Cerebral Palsy

UNIT 18 CEREBRAL PALSY

Structure
18.1 Introduction
18.2 Cerebral Palsy Definition and Nature?
18.2.2 Effects of Cerebral Palsy
18.3 Types of Cerebral Palsy
18.3.1 Spasticity (Stiff and Difficult Movements)
18.3.2 Athetosis (Involuntary and Uncontrolled Movements)
18.3.3 Ataxia (Unsteady and Shaky Movements)
18.3.4 Mixed Type
18.4 Causes of Cerebral Palsy
18.4.1 Causes before Birth
18.4.2 Causes during Birth
18.4.3 Causes after Birth
18.5 Screening and Early Detection of Cerebral Palsy
18.6 Early Signs of Cerebral Palsy
18.7 Early Intervention for a Child with Cerebral Palsy
18.8 Let Us Sum Up
18.9 Answers to Check Your Progress Exercises
18.10 Some Common Questions Asked by Parents

18.1 INTRODUCTION
Example 1
When I gave birth to Radha, I felt wonderful at having become a mother.
Radha was a weak and premature baby. I had difficulty in feeding Radha
since she could not suck properly, but I managed somehow. The pediatrician
who saw my daughter said that her brain might have been affected during the
process of being born, and that she might have problems in movement. I
wondered what kind of movement problems she might have.

Radha’s development compared to other children was slow. At 10 months,

she had still not started sitting or crawling. I had difficulty in taking care of
her since she would suddenly become stiff like a wooden board whenever I
would carry, bath and dress her. I used to feel helpless and found it difficult
to organize myself.

When Radha was ten months old, we went back to the hospital for a follow-
up and were told that Radha has cerebral palsy. I could not understand what
it meant. I had so many things to ask, but my first question was: “What is
cerebral palsy?”
The doctor shared information about the condition and referred us to
organizations that helped us to learn how to enhance Radha’s abilities.
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Locomotor Disability Gradually, though her development was slower as compared to other
children, Radha started showing improvement. At present, she has not started
walking, but is able to stand on her own for a few seconds.

Radha is now four years old and these last three years have been very
challenging but fulfilling years in our lives.

Objectives
After studying this Unit, you will be able to:

 Explain the nature and characteristics of cerebral palsy;

 Describe the features of various types of cerebral palsy;
 State the causes of cerebral palsy;
 Explain the importance of early identification and how to carry out
screening; and
 Describe aspects that you need to consider while proving early
intervention.

18.2 CEREBRAL PALSY – DEFINITION AND

NATURE
As you know, the brain controls the functions of the various parts of our
body. Different parts of the brain are responsible for the functioning of
different body parts. Thus, a particular area in the brain is responsible for
vision, another for hearing, another for speech, another for movement,
another for thinking and so on.

‘Cerebral Palsy’ refers to a group of disorders caused by damage to that

part of the developing brain that controls motor functions (movement)
and coordination. It is a neurological disability – this means that the
nerves controlling the motor functions are affected. A child with cerebral
palsy has difficulty primarily with movement, maintaining posture, with
hand functions and speech (as speech is also a motor function). A child may
have associatedconditions of intellectual disability or learning disabilities or
vision or hearing loss. They may be prone to seizures as well.

This damage occurs when the child’s brain is still developing (before, during
or after birth in the very early years of life). The damage causedto the brain
will not get worse or increase with time; in other words, the damage is non-
progressive. The damage is irreversible as the damaged parts of the brain
cannot recover (scientific advancement may change this state of
affairs).Thesymptoms may change over time – these may get better or worse
depending upon the type of intervention and support the child receives.

Cerebral palsy is not infectious. It is not a disease and so it cannot be cured. It

is a disability.

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 Cerebral Palsy

(a) (b)
Fig. 18.1 (a) & (b): Some children with cerebral palsy

No two children with cerebral palsy are alike. Some children with
cerebral palsy are only mildly affected while others may be more
severely affected.
As per the Rights of Person’s with Disabilities Act 2016, “cerebral palsy”
means a group of non-progressive neurological condition affecting body
movements and muscle coordination, caused by damage to one or more
specific areas of the brain, usually occurring before, during or shortly after
birth’.

18.2.1 Effects of Cerebral Palsy

The kind of difficulties that a person with cerebral palsy faces in
movement, co-ordination and posture as well as the severity of the
difficulty would depend upon the extent of brain damage and the part of
the brain that has been damaged. Some children with cerebral palsy are
only mildly affected, and you will hardly notice that they have any difficulty.
Others may bemore severely affected and have considerable difficulty in
sitting, walking and balancing. Some children may never be able to walk,
while others may take a longer time to learn to do so and might learn to do so
a little ‘differently’ as compared to the other children.

Sometimes, the damage may affect other parts of the brain also, apart
from the parts concerned with movement. In such a case, besides
movement, coordination and posture, other areas of development such as
vision, hearing, speech and learning may also be affected. Thus, the child
may have difficulty in communicating and speaking; seeing or hearing;
understanding, thinking and remembering; forming relationships with people,
if the parts of the brain concerned with these areas of development are also
damaged. Thus, children with cerebral palsy may have multiple
disabilities. Thus, cerebral palsy may also occur along with other
conditions like intellectual disability, autism, epilepsy, impairment in
vision, hearing or perception.
Depending on the area of the brain that is damaged and the extent of
damage, some of the following features may be present in a child with
cerebral palsy:
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ACID Attack Victims  Lack of proper muscle tone, which causes difficulty in movement
 Inappropriate reflexes
 Delayed gross and fine motor milestones
 Difficulty in coordinating movements
 Slow movement, leading to longer time to complete a task
 Involuntary movements
 Inappropriate body posture
 Difficulty in balancing
 Breathing difficulties
 Perceptual difficulties
 Difficulties in feeding, dressing and other self-care activities
 Poor bladder control (i.e., poor control over urination)
 Epilepsy (fits)
 Difficulties in seeing/hearing/talking
 Difficulties in speech and communication
 Difficulties in understanding, thinking and remembering (cognitive
difficulties)
 Social and emotional difficulties

What we need to remember is that no two people with cerebral palsy

willbe affected in quite the same way. Each person will face a different
set of problems.

(a) A person walking using a tetrapod (b) A person using a rollator

Fig. 18.2 (a) &(b): Some children with cerebral palsy may be able to more around with
the help of tetrapods, calipers, rollators and wheelchairs while others may be able to
walk independently

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Check Your Progress Exercise 1 Cerebral Palsy

1) State whether the following statements are correct or incorrect.

a) The damage caused to the brain of a child with cerebral palsy does
not get worse as the child grows. ()
b) The damage to the brain can be cured after the child grows into an
adult. ()
c) The severity of the difficulties in movement or posture faced by a
child with cerebral palsy depends on the extent brain damage and the
area of the brain affected. ()
d) A child with cerebral palsy may also have other disabilities like
intellectual disability, epilepsy etc. ()
2) Explain what is cerebral palsy?
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3) List five features that are commonly present in a child with cerebral
palsy.
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18.3 TYPES OF CEREBRAL PALSY

As we said earlier, the damage to the brain affects the movement,
coordination and posture differently in each person. Thus, cerebral palsy
can be of different types. The child’s ability to function and carry out
various activities will also be determined by the type of cerebral palsy
she has.

When diagnosing which kind (or type) of cerebral palsy a child has, youhave
to consider two aspects:

i) the parts of the body affected and

ii) the quality of the child’s muscle tone.
Let us read about these aspects.
a) Parts of the Body Affected
When all the four limbs (arms as well as legs) including the trunk are
affected, it is called quadriplegia.

When the lower limbs are mostly affected, it is called diplegia; A young 435
ACID Attack Victims child with diplegia may also show some stiffness in her arms and trunk, but
these parts will be much less affected.

When one entire side of the body is affected (upper and lower limbs on one
side), it is called hemiplegia.

Fig. 18.3: Types of cerebral palsy on the basis of the parts of the body affected

b) Quality of Muscle Tone

The next step is to diagnose the quality of the child’s muscle tone. The
damage to the brain in cerebral palsy affects the muscle tone of the body.
In different children, the muscle tone gets affected differently due to the
damage. Children with cerebral palsy can have increased muscle tone,
reduced muscle tone or fluctuating muscle tone (this means that muscle
tone is increased in some muscles and decreased in other muscles).

Depending upon the type of muscle tone, cerebral palsy can be classified
into four types. These are:

 spasticity
 athetosis
 ataxia
 mixed

Before describing the features of each of these types of cerebral palsy, let us
first understand what is ‘muscle tone’.

‘Muscle tone’ refers to the amount of tension or resistance to movement

in a muscle. For example, to brush your teeth, you bend your arm; hence, the
degree to which you can bend your arm depends upon the tension/resistance
provided to the movement by the muscles of the arm. If the muscles are too
tight or rigid (in other words, too much tension), the arm will not bend at all
due to stiffness and this condition is called ‘hypertonia’. In case the muscles
do not provide any resistance at all to movement (in other words, too little
tension in the muscles), the affected body parts are floppy (i.e. the child is
very limp and arms and legs are not kept in proper position due to lack of
muscle tension, giving the impression as if the body parts are ‘falling apart’).
This condition is called ‘hypotonia’. To complete a task, the muscle tension
has to be just right – neither too much (hypertonia) nor too less (hypotonia).

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Let us read about the features of each of the four types of cerebral palsy. Cerebral Palsy

18.3.1 Spasticity (Stiff and Difficult Movements)

This is the most common type of cerebral palsy. The person who has
‘spasticity of muscles’ has muscle stiffness or increased muscle tension.
This muscle stiffness may be mild, moderate or severe.

a) Severe Spasticity

When a child has severe spasticity, the muscles are very tight and
hypertonic. There is resistance to moving the child’s limb in any direction.
This leads to the following characteristics.

Fig. 18.4(a): The child without Fig. 18.4(b): The child with
disability adapts his body to cerebral palsy becomes stiff
that of his mother when he like a board and does not
is picked up adapt his body to that of his
mother. His body is totally
extended, causing difficulty in
handling

 When a child with severe spasticity tries to move, or when she is handled
and moved by others, she can become very flexed (bent) or very
extended (very rigidly straight). The child may suddenly stiffen like a
wooden board, so that it seems one will not be able to carry or hold her.
Because of this, the child is not able to adjust her body to that of the
caregiver, like other children do, when they are picked or handled. See
Figs. 4(a) & 4(b). While sitting she has a stiff and extended posture.

 A child with spasticity will find it difficult to initiate movement since her
muscles are tight. She is able to make limited movements only. The
muscles of a child with spasticity become overactive when she tries to
use them and so the child is not able to make the movement freely. The
more the child attempts to make the movement and becomes conscious
of it, the more the stiffness increases. When the child makes an effort to
move one part of the body, the tone in another part of the body increases.
Often, this stiffness increases when the child is upset, excited or is in 437
ACID Attack Victims certain positions. Thus, the child’s movements are slow, uncoordinated,
stiff and laboured.

 The child has poor balance or protective reactions. Protective or balance

reactions are those automatic movements that the body makes to protect
itself from injury. For example, when we loose our balance, we
automatically take a step or stretch our arms in a position that will
prevent or protect us from falling.

The typical posture that a child with severe spasticity adopts when lying on
the bed, on the back, is shown in the Figs. 5 (a), (b), (c) & (d).

Fig. 18.5: The child with severe spasticity assumes these postures when laid on the back

When the child is put on the stomach, she adopts the following position, as
shown in Fig. 6.

Fig. 18.6: Posture of a child with severe spasticity when on stomach

When you try to make the child stand, her legs stiffen or cross at the knees as
shown in Fig. 7. This is also called scissoring of the legs.

Fig. 18.7: Scissoring of legs when the child with spasticity stands up or walks

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b) Moderate Spasticity Cerebral Palsy

A child with moderate spasticity has a changeable muscle tone. Thus, the
muscle tone may be relatively normal at rest and becomes high or very high
with stimulation or when the child makes an effort, or when she speaks or
experiences a strong emotion like fear. A child with moderate spasticity will
be able to move about and be able to do something for herself but the pattern
of movement may be abnormal and she will be putting in quite a bit of an
effort to do so. See Figs. 8 (a) & (b).

(a) (b)

Fig. 18.8(a) & (b): A child with moderate spasticity can move with abnormal pattern
with lot of effort

18.3.2 Athetosis (Involuntary and Uncontrolled Movements)

‘Athetosis’ means uncontrolled movements. The child shows jerky or
slow wriggly movements of the legs, arms, hands or face. Abnormal
body positions come and go as muscles change from stiff (high muscle
tone) to floppy (low muscle tone). The muscle tone keeps fluctuating.
This constant change makes it difficult for the child to keep still and so the
balance is poor. A person with athetosis has trouble holding herself in an
upright, steady position; she finds it difficult to balance herself. This
happens because she is not able to bring her hand and trunk in a straight line (
i.e., she is not able to align them). See Fig. 9 (a).

Let us understand what we mean by ‘alignment’. If you were to draw an

imaginary line through the centre of your body from head to toe when you
stand straight, you will find that the right and left half of your body are
symmetrical. The head and trunk are in a straight line, and we say that they
are in alignment, because of which you can balance yourself well. But the
head, shoulders and trunk of a person with athetosis are not in alignment
because of which she has reduced stability and balance, particularly in the
head and trunk region. The two halves of the person’s body show
asymmetry. See Figs. 9 (a). & (b).

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ACID Attack Victims

Fig. 18.9 (a): Poor balance, asymmetrical body position and involuntary movements in
a child with athetosis

Fig. 18.9 (b): The child without disability sits symmetrically

Many children with athetoid type of cerebral palsy show movements of

the face, arms, upper body and legs that they do not mean to make. Such
movements are involuntary movements – this means that the child does not
have control over these movements. The arms or legs move without the
person wanting them to move. This happens because the head position
determines the posture of the rest of the body, and since the child finds it
difficult to hold her head in midline (in other words, she is not able to hold
the head in the centre of the body – the head is either inclined to the left or
the right), any movement of the head causes involuntary movements in all the
limbs. Thus, the child with athetosis moves constantly, but not in a
purposeful way.

The involuntary movements that occur interfere when the child is

speaking, eating, reaching for objects, grasping, or doing other activity.
For example, an involuntary grimacing (involuntary facial movement), and
tongue thrusting (protruding of the tongue from the mouth) may lead to
difficulty in swallowing, causing drooling of saliva and unclear speech,
making it difficult for others to understand her. These involuntary
movements often increase during periods of emotional stress and disappear
during sleep.

The child with athetosis is not able to carry out a movement smoothly.
For example, to pick up a glass from a table, you have to move your arm
smoothly towards it. However, a child with athetosis may show slow and
wriggly movement of the hand and then suddenly that movement may
become very fast and quick. She can move from full flexion (bending) in a
joint to full extension (stretching) very suddenly. Due to this sudden change
of movement, the body part may move too fast, too far. Thus, the person may
become stuck in extreme positions and must wait for sometime before she
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can move out of that position. In other words, there is lack of grading of Cerebral Palsy
movement – the movement does not gradually change from slow to fast;
instead the change is sudden.

The child also has inadequate balance and protective responses, which
can lead to a tendency to fall. A typical standing posture of a child with
involuntary movements and intermittent spasms, is shown in Fig. 10. To
compensate for her lack of postural control and lack of stability, she often
‘fixes’ herself by clasping her hands together and ‘gripping’ with her toes to
prevent herself from falling backwards.

Fig. 18.10: A child with athetoid cerebral palsy finds it difficult to balance himself

Children with athetosis have higher probability of hearing loss as compared to children
with other types of cerebral palsy.

18.3.3 Ataxia (Unsteady and Shaky Movements)

‘Ataxia’ means unsteady, shaky movements. Low muscle tone
(hypotonia) and poor coordination of movements are the characteristics
of ataxic type of cerebral palsy. The child can move and function fairly
well, but the quality of movement and posture ispoor. Due to low muscle
tone, people with ataxic cerebral palsy are very unsteady, shaky and wobbly
— their balance is poor. This form of cerebral palsy can also affect the
sense of balance and depth perception. This means that the person is not
able to perceive and judge the distance between herself and the ground, or
between herself andother objects, correctly – thus, the person walks
unsteadily, placing her feet too far apart in an attempt to balance herself. Her
movements resemble that of a person who is drunk. See Fig. 11.

Fig. 18.11: To keep his balance, the child with ataxia walks bent forward with feet wide
a part. He takes irregular steps.

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ACID Attack Victims When the child tries to hold a small object such as a pen, her hands shake -
like a tremor you might have seen in an old person. The child also has
inadequate balance reactions, slow or delayed protective responses and
poor grading of movement. Children with ataxia have a higher chance of
visual problems (such as squint) as compared to children with other
types of cerebral palsy.

18.3.4 Mixed Type

Sometimes when there is brain injury in different areas of the brain, it
may result in a combination of the types of cerebral palsy. Such a type is
called mixed cerebral palsy.

For example, if a child has both spastic and athetoid cerebral palsy, then
some of the muscles may have stiffness and some may have involuntary
movements. Usually, the spastic cerebral palsy is more obvious at first than
the involuntary movements. Mixed type of cerebral palsy reflects damage in
more than one area of the brain. Loss of hearing, visual problems and
difficulties in eating and speech often accompanythis type of cerebral
palsy.
Check Your Progress Exercise 2
1) State whether the following statements are correct of incorrect.
a) ‘Hypertonia’ is a condition when the muscles become too stiff or
tight. ()
b) A person who has uncontrolled movements of the legs, arms, hands
etc. is said to have spasticity. ()
c) The amount of tension or resistance to the movement in a muscle is
called muscle tone. ()
d) A child with moderate spasticity has hypertonia. ()
e) When a child has ataxia, the two halves of the body show
asymmetry. ()
2) What are the different types of cerebral palsy?
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3) What are the features and characteristics of different types of cerebral
palsy?
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4) i) Spasticity Cerebral Palsy

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ii) Athetosis
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iii) Ataxia
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iv) Mixed type
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18.4 CAUSES OF CEREBRAL PALSY

By now, you know that cerebral palsy is caused due to damage to parts of the
brain. But, then, what are the various factors which cause brain damage?
There can be a number of factors responsible for brain damage and these can
be present before birth, during birth or after birth.

Let us look at each, one by one.

18.4.1 Causes Before Birth

If a child has cerebral palsy before birth, it is called congenital cerebral
palsy. The presence of congenital cerebral palsy means that damage
happened to the brain when it was in the process of development in the
mother’s womb. The factors that may hamper the development of the brain
during the period of pregnancy are as follows:

a) Infections: Infection in the mother while she is pregnant can cause

brain damage. Though the brain continues to develop during the entire
duration of pregnancy, and even after the child is born, yet the first three
months of pregnancy are critical for the development of the brain. If the
mother catches an infection in the first three months of pregnancy,
the chances of damage to the brain are much higher than if she had
the infection in the last three months of pregnancy. German measles
and herpes zoster (shingles) are two infections which, if contacted by the
pregnant woman, can affect the brain of the growing foetus causing
impairment. If the woman catches these infections in the first three
months, the baby may have brain damage, malformations in the heart and
loss of vision. To prevent the pregnant woman from catching the
infection, advise her not to be near a person who has these infections,
especially in the first trimester of the pregnancy. The doctor must be 443
ACID Attack Victims contacted immediately, in case the pregnant woman has fever
accompanied by a rash – this could be a symptom of German
measles. This infection can also be prevented by giving the woman
immunization before she becomes pregnant.

b) Rh incompatibility: To understand what Rh incompatibility is, we need

to first understand the concept of ‘blood group’. You must have heard
statements like: “Her blood group is A + (A positive) and his blood
group is O - (O negative).” Well, human blood is divided into 4 groups
— A, B, AB and O. Further, there is a blood protein called the ‘Rh
factor’. If this protein is present in the blood, then the blood type is
called ‘Rh positive’; if it is not present, the blood type is called ‘Rh
negative’.

‘Rh incompatibility’ is a condition which develops when the blood

type of the pregnant woman is Rh negative while that of the foetus
(developing child in the womb) is Rh positive, since the father’s
blood group is Rh positive. If this happens, then complications can
arise. While the first born child is usually safe, the danger increases for
each subsequent pregnancy. If the second baby is Rh positive, then the
Rh incompatibility (between the blood type of the mother, which is Rh
negative, and the blood type of the foetus in the womb, which is Rh
positive) could result in brain damage, damage to the heart muscles, and
even death of the baby. Fortunately, the harmful effects of Rh
incompatibility can be prevented in most cases. It is important for the
mother to know her blood group before conceiving the child. After the
birth of the first baby who is Rh positive, the Rh negative mother is
given a vaccine immediately/within 24 hours, which prevents any harm
to the subsequent child due to Rh incompatibility.

c) Toxaemia: This condition is usually seen after the 30th week of

pregnancy and is more likely to occur in a woman who is pregnant for
the first time. The common signs and symptoms are swelling of the
ankles and feet, persistent high blood pressure and/or appearance of
protein in the urine. If the pregnant women does not take these signs
seriously and does not seek medical advice, another severe condition
may develop leading to headache, swelling all over the body and fits.
She may also become unconscious. All these conditions are extremely
harmful for the growing brain of the foetus. The woman must be
referred immediately to the doctor for advice and treatment if she
has toxaemia.
d) Poor maternal nutrition: Severe malnutrition in the pregnant
woman can also affect the brain growth of the foetus. Many nutrients
like iron and iodine are important for brain growth and development. If
these nutrients are not present in the diet of the woman or are not given
to her through other sources (such as capsules), then it can affect the
development of the brain of the foetus. Let us understand this further.
Haemoglobin in the blood carries oxygen to all the cells in the mother’s
body as well as to the baby in the uterus. If there is not enough
hemoglobin in the mother’s blood, there may not be enough oxygen
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 reaching the foetus, which will affect its brain development and growth. Cerebral Palsy
To avoid iron deficiency, the pregnant woman should eat food items
which are good sources of iron. Some such food items are liver,
mutton, green leafy vegetables, rice flakes, bajra, soyabean, pulses and
legumes, dates and apricot. Along with these, she should eat food items
that are rich in carbohydrates, proteins, fats, vitamins and minerals.

Similarly, deficiency of iodine in the mother’s diet can lead to brain

damage of the foetus. Hence, use of iodized salt in cooking and eating
seafood is recommended to prevent iodine deficiency.

e) Bleeding during pregnancy: Vaginal bleeding during pregnancy

requires immediate attention. You know that the foetus is attached to
the uterine wall (wall of the uterus) through the umbilical cord and
receives nutrients and oxygen through it. Vaginal bleeding can mean that
the foetus is no longer attached to uterine wall and may be deprived of
essential nutrients and oxygen, which will hamper the growth of the
brain. Vaginal bleeding during pregnancy can be serious and should
be notified to the health worker/doctor immediately. It requires
immediate treatment and the women must be taken immediately to
the nearest Primary Health Centre or hospital.
f) Chemicals: Many chemicals can adversely affect the development of
the brain of the baby in the womb. Intake of alcohol, cigarette and
drugs by the pregnant women can interfere with the development of the
brain of the baby, causing brain damage. These factors interfere with the
supply of oxygen to the growing factors and the absorption of many
important nutrients required for development of the foetus.

g) Metabolic disorders during pregnancy: Disorders such as diabetes,

hyperthyroidism or hypothyroidism can interfere with brain
development of the foetus.
‘Diabetes’ is a condition where there is a high level of glucose in the
blood of the mother. When this glucose-rich blood reaches the foetal
blood, it can affect the development of the baby’s internal organs,
leading to abnormalities. To avoid these conditions, the pregnant
woman must get her sugar level checked regularly, if she has a
tendency towards diabetes. In case the woman is already diabetic,
care must begin before she gets pregnant.

Achieving and maintaining blood glucose levels should be the main goal
in any case.

‘Thyroidism’ is a condition where there is either an excess or lack of

proper amount of thyroid hormone in the blood. This hormone is
essential for brain development and any changes in the level of the
hormone in the mother’s blood can affect the developing brain of the
foetus. Pregnant women at risk of developing thyroidism or those
already suffering from it must get their blood thyroxine level
checked regularly.
h) Multiple pregnancy: ‘Multiple pregnancy’ refers to more than two 445
ACID Attack Victims babies in the womb. Such infants are at risk for various complications
such as low birth weight, birth defects (malformations) and premature
delivery. These can cause neurological (brain) damage, leading to
cerebral palsy.

Prevention

To have a healthy baby, the pregnant woman should:

— have regular medical check-ups

— follow medical advice

— stay away from people who have infectious diseases

— not take medication without prescription

— not attempt abortion on her own or by an unqualified person

— have a nutritious and adequate diet

— be careful and avoid accidents

18.4.2 Causes During Birth

Complications during the birth process can also lead to cerebral palsy.
Some of these complications are the following:

a) Lack of oxygen to the brain (asphyxia) during the time of birth: This
is one of the significant factors responsible for cerebral palsy during
the birth process and it usually occurs due to medical negligence.
You have already read in the earlier section that low levels of oxygen in
the mother’s blood affect the development of the brain of the foetus.
Continuous supply of oxygen is required to keep the cells alive. When
the baby is in the womb, this continuous supply of oxygen is maintained
through the mother’s blood. As soon as the baby is delivered and the
umbilical cord is cut, this supply of oxygen through the mother’s blood
is cut and now the baby has to learn to breathe. The process of crying,
also known as the ‘birth cry’, results in a sudden intake of the life-giving
breath of air. In case the baby fails to breathe soon after birth or has
a feeble birth cry, it leads to a lack of oxygen to the body, which can
cause brain damage. Blue skin or blue colour at the extremities of the
body indicate lack of oxygen and requires immediate medical care.

Prolonged labour, the twisting of the umbilical cord around the baby’s
neck or improper positioning of the baby in the womb are some other
situations which reduce the oxygen supply to the child’s brain, thereby
leading to cerebral palsy. Immediate medical help and sustained effort
by the doctors present during delivery can prevent asphyxia by
restoring normal breathing.
b) Injuries to the brain at the time of birth: Brain damage can also be a
result of birth injury caused by negligence or lack of training or
446 inexperience of the doctor or dai (mid-wife) during delivery. Injury
 can also be caused due to the improper use of forceps during delivery. If Cerebral Palsy
the head of the baby is pressed too much or is pushed out of shape in the
process of delivery, it can cause brain damage. To prevent such
situations, always have the delivery conducted at the hospital. If the
delivery is conducted at home, then a well-trained dai /midwife
should be present.

c) Prematurity and low birth weight: Premature babies (born before 37

weeks of pregnancy) and low birth weight babies (less than 2.5 kg at
birth) are at a higher risk to develop cerebral palsy than full-term babies.

Prevention

To prevent the occurrence of cerebral palsy during birth

— have the delivery conducted at the hospital. If the delivery is conducted

at home, it must be attended to by a well-trained midwife (‘dai’).

— make sure that the child cries immediately after birth, as that is the first
breathing by the child.

— Immediately get medical help, if the pregnant woman has untimely

abdominal pain, or any other sign of a problem.

18.4.3 Causes after Birth

If brain damage occurs in early childhood, within the first two years
after birth, it results in acquired cerebral palsy. Generally, the factors
responsible for this type of cerebral palsy are infections and diseases in the
child, accidents leading to head injuries, poisoning and tumors of the brain,
which affect its growth and development. Let us now read about some of
these causes in detail.

a) Infections of the brain and spinal cord: Brain and spinal cord are quite
resistant to infection; however, once infection sets in, it can result in
serious complications. Meningitis (inflammation of the covering of the
brain called meninges) and encephalitis (inflammation of the brain
itself) can cause brain damage, if left untreated. High fever, headache,
sore throat, stiff neck and vomiting are some of the early symptoms of
meningitis. An adult may become desperately ill within 24 hours and the
symptoms can progress to coma and finally death. In children up to two
years of age, meningitis usually causes fever, feeding problems,
vomiting, seizures and irritability. The skin over the fontanelles (the soft
spots between the skull bones) becomes taut / stretched and it may even
bulge. However, children under one year may not develop a stiff neck. If
you notice all these symptoms, take the child immediately to the
doctor. It is an emergency situation and can cause permanent damage
within hours. Vaccination is a good measure to prevent childhood
meningitis.
Apart from infections, very high fever especially if associated with
seizures, can also cause brain damage and impairment, leading to
cerebral palsy.
447
ACID Attack Victims Severe jaundice, very low glucose levels, metabolic disorders and
accumulation of fluid in the brain (hydrocephalous) can also cause
cerebral palsy.
b) Brain tumors: A brain tumor is a swelling caused by an overgrowth of
brain tissue. This overgrowth may grow slowly or rapidly and it damages
the healthy brain tissue. The common symptoms which indicate brain
tumors are seizures, poor coordination, headache (particularly early in
the morning), unclear speech, dizziness, increased head size in case of
infants, and sudden change in vision or sense of smell. Many a times,
these early warning signs are neglected. If you notice any such
symptoms in the child, get medical attention immediately.

c) Accidents leading to head injury: Children can get injured easily if the
environment is not safe. One needs to consciously avoid unsafe
environment. Playing near water tanks, factory areas and open drains can
be dangerous and can cause injuries and accidents. Drowning, gas
poisoning, injuries and insecticides can hamper the development of the
brain, leading to brain damage. If an accident occurs, avoid panic, give
first-aid immediately and go to the doctor.

Prevention

The following precautions must be taken after the child is born to

prevent cerebral palsy:
— If the child has low birth weight or looks abnormal or the development
seems to be slow, do not waste time. Immediately seek the doctor’s
advice.
— When a child develops fever, immediately bring it down by sponging the
child with a cloth. Get medical attention immediately.
— If the child had fits, get medical attention immediately. Do not ignore the
child or waste time with superstitious practices.
— From birth onwards, the infant must receive a nourishing, nutritious and
balanced diet. The diet should include nutrients such as proteins,
vitamins and minerals. The child should be breast fed for six months or
even longer, if possible. However, supplementary foods should be
introduced from four months onwards.
— Children must be immunized against infectious diseases at the
recommended ages. If the child still gets an infection, medical help must
be sought as soon as possible to prevent the condition from becoming
worse.
— See to it that small children do not roll over and fall off the bed or cot.
Do not leave them alone near staircases, etc.
— Children must never be hit on the head when being disciplined, as such
blows can cause damage. In fact, children should never be hit at all.

Awareness among the public with regard to causes and prevention of cerebral
448
palsy will certainly help. Cerebral Palsy

If cerebral palsy is suspected in a baby, a detailed assessment by a doctor can

help you to know about the child’s condition and its possible implications.
Then the therapy, education and other intervention plans can be decided
accordingly, at the earliest.

Check Your Progress Exercise 3

1. Fill in the Blanks
a) When a child has cerebral palsy before birth, then it is called
_______________________.
b) Two infections which can lead to cerebral palsy if contracted by the
pregnant woman in the first three months are _____________ and
____________
c) If the blood type of a pregnant woman is Rh negative and the blood
type of the foetus in her womb is Rh positive, then is called
___________________________________.
d) Metabolic disorders such as ___________, ___________and
___________ during pregnancy can interfere with the brain
development of the foetus.
e) The protein present in the blood is called _________________.
f) Lack of oxygen to the brain of the infant during the time of birth is
called __________________.
g) A swelling in the brain caused due to overgrowth of brain tissue is
called ___________________________.
2) How can one prevent cerebral palsy during the birth process?
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
3) List the causes of cerebral palsy after birth.
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................

18.5 SCREENING AND EARLY DETECTION OF

CEREBRAL PALSY
The most important step in the management of any disability is early
identification (detection) so that intervention can begin early. The word
‘early’ means ‘as early as possible’ — may be as soon as the child is born or 449
ACID Attack Victims even before birth. Research has shown that 90 percent of the brain
development occurs in the first six years of life. During this period, the
brain cells next to the damaged cells in the brain can learn to take up the
responsibilities of the damaged and dead cells. But to help them to learn to
take up the responsibilities, they need to be stimulated very early in life,
through early intervention programme. Providing intervention to the child
means giving therapy and providing a stimulating environment, where
the child has opportunities to explore, learn concepts and practice skills.
You will read more about how to provide early intervention and therapy in
Theory Courses 2 and 3.

Often, it is the parents who first notice that there is something wrong with
their child. The child’s inability to lift her hands or the stiffness of her
muscles, difficulty in sucking, delayed milestones of physical and motor
development (such as inability to hold/support the head by 3 months of age)
may indicate that the child is not growing as she should.

On the other hand, many parents may not notice anything unusual about their
child, especially when the degree of impairment or disability is mild or is
restricted to a part of the body which is not used much during infancy.
Therefore, they do not seek medical advice and so no intervention is provided
to the child. This period of ‘lag’ or ‘no intervention’ may prove to be
damaging to the child and lead to irreversible complications later on, as the
following case study brings out.

Example 2

Nalin’s mother developed complications during delivery, which caused

damage to Nalin’s brain. Nothing different was noticed till he started walking
on his own. Nalin started walking much later than other children. His mother
noticed that he would walk in an unusual way; his movements during walking
were uncoordinated and his style (gait)

of walking was unusual. His mother thought that perhaps Nalin liked walking
like this. He did not talk much and his mother thought that this was so
because he was a shy child. Nalin started going to school when he was 4
years old. The teacher in the school noticed that his manner of walking and
lack of speech made it difficult for him/her to participate in school activities.
She asked his mother to see a child specialist for guidance. This detection
and assessment, which was done when the child was four years of age, could
have been done much earlier in the child’s life, so that corrective measures
couldhave been taken early.

Thus, to start an early intervention programme, one needs to detect the

disability and assess the degree of disability early in life. Detection and
screening is the first step in assessment.

18.5.1 The Process of Early Identification — Screening

Screening is the preliminary process of collecting basic information
regarding the child which will help you to determine whether there is
any possibility of a disability, developmental delay or atypical behaviour.
450 ‘Developmental delay’ means that the child may be slower than other
children in learning to do certain things like walking, talking or learning how Cerebral Palsy
to read. ‘Atypical behaviour’ implies that the child behaves differently in
certain areas as compared to other children.

For example, her reaction to people or situations may be different as

compared to how most other children would respond.

Screening is the first level of assessment carried out with the specific
purpose of early identification of disability so that you as a
parent/teacher/community worker can take the child to the concerned
specialist and provide appropriate help as early as possible. Screening does
not tell you the details of the disability- it simply helps you to know
whether a child may have a certain disability, developmental delay or
atypical behaviour.

When can screening be done?

Screening could be conducted before birth, immediately after birth or at a

later stage when a disability or delay is suspected.

a) Screening before birth – This would be carried out by the

gynaecologist. The health of the developing baby in the womb can be
found out by the use of ultrasound and foetoscope. A pregnant woman
is usually advised by the doctor to get an ultrasound done at various
stages. The ultrasound helps to detect whether there are any structural
defects in the child developing inside the womb. ‘

b) Screening immediately after birth – This would be carried out by the

neonataologist or paediatrician who is present at the time of birth, if
the delivery is conducted in a hospital. The important assessment that
would help to assess the newborn’s status and health is the Apgar score.
This test is designed to quickly evaluate a newborn’s physical condition
after delivery and to determine any immediate need for emergency care
or extra medical attention. The areas assessed are – the heart rate,
breathing, activity and muscle tone, grimace response and
appearance/skin colour.

c) Screening at a later stage – In many cases, the child’s disability may

not be detected before birth or even at the time of birth. It may be
detected some months after birth when the child does not seem to be
growing as the rest of the children of her age. This screening at a later
stage could be done by the parent, the community worker, the teacher,
the doctor, the therapist or the survey team from the local hospital. In the
next Section we have listed some early signs of cerebral palsy which can
help in screening.

451
ACID Attack Victims
18.6 EARLY SIGNS FOR CEREBRAL PALSY
The early signs of stiffness or floppiness may be noticeable soon after birth.
Other signs may take several months before they become obvious. To be
sure the child has cerebral palsy, take her to a doctor. The following signs
are of concern if they are seen most of the time. Not every child will show
allof these signs.

Things Families Notice

Sudden stiffening
In some positions, like
lying on the back, it
becomes difficult to
bend the baby’s body, to
dress or cuddle her.

Floppiness
The baby’s head flops and
she cannot lift it. Her
hands and legs hang down
when she is held in the
air.
The baby moves too little.

Slow and delayed development

Learning to lift her head,
sit and use her hands
takes longer than
expected. She may use
one part of her body more
than another. For
example, some babies
only use one hand rather
then learning to use both.

Poor feeding Unusual behaviour

Sucking and swallowing is She may be a crying, irritable baby
poor. Her tongue pushes the who sleeps badly. Or she may be a
milk and food out. She has very quiet baby who sleeps too
difficulty closing her mouth. much. She may not smile by the
age of three months.

More Signs to Look For

The drawings on the left show the way normal babies move at some
important stages of development. The drawings on the right show how the
same movement might look when done by a child with cerebral palsy. To be
sure that the child has cerebral palsy, see a doctor.

452
 Cerebral Palsy

Let us understand a bit more about milestones of development. 453

ACID Attack Victims 18.6.1 Screening on the Basis of Milestones of Development
We are aware that development occurs in stages, in a sequential manner.
Children acquire a particular skill or reach a particular stage of development
at a certain age. For example, most children learn to sit by the time they are
six to eight months old, speak the first word around 1-1½ years, achieve toilet
control by two to three years of age and achieve the ability to think in
abstract terms around 12 years of age. Such skills and abilities which most
children acquire during a certain age range are referred to as
‘developmental milestones’.

Developmental milestones are important indicators which help in early

identification of disability. In a child with cerebral palsy, the milestones of
motor development are generally delayed. Milestones in other areas may
also be affected depending on the intensity and area of brain damage.

Thus, the child with cerebral palsy may not be able to hold her head steady
by 3-4 months of age, which is usually the time when most children gain
head control. She may not be able to sit independently by 8-9 months, which
is usually the time when most children are able to sit without support. Or, she
may not be able to speak words even though she is 1½ and 2 years of age.

Children with delayed milestones, who are slow to sit, stand or move around
in comparison to other children of their age, need training to learn these
skills. The earlier the training is provided, more effective it is likely to be.

18.7 EARLY INTERVENTION FOR A CHILD

WITH CEREBRAL PALSY
The physical appearance of a child with cerebral palsy can lead the people to
have a negative image about her. She might be seen as a person capable of no
independent action and needing help with most of the activities of daily
living. However, if the training and treatment are begun early, the child
can show tremendous improvement.

Anu’s parents, who themselves are well-educated, had given up all hopes
about her after trying all kinds of treatments given by local healers. They had
approached them even after consultation with a doctor. It was after a close
friend urged them to admit her in a school, that they decided to do so. Within
one year the girl showed remarkable improvement.

Depending upon the types and the extent of disabilities you would need to

 Help the child learn to move around independently or with some suitable
mechanical support.
 Enable the child to look after herself - for example, be able to go to the
toilet, wear clothes, eat and drink.
 Train her to communicate.
 Help her to be as normal as possible in her appearance.
 Assist the child in developing relationships with others.
454  Educate her, in keeping with the level of her intellectual functioning.
Of course, you would not be able to manage all this by yourself. The early Cerebral Palsy
training and stimulation should concentrate on increasing muscle
strength and dexterity of different body parts. The idea is to make the
child as self sufficient as possible. This training will need to be provided
under the guidance of a ‘physiotherapist’ who is specifically trained to help
the child improve her motor coordination. Help the parents contact the
Primary Health Centre (PHC)/health worker/hospital to find out about
physiotherapy. Carrying out physical exercise without the guidance of a
physiotherapist can cause damage to the child.
Besides exercises to improve movements and coordination between different
parts of the body, the child may also need training in speech, if this is
affected. For this, they would need to get in touch with a speech therapist. If
the parents are taking the child to a speech therapist or physiotherapist,
then they must carry out the exercises with the child at home.
Maintaining a regularity in the exercises is necessary - only then will the
child benefit from them.

The child may need to be provided with appliances or may have to undergo
surgery to enable her to walk. Medicines would be needed to control fits.
This means that you would need to refer the child to a hospital where these
services are available. Find out where these are available nearest to the child's
area.

While seeking the help of professionals for speech and mobility training is
important, do not forget the role of the parents. They are the ones who are
with the child for most of the day. Their attitude will have a crucial role in
determining how far the child is able to overcome limitations of her
disability.

Help the parents to understand cerebral palsy — they may not have seen
a child with this condition before. Explain to them how it affects mobility or
intellectual functioning or speech. They have to be trained in how to help the
child become independent in her activities. In fact, before the child is old
enough to join preschool, it is the parents who would have a major role in
training her.

 Working with the Child in the ECCE Centre

What about the education of child with cerebral palsy? What sort of activities
can you organize for such a child in your early childhood care and education
centre? While planning for the child's activities at the preschool centre you
would need to keep some factors in mind.

As you have read, a child with cerebral palsy may have severe motor
handicap, yet she might be above average in intellectual functioning.
Similarly, she may have mild physical problems but moderate intellectual
disability. The intellectual functioning is not related to the level of physical
limitation. Therefore, the type of activities you plan for the child will have
to be in keeping with her levels of both intellectual and physical
functioning. See what the child is able to do and build upon that. The goals
that you would keep for this child would be different from what you would
455
ACID Attack Victims expect of the rest of the children at your centre.

If the child does not suffer from intellectual disability, then she can
participate in the same activities as her peers - of course, within the limitation
of the physical handicap. The extent of the child's physical handicap would
affect the type of activities you can plan for her. A child with severe physical
problems will not be able to participate in outdoor activities with other
children. But remember that she would like to see the others playing. Do not
isolate her just because she cannot herself move up to the swing. You can
carry her there and help her to enjoy the swinging motion of the swing. Be
patient if the child takes longer to complete her painting or is not able to sing
the rhyme in tune with others.

If the intellectual functioning of the child with cerebral palsy is below

average, then training the child to acquire basic skills would proceed
differently. For not only will the child have difficulty in physical movement,
but may also find it difficult to understand instructions, remember and pay
attention. You have read about these aspects in the preceding Unit on
children with intellectual disability. In that case, you and the parents would
need to keep the principles explained in the earlier unit in mind as well. Can
you recall these principles and list them here?

What we are saying is that it is important to realize that a child with

cerebral palsy can attend a regular school along with other children. The
educator will have to be careful in giving extra attention and help to the child,
simplify the curriculum for her if required, modify the activities so that she
can also participate, and help her and the other children to relate to each
other. Sensitivity, patience and close observation of the child while working
with her in the centre would help you to understand the child better.
Specialists in physiotherapy and speech therapy would be able to give help in
specific areas. A regular health check-up by a pediatrician would help to
monitor her growth. Only if the child’s mental and physical handicap are
such that she cannot benefit from attending a regularpreschool, should
she be put in a special school.

Check Your Progress Exercise 4

1) Choose the correct answer:
a) The first step in the intervention persons is __________. (data
collection, screening, assessment)
b) In order to evaluate the newborn baby’s physical condition and
detect any need for emergency medical attention _____________ is
done. (screening, assessment, Apgar score)
2) What is meant by screening? When can screening be done?
………………….........................................................................................
………………….........................................................................................
………………….........................................................................................
………………….........................................................................................

456 ………………….........................................................................................
 Cerebral Palsy
18.8 LET US SUM UP
 In this Unit you have gained a basic understanding regarding the nature
of cerebral palsy. Cerebral palsy occurs due to damage that part of the
brain that is concerned with movement (motor area).

 The damage leads to difficulties in movement, coordination and posture.

 The damage can occur before, during or after birth.

 The severity of the disability and the kind of difficulties faced in

movement, coordination and posture would depend on the extent of
damage.

 Various factors before, during and after birth can cause cerebral palsy.
Many of these factors are preventable.

 Sometimes the damage affects other areas of the brain concerned with
vision, hearing, speech, or learning. Therefore, the child may have
difficulties in these aspects of development. Thus visual hearing,
learning or communication difficulties may accompany cerebral palsy.
Cerebral palsy may also be associated with other conditions like mental
retardation, autism or epilepsy.

 Depending upon how the muscle tone has been affected due to damage
to the motor area of the brain, a child may have one of the four kinds of
cerebral palsy – spasticity, athetosis, ataxic and mixed.

 Early identification is crucial so that the required training and therapy

input can begin to minimize/reduce the effects of cerebral palsy.

Fig.18.12 : When family members spend time with the child, it helps the child to feel
loved and foster his all round development
 Early identification can be done through ‘screening’. Screening is a
process which helps us determine whether there is delay or disability in
the child. It can be done at various stages – before birth, during birth and
after birth.
 Screening after birth is done by comparing the child’s growth pattern
with the developmental milestones.
457
ACID Attack Victims  While observing the child for screening, observe her in her routine day to
day activities.
 If the training and treatment are begun early, the child can show
tremendous improvement.
 The early training and stimulation should concentrate on increasing
muscle strength and dexterity of different body parts.
 The role of the parents is most important, their attitude determines how
far the child is able to overcome limitations of her disability.
 Since the intellectual functioning is not related to the level of physical
limitation, the type of activities you plan for the child will have to be in
keeping with her levels of both intellectual and physical functioning.
 It is important that a child with cerebral palsy goes to a regular school
along with other children. Only if the child’s mental and physical
handicap are such that she cannot benefit from attending a regular
preschool, should she be put in a special school.
Remember
Children with cerebral palsy have the same basic needs as other children, i.e.,
the need for love, security, fun, encouragement and opportunities to
experience and learn. Like other children, they have their own unique
personalities, specific strengths and limitations.

18.9 ANSWERS TO CHECK YOUR PROGRESS

EXERCISES
Check Your Progress 1
1) a) Correct
b) Incorrect – The damage to the brain is irreversible and cannot be
cured. But the problems of movement, co-ordination and posture can
be lessened and functioning can be improved by proper positioning
and handling of the child along with a management programme
including surgery, therapy and use of assistive devices.
3) Correct
4) Correct
2) a) ‘Cerebral’ means brain, and ‘Palsy’ refers to loss of control over or
weakness in movement. Putting the two words together, cerebral
palsy (CP) means paralysis due to a damage to that part of the brain
which controls movement. This causes difficulty in movement,
coordination and positioning (posture) of the body.
b) Any of the five features stated in 18.2.1 are correct.
Check Your Progress 2
1) a) Correct
b) Incorrect. Person has athetosis
c) Correct

458 d) Incorrect. Child has changeable muscle tone.

 e) Incorrect. The child has athetosis Cerebral Palsy

2. Cerebral palsy is of different types and is categorized by considering two

aspects – (i)the parts of the body affected and (ii) the quality of muscle
tone.
i) On the basis of the parts of the body affected, it is of 3 types -
Quadriplegia.; Diplegia ; Hemiplegia
ii) On the basis of the quality of muscle tone, it is of four types -
Spasticity, Athetosis, Ataxia and Mixed
3) i) Spasticity: Tight muscles; resistance to movement leading to stiff
movements; difficulty in imitating movement; poor balance or
protective reactions.
ii) Athetosis: Uncontrolled and involuntary movements; fluctuating
muscle tone; difficulty in balancing and holding body upright and
steady, grading of movement
iii) Ataxia - Unsteady and shaky movements; poor co-ordination of
movements, poor balance, inadequate protective reactions.
iv) Mixed - Combination of types of cerebral palsy - for example,
spasticity and athetosis together.
Check Your Progress 3
1) a) Congenital Cerebral Palsy
b) German measles, herpes zoster
c) Rh incompatibility
d) Diabetes, hypothyroidism, hyperthyroidism
e) ‘Rh factor’
f) Asphyxia
g) Brain tumor
2) i) By having delivery conducted at a hospital or by a well-trained mid
wife at home
ii) by ensuring child cries immediately after birth.
iii) getting medical help if pregnant women has untimely pain or
complains about something else.
3) i) Infections of brain and spinal cord
ii) Brain tumors
iii) Accident leading to head injury
Check Your Progress 4
1) a) Screening
b) Apgar Score
2) Screening is the first level of assessment of the child which will help in
determining whether there is any possibility of disability, developmental
delay or atypical behavior. Screening can be done before birth,
immediately after birth or at a later stage when delay is detected.
459
ACID Attack Victims Annexure 1

Apgar Score
This test is done on the newborn twice – once at 1 minute after birth and
again at 5 minutes after birth. If there are serious problems with the baby’s
condition, and the first two scores are low, then the test is done for a third
time 10 minutes after birth, but this happens rarely. The five factors listed
below are assessed in order to evaluate the child’s condition and scores are
given as explained below. Each factor is scored on a scale of 0-2 based on the
following guidelines -

1) Heart rate (pulse)

0 No heart rate
1 Fewer than 100 beats per minute, baby is not very responsive
2 More than 100 beats per minute, very vigorous movements can
beseen
2) Breathing/Respiration
0 Not breathing(rate and effort)
1 Weak cry – may sound like whimpering or grunting
2 Strong/good cry

3) Activity and muscle tone

0 Limp
1 Some flexing (bending of arms)
3 Active motion
4) Grimace response (reflex)
0 No response to airways being suctioned
1 Grimace during suctioning
2 Grimace and cough/sneeze during suctioning
5) Appearance/skin color
0 Body is completely blue or pale
1 Good color in body with blue hands or feet
2 Completely pink or good color
Highest possible score is 10. A newborn with an Apgar score less than 4
generally requires emergency measures or advanced medical care like
assisted breathing, administration of fluids or medication. Five minutes after
birth, the score is re-calculated. If the score has not improved to 7 or greater,
necessary medical care and close monitoring continues.
Low Apgar scores are also usually seen in premature babies – who usually
have less muscle tone and immature lungs as compared to full-term babies. A
low Apgar score at 10-20 minutes after delivery is often considered as an
important sign of potential problems like brain damage. Such babies are
at a risk of developing complications and come under the category of ‘high
risk’. Such a child may have cerebral palsy. They would require close
monitoring and regular check-ups.

460