Kids, Strokes & Speech
High- and low-tech therapies help children who have had a cerebrovascular accident
September 2, 2013
"I knew adults suffered strokes, but I didn't know kids could have strokes too," said Julie Ring of San Antonio, Texas. "Then, when it happens to your child you go through so many emotions, grief, guilt, blame, concern for their future life."
More than 5 years ago, Ring's youngest child suffered a stroke soon after birth. "Evan was 5 months old when we noticed he wasn't using his right hand. Instead of reaching for things with both hands, which babies often do, he would reach with his left hand only."
What Ring didn't know at the time, is that this is one of the classic signs that a stroke has occurred. "A child who favors one hand, leaves the other hand in a fist or doesn't bring both hands together during play needs to be referred to an early intervention program and a pediatric neurologist for further testing," according to the Children's Hemiplegia and Stroke Association (CHASA) (http://www.chasa.org/medical/pediatric-stroke).
"Fortunately, we had an amazing pediatrician, who even before the neurologist confirmed it was a stroke, had Evan doing physical therapy," Ring told ADVANCE. That eventually led to occupational and speech therapy.
Knowing the Numbers
Stroke is the sixth leading cause of death in children and occurs in one in every 2,700 live births, according to CHASA. The risk of stroke is highest in the first year of life and peaks during the first few weeks before and after birth. Doctors believe Evan suffered his stroke shortly after birth, possibly due to some genetic clotting issues.
Strokes, a disruption of normal blood flow to the brain, can occur for various reasons, for example: venous or arterial malformations, brain injury, aneurysm, tumors or cardiovascular deficits, according to Lindsay M. Stevens, MA, CCC-SLP, pediatric acute care speech pathologist at Phoenix Children's Hospital, associated with Barrow Neurological Institute in Phoenix, Ariz.
While 60% of infants with a stroke exhibit identifiable symptoms early, 40% do not and this can delay diagnosis and child development. In Evan's case, his parents noticed he didn't use his right hand and thought it was just his preference. When his grandmothers' noticed it they felt it was not normal and urged the family to seek a medical opinion.
"We frequently see speech, language, cognitive, swallowing, oral, motor, and/or oral sensory deficits in this population," explained Stevens. "Children may have difficulty expressing their thoughts, using or feeling one side of their face and swallowing liquids or solids."
First, the Basics
As a speech-language pathologist, Stevens' involvement often begins "in the ICU, as soon as a child is stabilized and extubated," Stevens said. "We typically start with swallowing to determine if the child is safe to eat by mouth."
"We work closely with the physicians and dietitians to find the safest and most beneficial feeding plan," continued Stevens, whose specialty is feeding and swallowing therapies. "If children are not ready to eat by mouth, we often intervene with thermal gustatory stimulation or tactile stimulation to facilitate functional oral motor movement, sensation and promote positive experiences in the mouth."
Another therapy Stevens and colleagues have been doing at Phoenix Children's Hospital for 10 years is an adjunctive therapy - neuromuscular electrical stimulation for swallowing or facial movement. "The system's lead wires are connected to electrodes that are externally placed on the patient's throat and/or face to stimulate the nerves that control the muscles needed for swallowing or facial movement," explained Stevens. "The system causes the muscles to contract where otherwise they wouldn't contract."
The goal of this therapy is to strengthen muscles, restore function and help the brain reorganize or remap for swallowing or facial movement, according to Stevens. "Used in the right fashion with the right patient this is an effective treatment."
If the peripheral nerves are intact, this can be an valuable therapy. "If the peripheral nerves are damaged, then this is not the therapy for that patient," she said.
Often, concomitant with swallowing problems are difficulties chewing food. "We can do exercises to facilitate age-appropriate chewing patterns," said Stevens. "We also can modify a patient's diet or teach compensatory strategies to ensure the patient is eating safely."
To facilitate severe communication impairments, clinicians try to utilize assistive or augmentative communication, such as picture boards. "We're using iPads and more high-tech devices in our outpatient setting," explained Stevens.
One intervention that might seem low tech but is essential is family involvement. "Therapy is more successful when the family is involved, said Stevens. "We use evidence based practice therapies and are always researching new methods, but what is so valuable is when families are present during therapy and carry over the therapy when we're not there."
Family involvement has been a big factor in Evan Ring's therapy. With two older siblings - one 18, the other 8 - Evan, now a talkative 6 year old, gets read to every day, said his mother, who is now a board member and vice president of the Children's Hemiplegia and Stroke Association.
"There is constant chatter in our house and Evan is always involved in the conversation," laughed Ring, who explained Evan has cerebral palsy as a result of his stroke, doesn't use his right hand as much as he should and still requires speech therapy for word enunciation.
Part of the difficulty, Ring said, with young children who have had a stroke is "you don't know what delays your child may have until they don't reach the milestones other children would have reached."
Evan began speech therapy when he was more than a year old; he was making sounds but not forming words. "You start to trust the resources that are there for you," explained Ring. "When our OT suggested Evan have speech therapy, we did. After he began speech therapy there was a consistent increase in the words he would use."
"Trust your gut," Ring advised parents faced with what she and her family have experienced with Evan. "If you think there's a problem, you are your child's voice. You need to make sure they get the medical attention, intervention and therapy."
Gail O. Guterl is a freelance writer.