eMedicine Specialties > Neurology > Pediatric Neurology

Cerebral Palsy: Follow-up

Author: Ari S Zeldin, MD, Fellow, Divison of Pediatric Neurology, Department of Neurosciences, University of California at San Diego School of Medicine
Coauthor(s): Boosara Ratanawongsa, MD, Associate in Neurology, Department of Pediatric Neurology, Children's Specialists, University of California at San Diego; Alicia T F Bazzano, MD, MPH, Fellow and Clinical Instructor in Pediatrics, University of California at Los Angeles; Consulting Staff, Division of Pediatric Emergency Medicine, Harbor/UCLA Medical Center, Children's Hospital Los Angeles
Contributor Information and Disclosures

Updated: Mar 30, 2007

Follow-up

Further Outpatient Care

  • Habilitation is a "comprehensive intervention strategy designed to facilitate adaptation to and participation in an increasing number and variety of settings in a particular society and culture."
  • Management often requires the involvement of multiple specialists (see Consultations) in addition to close neurological follow-up.
  • Multidisciplinary CP clinics can allow for the frequent, comprehensive follow-up of children with CP while decreasing the need for patient travel.

Complications

  • Gastrointestinal and nutritional
    • Failure to thrive due to feeding and swallowing difficulties secondary to poor oromotor control
    • Obesity, less frequently than failure to thrive: Maintaining weight close to idea body weight is important for wheelchair-bound patients or those with ambulatory dysfunction.
    • Gastroesophageal reflux and associated aspiration pneumonia
    • Constipation
    • Dental caries
  • Respiratory
    • Increased risk of aspiration pneumonia because of oromotor dysfunction
    • Chronic lung disease/bronchopulmonary dysplasia
    • Bronchiolitis/asthma
  • Skin - Decubitus ulcers and sores
  • Orthopedic
    • Contractures
    • Hip dislocation
    • Scoliosis
  • Neurologic
    • Epilepsy: Epilepsy occurs in 15-60% of children with CP and is more common in patients with spastic quadriplegia or mental retardation. When compared with controls, children with CP have a higher incidence of epilepsy with onset within the first year of life and are more likely to have a history of neonatal seizures, status epilepticus, polytherapy, and treatment with second-line anticonvulsants. Factors associated with a seizure-free period of at least 1 year include normal intelligence, single seizure type, monotherapy, and spastic diplegia.
    • Hearing loss: This occurs particularly in patients who had acute bilirubin encephalopathy (kernicterus).
    • Vision: Visual acuity decreases in premature infants because of retinopathy of prematurity with hypervascularization and possible retinal detachment.
    • Visual-field abnormalities due to cortical injury
    • Strabismus
  • Cognitive/psychological/behavioral
    • Mental retardation (30-50%)
    • Attention-deficit/hyperactivity disorder
    • Learning disabilities
    • Impact on academic performance and self-esteem
    • Increased prevalence of depression
    • Sensory integration difficulties
    • Increased prevalence of progressive development disorder or autism associated with concurrent diagnosis of CP

Prognosis

  • Patients with severe forms of CP may have a significantly reduced life span. Patients with milder forms of CP have a life expectancy close to the general population, although still somewhat reduced (Hemming, 2006; Hemming, 2005; Hutton, 2006).
  • Morbidity and mortality relate to the severity of CP and concomitant medical complications, such as respiratory and GI difficulties. In patients with quadriplegia, the likelihood of epilepsy, extrapyramidal abnormalities, and severe cognitive impairment is greater than in those with diplegia or hemiplegia.
  • Cognitive impairment occurs more frequently in persons with CP than in the general population. The overall rate of mental retardation in persons with CP is thought to be 30-50%. Some form of learning disability (including mental retardation) has been estimated to occur in perhaps 75% of patients. However, standardized cognitive testing primarily evaluates verbal skills and may result in the underestimation of cognitive abilities in some individuals.
  • In some studies, 25% of patients with CP are unable to walk. However, many patients with CP (particularly those with spastic diplegia and spastic hemiplegia types) can ambulate independently or with assistive equipment. A prospective study of children has suggested that being able to sit by age 2 years is a good predictive sign of eventual ambulation. Children who did not sit by age 4 years did not ambulate.
  • In patients with spastic quadriplegia, a less favorable prognosis correlated with a longer delay in the resolution of extensor tone. At times, hypertonicity and spasticity may improve or resolve over time in patients with CP. Spasticity in patients with spastic quadriplegia can be more resistant even with services and orthopedic and rehabilitative intervention. Approximately 25% of children with CP have mild involvement with minimal or no functional limitation in ambulation, self-care, and other activities. Approximately half are moderately impaired to the extent that complete independence is unlikely but function is satisfactory. Only 25% are so severely disabled that they require extensive care and are nonambulatory. Maintenance of sitting by age 2 years and suppression of obligatory infantile reflexes by age 18 months are thought to be good prognostic indicators of eventual ambulation.
  • As the brain continues to develop postnatally, abnormalities of motor tone or movement in the first several weeks or months after birth may gradually improve over the first year of life (or even later). The Collaborative Perinatal Project found that almost 50% of individuals diagnosed with CP and 66% of children diagnosed with spastic diplegia "outgrew" findings that were suggestive of CP by age 7 years. Others do not manifest full motor signs suggestive of CP until aged 1-2 years. Thus, some propose that the diagnosis of CP should be deferred until the child is aged 2 years or older.
  • With appropriate therapeutic services, patients may be able to fully integrate academically and socially.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Medicolegal issues are outlined extensively in a 1997 review article by Perlman. Obstetricians are at risk of malpractice claims because of the association of CP with birth asphyxia, even though most CP cases are thought to be caused by prenatal insult.
  • To determine the presence of medical negligence related to birth asphyxia, the following must be documented:
    • An adverse outcome occurred (eg, CP as a consequence of intrapartum asphyxia).
    • Standard of care was breached during labor or delivery, directly causing the asphyxia.
    • An alternative medical strategy more likely than not would have altered the outcome in a positive fashion.
  • To ascribe the cause of CP to intrapartum asphyxia, the following must not be present: (1) clinical evidence indicating any potential antenatal injury, (2) neuroimaging evidence of antenatal cerebral injury, (3) clinical evidence of severe perinatal asphyxia, and (4) evidence of other causes of neonatal encephalopathy.
  • Given that prenatal factors greatly outnumber perinatal and postnatal factors in the origin of CP and that prenatal factors are difficult to isolate from perinatal and postnatal factors as a cause for CP, determining causality due to intrapartum asphyxia or medical neglect is difficult.

Special Concerns

  • Advances in neonatal neurology continue to focus on potentially modifiable factors during the neonatal period that contribute to the development of CP. Many of these studies focus on the role of excitable amino acids and their role in neurological injury. The hope is that more can be done in the neonatal period to prevent the permanent neurologic deficit resulting in CP.
 


More on Cerebral Palsy

Overview: Cerebral Palsy
Differential Diagnoses & Workup: Cerebral Palsy
Treatment & Medication: Cerebral Palsy
Follow-up: Cerebral Palsy
Multimedia: Cerebral Palsy
References
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References

  1. Abbott R. The management of cerebral palsy: how can neurosurgery help?. Pediatr Ann. Oct 1997;26(1O):591-8. [Medline].

  2. Abbott R. Sensory rhizotomy for the treatment of childhood spasticity. J Child Neurol. Nov 1996;11 Suppl 1:S36-42. [Medline].

  3. Albright AL. Spasticity and movement disorders in cerebral palsy. J Child Neurol. Nov 1996;11 Suppl 1:S1-4. [Medline].

  4. American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology. Washington, DC: American College of Obstetricians and Gynecologists; 2003. [Full Text].

  5. Ancel PY, Livinec F, Larroque B, et al. Cerebral palsy among very preterm children in relation to gestational age and neonatal ultrasound abnormalities: the EPIPAGE cohort study. Pediatrics. Mar 2006;117(3):828-35. [Medline].

  6. 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. Mar 23 2004;62(6):851-63. [Medline].

  7. Barry MJ. Physical therapy interventions for patients with movement disorders due to cerebral palsy. J Child Neurol. Nov 1996;11 Suppl 1:S51-60. [Medline].

  8. Bax M, Goldstein M, Rosenbaum P, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. Aug 2005;47(8):571-6. [Medline].

  9. Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy Study. JAMA. Oct 4 2006;296(13):1602-8. [Medline].

  10. Boehm FH. Intrapartum fetal heart rate monitoring. Obstet Gynecol Clin North Am. Dec 1999;26(4):623-39, vi-vii. [Medline].

  11. Capute A, Accardo P. Developmental Disabilities in infancy and Childhood. Vol 2. 2nd ed. Baltimore, Md: Brookes Publishing; 2001.

  12. Cioni G, Di Paco MC, Bertuccelli B, et al. MRI findings and sensorimotor development in infants with bilateral spastic cerebral palsy. Brain Dev. Jun 1997;19(4):245-53. [Medline].

  13. De Salles AA. Role of stereotaxis in the treatment of cerebral palsy. J Child Neurol. Nov 1996;11 Suppl 1:S43-50. [Medline].

  14. DeLuca PA. The musculoskeletal management of children with cerebral palsy. Pediatr Clin North Am. Oct 1996;43(5):1135-50. [Medline].

  15. Dolk H, Pattenden S, Johnson A. Cerebral palsy, low birthweight and socio-economic deprivation: inequalities in a major cause of childhood disability. Paediatr Perinat Epidemiol. Oct 2001;15(4):359-63. [Medline].

  16. Gordon N. The role of botulinus toxin type A in treatment--with special reference to children. Brain Dev. Apr 1999;21(3):147-51. [Medline].

  17. Hemming K, Hutton JL, Pharoah PO. Long-term survival for a cohort of adults with cerebral palsy. Dev Med Child Neurol. Feb 2006;48(2):90-5. [Medline].

  18. Hemming K, Hutton JL, Colver A, Platt MJ. Regional variation in survival of people with cerebral palsy in the United Kingdom. Pediatrics. Dec 2005;116(6):1383-90. [Medline].

  19. Hoon AH, Reinhardt EM, Kelley RI, et al. Brain magnetic resonance imaging in suspected extrapyramidal cerebral palsy: observations in distinguishing genetic-metabolic from acquired causes. J Pediatr. Aug 1997;131(2):240-5. [Medline].

  20. Hutton JL, Pharoah PO. Life expectancy in severe cerebral palsy. Arch Dis Child. Mar 2006;91(3):254-8. [Medline].

  21. Jacobsson B, Hagberg G. Antenatal risk factors for cerebral palsy. Best Pract Res Clin Obstet Gynaecol. Jun 2004;18(3):425-36. [Medline].

  22. Koman LA, Mooney JF, Smith BP. Neuromuscular blockade in the management of cerebral palsy. J Child Neurol. Nov 1996;11 Suppl 1:S23-8. [Medline].

  23. Kuban KC, Leviton A. Cerebral palsy. N Engl J Med. Jan 20 1994;330(3):188-95. [Medline].

  24. Kwong KL, Wong SN, So KT. Epilepsy in children with cerebral palsy. Pediatr Neurol. Jul 1998;19(1):31-6. [Medline].

  25. Leach J. Children undergoing treatment with botulinum toxin: the role of the physical therapist. Muscle Nerve Suppl. 1997;6:S194-207. [Medline].

  26. Majnemer A, Mazer B. New directions in the outcome evaluation of children with cerebral palsy. Semin Pediatr Neurol. Mar 2004;11(1):11-17. [Medline].

  27. Matthews D, Wilson P. Cerebral Palsy. In: Molnar G, Alexander M, eds. Pediatric Rehabilitation. 3rd ed. Philadelphia, Pa: Hanley & Belfus; 1998:. 193-207.

  28. Mutch L, Alberman E, Hagberg B, et al. Cerebral palsy epidemiology: where are we now and where are we going?. Dev Med Child Neurol. Jun 1992;34(6):547-51. [Medline].

  29. Nelson KB, Ellenberg JH. Antecedents of cerebral palsy. Multivariate analysis of risk. N Engl J Med. Jul 10 1986;315(2):81-6. [Medline].

  30. Nelson KB. Can we prevent cerebral palsy?. N Engl J Med. Oct 30 2003;349(18):1765-9. [Medline].

  31. Niemann G, Grodd W, Schoning M. Late remission of congenital hemiparesis: the value of MRI. Neuropediatrics. Aug 1996;27(4):197-201. [Medline].

  32. Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. Feb 28 2006;28(4):183-91. [Medline].

  33. Okumura A, Hayakawa F, Kato T, et al. MRI findings in patients with spastic cerebral palsy. I: Correlation with gestational age at birth. Dev Med Child Neurol. Jun 1997;39(6):363-8. [Medline].

  34. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. Apr 1978;92(4):529-34. [Medline].

  35. Perlman JM. Intrapartum hypoxic-ischemic cerebral injury and subsequent cerebral palsy: medicolegal issues. Pediatrics. Jun 1997;99(6):851-9. [Medline].

  36. Pranzatelli MR. Oral pharmacotherapy for the movement disorders of cerebral palsy. J Child Neurol. Nov 1996;11 Suppl 1:S13-22. [Medline].

  37. Rubin IL. The perinatal period: antecedents and sequelae. Pediatr Ann. Oct 1989;18(10):653-61. [Medline].

  38. Russman BS, Gage JR. Cerebral palsy. Curr Probl Pediatr. Feb 1989;19(2):65-111. [Medline].

  39. Russman BS, Ashwal S. Evaluation of the child with cerebral palsy. Semin Pediatr Neurol. Mar 2004;11(1):47-57. [Medline].

  40. Shevell MI, Bodensteiner JB. Cerebral palsy: defining the problem. Semin Pediatr Neurol. Mar 2004;11(1):2-4. [Medline].

  41. Shevell MI. The "Bermuda triangle" of neonatal neurology: cerebral palsy, neonatal encephalopathy, and intrapartum asphyxia. Semin Pediatr Neurol. Mar 2004;11(1):24-30. [Medline].

  42. Stanley F, Blair E, Alberman E. Cerebal Palsies: Epidemiology and Causal Pathways. London: MacKeith Press; 2000.

  43. Stevenson DK, Benitz WE, Sunshine P. Fetal and Neonatal Brain Injury Mechanisms, Management and the Risks of Practice. 3rd ed. New York: Cambridge University Press; 2003.

  44. Topp M, Langhoff-Roos J, Uldall P. Preterm birth and cerebral palsy. Predictive value of pregnancy complications, mode of delivery, and Apgar scores. Acta Obstet Gynecol Scand. Oct 1997;76(9):843-8. [Medline].

  45. Vincer MJ, Allen AC, Joseph KS, et al. Increasing prevalence of cerebral palsy among very preterm infants: a population-based study. Pediatrics. Dec 2006;118(6):e1621-6. [Medline].

  46. Volpe JJ. Neurology of the Newborn. 4th ed. Philadelphia, Pa: WB Saunders; 2001:. 4.

  47. Waters PM, Van Heest A. Spastic hemiplegia of the upper extremity in children. Hand Clin. Feb 1998;14(1):119-34. [Medline].

  48. Woodward LJ, Anderson PJ, Austin NC, et al. Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. N Engl J Med. Aug 17 2006;355(7):685-94. [Medline].

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Further Reading

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Keywords

CP, MRCP, brain paralysis, static encephalopathy, periventricular leukomalacia, cerebral injury, premature birth, hypoperfusion, germinal matrix hemorrhage, spastic diplegia, periventricular hemorrhage, intraventricular hemorrhage, subependymal hemorrhage, germinal matrix hemorrhage, periventricular hemorrhagic venous infarction, intraparenchymal hemorrhage, ipsilateral germinal matrix hemorrhage, acute hyperbilirubin encephalopathy, chorionitis, spastic hemiplegia

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Contributor Information and Disclosures

Author

Ari S Zeldin, MD, Fellow, Divison of Pediatric Neurology, Department of Neurosciences, University of California at San Diego School of Medicine
Ari S Zeldin, MD is a member of the following medical societies: American Academy of Cerebral Palsy and Developmental Medicine and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Boosara Ratanawongsa, MD, Associate in Neurology, Department of Pediatric Neurology, Children's Specialists, University of California at San Diego
Boosara Ratanawongsa, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, and Child Neurology Society
Disclosure: Nothing to disclose.

Alicia T F Bazzano, MD, MPH, Fellow and Clinical Instructor in Pediatrics, University of California at Los Angeles; Consulting Staff, Division of Pediatric Emergency Medicine, Harbor/UCLA Medical Center, Children's Hospital Los Angeles
Alicia T F Bazzano, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Public Health Association, and American Society for Bioethics and Humanities
Disclosure: Nothing to disclose.

Medical Editor

Ann M Neumeyer, MD, Clinic Director, Instructor, Departments of Neurology and Pediatrics, Massachusetts General Hospital, Harvard Medical School
Ann M Neumeyer, MD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kenneth J Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic
Kenneth J Mack, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, Phi Beta Kappa, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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