Nigerian Journal of
Paediatrics 2011;38(3)115 -119
ORIGINAL
Frank-Briggs A I
Sociocultural issues and causes of cerebral
Alikor
EAD
palsy in Port Harcourt, Nigeria
Received: 28th February
2011
Abstract
Background .
Cerebral
Majority of the
children 668
Accepted: 4th May
2011
palsy (CP) is a
common
(80.09%) had spastic
CP. Eighty
neurological disorder
of childhood
seven (10.43%) had
hypotonic and
Frank-Briggs AI (
)
with significant
neurological
57 (6.83%)
extrapyramidal types,
Alikor EAD
complications and
associated
the mixed type 22
(2.64%) was the
Department of
Paediatrics,
comorbidities.
least common. Asphyxia
(27.94%),
University of Port
Harcourt The aim
of this study
was to
kernicterus (26.26%)
and Central
Teaching
Hospital,
determine the socio-
cultural
Nerves System
infections (15.95%)
Port Harcourt
characteristics and
causes of CP in
were the leading
identified causes.
Email: afrankbriggs@yahoo.com
children who presented
to the
Co-morbidities such as
seizures,
Tel:
+2348033092885
Paediatric neurology
clinic in Port
microcephaly and speech
and
Harcourt,
Nigeria.
auditory deficits were
present in
Method: Hospital records of 834
majority of the
subjects. Seizures
children with CP who
presented
and microcephaly were
commoner
between 1 June 2008 and
1 June
st
st
among CP cases
associated with
.2010 were
reviewed
asphyxia than those
associated with
Demographic data were
extracted
kernicterus.
and a validated
socio-economic
Conclusion:
Cerebral palsy
was
classification of
parents was used.
commoner amongst those
in low
Data was analyzed using
SPSS
socio-economic status
with
version 15
software.
perinatal problems.
Improved
Results: of
the 2,288
patients with
perinatal care will
reduce the
neurological disorders
seen. 834
burden of CP.
Continuing training
had cerebral palsy
giving a
of health workers and
traditional
prevalence of 36.45%.
Theirages
birth attendants are
essential.
ranged from 5 months to
13 years.
Socio-economic
stratification of
Keywords: Cerebral
palsy, Social
the patients showed
concentration
cultural issues, Port
Harcourt.
in the lower
socioeconomic groups
IV (35.73%) and V
(56.35%).
Introduction
pregnancy, during
childbirth or after birth up to about
age three. This results
in limitation in movement and
4
Cerebral palsy (CP) is
a chronic disabling condition
posture and are often
accompanied by disturbances of
resulting from
permanent damage to the immature
sensation, depth
perception and other sight-based
brain. It is commonly
encountered worldwide.
1-3
In
perceptual problems,
speech disorders, and
the industrialized
world the incidence of cerebral
sometimes even
cognitive impairement; CP may be
palsy is about 2 per
1000 live births. The incidence
3
accompanied by
epilepsy. While in certain cases there
is higher in males than
in females 1.3:1. It is caused
is no identifiable
cause, typical causes include
by damage to the
cerebral cortex and other parts of
problems in
intrauterine development (e.g.
the brain such as the
cerebellum. The damage affects
infections, exposure to
radiation), birth asphyxia,
the developing brain
which can occur during
birth trauma, severe
jaundice, meningitis and
encephalitis during
early childhood.
5
116
The consequences of CP
include retardation of
Palsy Was based on
clinical evaluation but
growth and delay in
motor development as well as
investigations carried
out for some of the patients
cognitive and social
problems. For many children
included skull and
spine radiographs, transfontanel
with CP, parents are
heavily involved in their self-
ultrasound scan,
computerised tomography scan and
care activities.
Self-care activities, such as bathing,
or magnetic resonance
imaging studies.
dressing, grooming and
eating, can be difficult for
these children as
self-care depends primarily on use
These tests were
carried out for individual patients as
of the upper
limbs.
6,7
For those living with
CP,
needed, especially for
those whose diagnosis was
impaired upper limb
function affects almost 50% of
difficult to ascertain
clinically.
Parental socio-
children and is
considered the main factor
economic classification
into the upper (I, II), middle (
contributing to
decreased activity and participation
III) and lower (IV and
V) groups was done using the
in daily activities.
Since the hands are used for many
7
method recommended by
Oyedeji.
9
Data was
self-care tasks, it is
logical that sensory and motor
analyzed using SPSS
version 15 software and
impairments would
impact negatively on daily self-
presented in frequency
distribution tables and
care activities.
8
percentages.
The ideal management of
CP is comprehensive and
effective physical
rehabilitation,
7
which is
unfortunately
expensive. However, even with the
Results
best rehabilitation,
functional and physical recovery
in CP is rarely
complete. Prevention therefore is of
General characteristics
central importance.
This study was conducted to
determine the
socio-cultural issues and probable
A total of 2,288
patients with neurological disorders
causes of CP in
children presenting to a tertiary
were seen in the
Paediatric neurology unit of the
hospital in Nigeria.
These may help in identifying
hospital during the
study period. Of these, 834 had
factors that need
further study in order to reduce the
cerebral palsy.
burden of CPin the
country.
The prevalence of CP at
the Paediatric Neurology
Clinic for the study
period was 36.45%
Their ages
ranged from 5 months to
13 years.
(Table 1)
There were 536(64.27%)
males and
298(35.73%) females
giving a male to female ratio of
Materials and Method
1.8: 1. Socio-economic
stratification of the patients
showed concentration in
the lower socioeconomic
The study was a
retrospective survey of medical
groups IV (35.73%) and
V (56.35%), the others are
records of children who
were seen in the Paediatric
shown on Table
2.
Neurology unit of the
University of Port-Harcourt
Teaching Hospital,
Nigeria from June 2008 to June
Mode and Places of delivery of the children with CP.
2010. Port Harcourt is
the capital of Rivers State
with a population of
about 5 million. The teaching
Most 534(64.03%) of the
children were delivered by
hospital is the only
tertiary hospital located in the
spontaneous vertex
delivery. Two hundred and eighty
Port Harcourt
metropolis. It is a 500 bedded hospital
six (34.29%) were by
assisted mode of delivery while
and serves as a
referral centre for hospitals within the
14(1.68%) of them had
caesarean section. Majority of
state and neighboring
states.
the children were
delivered at home 310 (37.17%).
Only 24 children
(2.88%) were delivered in the
Data on age, gender,
clinical history and
University of Port
Harcourt teaching hospital. The
examination findings,
diagnosis and treatment
group of children
belonging to others included those
outcome were collected
from their case records. It
who were delivered in a
motor vehicle on their way to
was noted that children
who had other neurological
the place intended for
delivery 7(0.84%) and in the
disorders had
multidisciplinary evaluation of their
farm 4(0.48%). Table
3
problems. They were co
managed with other
specialists like the
ophthalmologists, audiologists,
Clinical classification of Cerebral Palsy
physiotherapists and
clinical psychologists. The
case notes of the
patients were coded for easy
Majority of the
children 668 (80.09%) had spastic
identification in order
to ensure that duplication did
CP. Eighty seven
(10.43%) had hypotonic and 57
not occur in recruiting
the patients into the study.
(6.83%) extrapyramidal
types, the mixed type 22
(2.64%) was the least
common. Of the 668 children
A colored marker was
used to inscribe a mark as
withspastic CP,
458(68.56%), 285 (42.67%) and 91
soon as the folder was
used. Diagnosis of cerebral
(13.62%) were
quadriplegic, hemiplegic and
diplegic,
respectively.
117
Aetiological factors
Table 3: showing place of delivery of the
children
with cerebral
palsy
Table 4 shows various
aetiological factors that
contributed to cerebral
palsy amongst the study
Place of
Delivery
No
%
group. Birth asphyxia
accounted for about 28% of
cases, closely followed
by kernicterus in 26 %. The
Home
310
37.17
others are shown on the
table. In 466 (55.87%) of the
Local maternity
home
212
25.42
children only one cause
was identified, 87(10.43%)
Church
109
13.07
had multiple causes,
and 281(33.69% ) had no
Primary health
center
98
11.75
identifiable
cause.
The perinatal causes
included
General hospital
52
6.25
asphyxia, kernicterus
and prematurity, while central
Tertiary
hospital
24
2.88
nervous system (CNS)
infections and head injuries
Privately owned
hospital
18
2.16
were the major
post-natal causes.
Others
11
1.32
Neurological co-morbidities
Table 4: Causes of cerebral palsy among the
834
children
The majority of
children (84.65%) had CP with
Causes
No
%
various comorbidities;
some of the children had
more than one disorder.
Seizures, microcephaly and
speech impairment were
the commonest co-
Asphyxia
233
27.94
morbidities, affecting
418 (50.12%), 308 (36.93%)
Kernicterus
219
26.26
and 240 (28.78%)
children, respectively. Table 5
CNS infections*
133
15.95
shows these
comorbidities. One hundred and twenty
Prematurity-associated
eight (15.35%) had no
comorbidities.
complications
64
7.67
Neonatal seizures
23
2.76
Table 1 .
Age distribution
of the
children with
Head injury
11
1.32
cerebral palsy at
presentation
Unknown
151
18.11
Total
834
100
Age
No
%
KEY:*CNS infections =
central nervous system
<1 year
261
31.29
infections (meningitis
and encephalitis).
1 - 3 years
428
51.32
4 - 6 years
98
11.75
Table 5: Co-morbidities among the children
with
7 - 9 years
26
3.12
Cerebral Palsy
=10 years
21
2.52
Co-morbidities
No
%
Total
834
100.0
Seizures
418
50.12
Table
2:
Socio-economic
classification of the
Microcephaly
308
36.93
children with cerebral
palsy
Speech
impairment
240
28.78
Socio-economic
group
No
%
Mental
retardation
211
25.30
Visual deficits
188
22.54
I (upper)
7
0.84
Hearing
impairment
102
12.23
II (upper)
18
2.16
Behavioural
disorder
31
3.72
III (middle)
41
4.92
IV (lower)
298
35.73
Hydrocephalus
10
1.20
V (lower)
470
56.35
None
128
15.35
Total
834
100.0
Improve
Discussion
This study recorded a
higher prevalence of CP than
the 16% and 16.2%
previously reported from other
4
6
centers in Nigeria.
This may be due to increasing
awareness that CPcan be
managed in hospital setting,
making more parents and
caregivers come with their
children to seek
medical attention instead of seeking
help in the homes of
traditional healers and other
unorthodox places. The
number of unsupervised
118
deliveries resulting in
significant cerebral damage
report of a
predominance of brain infections from
India
13,16
may have contributed to
this high number as well. In
and problems of low
birth weight from the
Netherlands.
4,13
the developed nations
of the world CP is also on the
Also, sometimes the
cause may not be
increase due to
improved intensive care and better
identified or known (
idiopathic CP). This study
management of very low
birth weight and severely
recorded cases of
unknown aetiology. Some genetic/
premature babies. These
babies survive but come
chromosomal disorders
contribute to CP.
down with neurological
sequelae including different
types of cerebral
palsy.
4, 5, 10
In our study few were
identified clinically. The
clinical parameters
used included children with
The age distribution of
the children showed that
microcephaly,
dysmorphic facial features with/
about half (51.32%) of
them were between 1-3 years
without seizures. Lack
of advanced hi-tech
old. This late
presentation is not strange. When a
laboratory (biochemical
assays, chromosomal
child has delayed motor
milestone and other
analysis) and
radiological gadgets limited arriving at
comorbid problems such
as seizures, it is usually
a definitive
diagnosis.
attributed to evil
spirit possession and witchcraft,
therefore orthodox
medication and therapy is the last
It is not surprising to
see many comorbid neurological
option. Parents and
caregivers usually seek solution
disorders in these
children with cerebral palsy.
elsewhere such as
spiritual homes, native doctors
Neurological
co-morbidities such as those found in
and traditional healers
before presenting to the
this study have been
reported by others.
5,17
The CP
hospital.
11
from prematurity may
have been due to
sepsis,
intracranial bleeding
and metabolic complications in
Majority of the parents
were in the lower socio-
this group of babies.
High rates of co-morbidity are
economic groups. This
finding is consistent with
likely to increase the
burden of management of CP, as
previous association of
CP with poor education and
anticonvulsants, speech
therapy, hearing aids, special
poverty.
5
These factors in
combination with
education amongst
others will become necessary.
ignorance result in
poor utilization of antenatal and
Furthermore, looking
after physically challenged
proper delivery
services.
12
Good antenatal
services
children has been shown
to cause psycho-morbidities
in the
caregivers.
18-20
are expensive and out
of reach to the parents of low
socioeconomic status.
Improved access to quality
prenatal, obstetric and
neonatal care services should
be provided free or
with minimal charge, particularly
for the poor. This will
reduce birth asphyxia,
kernicterus, perinatal
and neonatal infections which
Conclusion and recommendation
are major contributor
to cerebral palsy in our
environment.
CP is mainly associated
with perinatal events and low
socio-economic status.
Stringent efforts should be
The study also showed
that more than 75% of the
made to prevent these
conditions. Traditional birth
subjects were delivered
at home with the help of a
neighbour, grandmother
or friend; church or at the
attendants should be
taught simple ways of
place of a traditional
birth attendance. Deliveries in
identifying fetal
distress and the need for prompt
these places are risky
because fetal distress and other
referral. Mothers and
health workers should also be
non anticipative
obstetrics complications may not be
taught simple ways of
recognizing jaundice in babies
and ensure proper
management.
18
identified early enough
for proper referral and
The rarity of
prompt
management.
prenatal causes of CP
in this study may reflect
inability to
investigate high-risk pregnant women
The commonest type of
CP being the spastic type of
and their infants
adequately, particularly for intra-
CP in this study is
similar to that reported by others.
11,13
The three most common
aetiological factors
uterine infections.
Counseling from health visitors
being hypoxic
encephalopathy, bilirubin toxicity (
could improve
compliance and the chances of
kernicterus) and CNS
infections is in keeping with
rehabilitation.
Continuing education of health
findings in
other
reports.
5,14,15
Perinatal events
workers and traditional
birth attendants about the
are the commonest
causes of CP in resource poor
prevention of asphyxia
and training to identify
settings like
Nigeria.
11,12
This contrasts with
the
jaundice and neonatal
infections will reduce the
morbidity and mortality
associated with cerebral
palsy.
119
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