Cerebral palsy is a cluster of permanent neurological and developmental disorders of posture and movement, which trigger activity limitation. It is caused by non-progressive disturbances which affect the evolving fetal or infant brain. This implies that the onset of cerebral palsy (CP) is usually in the early childhood. CP is a common neurologic syndrome in childhood, reported occurring in approximately four infants in 1,000 live births globally.
Pediatric epidemiologists contend that the risk factors for this condition include preterm births, difficult delivery, and some infections during pregnancy. Currently, large population-based registries are the primary surveillance and reporting methods due to the complexity of the condition and the process’ ability to capture multiple aspects of CP. Although multiple tests and screening can provide accurate diagnosis for CP, nurse practitioners can initiate physical, occupational, and speech therapies to mitigate the impairments and reduce the risk of developing other associated conditions.
Background and Significance of Cerebral Palsy
Cerebral palsy is the most prevalent cause of early-onset physical disability with lifelong impairment of movement, balance, reflexes, posture, and poor muscle control, resulting in the limited physical activity of a child. This implies that the resultant complications and challenges stemming from the non-progressive condition continue and evolve into adulthood (Hanes et al., 2019). Notably, CP is a cluster of related symptoms, etiologies, phenotypes, and comorbid disorders, including behavioral challenges, sensory problems, epilepsy, and intellectual impairment, attributed to the non-progressive strain in the developing fetal brain, among other causes (Stavsky et al., 2017).
The most prominent signs of CP are difficulties in standing even when using support, favoring one side of the body, floppy or too stiff parts, and delays in the development of motor skill and movement. In this regard, infants with CP experience impaired effectiveness in hearing, swallowing, speaking, sensation, vision, and activities such as walking, sitting, and crawling. Therefore, the motor disorders are usually accompanied by disturbances of cognition, behavior, perception, communication, epilepsy, and the secondary musculoskeletal impairment.
CP is an exceptionally common condition in early childhood with lifelong motor impairments. Global population-based estimates indicate that CP”s incidence range between one to nearly four per 1,000 live births (Centers for Disease Control and Prevention, 2020; McGuire et al., 2019). In the United States, the national average statistics reveal that approximately 764,000 people currently have CP, with projections that about 10,000 infants born every year will develop the condition. Further, estimated 8,000-10,000 babies are diagnosed with the syndrome annually. Overall, spastic CP is the most prevalent subtype, affecting an estimated 61-77% of all cases. However, only national data is available, which limits the comparative analysis of the federal statistical with the state figures.
Note: Data from the State of Texas regarding the prevalence and incidence of CP is unavailable.
Surveillance and Reporting of Cerebral Palsy
The surveillance and reporting of CP are critical in monitoring and evaluating the emerging trends and patterns as well as enhancing the prevention, management, and collaborative research of the condition. This emphasizes the significance of large population-based surveillance systems with standardized descriptions, definitions, and consistency in case selection for a comprehensive in-depth understanding. The continuous monitoring generates critical information of sufficient quality which guides policy development for epidemiologic research, disease prevention, and improving public health (Groseclose & Buckeridge, 2017). For instance, surveillance and accurate reporting can significantly enhance the comprehension of the ethnic and racial disparities in CP and the underlying mechanisms.
The current surveillance methods and mandated monitoring processes are the population and hospital-based registries, which pool harmonized data of congenital and postnatal CP. Notably, these two approaches generate useful multifaceted data in accordance with the aims and purposes of the 2009 World CP Register Congress24 registries. More specifically, the information collected through this index can enhance the planning, prevention, increase awareness among the community and professional groups, and determine the diagnosis’ prevalence within a defined population.
Additionally, the 2009 World CP Register Congress24 standardizes the data collection and reporting methods, providing an unambiguous and universally acceptable description of the motor condition, the associated complications, and impairments (Goldsmith et al., 2016). For instance, datasets on gestational age, birth weight, and the existence of any malformations facilitate the comprehensive analyses on the causal pathways in a standard format. Additionally, the captured information can be aggregated into significant metadata, fostering a comprehensive and holistic understanding of the condition from a universal perspective.
Epidemiological Analysis of Cerebral Palsy
The CP syndrome is the manifestation of intrapartum complications, intrauterine pathologies, and the postnatal sequel, particularly in preterm neonates. A comprehensive epidemiologic analysis evaluates the distribution and the determinants of health-affiliated events within specified populations and the subsequent utilization of the acquired information to control health challenges.
Researchers accomplish a comprehensive descriptive epidemiology by focusing on the affected section of the population (who), the exact health challenges (what), and when the time problem commences (when). Moreover, epidemiologists evaluate the scope or spread of the disease (where) and the reason behind the occurrence of the event (why). The principal objective of the 5Ws is to prevent and reverse negative health occurrences to save lives and improve the global long-term wellbeing of populations.
CP is a cluster of prenatal or postnatal neurologic conditions resulting from disturbances which adversely affect the developing fetal or infantile brain. This implies that this disorder is a global phenomenon which can only occur before, during birth, within a month after delivery, or in the first years of an infant’s life when the brain is actively evolving (CDC, 2020). While the condition’s etiology has been associated with perinatal adversity, the knowledge of the causal pathways has evolved to integrate prenatal biological risk factors, such as infections, congenital malformations, and genomics (Oskoui & Messerlian, 2018).
Additionally, social and environmental factors are significant predictors of CP (Tseng et al., 2018). For instance, pregnant mothers’ exposure to high levels of some toxic substances, such as methyl mercury, increases the risk of congenital malformations and birth defects, which can impair brain development (Li et al., 2018). CP is a non-infectious and non-communicable disorder caused by disruptions in the developing brain during pregnancy or early infancy. From this perspective, CP is an early-onset complication exclusively occurring in the initial years of life.
CP can be triggered by any event affecting the neonatal and fetal brain development. Low birth weight and premature births, particularly before 28 weeks of gestation rank as the leading risk factor, which increases correspondingly with a decrease in pregnancy age. For instance, a study revealed that CP’s prevalence in 1,000 live births for neonates born before 28 weeks of gestation was 82 and fell significantly to 1.4 in infants delivered at 36 weeks (Stavsky et al., 2017). However, post-term pregnancy at or after the 42nd week increases the risk of this condition. The global prevalence of CP ranges between 1.5 to over 4 per 1,000 live births, although slight disparities may exist due to variations in reporting, classification, and case definition.
In the absence of any known cure, CP is a non-progressive permanent condition imposing a life-long physical disability challenge on the affected persons. In this regard, it has severe financial and social costs due to the lifetime treatment expenditures and the disruptions in the caregivers’ social life. For instance, there are numerous pharmaceutical, hospital, and out-of-hospital fees, such as walking aids and special education, which increase the overall financial burden of the condition. Additionally, people living with CP and their caretakers have reduced total productivity due to frequent incidences of absenteeism from workplaces and reduced quality of life. Stavsky et al. (2017) contend that CP’s associative conditions, including epilepsy, hearing and vision impairments, intellectual, and learning disabilities exert additional pressure on the existing health systems. Therefore, CP has disproportionately high financial and social costs for the affected persons, their families, and the community.
Screening and Guidelines
The diagnosis, screening, and guidelines for CP have historically been premised on physical examination and the child’s developmental record. Although there is no single conclusively definitive test, multiple examinations and observations over time can enhance the accuracy of a diagnosis, and help to eliminate other conditions.
In addition to the developmental assessment, specialists might consider brain imaging tests, such as magnetic resonance imaging, x-ray computed tomography, electroencephalogram, metabolic, and genetic evaluation (te Velde et al., 2019). Indeed, these additional tests are critical since the severity of CP varies and does not always result in profound disabilities for most people. However, collaborative approaches of child neurologists, developmental pediatricians, and pediatric psychiatrists can significantly increase the accuracy of the diagnosis.
Generally, the screening guidelines for CP entail determining the presence of altered postures and movement, which cause abnormal motor functioning. For instance, the Hand Assessment of Infants (HAI) provides reliable information regarding whether the hand function is developing as anticipated. However, the integral defining concept for screening is the activity limitation attributable to motor disorder (te Velde et al., 2019). This implies that an infant with a brain lesion but without activity impairment does not meet the criteria for CP. Further, the brain lesion should be non-progressive and the condition unchanging.
The General Movement Assessment (GMA) is a commonly used screening and diagnostic test for CP. It involves measuring specific primitive reflexes, which occur spontaneously, including tonic neck, grasp, Moro, rooting, and tongue thrust. Notably, the sensitivity of this assessment model is significantly high due to its ability to detect a true positive, the correct identification of all the affected persons, and the limited generation of false negative tests. GMA is a non-invasive cost-effective diagnostic tool with over 95% sensitivity, 90% specificity, relatively high negative and low positive predictive values (Tomantschger et al., 2018; Seesahai et al., 2020). Therefore, this screening instrument is substantially reliable in identifying neonates at risk of neuromotor impairments.
Plan: Integrating Evidence
A care plan is a fundamental roadmap which can significantly improve a child’s psychological, developmental, and physical wellbeing. Typically, evidence-based care plans encompass therapeutic interventions, such as physical, occupational, speech, and language therapies, which are designed to expand the infant’s capabilities and mitigate the adverse effects of the impairments. For instance, Das and Ganesh (2019) argue that physiotherapy is a highly effective treatment option for children with CP, notwithstanding the severity of the disorder or the age of the infant. However, a comprehensive treatment plan encompasses primary, secondary, and tertiary interventions.
One of the primary measures to mitigate the occurrence of CP is reducing the likelihood of preterm neonates by decreasing the risk of preterm delivery and prolonging gestation. For instance, I will provide magnesium sulfate to pregnant mothers who are susceptible to preterm labor. According Burhouse et al. (2017), magnesium sulfate is an effective intervention which inhibits contraction to stop preterm labor, improves neurodevelopmental outcomes, and prevents injuries to the unborn child’s brain. The secondary intervention will entail regular screening and examinations to detect the disease in its earliest phases.
For instance, continuous monitoring will help to discover biomarkers and the initiation of remedial measures (Hu et al., 2020). This will be conducted through community outreach programs as an active implementation of the CP health policy advocacy. From the tertiary level, physical therapy will be conducted to the infants to help their flexibility, strength, motor development, mobility, gait, and balance. For instance, guided and goal-oriented exercises foster functional improvement without triggering any adverse effects (Das & Ganesh, 2019). Thus, prolonging gestation, regular monitoring of possible infections, and physical therapy will constitute the comprehensive care plan.
Conclusively, CP is a cluster of early-onset disorders which impose permanent movement challenges on an individual. The global prevalence ranges from one to almost 4 infants per 1,000 live births, with an estimated 764,000 people living with CP in the United States. Currently, hospital and population-based surveillance and reporting methods are used for comprehensive epidemiological analysis. Although there is no single comprehensive diagnostic tool, the General Movement Assessment approach is highly effective in its specificity, predictive value, cost, and sensitivity. Despite the absence of any cure, various primary, tertiary, and secondary interventions can be implemented to prevent the occurrence and improve the developmental outcomes of infants with CP.
Burhouse, A., Lea, C., Ray, S., Bailey, H., Davies, R., Harding, H., Howard, R., Jordan, S., Menzies, N., White, S., Phillips, K., & Luyt, K. (2017). Preventing cerebral palsy in preterm labor: A multi-organizational quality improvement approach to the adoption and spread of magnesium sulfate for neuro-protection. BMJ open quality, 6(2), 1–12. Web.
Centers for Disease Control and Prevention. (2020). Cerebral palsy. Web.
Das, S. P., & Ganesh, G. S. (2019). Evidence-based approach to physical therapy in cerebral palsy. Indian Journal of Orthopedics, 53(1), 20–34. Web.
Edelstein, M., Lee, L., Herten-Crabb, A., Heymann, D., & Harper, D. (2018). Strengthening global public health surveillance through data and benefit sharing. Emerging Infectious Diseases, 24(7), 1324–1330. Web.
Groseclose, S. & Buckeridge, D. (2017). Public health surveillance systems: Recent advances in their use and evaluation. Annual Review of Public Health, 38(1), 57–79. Web.
Goldsmith, S., McIntyre, S., Smithers-Sheedy, H., Blair, E., Cans, C., Watson, L., & Yeargin-Allsopp, M. (2016). An international survey of cerebral palsy registers and surveillance systems. Developmental Medicine & Child Neurology, 58, 11–17. Web.
Hanes, J., Hlyva, O., Rosenbaum, P., Freeman, M., Nguyen, T., Palisano, R., & Gorter, J. (2019). Beyond stereotypes of cerebral palsy: Exploring the lived experiences of young Canadians. Child: Care, Health and Development, 45(5), 613–622. Web.
Li, L., Wang, Z., Liang, H., Yang, F., Yuan, W., Gelaye, B., Yu, Y., Miao, M., Nørgaard, M., & Li, J. (2018). Risk of childhood cerebral palsy following prenatal exposure to ß2-adrenergic receptor agonist: A nationwide cohort study. PLOS ONE, 13(8), 1–13. Web.
McGuire, D. O., Tian, L. H., Yeargin-Allsopp, M., Dowling, N. F., & Christensen, D. L. (2019). Prevalence of cerebral palsy, intellectual disability, hearing loss, and blindness, National Health Interview Survey, 2009–2016. Disability and Health Journal, 12(3), 443–451. Web.
Oskoui, M., & Messerlian, C. (2018). How socio‐economic disadvantage modifies health outcomes in children with cerebral palsy. Developmental Medicine & Child Neurology, 61(5), 509–509. Web.
Seesahai, J., Luther, M., Rhoden, C., Church, P., Asztalos, E., & Banihani, R. (2020). The general movements’ assessment in term and late-preterm infants diagnosed with neonatal encephalopathy, as a predictive tool of cerebral palsy by 2 years of age: A scoping review protocol. Systematic Reviews, 9, 1–8. Web.
Stavsky, M., Mor, O., Mastrolia, S., Greenbaum, S., Than, N. & Erez, O. (2017). Cerebral palsy—Trends in epidemiology and recent development in prenatal mechanisms of disease, treatment, and prevention. Frontiers in Pediatrics, 5, 1–10. Web.
Tomantschger, I., Herrero, D., Einspieler, C., Hamamura, C., Voos, M., & Marschik, P. (2018). The general movement assessment in non-European low- and middle-income countries. Revista De Saúde Pública, 52(8), 6. Web.
Tseng, S., Lee, J., Chou, Y., Sheu, M., & Lee, Y. (2018). Association between socioeconomic status and cerebral palsy. PLOS ONE, 13(1), 1–9. Web.
te Velde, A., Morgan, C., Novak, I., Tantsis, E., & Badawi, N. (2019). Early diagnosis and classification of cerebral palsy: A historical perspective and barriers to an early diagnosis. Journal of Clinical Medicine, 8(10), 1599. Web.
Xu, H., Zhang, L., Xuan, X., Zhu, M., Tang, J., & Zhao, X. (2020). Intrauterine cytomegalovirus infection: a possible risk for cerebral palsy and related to its clinical features, neuroimaging findings: a retrospective study. BMC Pediatrics, 20, 1–9. Web.