A 2-month-old boy is evaluated in the neonatal intensive care unit for new-onset seizure activity. The patient was delivered at 26 weeks gestation due to a nonreassuring fetal status. The boy has required intensive care since birth due to an oxygen requirement and poor feeding. Today, he developed repetitive twitching movements of both arms and legs. The mother had a self-resolving viral illness during the second trimester but otherwise had no complications with the pregnancy. Temperature is 36.6 C (97.9 F), pulse is 150/min, and respirations are 50/min. Cardiopulmonary and abdominal examinations are normal. Tone and reflexes are increased in the legs and arms bilaterally. Electroencephalogram confirms seizure activity, and MRI of the head reveals bilateral intraventricular hemorrhage with periventricular white matter changes. When discussing the patient's diagnosis with the parents, the mother begins to cry and asks if she is responsible for her son's condition. Which of the following is the most appropriate response?
Cerebral palsy | |
Diagnosis |
|
Management |
|
Comorbidities |
|
Prognosis |
|
This child has cerebral palsy (CP), a nonprogressive condition due to a neurologic injury that occurs in the prenatal or perinatal period. Premature infants are at greatest risk for CP due to ischemia and necrosis in the poorly perfused area adjacent to the lateral ventricles (ie, periventricular leukomalacia). They also have friable germinal matrix vessels that predispose to intraventricular hemorrhage (IVH), as seen in this patient. Classic neurologic findings include upper motor neuron signs, such as hypertonia and hyperreflexia. In addition, seizures occur in up to half of patients with CP, particularly in those with severe spastic quadriplegia (ie, bilateral arms and legs affected).
Parents of a child with CP can experience severe guilt over the thought of causing their child's condition. It is important for physicians to allow parents to express their emotions and engage compassionately. Physicians should relieve feelings of guilt by providing reassurance that the parents did not cause the condition and that they should not blame themselves. Counseling is often necessary to help the family deal with the grief and frustration that is to be expected after receiving this diagnosis.
(Choices A and E) Although CP can be associated with intrauterine infection, prematurity is the predominant risk factor and is consistent with this patient's MRI findings that are specific to those seen in premature neonates (ie, periventricular leukomalacia, IVH). In this case, suggesting that results of additional testing could identify a preventable cause inappropriately conveys that the parents' actions could be to blame.
(Choice B) Discussing the long-term prognosis of a condition while delivering a diagnosis can be overwhelming and does not address this mother's current concerns. Moreover, because the outcome of CP is so variable, physicians should avoid predicting the long-term prognosis in a young infant. Ongoing conversations with the parents are required to continue to set realistic expectations for the child's functional abilities as the degree of neurologic impairment becomes more apparent.
(Choice D) Asking open-ended questions is typically the best approach, but in this case asking the mother why she feels responsible suggests that there may have been direct and preventable actions that caused the child's condition. Instead, the provider should immediately remove blame and provide comfort.
Educational objective:
Cerebral palsy is a nonprogressive motor dysfunction (eg, hypertonia, hyperreflexia, seizures) that most commonly occurs in premature infants due to periventricular leukomalacia and intraventricular hemorrhage. Parents should be reassured that they are not to blame and did not cause the condition.