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 non-
progressive 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,
such 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 fist with the thumb in the
palm),
Impaired sensation, impaired 2-point
discrimination, and/or impaired position
sense.
B)Hypotonic (Atonic ) cerebral plasy:-
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
Eyes-
Nearly half of the patients have
strabismus, paralysis of gaze, cataracts,
coloboma, retrolental fibroplasis,
perceptual and refractive errors.
Ears-

Partial or complete loss of hearing is usual

in kernictures. Brain damage due to
rubella may be followed by receptive
auditory aphasia.
Contd..
Speech-
Aphasia,dysarthria and dyslalia are common
among dyskinetic individuals.
Sensory defects-

Astereognosis 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.
Miscellaneous-

Inadequate 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 clear-cut 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 effusion-

Head 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 neuropathy-
The term metabolic neuropathy includes a
wide spectrum of peripheral nerve
disorders associated with systemic
diseases of metabolic origin.
Contd..
Muscle disorders-
Congenital myopathies and muscular
dystrophies can mimic cerebral palsy.
Distribution of muscle weakness and
other features is characteristic,hypotonia
is associated with diminished reflexes.
Ataxia telangiectasia-

Ataxia 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) Educational-
The defect of vision, perception, speech and
learning are managed by adequate special
education experiences.
F) Orthopedic support-
Tendon, 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.
I) 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.
Nursing Diagnosis for Cerebral Palsy
a) Risk for injury r/t spasms, uncontrolled movements
and seizures
b) Impaired Physical mobility r/t spasms and muscle
weakness.
c) Altered health maintenance R/T deviations from
normal growth and development.
d) Impaired verbal communicationr/t difficulty in
articulation.
e) Risk for aspiration r/t neuromuscular disorders
Changes in thought processes r/th cerebral injury,
learning disabilities.
f) Self-care Deficit r/t muscle spasms, increased activity,
cognitive changes.
g) Deficient Knowledge r/t home care and therapeutic
needs.
 Goal:
1. Children will always be safe and free from injury.
2. Children will have maximum movement ability and not
have contractures.
3. Children will explore how to learn and participate with
other children in doing some activities.
4. Children will express their needs and develop a body
weight within normal limits.
5. Children do not have aspirations.
6. The child will demonstrate an appropriate level of
learning ability.
7. Daily needs of the child tetpenuhi.
8. Parents / family demonstrate understanding of the needs
of child care that is characterized by taking an active role
in child care.
9. 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.
2. Watch the children during activity.
3. Give the kids a break when tired.
4. Use safety equipment when necessary.
5. When a seizure; install a safety device in the
mouth so that the tongue is not bitten.
6. Do suction.
7. The provision of anti-seizure in the event of a
seizure.
 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 semi-
sitting 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.