Common Health Problems Associated With Cerebral Palsy

Certain health problems are more common in individuals with cerebral palsy.

Drooling

Drooling can cause severe skin irritation, bad breath, create a social barrier, and can contribute to lung issues. Drooling results from problems with swallowing such as difficulty with coordination or reduced frequency of swallow. It is not caused by excessive saliva production. Drooling should be openly discussed with a doctor as part of routine health management. In some cases, oral hygiene and use of bibs to absorb the saliva is adequate for management. Certain medications can reduce the amount of saliva produced, which in some cases helps reduce the extent of drooling, however not all children tolerate or benefit from these medications. A speech therapist can help to teach the child better oral coordination and to encourage swallowing frequency but often, while the child swallows more frequently during therapy, they may not continue this outside of therapy sessions.  Botox can be injected into the major salivary glands which inhibit nerve endings and reduce the amount of saliva produced. However this treatment is somewhat invasive, has to be repeated every 3-6 months, and can sometimes result in excessive dry mouth. Surgery to remove major salivary glands may be an option when issues are severe.

Nutrition

Poor nutrition can be associated with serious health problems in children with cerebral palsy. Chewing and swallowing difficulties, which occur in about one-third of all cases, are most responsible for the problems with under nutrition. In some cases, use of oral motor therapy, optimizing positioning and frequency of feeding and use of high density supplements can optimize growth and nutrition. However, for other children, a feeding tube (usually placed through the abdominal wall into the stomach using an endoscope or surgery) is important to support optimal hydration and nutrition. Some children with CP may develop obesity. In some cases this is due to lifestyle choices while in other cases it may be due to overzealous treatment of under nutrition with oral supplements or through a feeding tube. In addition to issues with over and under nutrition, children with CP can be at risk for deficient intake of certain micro-nutrients, protein, and fiber. In particular iron deficiency, inadequate calcium intake and sub-optimal vitamin D levels have occurred with increased frequency in this population. It is critical that all children with CP have ongoing nutritional assessment by a clinician skilled in this area.

Bladder Dysfunction

Bladder dysfunction can also be a serious health problem for children with cerebral palsy and may require treatment from a physician who specializes in bladder function. Incomplete bladder emptying (resulting in urinary tract infections), increased accidents due to bladder muscle tone abnormalities, bed wetting, stress incontinence and dribbling are all issues that may occur with increased frequency in children with cerebral palsy.

Gastrointestinal Issues

Gastroesophageal reflux (food in the stomach being able to sneak back up the esophagus) is a common problem in children with CP and is usually treated by adjusting feeding schedule, optimal positioning, acid blocking medication and sometimes medication to help stomach motility.

Constipation

Constipation is a common complication of cerebral palsy. Many factors may contribute to constipation including reduced fiber and fluid intake, reduced mobility, the impact of certain medications on intestinal motility (e.g. seizure medications), weak abdominal muscles, difficulty coordinating the act of pooping and sub-optimal positioning for pooping. All of these factors should be addressed when treating constipation.

Puberty

Information about pubertal development in CP is somewhat limited. Overall, children with CP should be expected to pass through puberty at similar ages to the general population. However, one cross-sectional survey of children with moderate to severe CP showed that there was a caveat. First, a subset of children with CP develop pubic hair earlier than the general population without other signs of puberty such as breast development. This is likely not true puberty but a benign condition known as premature adrenarche. Additionally there seems to be a subset of children with CP who do start puberty (indicated by breast development) slightly earlier and a subset that finish puberty slightly later than the general population.

It is important for teens with CP to receive all the usual care that is typical for teens (e.g. treatment of acne, cognitively appropriate information on substance abuse, sexuality and safety information, standard immunizations, management of menstrual issues like pain or excessive bleeding). Some girls with CP may benefit from medical suppression of menses.  Fertility rates have not been evaluated in individuals with CP but many individuals with CP have had children.

Respiratory Issues in Cerebral Palsy

Oral motor challenges and gastroesophageal reflux may both contribute to chronic aspiration of saliva, food and/or refluxed gastric contents into the lungs. This may cause illness with pneumonia or lead injuring the lungs called “chronic lung disease.” Evaluation and management by a specialist skilled in lung function (e.g. a pulmonary specialist) is important for all children with recurrent pneumonias or other chronic respiratory issues.

Sleep

Sleep issues are common in children with CP and may include difficulty with falling asleep, difficulty separating from parents at bedtime, difficulty staying asleep due to pain, seizures, respiratory or gastrointestinal issues, not breathing adequately in sleep (a condition call sleep hypoventilation), changes in respiratory pattern during sleep due to brain function (e.g. central sleep apnea) or having obstruction of the airway during sleep (sleep obstructive apnea). If a child with CP is having difficulty with sleep, it should be discussed with the health care provider and in some cases involvement of a certified sleep doctor or evaluation with a sleep study may be indicated.

Pain and Cerebral Palsy

Hip pain in children with cerebral palsy is a very common problem. Only recently has general pain in children with cerebral palsy been recognized and studied. According to a questionnaire, two-thirds of the parents felt that their children experienced pain for at least several days during the month before the completion of the questionnaire. But it can be difficult to tell when children with cerebral palsy are in pain if they have limitations in their communication skills (Nolan et al., 2000). Research regarding pain management specific to cerebral palsy is limited.

Other Health Problems

In addition to the mentioned problems above, patients with cerebral palsy often have other health problems including:

  • Muscle and skeletal issues including contractures, scoliosis and hip dislocation
  • Seizures
  • Vision and hearing concerns
  • A higher risk of pressure sores
  • Dental care concerns including identifying a dentist skilled in caring for children with special needs, a higher risk for cavities if there are challenges with providing regular oral care and orthodontic issues.

Other Concerns

Due to brain injury or abnormal brain development, many children with cerebral palsy have associated learning concerns including specific learning disabilities or intellectual disability (a globally lowered intelligence). Children with CP may also have a higher risk of difficulties with focus, impulse control, or managing activity level (ADHD). Some children with CP may also have challenges with development of communication in a pattern consistent with a diagnosis of autism.

Speech and language challenges may occur in this group of children. Contributing factors include oral motor dysfunction (difficulties with motor control of the oral muscles), hearing impairments and cognitive concerns.

Mental Health Concerns including behavioral challenges, difficulties with emotional regulation, anxiety and depression may occur in individuals with CP. Unfortunately; these often go unrecognized or untreated due to the challenges in recognizing and treating these conditions in children with disability. If a parent has concern, evaluation by a mental health professional skilled in “dual diagnosis” (the combination of a mental health issue and developmental disability) is important.

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Resources:

Brain Injury Research Foundation
www.birf.info

National Institute of Neurological Disorders and Stroke
www.ninds.nih.gov

Children’s Hemiplegia and Stroke Association
www.chasa.org