脑瘫

50%患者存在胃肠道及喂养问题。

吸吮、吞咽、咀嚼障碍患儿 可以通过经皮胃造口术来解决。

痉挛性四肢瘫痪的患者口腔运动障碍、智力和视力障碍发生率更高。

脑瘫患儿喂养和营养干预的回顾研究认为经胃造口喂养的儿童体重增加，但对于生长发育的其他测量结果影响尚不清楚。[219]Agency for Healthcare Research and Quality. Interventions for feeding and nutrition in cerebral palsy: comparative effectiveness review no. 94. Mar 2013 [internet publication].https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0054978/pdf/PubMedHealth_PMH0054978.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/23596639?tool=bestpractice.com 大多患儿体重偏轻，尽管目前尚缺乏脑瘫患儿正常体重的参考标准。 一些特殊方法已经被应用于评估脑瘫患儿的营养，其中测量身高的方法一点也不简单。[220]Samson-Fang L, Bell KL. Assessment of growth and nutrition in children with cerebral palsy. Eur J Clin Nutr. 2013 Dec;67 Suppl 2:S5-8.https://www.nature.com/articles/ejcn2013223http://www.ncbi.nlm.nih.gov/pubmed/24301007?tool=bestpractice.com

Disorders of infant feeding

小头提示小头畸形反映大脑发育不良。

头围过大提示存在脑积水，需行脑室腹腔分流术。

Normal pressure hydrocephalus

流涎是一个常见问题，应给予口服药物治疗。[227]Eiland LS. Glycopyrrolate for chronic drooling in children. Clin Ther. 2012 Apr;34(4):735-42.http://www.ncbi.nlm.nih.gov/pubmed/22445330?tool=bestpractice.com 东莨菪碱贴剂、[228]Mato A, Limeres J, Tomás I, et al. Management of drooling in disabled patients with scopolamine patches. Br J Clin Pharmacol. 2010 Jun;69(6):684-8.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883761/http://www.ncbi.nlm.nih.gov/pubmed/20565460?tool=bestpractice.com 肉毒毒素、[229]Reddihough D, Erasmus CE, Johnson H, et al. Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement. Eur J Neurol. 2010 Aug;17 Suppl 2:109-21.http://www.ncbi.nlm.nih.gov/pubmed/20633182?tool=bestpractice.com[230]Schroeder AS, Kling T, Huss K, et al. Botulinum toxin type A and B for the reduction of hypersalivation in children with neurological disorders: a focus on effectiveness and therapy adherence. Neuropediatrics. 2012 Feb;43(1):27-36.http://www.ncbi.nlm.nih.gov/pubmed/22430158?tool=bestpractice.com[231]Nordgarden H, Østerhus I, Møystad A, et al. Drooling: are botulinum toxin injections into the major salivary glands a good treatment option? J Child Neurol. 2012 Apr;27(4):458-64.http://www.ncbi.nlm.nih.gov/pubmed/21940695?tool=bestpractice.com[232]Rodwell K, Edwards P, Ware RS, et al. Salivary gland botulinum toxin injections for drooling in children with cerebral palsy and neurodevelopmental disability: a systematic review. Dev Med Child Neurol. 2012 Nov;54(11):977-87.http://www.ncbi.nlm.nih.gov/pubmed/22946706?tool=bestpractice.com 和手术治疗。[233]Khadivi E, Ashraf Zadeh F, Bakhshaee M, et al. Bilateral submandibular duct rerouting: Assessment of results on drooling in cerebral palsy cases. Auris Nasus Larynx. 2013 Oct;40(5):487-90.http://www.ncbi.nlm.nih.gov/pubmed/23489831?tool=bestpractice.com[234]Stern Y, Feinmesser R, Collins M, et al. Bilateral submandibular gland excision with parotid duct ligation for treatment of sialorrhea in children: long-term results. Arch Otolaryngol Head Neck Surg. 2002 Jul;128(7):801-3.https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/482946http://www.ncbi.nlm.nih.gov/pubmed/12117339?tool=bestpractice.com

进行矫形咨询，并予维生素D和钙治疗。 也可以考虑其他药物如帕米磷酸钠或其他双磷酸盐。[235]Iwasaki T, Nonoda Y, Ishii M. Long-term outcomes of children and adolescents who had cerebral palsy with secondary osteoporosis. Curr Med Res Opin. 2012 May;28(5):737-47.http://www.ncbi.nlm.nih.gov/pubmed/22126423?tool=bestpractice.com[236]Fehlings D, Switzer L, Agarwal P, et al. Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: a systematic review. Dev Med Child Neurol. 2012 Feb;54(2):106-16.https://onlinelibrary.wiley.com/doi/full/10.1111/j.1469-8749.2011.04091.xhttp://www.ncbi.nlm.nih.gov/pubmed/22111966?tool=bestpractice.com

Osteoporosis

遗传性疾病中更常见。

Assessment of hearing loss

在没有外伤或其他前期时间的情况下，患者出现缓慢的、潜伏的功能退化时应考虑颈部脊髓病变的可能性。 移动能力丧失、上肢功能、肠道或膀胱控制障碍不是脑瘫患儿常规病史的一部分。

X 光片和颈部磁共振成像可确认颈脊髓病。这种疾病在运动障碍患者中最常出现，但在出现痉挛状态的患者中已被报道。[237]Duruflé A, Pétrilli S, Le Guiet JL, et. al. Cervical spondylotic myelopathy in athetoid cerebral palsy patients: about five cases. Joint Bone Spine. 2005 May;72(3):270-4.http://www.ncbi.nlm.nih.gov/pubmed/15851002?tool=bestpractice.com[238]Ho H, Park-Ko I. Spinal cord injury secondary to cervical disc herniation in ambulatory patients with cerebral palsy. Spinal Cord. 1998 Apr;36(4):288-92.http://www.ncbi.nlm.nih.gov/pubmed/9589531?tool=bestpractice.com

脑瘫患儿行为问题比正常儿童发生率高5倍。 这些通过社会心理方法解决，例如家长咨询和对儿童本身的更多直接干预。[221]Whittingham K, Sanders M, McKinlay L, et al. Interventions to reduce behavioral problems in children with cerebral palsy: an RCT. Pediatrics. 2014 May;133(5):e1249-57.http://pediatrics.aappublications.org/content/133/5/e1249.longhttp://www.ncbi.nlm.nih.gov/pubmed/24709926?tool=bestpractice.com

仅次于痉挛、无力或运动障碍的口腔和咽部运动控制问题常常存在。 痉挛性四肢瘫痪的患者口腔运动障碍、智力和视力障碍发生率更高。

应该在患儿进食时进行吞咽困难的评估,包括任何窒息、咳嗽、恶心或呕吐。 误吸在没有症状时也不容易被发现。

对于可能发生误吸患者行吞咽研究。 随访内容包括肺炎、哮喘以及其他慢性呼吸疾病感染情况。[222]Jones MW, Morgan E, Shelton JE. Primary care of the child with cerebral palsy: a review of systems (part II). J Pediatr Health Care. 2007 Jul-Aug;21(4):226-37.http://www.ncbi.nlm.nih.gov/pubmed/17606159?tool=bestpractice.com

Acute aspiration

脑瘫患儿常常生长发育不良，尤其是四肢瘫痪的患儿。 所有孩子均应有身高、体重、头围随年龄性别变化的曲线表。 营养需求应该重视。[223]Marchand V; Canadian Paediatric Society. Nutrition in neurologically impaired children. Paediatr Child Health. 2009 Jul;14(6):395-401.https://academic.oup.com/pch/article/14/6/395/2639291http://www.ncbi.nlm.nih.gov/pubmed/20592978?tool=bestpractice.com

Failure to thrive

见于 40% 的脑瘫患者。患者需要使用抗癫痫药物进行治疗。脑电图可对癫痫患者进行评估。[66]Ashwal S, Russman BS, Blasco PA, et al. Practice parameter: diagnostic assessment of the child with cerebral palsy. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2004 Mar 23;62(6):851-63.http://n.neurology.org/content/62/6/851.fullhttp://www.ncbi.nlm.nih.gov/pubmed/15037681?tool=bestpractice.com

Overview of seizure disorder

75%脑瘫患儿存在视力下降。常见于有早产史的患者。痉挛型四肢瘫的患儿视力损害、智力残疾、口腔运动功能障碍患病率更高。

Assessment of vision loss

见于25%的患者

胃食管反流病常与贫血、营养不良、呼吸疾病高复发率及低体重并存。[224]Spiroglou K, Xinias I, Karatzas N, et al. Gastric emptying in children with cerebral palsy and gastroesophageal reflux. Pediatr Neurol. 2004 Sep;31(3):177-82.http://www.ncbi.nlm.nih.gov/pubmed/15351016?tool=bestpractice.com 疑患有胃食管反流病的患者应进行消化道吞咽检查。

Gastro-oesophageal reflux disease

既往对脑瘫患儿睡眠问题研究较少。有证据表明褪黑激素有助于提高睡眠质量。[225]Galland BC, Elder DE, Taylor BJ. Interventions with a sleep outcome for children with cerebral palsy or a post-traumatic brain injury: a systematic review. Sleep Med Rev. 2012 Dec;16(6):561-73.http://www.ncbi.nlm.nih.gov/pubmed/22609124?tool=bestpractice.com

负重（使用站立或步行辅助器具）最大化避免骨质减少。 参照钙和维生素D日推荐量对患儿的摄入量进行评估。 避免摄入量过多以免肾结石形成。[222]Jones MW, Morgan E, Shelton JE. Primary care of the child with cerebral palsy: a review of systems (part II). J Pediatr Health Care. 2007 Jul-Aug;21(4):226-37.http://www.ncbi.nlm.nih.gov/pubmed/17606159?tool=bestpractice.com[226]Castiglia P. Dietary supplements for children. J Pediatr Health Care. 2000 Nov-Dec;14(6):309-11.http://www.ncbi.nlm.nih.gov/pubmed/11112924?tool=bestpractice.com