Paediatrics Lecture Series

Cerebral Palsy Case

Discussion
Dr.Balaji Chinnasami M.D.,
Patron – Medusane Inc. ,
Professor of Paediatrics,
SRM Medical College, Chennai.
CEREBRAL PALSY
Prashanth S
Final MBBS
A 10 month/Male child, Master Moderator’s Note:
Mahesh from Ambattur,1st born child Examples
of non-consanguineous marriage was Definition- Static, motor, growing brain
brought by his mother whose was able Associations
to provide fairly reliable information. Consanguinity

The child has a

❑ H/O stiffness of all 4 limbs noted
since birth Mother’s own words
❑ H/O - not attained age appropriate
milestones
H/O OF PRESENTING ILLNESS: Moderator’s Note:
❖ H/O of stiffness of all 4 limbs noted since
birth which was progressively increasing in Progressively increasing
nature
❖ H/O of fisting of both upper limb
Early markers of CP
❖ H/O of scissoring of both lower limb
❖ H/O of difficulty in putting diapers and Scissoring ?
trousers
❖ H/O of turning head to one side Developmental delay- Part of
presenting history
COMPLICATIONS: Moderator’s Note:
❖ No H/O of any abnormal movements
❖ No H/O of any vomiting / feeding difficulties/ poor
weight gain Associated complications
❖ No H/O of any deformities / bed sores
❖ No H/O of RRTI / constipation
❖ H/O of seizure in the neonatal period for which the
child was on antiepileptic drugs
❖ H/O of sleep disturbances / behavioural
disturbances
 Moderator’s Note:
HIGHER FUNCTION:
❖ Child interacts with mother An attempt to assess CNS findings
❖ Sleeps well throughout the night through history.

CRANIAL NERVES:
❖ Mother gives H/O that the child is recognising and Reaching for objects
following light (2nd nerve)
❖ No H/O of abnormal eye position (3rd, 4th, 6th nerve)
❖ No H/O of defective sucking (5th nerve)
❖ No H/O of deviation of angle of mouth [drooling of Moderator’s Note:
saliva (7th nerve)], facial asymmetry
❖ Mother gives H/O that child is not turning to sounds
(8th nerve) Not turning sounds ?
❖ No H/O of regurgitation (nasal) while feeding , What is the implication ?
pooling of secretions(9th nerve)
❖ No H/O of abnormal movements of the tongue
MOTOR : Child is moving all 4 limbs
SENSORY : Child is able to perceive sensation while
bathing
AUTONOMIC : Bowel and Bladder control not
attained
ANTENATAL LIFE:
1st TRIMESTER: Moderator’s Note:
❖ Age at marriage – 23 years
Phenotype- Developmental, genetic,
❖ Spontaneous conception after 1 month
❖ No H/O of abortion / miscarriages metabolic, ischemic, infectious
❖ No H/O of infertility treatment
❖ Registered and immunised – 2 doses of TT given
❖ Took IFA tablets
Aetiology - Antenatal (Fetal & maternal)
❖ No H/O of fever with rash / lymphadenopathy Perinatal
❖ No H/O of PIH / GDM / Anemia / blood transfusion in
Postnatal
mother
❖ No H/O of drug intake / radiation exposure / seizure
disorder
Infections, Multiple pregnancy,
Prematurity, boy baby with IUGR
NATAL H/O: Moderator’s Note:
❖ Full term normal vaginal delivery in Normal vaginal delivery ?
Ponneri GH
❖ Birth weight – 2.2 kg
❖ Baby not cried immediately after birth
❖ (Bag and mask ventilation initiated) and
was admitted in NICU in ICH
❖ Labour - prolonged labour – poor
maternal effort and delivered at forceps
POSTNATAL H/O: Moderator’s Note:
❖ H/O of neonatal seizure at 7 hours of life,
Normal transition ? - Feeding, NICU
ventilated for 1 week in ICH – NICU for which
the child was started on AEDs
❖ Nose tube feeds at 15th day Seizures in Day 1 ?
❖ Child had 5 episodes of seizures during the stay
in hospital and was started on AED. Imaging was
done and was said to be abnormal and discharged
❖ No H/O of any difficulty in sucking
❖ No H/O of neonatal jaundice / cyanosis/ birth
injury
DEVELOPMENTAL H/O:

GROSS MOTOR:
Moderator’s Note:
Neck holding attained
How to present developmental history
FINE MOTOR:
Bidextrous reach

SOCIAL AND ADAPTIVE

MILESTONES: Global delay or developmental dissociation
Social smile – attained at 2 months of age
Developmental regression
LANGUAGE MILESTONES:
Coos

VISION AND HEARING:

Pincer grasp
Vision – fairly normal
Hearing – does not respond to calls

Windows to development
DIET H/O:
❖ Exclusive breastfeeding adequately given till 6
Moderator’s Note:
months of age
❖ After that , Complementary feeds were started
Feeding difficulties in CP
such as smashed food, idly etc

FAMILY H/O:

Family history suggests genetic

component

❖ No H/O similar illness / seizure disorder in family

IMMUNISATION H/O: Moderator’s Note:
❖ Immunized upto age according to NIS Prone for RTI
❖ Last vaccine – 14 weeks of age (pentavalent,
OPV, rota, IPV)
❖ Optional vaccine – not given
SOCIOECONOMIC H/O:
Lower middle class according to modified
kuppusamy scale
TREATMENT H/O:
❖ Physiotherapy × 3 months
 SUMMARY:
10 month/M who is a 1st born child of non-consanguineous marriage, term, normal birth weight baby, has a H/O
of delay in milestones and stiffening of all 4 limbs with abnormal / eventful perinatal period with neonatal seizure
and NICU admission for 10 days.
❖ Probably – spastic quadriparesis due to HIE sequelae with hearing impairment

Normal birth weight/ Low birth weight

GDD/Dissociation with DQ, Regression
Associated complaints
Aetiology
GENERAL EXAMINATION:
Moderator’s Note:
❖ Child is alert, awake, quiet in mothers lap
❖ Presence of stridor
Behavioural disturbances
POSTURE:
UPPER LIMB :
❖ adducted at shoulder joint
❖ flexed at elbow
Spasticity - One feature
❖ slightly flexed at wrist Cortical thumb ?
❖ Flexion of finger
❖ Presence of Cortical thumb
LOWER LIMB:
❖ Extended at hip joint and adducted
❖ Extended at knee joint
Scissoring ?
❖ Plantar flexion in ankle joint
❖ Scissoring of lower limb - positive
HEAD TO FOOT EXAMINATION: Moderator’s Note:
❖ Microcephaly (HC – 36cm (<3rd centile)) Definition of microcephaly
❖ AF open – 2*1 cm
❖ No overriding of suture
❖ Hair - normal
❖ No loss of occiput hair
❖ EYES – No cataract, No squint, No nystagmus, no
Not fixing to light
ptosis, not fixed and following light
❖ EARS – Normal, No startle response to sounds No startle response
 Moderator’s Note:
❖ SKIN – No neurocutaneous markers, bed sores /
signs of vitamin deficiency
CNS- Neurocutaneous markers
❖ intermittent opisthotonous positive Any paediatrics - Vitamin def
❖ Spine – normal
Oral hygiene
❖ No pallor
❖ Presence of Cortical thumb
❖ External genitalia - normal
VITAL SIGNS:
Moderator’s Note:
▪ HR – 110/min, regular in rhythm
▪ RR – 28/min
▪ BP – 80/60 in right upper limb
▪ SpO2 – 99% in room air
▪ Temperature – 98.6°F

ANTHROPOMETRY:
We should not be a tailor/ hotel server
▪ Weight – 6.5 kg
WHO growth chart
▪ Length – 66 cm
▪ HC – 45 cm (<3rd centile)
CNS EXAMINATION:
HIGHER FUNCTION : Social smile ?

▪ awake , does not responds to call, not recognising mother

CRANIAL NERVES:
▪ 1st – could not be tested Absent fixation but
▪ 2nd – not fixing and following light, menace reflex – absent, B/L pupil normal pupillary reflex?

equally reacting to light, fundus – not tested

▪ 3rd , 4th , 6th – No ptosis / nystagmus/ squint, child not following light
▪ 5th – No wasting of temporal muscles, corneal and conjunctival reflex
are positive, jaw jerk
▪ 7th – No facial asymmetry while crying, no deviation of angle of
mouth, Nasolabial fold seen equally in both sides, No drooling of
saliva
▪ 8th – Not turning to sounds
▪ 9th, 10th – uvula in midline,with pooling of secretions
▪ 11th nerve – turns head to both sides
 SPINOMOTOR SYSTEM:
❑ Pull to sit – head lag not seen
Moderator’s Note:
❑ Ventral suspension – head lies at the plane
of body
Floppiness vs hypertonia
❑ Vertical suspension – scissoring of limbs Spasticity Vs Rigidity
❑ Bulk – equal in both upper and lower
limbs
❑ No muscle wasting
Why not 4/5 ?
Contractures vs spasticity
Right Left
Tone Upper limb Spasticity in all
Lower limb 4 limbs

Power Upper limb 3/5 3/5

Lower limb 3/5 3/5 Best observed
Reflexes:
DTR:
Right Left
Upper limb (R,T,S) Brisk Brisk Jaw jerk ,
Lower limb(K,A) Brisk Brisk adductor,crossed

Ankle clonus - -

SUPERFICIAL: Brisk vs Exaggerated ?

B/L plantar extensor L5S1 How to elicit Plantar ?
Palate and pharyngeal, cremasteric L1L2 UMN lesion/ pyramidal tract involvement

Right Left
Corneal + + S1-7
Conjunctival + + S1-7
Abdominal + + T6-T12
PRIMITIVE REFLEX:
❑ Moros reflex – absent
❑ ATNR - present Moderator’s Note:
❑ No abnormal startle
Abnormal persistence/ non appearance
❑ Palmar grasp – positive
❑ Plantar grasp – positive
of primitive reflexes
❑ Sucking – positive
SENSORY: Child able to perceive pain sensation
AUTONOMIC SYSTEM : Could not be assessed
CEREBELLAR SYSTEM:
❑ No nystagmus
❑ No head nodding
Reaching out for objects
❑ Other signs could not be elicited
❑ No abnormal involuntary movements
❑ No meningeal signs
❑ Spine and cranium normal
Completion
OTHER SYSTEMS:
❑ CVS – S1 S2 – positive – No murmur
Moderator’s Note:
❑ RS – Bilateral air entry present– No added
Organomegaly - Storage disorder
sounds
❑ Abdominal – soft – No organomegaly, Summarize positive examination findings
mass – fecolith

DIAGNOSIS:
❑ Spastic quadriparesis – cerebral palsy
❑ Microcephaly - vision and hearing
impairment/ Global development delay Physiological ,Topographical, Functional
❑ Probably due to HIE sequelae (GMFCS classification)
Associated complications
Aetiology, Development, Nutrition
 Questions to discuss

• Spastic hemiplegia (handedness), spastic diplegia (commando crawl & scissoring),

• Spastic quadriplegia (Swallowing difficulties), Choreoathetoid (feeding difficulties)

• Investigations- MRI, vision, hearing assessment, EEG

• Progressive disorder - additional tests (IEM, Karyotype)
• Mimics- Spastic diplegia- Arginase def, Krabbe disease

• Rx- Prevention
• Multidisciplinary team
• Spastic diplegia - Orthoses to adductor tenotomy & rhizotomy
• Tenotomy of achilles, Hemiplegic- Constraint induced movement Rx,
• BZD, Baclofen, dantrolene, Levodopa, trihexyphenydyl -dystonia, Botulinum toxin,
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