs of special equipment for eating,
writing and reading and activities.
5) Teach the use of a walker.
6) Teach how to sit, crawl in young children, walking, and
others.
7) Teaches how to reach for objects.
8) Taught to move the limbs.
9) Teach appropriate ROM.
10) provide a rest period.

Altered health maintenance R/T deviations from

normal growth and development. Examine the
growth and development.

Teach parents the special care needed.

Teach them the techniques for feeding.
Plan activities so that rest and sleep are facilitated.
Stress regular follow up and need for
physiotherapy.
Teaching for early intervention with therapeutic
recreation and school activities.
Provide appropriate activities, withdrawal and can
be done by a child

Improve communication

1) examines the response tocommunication.

2) Use the cards / pictures / whiteboards to facilitate
communication.
3) Involve the family in training a child to
communicate.
4) Refer to a speech therapist.
5) Teach and assess non-verbal meaning.
6) Trained in the use of the lips, mouth and tongue.

Improve the nutritional status needs

1) Examines the diet of children.
2) Weigh weight every day.
3) Provide adequate nutrition and food preferences, lots of protein,
minerals and vitamins. Plan a balanced age appropriate menu.
Use 3 finger jaw control technique for feeding.
Excessive drooling is managed by frequent wipes.
Correction of dental problems and speech therapy.
4) Give extra foods that contain lots of calories.
5) Help your child meet their daily needs with the ability

Prevent the occurrence of aspiration

1) Do immediately when there are suction

secretions.
2) Provide an upright position or semisitting while eating and drinking.
3) Examine the pattern of breathing

Increase the need for intellectual

1) Review the child's level of understanding.
2) Teach in understanding conversations with
verbal or non verbal.
3) Teach writing using whiteboards or other
devices that can be used according to the
ability of parents and children.
4) Teaching reading and writing according to his
needs

Enhance the knowledge and the role

of parents in meeting child care needs
1) Examine the level of parental knowledge.
2) Teach parents to express their feelings about the child's
condition.
3) Teach parents in meeting child care needs.
4) Teach about the conditions experienced by children and are
related to physical therapy and exercise needs.
5) Emphasize that parents and families have an important role in
helping meet the needs.
6) Explain the importance of play and socialization needs of
others.

Prevent to impaired skin integrity

1) Examine the area that is attached
ancillary equipment.
2) Use a skin lotion to prevent dry skin.
3) Do the massage in a depressed area.
4) Provide a comfortable position and
provide support with pillows.
5) Ensure that ancillary equipment or
dressing appropriately and fixed.

Prognosis

CP is not a progressive disorder (meaning the brain damage does not

worsen), but the symptoms can become more severe over time.
A person with the disorder may improve somewhat during childhood if
he or she receives extensive care, but once bones and musculature
become more established, orthopedic surgery may be required.
Intellectual level among people with CP varies from genius to
intellectually impaired, as it does in the general population, and experts
have stated that it is important not to underestimate the capabilities of a
person with CP and to give them every opportunity to learn.
The life expectancy of those with CP is less than that of the general
population but has improved with the utilization of modern medicine.

Summary

Cerebral palsy is defined as "a group of permanent disorders of the

development of movement and posture, causing activity limitations,
which are attributed to non-progressive disturbances that occurred in
the developing fetal or infant brain.
Cerebral palsy is characterized by abnormal muscle tone , reflexes,
or motor development and coordination.
There can be joint and bone deformities
and contractures (permanently fixed, tight muscles and joints).
The classical symptoms are spasticity, spasms, other involuntary
movements (e.g., facial gestures), unsteady gait, problems with
balance, and/or soft tissue findings consisting largely of decreased
muscle mass.

Conclusion
So we have concluded that babies born with
severe CP often have an irregular posture; their
bodies may be either very floppy or very stiff.
Birth defects, such as spinal curvature, a small
jawbone, or a small head sometimes occur along
with CP.
Symptoms may appear or change as a child gets
older. Some babies born with CP do not show
obvious signs right away.