Home > Diagnoses & Conditions > Cerebral Palsy > Ongoing Assessment
Cerebral Palsy - Ongoing Assessment
Overview
Every child with CP should have routine well-child visits and most will benefit from additional routine visits for chronic care assessment and management. See Parent Concerns Questionnaire - CP (
37 KB)
. The Medical Home clinician should be watchful for regression in developmental abilities which may signal an unknown underlying
etiology or a new problem such as the appearance of frequent seizures interfering with concentration or other abilities.
Diagnostic Criteria
Basic diagnostic criteria include the presence of a non-progressive neurologic deficit secondary to a brain maldevelopment or injury to the developing brain.Pearls And Alerts
Because new causes for apparent CP are being recognized, [Hoon: 1997] the clinician should consider (or reconsider) the diagnosis of CP at each visit in any child with CP without an obvious historical cause, even in older children. If there is any question about the diagnosis, the child should be referred to neurology or genetics.
History And Examination
Interim History
Mobility: Does the child have age appropriate mobility (rolling, crawling, walking)? Have they made progress in activities of daily living? Any changes in the therapies the child is receiving? Any changes in spasticity treatments, equipment, orthopedic surgeries, contractures, stander? Any change in exercise tolerance?Growth and nutrition: Is nutritional status or growth a concern? See Nutrition and growth in children with CP. Is the child fed orally or by feeding tube? (See Feeding tube issues (general)). Is the child receiving any therapy to improve oral feeding skills? What is the child's usual calcium intake?
GI: New or ongoing issues with constipation? Is he/she toilet trained? Also see Constipation treatment (general) and Toilet Training (general). Problems with gastroesophageal reflux?
Swallowing and drooling: Does the child cough and/or choke during eating and drinking? How long does it take for the child to eat or be fed? Is swallowing or drooling a problem?
Pulmonary: Are there respiratory concerns? Has the child had pneumonia? Does the child have difficulty sleeping? Frequent snoring?
Neurology: Has there been developmental regression Has the child had seizures or concerning episodes? See the Seizure module for more information. Does the child have a ventriculo-peritoneal shunt in place? Any signs of shunt malfunction (e.g., headache, mood or activity change, emesis)?
Sleep Problems: Ask about sleeping problems. Does the child snore? Does the child have excessive daytime sleepiness?
Musculoskeletal/Bone: Has the child had fractures? Fractures without clinical explanation prompt concerns for osteopenia/osteoporosis, especially in the child on antiepileptic medications, or abuse. Do they have a standing program? Are joint contractures limiting mobility?
Urinary: Does the child have urinary frequency, urgency, or dribbling? Is he/she toilet trained? Also see Neurogenic Bladder (general).
Other: Is there evidence of chronic pain? Does the family use any complimentary alternative medicine (CAMS)?
Developmental and Educational Progress
What are the child's abilities? At what age level does the child understand language? Parents' estimate of the child's mental age? How does the child communicate (e.g., differential cries, eye gaze, verbal, signing, augmentative device). Describe the child's early intervention or school program. Are there new concerns about school or early intervention?Social and Family Functioning
How is the family coping? Are there siblings of the child with CP? Is the child functioning well at school? Does the child have recreational activities and opportunities for friendships? Are there behavioral problems or depression? Is the family accessing available financial resources? Respite? What about the extended family?Physical Exam
General
Follow general appearance and interaction of the child with the environment. Mobility aids, hearing aids, glasses? General appearance of head, shunt palpable? Nutritional status?Growth Parameters
Height | weight | head circumference (HC) Children who were born prematurely may need to be followed on preterm growth charts; if standard growth charts are used, prematurity should be corrected for until 18-24 months of age.Weight should be followed for obesity or, more likely, malnutrition. See Nutrition and growth in children with CP.
Children who have low weight, height and head circumference for age may have an underlying genetic syndrome.
HC is particularly important to track; a HC crossing percentile lines in the upward direction may signal hydrocephalus whereas a HC crossing percentile lines in the downward direction may reflect microcephaly.
Neurologic Exam
Watch for new focal findings that might signify a progressive course and for signs of increasing spasticity or dystonia that might need new therapeutic interventions.Musculoskeletal
Check for scoliosis and joint contractures. See Musculoskeletal Assessment in the Primary Care Setting ( 99 KB)
.
HEENT
Check for strabismus, dental problems, drooling, and swallowing problems. Middle ear fluid should be treated aggressively as it might contribute to hearing loss.Skin
Look for pressure sores in children with decreased mobility, including under ankle-foot orthotics.Testing
Sensory Testing
Children with CP frequently have problems with vision and hearing and need regular screening.Imaging and EEG
MRI should be considered if there is a change in the child's clinical course. EEG is only necessary if seizures are clinically suspected.Genetic Testing
If suspicion arises about a genetic etiology for a child's CP, either directed genetic testing or a referral to genetics should be considered.Other Testing
Modified barium swallow (sometimes called a cookie swallow or video swallow) - performed in collaboration with a speech therapist to assess swallowing function and whether the child is aspirating.DEXA scan - consider if bones look hypodense on X-ray, if the child is non-mobile, on antiepileptic medication, or has a history of fractures. If osteoporosis is confirmed, further evaluation should focus on diet and vitamin adequacy, weight-bearing potential (ie., standing program), and exclusion of other potential causes of osteoporosis. DEXA scans are of limited value before age three years due to lack of normative data.
Sleep study - A sleep study should be considered if the child has difficulty sleeping, disrupted sleep, or signs of obstructive sleep apnea (e.g., snoring, day time sleepiness, etc).
Subspecialist Collaborations and Other Resources
Children with CP often need access to a number of subspecialists. The Medical Home should be the initiator and coordinator of these referrals with input from the family. The goal is to have the child see needed subspecialists and to avoid duplication of services or unnecessary appointments.
Developmental Pediatrics (see Services below for relevant providers)
Developmental pediatric specialists provide neurodevelopmental consultation for the ongoing evaluation of children with CP.
Pediatric Neurology (see Services below for relevant providers)
Neurology should evaluate the child's clinical status yearly, or more often if indicated. A neurology consultant can offer expertise in management of seizure disorder or evaluation of new neurological changes. A child with ataxia should be followed closely by neurology to watch for progression.
Pediatric Physical Medicine & Rehab (see Services below for relevant providers)
Pediatric physiatry will assist in improving functional quality of life using assistive devices, medications, and guiding physical, occupational, and speech therapy.
Pediatric Neurosurgery (see Services below for relevant providers)
Neurosurgery should follow children with ventriculo-peritoneal shunts approximately yearly, with additional visits as needed for shunt problems.
Pediatric Orthopedics (see Services below for relevant providers)
Most children with CP and significant tonal abnormalities should be followed by an orthopedic specialist to monitor for contractures, scoliosis, hip subluxation, and to guide interventions to optimize gait efficiency.
Pediatric Gastroenterology (see Services below for relevant providers)
Children with difficulty gaining weight, feeding problems, GERD, and severe constipation may need referral to gastroenterology.
General Pediatric Surgery (see Services below for relevant providers)
Referral may be indicated for placement of a feeding tube. Alternatively, a percutaneous gastrostomy may be available through gastaroenterology.
Pediatric Dentistry (see Services below for relevant providers)
Children with CP should be seen by pediatric dentists if possible as they may be more prone to caries and may need anesthesia for some dental procedures. Caries may lead to food refusal and systemic disease if untreated.
Pediatric Otolaryngology (see Services below for relevant providers)
To evaluate and treat drooling and swallowing difficulties as well as to consider PE tubes, if there are frequent ear infections, to optimize hearing.
Pediatric Pulmonology (see Services below for relevant providers)
To assess difficulties the child may be having with cough, breathing during sleep, frequent respiratory infections.
Pediatric Ophthalmology (see Services below for relevant providers)
Children with CP may need ongoing care by a pediatric ophthalmologist if they have strabismus, acuity loss, or cortical visual impairment.
Resources
Information & Support
For Professionals
Information on spasticity, choreoathetosis, more (WE MOVE)
The Worldwide Education and Awareness for Movement Disorders.
For Parents and Patients
Support
Cerebral palsy support groups (Children's Disability Information)
A list of support groups for different types of CP as well as other resources
United Cerebral Palsy
This national non-profit organization, provides information on a variety of topics including advocacy, conferences, insurance,
sexuality, policy, and other items for the public and providers.
General
CP information (MedlinePlus)
from the National Library of Medicine; basic information and links to many additional sources of reliable information
NINDS Cerebral Palsy Information Page
A webpage of the National Institute of Neurological Disorders and Strokes (NINDS) providing a thorough overview of CP plus
links to multiple organizations, publications, and education tools. For physicians as well as patients and families
Practice Guidelines
Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M, Stevenson R.
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;62(6):851-63.
PubMed abstract / Full Text
Evidence based summary of indicated diagnostic evaluation for children with cerebral palsy.
Tools
Musculoskeletal Assessment in the Primary Care Setting
( 99 KB)
A concise, easy to use tool to document the limitations of a child's musculoskeletal abilities and exam.
Parent Concerns Questionnaire - CP
( 37 KB)
One-page list of issues to aid parents and physicians in organizing their thoughts and the visit.
Services
Developmental Pediatrics
Child Development Clinic,
more info...
44 Mario Capecchi Drive
Salt Lake City, UT 84114
Phone: 801-584-8510
Toll Free Phone: 800-829-8200
Fax: 801-584-8579
http://health.utah.gov/cshcn/cdc/
See all Developmental Pediatrics services providers (2) in our database.
Pediatric Gastroenterology
See all Pediatric Gastroenterology services providers (2) in our database.
Pediatric Physical Medicine & Rehab
See all Pediatric Physical Medicine & Rehab services providers (6) in our database.
For other services related to this condition, browse our Services categories or search our database.
Authors
| Authors: | Lisa Samson-Fang MD, 3/2008 Lynne M Kerr MD, PhD, 3/2008 |
| Content Last Updated: | 5/2011 |
Page Bibliography
Hoon AH Jr, Reinhardt EM, Kelley RI, Breiter SN, Morton DH, Naidu SB, Johnston MV.
Brain magnetic resonance imaging in suspected extrapyramidal cerebral palsy: observations in distinguishing genetic-metabolic
from acquired causes.
J Pediatr.
1997;131(2):240-5.
PubMed abstract
Case series of children with motor disorders in which the MRI provided diagnostic clues.