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Paraparesis and incontinence

Paraparesis (paralysis of both legs) is usually due to a spinal cord problem. This may be congenital, as in spina bifida, or acquired (e.g. following trauma, infection or malignancy). Some causes are treatable if diagnosed early (e.g. TB of the spine). Burkitt’s lymphoma with paraparesis is a sign of advanced disease and is often associated with a poor prognosis. Both thorough clinical assessment to estab- lish the level of the lesion, and reassessment to look for changes, are essential. Any suspected space-occupying lesion needs surgical advice.

TABLE 4.2.C.3 Problems in children with cerebral palsy


Problem

Action

Visual and hearing impairment

Refer to appropriate specialist

Epilepsy

Anti-epileptic drugs

Contractures

Physiotherapy and (rarely) surgery

Dislocation of hips

Surgery to relieve pain

Feeding difficulties, failure to thrive

Monitor intake

Correct positioning for feeding Increase energy content of food Consider gastro-oesophageal reflux

Recurrent aspiration

Close attention to feeding position, pacing of feeds, and positioning

Respiratory infections

Antibiotics

Gastro-oesophageal reflux

Feed thickener (starch), H2-receptor antagonist (e.g. ranitidine) or proton- pump inhibitor (e.g. omeprazole)

Exclude oesophageal stricture and/ or aspiration

Constipation

Diet and stool softeners

Learning difficulties

Additional help with education



Many children with paraparesis will suffer preventable complications unless carers and staff are aware of the risks of the following:

O Poor nutrition: many children with paraparesis find it difficult to eat and drink. They need good food to enable them to withstand infection, keep their muscles from wasting, prevent constipation and maintain good skin.

O Contractures: all joints need to be moved through their full range of movement to prevent contractures develop- ing. If the child has presented late and contractures are already established, a programme of gradual passive stretching may help to improve the range of movement.

O Pressure sores: these are prevented by ensuring that the child is moved regularly. The child can often learn to do this by using their arms and upper body strength to pull on a suspended strap or ring to move their own position. The child can use a mirror to inspect their own skin to look for sore patches. Established pressure sores take a long time to heal. They must therefore be kept clean and free from pressure.


Rehabilitation should start immediately, but will depend on whether the child’s spine is stable. A creative approach to mobility, using locally available materials (see Disabled Village Children by David Werner), is more likely to succeed than waiting for sophisticated rehabilitation equipment to be purchased.

Incontinence is usually associated with paraparesis, and can be both socially and medically disastrous. Some children have neuropathic bladders which are usually full, empty incompletely and may lead to reflux nephropathy, hydronephrosis and renal damage. These children need intermittent clean catheterisation to prevent back pressure and infection. Clean catheterisation may be required up to every 3 or 4 hours. This technique can be easily learned by


a carer or by the older child. Other children have bladders that are not full and which empty themselves frequently. These children are at less medical risk of kidney prob- lems, but it is much more difficult to enable them to be socially dry without complex surgery to enhance the size of the bladder.

Most children with bowel continence problems associ- ated with paraparesis will be constipated due to their relative immobility. A healthy diet and plenty of fluids will prevent constipation. Bowel evacuation in young children is often managed by abdominal massage. Older children can learn to use a Shandling catheter, which is a plastic tube that is passed up the rectum for a washout of the bowel contents with saline.


Learning difficulties and developmental delay 

O Children who do not meet their expected developmental milestones should be assessed for possible causes.

O Some children have specific learning difficulties and may be assumed to have general learning difficulties unless they are carefully assessed. Full psychological assessment is helpful (if available).

O Treatable causes (e.g. hypothyroidism, abuse/neglect, malnutrition, anaemia, etc.) should be ascertained. Problems such as autism and attention deficit disorder, with or without hyperactivity, should be documented.

O In planning services for these children, social and educational involvement is essential.


 

Severe learning difficultiesAutism and communication disorders

  

 

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