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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