What is the approach to managing cerebral palsy (CP) in children?

Approach to Cerebral Palsy Management

Children with cerebral palsy require immediate initiation of task-specific, intensive motor interventions upon diagnosis or high suspicion, as delaying treatment causes progressively irreversible modifications to muscle and bone growth that become harder to reverse over time. 1, 2

Early Diagnosis Framework

Diagnostic Timing and Tools

• Diagnose as early as possible, ideally before 5 months corrected age, using standardized assessment tools to enable early intervention when neuroplasticity is maximal 3
• Before 5 months corrected age: Use MRI (80-90% predictive), General Movements assessment (95-98% predictive), or Hammersmith Infant Neurological Examination (HINE) with scores <57 at 3 months (96% predictive) 3
• After 5 months corrected age: Combine MRI with HINE (scores <73 at 6-12 months indicate 90% CP risk) 3
• Use interim diagnosis of "high risk of CP" when certainty is lacking but suspicion exists, allowing immediate intervention while monitoring continues 3

Red Flags Requiring Immediate Assessment

• Inability to sit independently by 9 months 3
• Hand function asymmetry at any age 3, 4
• Inability to bear weight through plantar surface of feet 3

Motor Rehabilitation: The Core Intervention

Immediate Motor Training Protocol

• Start constraint-induced movement therapy (CIMT) for hemiplegia or Goals-Activity-Motor Enrichment (GAME) for all CP subtypes immediately upon diagnosis 1, 2
• Deliver interventions in home-based settings whenever possible, as home programs produce superior motor and cognitive outcomes compared to clinic-based approaches 1, 4
• Incorporate child-initiated movement, task-specific practice, environmental adaptations, repetitive exercises, and age-appropriate activities 1, 2
• Interventions must be intense and enriched—infants who do not actively use their motor cortex risk losing cortical connections permanently 1

Communication and Cognitive Development

• Implement speech-language pathology using Hanen "It Takes Two to Talk" and "More Than Words" programs 3
• Provide alternative and augmentative communication when speech is inadequate or impossible 3
• Foster parent-infant transactions to optimize communication development 3

Systematic Surveillance for Secondary Complications

Hip Surveillance Protocol

• Obtain anteroposterior pelvic radiographs every 6-12 months starting at age 12 months to prevent hip displacement, which affects 28% of children with CP 3, 2, 4

Pain Management (Affects 75% of Children)

• Implement preemptive analgesia for all procedural pain, as untreated procedural pain elevates risk for long-term neuropathic pain 3
• Use pharmacological therapy and environmental interventions for ongoing chronic pain 3, 2
• Consider acetaminophen or ibuprofen for musculoskeletal pain 4

Orthopedic Management

• Prescribe ankle-foot orthosis (AFO) immediately for foot drop in hemiplegic CP to improve gait mechanics and prevent contractures 4
• Implement regular surveillance and early intervention to reduce contracture and scoliosis rates, particularly in bilateral CP 1, 2

Neurological Complications

• For epilepsy (affects 35% of cases): Use standard antiepileptic pharmacological management 2

Sleep Disorders (Affect 23% of Cases)

• Conduct specialist assessments and treat before secondary academic and behavioral problems emerge 3, 2
• Implement sleep hygiene, parental education, spasticity management, melatonin 2.5-10 mg, and gabapentin 5 mg/kg 3, 2

Feeding and Nutrition

• Comprehensively assess swallowing safety if pneumonia history exists or feeding concerns arise, as pneumonia is the leading cause of death in CP and is mitigated by tube feeding 3, 2
• Measure weight regularly, as severe physical disability elevates malnutrition risk 3

Vision and Hearing

• Assess vision in first 48 hours of life; any infant with abnormal vision at term-equivalent age requires vision intervention and reassessment at 3 months 3, 2
• Provide standard early hearing accommodations 3, 2

Urinary Tract

• Conduct medical investigations for bladder function, as abnormal anatomical findings are common 3, 2
• Provide standard toilet training over longer duration, as control may take longer 3, 2

Oral Care

• For sialorrhea: Consider botulinum toxin A, benztropine mesylate, or glycopyrrolate 3

Multidisciplinary Team Structure

Essential team members include: pediatric neurologist, pediatrician, orthopedic surgeon, physical therapist, occupational therapist, psychologist, and education specialist 1, 2, 5

Family Support and Mental Health

• Screen parental mental health routinely, as 1 in 4 children have behavior disorders that compound parental stress, anxiety, and depression 3
• Provide immediate counseling and goal-setting with parents at intervention start to reduce depression and anger 4
• Involve parents actively in comprehensive treatment from first days after diagnosis, as success depends on complete parental involvement 5
• Offer attachment support and facilitate parent-infant interactions 4

Expected Outcomes with Appropriate Management

With early intervention and comprehensive management: 2 in 3 individuals will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence 1, 2

Critical Pitfalls to Avoid

• Never delay intervention while awaiting diagnostic certainty—use "high risk of CP" diagnosis to start treatment immediately 3
• False negatives resulting in late diagnosis are detrimental to parents, caregivers, and infants—standardized tools have <5% false positive rate 3
• Do not rely solely on clinic-based therapy—home-based programs are superior 1, 4
• Avoid undertreating procedural pain, as this creates long-term neuropathic pain risk 3