Diagnostic Considerations

The diagnosis of cerebral palsy is generally made based on the clinical picture; however, some authors propose that the diagnosis should be deferred until the child is age 2 years or older. 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 cerebral palsy and 66% of children diagnosed with spastic diplegia outgrew findings that were suggestive of cerebral palsy by age 7 years. Others did not manifest full motor signs suggestive of this disorder until aged 1-2 years.

Other conditions that should be considered when evaluating a patient with suspected cerebral palsy include metabolic and genetic diseases, hereditary spastic paraplegias, Rett syndrome, and tethered spinal cord.

Differential Diagnoses

Workup

Simpson DM, Gracies JM, Graham HK, Miyasaki JM, Naumann M, Russman B, et al. Assessment: Botulinum neurotoxin for the treatment of spasticity (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2008 May 6. 70(19):1691-8. [QxMD MEDLINE Link].
Scholtes VA, Dallmeijer AJ, Knol DL, Speth LA, Maathuis CG, Jongerius PH, et al. The combined effect of lower-limb multilevel botulinum toxin type a and comprehensive rehabilitation on mobility in children with cerebral palsy: a randomized clinical trial. Arch Phys Med Rehabil. 2006 Dec. 87(12):1551-8. [QxMD MEDLINE Link].
Dai AI, Wasay M, Awan S. Botulinum toxin type A with oral baclofen versus oral tizanidine: a nonrandomized pilot comparison in patients with cerebral palsy and spastic equinus foot deformity. J Child Neurol. 2008 Dec. 23(12):1464-6. [QxMD MEDLINE Link].
Yang EJ, Rha DW, Kim HW, Park ES. Comparison of botulinum toxin type A injection and soft-tissue surgery to treat hip subluxation in children with cerebral palsy. Arch Phys Med Rehabil. 2008 Nov. 89(11):2108-13. [QxMD MEDLINE Link].
Pascual-Pascual SI, Pascual-Castroviejo I. Safety of botulinum toxin type A in children younger than 2 years. Eur J Paediatr Neurol. 2009 Nov. 13(6):511-5. [QxMD MEDLINE Link].
Hoving MA, van Raak EP, Spincemaille GH, Palmans LJ, Becher JG, Vles JS. Efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a randomised controlled trial. Eur J Paediatr Neurol. 2009 May. 13(3):240-6. [QxMD MEDLINE Link].
Trost JP, Schwartz MH, Krach LE, Dunn ME, Novacheck TF. Comprehensive short-term outcome assessment of selective dorsal rhizotomy. Dev Med Child Neurol. 2008 Oct. 50(10):765-71. [QxMD MEDLINE Link].
Nordmark E, Josenby AL, Lagergren J, Andersson G, Strömblad LG, Westbom L. Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatr. 2008 Dec 14. 8:54. [QxMD MEDLINE Link]. [Full Text].
Mutch L, Alberman E, Hagberg B, Kodama K, Perat MV. Cerebral palsy epidemiology: where are we now and where are we going?. Dev Med Child Neurol. 1992 Jun. 34(6):547-51. [QxMD MEDLINE Link].
Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Aug. 47(8):571-6. [QxMD MEDLINE Link].
Shevell MI, Bodensteiner JB. Cerebral palsy: defining the problem. Semin Pediatr Neurol. 2004 Mar. 11(1):2-4. [QxMD MEDLINE Link].
Stanley F, Blair E, Alberman E. Cerebal Palsies: Epidemiology and Causal Pathways. London, United Kingdom: MacKeith Press; 2000.
Jacobsson B, Hagberg G. Antenatal risk factors for cerebral palsy. Best Pract Res Clin Obstet Gynaecol. 2004 Jun. 18(3):425-36. [QxMD MEDLINE Link].
Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006 Feb 28. 28(4):183-91. [QxMD MEDLINE Link].
Russman BS, Ashwal S. Evaluation of the child with cerebral palsy. Semin Pediatr Neurol. 2004 Mar. 11(1):47-57. [QxMD MEDLINE Link].
Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev. 2009 Jan 21. CD004661. [QxMD MEDLINE Link].
Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, et al. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. N Engl J Med. 2008 Aug 28. 359(9):895-905. [QxMD MEDLINE Link]. [Full Text].
Conde-Agudelo A, Romero R. Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeks' gestation: a systematic review and metaanalysis. Am J Obstet Gynecol. 2009 Jun. 200(6):595-609. [QxMD MEDLINE Link].
Volpe JJ. Neurology of the Newborn. 4th ed. Philadelphia, Pa: WB Saunders; 2001. 4.
Moster D, Wilcox AJ, Vollset SE, Markestad T, Lie RT. Cerebral palsy among term and postterm births. JAMA. 2010 Sep 1. 304(9):976-82. [QxMD MEDLINE Link].
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. 1978 Apr. 92(4):529-34. [QxMD MEDLINE Link].
Nelson KB. Can we prevent cerebral palsy?. N Engl J Med. 2003 Oct 30. 349(18):1765-9. [QxMD MEDLINE Link].
Lie KK, Grøholt EK, Eskild A. Association of cerebral palsy with Apgar score in low and normal birthweight infants: population based cohort study. BMJ. 2010 Oct 6. 341:c4990. [QxMD MEDLINE Link]. [Full Text].
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].
Capute AJ, Accardo PJ, eds. Developmental Disabilities in infancy and Childhood. 2nd ed. Baltimore, Md: Brookes Publishing; 2001. Vol 2.:
Majnemer A, Mazer B. New directions in the outcome evaluation of children with cerebral palsy. Semin Pediatr Neurol. 2004 Mar. 11(1):11-7. [QxMD MEDLINE Link].
Vincer MJ, Allen AC, Joseph KS, Stinson DA, Scott H, Wood E. Increasing prevalence of cerebral palsy among very preterm infants: a population-based study. Pediatrics. 2006 Dec. 118(6):e1621-6. [QxMD MEDLINE Link].
Ancel PY, Livinec F, Larroque B, Marret S, Arnaud C, Pierrat V, et al. Cerebral palsy among very preterm children in relation to gestational age and neonatal ultrasound abnormalities: the EPIPAGE cohort study. Pediatrics. 2006 Mar. 117(3):828-35. [QxMD MEDLINE Link].
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. 2001 Oct. 15(4):359-63. [QxMD MEDLINE Link].
Strauss D, Shavelle R, Reynolds R, Rosenbloom L, Day S. Survival in cerebral palsy in the last 20 years: signs of improvement?. Dev Med Child Neurol. 2007 Feb. 49(2):86-92. [QxMD MEDLINE Link].
Hemming K, Hutton JL, Colver A, Platt MJ. Regional variation in survival of people with cerebral palsy in the United Kingdom. Pediatrics. 2005 Dec. 116(6):1383-90. [QxMD MEDLINE Link].
Hemming K, Hutton JL, Pharoah PO. Long-term survival for a cohort of adults with cerebral palsy. Dev Med Child Neurol. 2006 Feb. 48(2):90-5. [QxMD MEDLINE Link].
Hutton JL, Pharoah PO. Life expectancy in severe cerebral palsy. Arch Dis Child. 2006 Mar. 91(3):254-8. [QxMD MEDLINE Link]. [Full Text].
Verrall TC, Berenbaum S, Chad KE, Nanson JL, Zello GA. Children with Cerebral Palsy: Caregivers' Nutrition Knowledge, Attitudes and Beliefs. Can J Diet Pract Res. 2000 Autumn. 61(3):128-134. [QxMD MEDLINE Link].
Segel R, Ben-Pazi H, Zeligson S, Fatal-Valevski A, Aran A, et al. Copy number variations in cryptogenic cerebral palsy. Neurology. 2015 April. 84(16):1660-8. [QxMD MEDLINE Link].
Oskoui M, Gazzellone MJ, Thiruvahindrapuram B, Zarrei M, Andersen J, et al. Clinically relevant copy number variations detected in cerebral palsy. Nat Commun. 2015 Aug. 6:7949. [QxMD MEDLINE Link].
Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy Study. JAMA. 2006 Oct 4. 296(13):1602-8. [QxMD MEDLINE Link].
Woodward LJ, Anderson PJ, Austin NC, Howard K, Inder TE. Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. N Engl J Med. 2006 Aug 17. 355(7):685-94. [QxMD MEDLINE Link].
Wyatt K, Edwards V, Franck L, Britten N, Creanor S, Maddick A, et al. Cranial osteopathy for children with cerebral palsy: a randomised controlled trial. Arch Dis Child. 2011 Jun. 96(6):505-12. [QxMD MEDLINE Link].
Delgado MR, Tilton A, Russman B, Benavides O, Bonikowski M, Carranza J, et al. AbobotulinumtoxinA for Equinus Foot Deformity in Cerebral Palsy: A Randomized Controlled Trial. Pediatrics. 2016 Feb. 137 (2):e20152830. [QxMD MEDLINE Link].
Edwards P, Sakzewski L, Copeland L, Gascoigne-Pees L, McLennan K, Thorley M, et al. Safety of Botulinum Toxin Type A for Children With Nonambulatory Cerebral Palsy. Pediatrics. 2015 Nov. 136 (5):895-904. [QxMD MEDLINE Link].
Blackmore AM, Boettcher-Hunt E, Jordan M, Chan MD. A systematic review of the effects of casting on equinus in children with cerebral palsy: an evidence report of the AACPDM. Dev Med Child Neurol. 2007 Oct. 49(10):781-90. [QxMD MEDLINE Link].
Delgado MR, Hirtz D, Aisen M, et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010 Jan 26. 74(4):336-43. [QxMD MEDLINE Link].
Elia AE, Bagella CF, Ferré F, Zorzi G, Calandrella D, et al. Deep brain stimulation for dystonia due to cerebral palsy: A review. Eur J Paediatr Neurol. 2018 Mar. 22(2):308-315. [QxMD MEDLINE Link].
Muthusamy K, Recktenwall SM, Friesen RM, Zuk J, Gralla J, Miller NH, et al. Effectiveness of an anesthetic continuous-infusion device in children with cerebral palsy undergoing orthopaedic surgery. J Pediatr Orthop. 2010 Dec. 30(8):840-5. [QxMD MEDLINE Link].
Perlman JM. Intrapartum hypoxic-ischemic cerebral injury and subsequent cerebral palsy: medicolegal issues. Pediatrics. 1997 Jun. 99(6):851-9. [QxMD MEDLINE Link]. [Full Text].
Du RY, McGrath CP, Yiu CK, King NM. Oral health behaviors of preschool children with cerebral palsy: a case-control community-based study. Spec Care Dentist. 2014 Nov-Dec. 34 (6):298-302. [QxMD MEDLINE Link].
Anderson P. FDA Clears Stimulation System for Foot Drop in Children. Medscape Medical News. Jan 25 2013. Available at http://www.medscape.com/viewarticle/778221. Accessed: August 4, 2018.
Dabney KW, Lipton GE, Miller F. Cerebral palsy. Curr Opin Pediatr. 1997 Feb. 9(1):81-8. [QxMD MEDLINE Link].
Girard S, Kadhim H, Roy M, Lavoie K, Brochu ME, Larouche A, et al. Role of perinatal inflammation in cerebral palsy. Pediatr Neurol. 2009 Mar. 40(3):168-74. [QxMD MEDLINE Link].
Jones MW, Morgan E, Shelton JE, Thorogood C. Cerebral palsy: introduction and diagnosis (part I). J Pediatr Health Care. 2007 May-Jun. 21(3):146-52. [QxMD MEDLINE Link].
Mattern-Baxter K. Effects of partial body weight supported treadmill training on children with cerebral palsy. Pediatr Phys Ther. 2009 Spring. 21(1):12-22. [QxMD MEDLINE Link].

Media Gallery

Magnetic resonance image (MRI) of a 1-year-old boy who was born at gestational week 27. The clinical examination was consistent with spastic diplegic cerebral palsy. Pseudocolpocephaly and decreased volume of the white matter posteriorly were consistent with periventricular leukomalacia. Evidence of diffuse polymicrogyria and thinning of the corpus callosum is noted in this image.
Magnetic resonance image (MRI) of a 16-month-old boy who was born at term but had an anoxic event at delivery. Examination findings were consistent with a spastic quadriplegic cerebral palsy with asymmetry (more prominent right-sided deficits). Cystic encephalomalacia in the left temporal and parietal regions, delayed myelination, decreased white matter volume, and enlarged ventricles can be seen in this image. These findings are most likely the sequelae of a neonatal insult (eg, periventricular leukomalacia with a superimposed left-sided cerebral infarct).
Magnetic resonance image (MRI) of a 9-day-old girl who was born at full term and had a perinatal hypoxic-ischemic event. Examination of the patient at 1 year revealed findings consistent with a mixed quadriparetic cerebral palsy notable for dystonia and spasticity. Severe hypoxic-ischemic injury to the medial aspect of the cerebellar hemispheres, medial temporal lobes, bilateral thalami, and bilateral corona radiata is observed in this image.

of 3

Author

Hoda Z Abdel-Hamid, MD Associate Professor, Department of Pediatrics, University of Pittsburgh School of Medicine; Director of EMG Laboratory and Neuromuscular Program, Director of Pediatric MDA Clinic, Division of Child Neurology, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center

Hoda Z Abdel-Hamid, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, Child Neurology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ari S Zeldin, MD, FAAP, FAAN Staff Pediatric Neurologist, Naval Medical Center San Diego

Ari S Zeldin, MD, FAAP, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society

Disclosure: Nothing to disclose.

Alicia T F Bazzano, MD, PhD, MPH Clinical Faculty, Division of Pediatric Emergency Medicine, Harbor/UCLA Medical Center; Chief Physician, Westside Regional Center

Alicia T F Bazzano, MD, PhD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Public Health Association, American Society for Bioethics and Humanities

Disclosure: Nothing to disclose.

Boosara Ratanawongsa, MD Clinical Assistant Professor of Pediatrics, Pennsylvania State University College of Medicine; Pediatric Neurologist, Pediatric Specialists of Lehigh Valley, Lehigh Valley Physician Group

Boosara Ratanawongsa, MD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society

Disclosure: Nothing to disclose.

Chief Editor

Amy Kao, MD Attending Neurologist, Children's National Medical Center

Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Child Neurology Society

Disclosure: Have stock (managed by a financial services company) in healthcare companies including Allergan, Cellectar Biosciences, CVS Health, Danaher Corp, Johnson & Johnson.

Acknowledgements

Ann M Neumeyer, MD Medical Director, Lurie Family Autism Center/LADDERS; Assistant Professor of Neurology, 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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment