Cerebral Palsy, Erb’s Palsy and Other Birth Injuries
Cerebral palsy, Erb’s palsy and brachial plexus palsy are types of neurological conditions that cause muscle weakness or lack of muscle movement and control in infants. These conditions result from damage to the brain and/or nerves or nerve fibers that can occur during birth.
According to the Centers for Disease Control and Prevention (CDC), cerebral palsy (CP) is the most common motor disability in childhood. Studies say CP affects about 1.5 to more than four in 1,000 live births or children of a certain age. About one in every 323 children has CP.
Furthermore, the CDC estimated that the lifetime cost to care for an individual with CP is approximately $1 million, with a combined lifetime cost for all people with CP in 2000 totaling $11.5 billion in direct and indirect costs.
A 2003 report by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) showed that contrary to prior belief, only a small number of cases of CP resulted from lack of oxygen during labor and delivery. But the CDC acknowledged that in many cases, a specific cause cannot be determined. Furthermore, the CDC reported that the majority of CP cases, approximately 85 to 90 percent, are congenital, meaning the damage to the brain happened before or during birth.
The American Pregnancy Association reported that about 70 percent of CP cases likely result from complications occurring before birth that interfere with proper brain development. Most prenatal complications associated with the development of CP in infants are preventable and/or treatable.
Other birth injuries can be directly related to nerve damage during a difficult delivery. As a result, newborns may experience a temporary or permanent loss of movement or weakness in the shoulder, arm, hand and/or fingers on the side of the body where the damage occurred.
What is Cerebral Palsy?
Cerebral palsy (CP) describes a group of neurological disorders that are apparent in infancy or early childhood and permanently affect body movement, muscle coordination and balance, as well as posture. Cerebral means having to do with the brain, and palsy means weakness or problems with using the muscles.
Some individuals with CP may also suffer from related conditions including:
- Intellectual disabilities
- Vision, hearing and/or speech impairments
- Changes in the spine, such as scoliosis
- Joint problems
- Other development disabilities, such as autism spectrum disorder (ASD)
CP is the result of abnormal brain development occurring prior to birth or damage to the developing brain occurring prior, during or after birth. The condition affects a person’s ability to maintain control of his or her muscles. The severity of CP may vary largely from person to person from mild to severe.
Types of Cerebral Palsy
The main classifications of CP exist dependent upon the type of movement disorder involved. Individuals can also experience symptoms of more than one type of CP, in which case they would have mixed CP. The most common type of mixed CP is a combination of spastic (stiff muscles) and dyskinetic (uncontrollable muscle movement) CP.
Spastic Cerebral Palsy
This is the most common type of CP affecting roughly 80 percent of the population of individuals with CP. Spastic CP is characterized by increased muscle tone, which results in stiff muscles and awkward movements. Spastic CP types are classified by affected body parts.
Plegia and paresis means paralyzed and/or weak. This type of spastic CP affects mainly the legs. Arms are either less affected or not affected at all. This condition can interfere with a person’s ability to walk due to their legs being pulled together, turned inward and/or crossed at the knees, which is also called scissoring.
Hemi means half, which explains why this type of spastic CP affects just one side of a person’s body, usually affecting the arm more than the leg.
This form of spastic CP is the most severe and affects all four limbs, the trunk of the body and the face. Individuals with this condition are usually unable to walk and often have other developmental or intellectual disabilities, including seizures or vision, hearing, or speech impairments.
Dyskinetic Cerebral Palsy
Dyskinetic literally means bad or difficult motion or movement. This type of CP is characterized by uncontrollable movements of an individual’s hands, arms, feet and legs, usually causing difficulty with walking and sitting. Movements can be fast or slow and spasmodic or twisting. If the face and tongue are affected, the individual may have trouble sucking, swallowing and talking. Muscle tone is constantly changing from too tight to too loose.
- Involuntary movements that are both slow and writhing
- A combination of involuntary movements, including both irregular contractions and writhing
- Involuntary repetitive muscle contractions resulting in twisting and abnormal postures
Ataxic Cerebral Palsy
This type of CP results in balance and coordination impairments. Individuals with ataxic CP may have an unsteady gait and may experience a difficult time with quick or controlled movements.
How is Cerebral Palsy Diagnosed?
The earlier CP is diagnosed, the better the patient’s long-term outlook is. CP is usually diagnosed within the first two years of a child’s life. However, the more mild the symptoms, the more difficult it is to make a diagnosis until the child is older.
Diagnosing CP can involve several steps, including a full neurologic exam and testing of cognitive functioning. Other tests may need to be performed first to rule out other possible disorders. After other possible conditions have been negated, a CP diagnosis may include three main steps.
This is also called surveillance, and is simply the monitoring of your child’s growth and development over a period of time.
During this step, a short test is given to see if the child is exhibiting specific developmental delays. This test may be in the form of an interview or a questionnaire completed by a parent, or the doctor may opt to give the test to the child. The American Academy of Pediatrics recommends that a screening test for developmental delays be performed at specific ages throughout a child’s early years of development regardless of specific concerns. These tests are recommended to be given at 9 months, 18 months and 24 or 30 months.
Developmental and Medical Evaluations
The purpose of this evaluation is to provide a diagnosis for the specific type of disorder that is affecting the child. This step in the process can also help to identify other conditions that often affect the child concurrently with CP, such as intellectual disabilities, seizures, and vision, hearing or speech problems. Specialists may also assist in this process.
Treatment and Complications of Cerebral Palsy
Presently, there is no cure for CP. It is a lifelong disorder with symptoms that can change throughout a person’s lifetime. However, CP does not get worse over time, and treatment can often improve a child’s future outlook. The earlier the treatment begins, the better likelihood the child will have of overcoming developmental lags and disabilities. For most people with CP, life expectancy is not affected by the disorder, but some individuals with more severe CP might still require extensive, lifelong assistance and care.
Types of Therapy
There is no standard therapy for CP, but several different forms of therapies exist to help improve upon specific impairments and to meet certain needs by targeting the core disabilities affecting each individual’s quality of life.
- Physical Therapy
- Physical therapy is usually started earlier on following a diagnosis. It is essential to the treatment of CP. It involves specific sets of exercises to maintain and build muscle strength, balance and motor skills.
- Occupational Therapy
- Occupational therapy focuses on making the most and best use of upper body function and mobility, and on the improvement of posture. It is designed to assist a child with ways to tackle everyday tasks, such as dressing, going to school and participating in other daily activities.
- Recreation Therapy
- Recreation therapy encourages the child’s participation in art, sports, and other activities and events that most children with CP might otherwise miss out on or intentionally avoid. Such participation has been shown to increase levels of self-esteem and emotional well-being, as well as improve upon speech and language skills.
- Speech and Language Therapy
- This type of therapy assists in the promotion of communication skills in children with CP. It can be used to help improve their ability to speak, and to speak more clearly, as well as to find new ways to communicate through the use of sign language or electronic or other assistive language devices.
- Problems with Eating and Drooling
- Certain therapies are available to help treat children with CP who have difficulties with eating and drinking due to little control over the muscles used in chewing and swallowing. Children with CP who have trouble in this area are also at risk for choking, aspirating, malnutrition, recurrent lung infections and progressive lung disease.
Causes and Risk Factors of Cerebral Palsy
Abnormal brain development while in utero can result in CP, but CP can also be the result of damage to the brain occurring prior to, during or after birth. There isn’t one specific cause of CP, and in many cases, the exact cause is unknown. However, the majority of children (85 to 90 percent) have what is known as congenital CP, meaning the effect to the brain happened before or during childbirth. A small number of children have what is called acquired CP, meaning the condition began more than 28 days after birth.
Congenital Cerebral Palsy
Congenital cerebral palsy (CP) is a type of brain damage that exists at birth, although it might not be diagnosed for months or even years. A cause of congenital CP is not always easy to identify. However, the condition can sometimes be the result of birth injuries or prolonged lack of oxygen to the infant occurring during the birthing process.
Causes of congenital CP may include:
- Genetic abnormalities
- Congenital brain malformations
- Maternal infections or fevers
- Fetal injury
- Low birth weight
- In newborns weighing under 5 1/2 pounds, but especially those weighing less than 3 1/2 pounds
- Premature birth
- Children born before 37 weeks gestation, but especially prior to 32 weeks
- Multiple births
- Especially when one of the babies dies before or shortly after the birth
- Assisted reproductive technology (ART) infertility treatments
- These are treatments taken by the mother to assist in getting pregnant
- Infections during pregnancy
- This can cause inflammation and potentially lead to brain damage in the fetus; fever can cause the same problem
- Jaundice and kernicterus
- Jaundice is a liver condition that causes yellowing of the baby’s skin and eyes; untreated jaundice can result in a condition called kernicterus, which can also occur from ABO or Rh blood type difference between the mother and baby
- Medical conditions of the mother
- Thyroid problems, intellectual disabilities or seizures in the mother can slightly increase a newborn’s chances of having CP
- Birth complications/injury
- Any condition or circumstance that depletes the baby’s supply of oxygen during pregnancy or birth, including detachment of the placenta, uterine rupture, severe low blood pressure in the mother or problems with the umbilical cord
Acquired Cerebral Palsy
In acquired cerebral palsy (CP), infants are born without damage to the brain. The brain damage is later acquired, generally more than 28 days after birth but prior to full brain development. It is typically easier to identify a specific cause of acquired CP.
Causes of acquired CP may include:
- Brain damage in the first few years of life
- Brain infections, such as bacterial meningitis or viral encephalitis
- Problems with blood flow to the brain – stroke, bleeding in the brain due to blood clotting problem, improperly formed blood vessels, heart defect or sickle cell disease
- Head injury resulting from a car accident, a fall or child abuse
- Because their brains are still developing and their skulls are not yet fused, infants are at a greater risk of experiencing brain damage as the result of a trauma compared to that of an older child
- Preterm or low birth weight
- A preterm birth is generally any birth occurring prior to 37 weeks gestation and a low birth weight is generally any newborn weighing under 5 pounds and 8 ounces
- Brain infections
- These include meningitis (inflammation of the brain and spinal cord membranes) and encephalitis (inflammation of the brain)
- Faulty safety measures, car accidents or other major traumatic events, lack of adult supervision, and child abuse can all contribute to a brain injury in a child
Types of Brain Damage
Certain types of brain damage result in characteristics that are more closely associated with the typical symptoms of CP than others. Certain risk factors can increase the likelihood of a developing fetus or newborn incurring brain damage as a result of trauma or exposure.
- Damage to White Matter
- This is the matter responsible for transmitting signals throughout the brain and the rest of the body. Researchers have found that between 26 and 34 weeks of pregnancy, the white matter of the developing fetus’ brain is especially vulnerable to injury and trauma.
- Abnormal Development
- Circumstances that can disrupt normal brain development include infections, fevers, trauma or any other condition that may cause harm to the fetus’ nervous system or the conditions of the mother’s womb.
- Bleeding (Hemorrhage)
- This is most common caused by fetal stroke. Strokes in fetuses can be caused by blood clots in the placenta, underdeveloped or weak blood vessels in the brain, blood-clotting abnormalities, or high blood pressure or infection in the mother.
- Lack of Oxygen (Asphyxia)
- The lengthened interruption of a baby’s oxygen supply in utero or during the birthing process can be caused by several factors including stress incurred by the infant due to a difficult labor and delivery. Fetal stress can also cause the infant to prematurely pass meconium (early stool usually passed by the newborn following birth). If the baby inhales the meconium during the birthing process it can cause a condition known as meconium aspiration syndrome (MAS), which can further deplete the infant’s oxygen levels.
Types of Birth Injuries
A birth injury is any injury or physical trauma experienced by an infant during the birthing process. Some birth injuries are more common than others; and some are unavoidable while others may be preventable.
- Swelling of the soft tissues of the baby’s scalp
- This condition, called caput succedaneum, is the result of the baby’s difficult journey through the birthing canal. The use of a vacuum during the birth can increase a baby’s likelihood of experiencing this injury.
- Bleeding in the skull
- This condition is medically termed cephalohematoma, and it involves a pooling of blood just beneath an infant’s skull. While it does not affect the newborn’s brain, it will appear as a large lump on the baby’s head and can take two weeks to three months to completely resolve.
- Bruising or forceps marks
- Bruising may appear on a newborn’s face or head following birth due to the nature of the birthing process. If forceps are used, this can result in additional bruising and temporary marks. A vacuum extraction can result in scalp bruising and even cuts.
- Broken blood vessel in the eye
- This is also called subconjunctival hemorrhage, and can occur in one or both eyes appearing as bright red lines in the white part of the eye. This condition usually resolves within one week to ten days.
- Injury to facial nerve
- Pressure on the baby’s face and head during delivery can cause damage to facial nerves resulting in facial paralysis. Forceps can also cause this type of injury. The condition can improve on its own if the nerve was simply bruised. However, surgery may be needed in cases where the nerve is torn.
- Fractures (bone breaks)
- The clavicle and the collarbone are the most commonly fractured bones in newborns during births. These breaks are usually the result of difficulty in delivering the baby’s shoulder or breech deliveries.
What is Brachial Plexus Palsy?
Another type of birth injury called brachial plexus palsy, involves a group of nerves in the shoulder that can become damaged as a result of a difficult labor and/or birth. This injury can result in the loss of movement or weakness in the newborn’s arm and/or hand on the side affected. Other symptoms of the condition may include the loss of the Moro reflex (an involuntary startled response in newborns), a bent arm at the elbow and held against the body, and a decreased grip.
Most infants will completely recover from this type of injury within three to nine months following birth. In some instances, recovery is not likely where separation of the nerve root from the spinal cord (avulsion) has occurred. Other complications may include temporary or permanent paralysis or weakness of the arm and abnormal muscle contractions and/or tightening of the muscles that may be permanent. One form of paralysis resulting from brachial plexus palsy is called Klumpke paralysis. This type of paralysis is much less common and affects only the lower arm and/or hand.
What is Erb’s Palsy?
Erb’s palsy is a form of brachial plexus palsy named after the doctor who first described the condition, Wilhelm Erb. In instances where brachial plexus palsy affects the upper nerves of the arm, the condition is diagnosed as Erb’s palsy.
- This is a stretch injury that usually heals within three months.
- This injury damages some of the nerve fibers and may result in scar tissue; this does not result in a total recovery.
- This type of injury results in the tearing (rupture) of the nerve itself; it will not heal on its own.
- This condition occurs when the nerve is torn from the spinal cord; this is the most serious type of nerve injury, and it is generally permanent.
Physical therapy, nerve grafts or nerve transfers may be able to restore some strength and range-of-motion. Most children with a brachial plexus injury will continue to experience some weakness in the shoulder, arm and/or hand on the affected side.
Causes of Birth Injuries
Typically, birth injuries occur as a result of a difficult labor and delivery.
Several factors can contribute to a more difficult birthing process including:
- Newborns weighing over 8 pounds and 13 ounces
- Babies born before 37 weeks gestation
- Size and shape of the mother’s pelvis and whether it’s adequate for a vaginal birth
- Difficult labor or childbirth
- Prolonged labor
- Breech deliveries
Some other causes specifically associated with brachial plexus injuries include:
- Infant’s head and neck pulling toward the side as the shoulders pass through the birth canal
- Stretching of the infant’s shoulders during normal delivery
- Pressure on baby’s raised arms in breech delivery
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