What are the recommended assessments and multidisciplinary management strategies for a child with cerebral palsy?

Cerebral Palsy: Recommended Assessments and Multidisciplinary Management

Children with cerebral palsy require early standardized diagnostic assessments followed by immediate referral to CP-specific interventions, with systematic screening for common comorbidities at every visit to optimize neuroplasticity, prevent secondary complications, and maximize long-term function. 1

Diagnostic Assessment Framework

Early Detection Tools (Before 5 Months Corrected Age)

• Prechtl Qualitative Assessment of General Movements (98% sensitivity) is the most predictive clinical tool 1, 2
• Term-age MRI (86-89% sensitivity) to detect white matter injury, gray matter lesions, or brain maldevelopments 1, 2
• Hammersmith Infant Neurological Examination (HINE) (90% sensitivity) provides objective severity information 1

Detection Tools (After 5 Months Corrected Age)

• HINE remains the strongest recommendation (90% predictive of CP at 2-24 months) 1
  • Score <73 indicates high risk of CP
  • Score <40 indicates abnormal outcome, usually CP
• MRI (86-89% sensitivity) where safe and feasible 1
• Developmental Assessment of Young Children (DAYC) (89% predictive) for motor delay quantification 1

Severity and Topography Assessment

• HINE cutoff scores predict motor severity: 1
  • Scores 50-73: likely unilateral CP (95-99% will walk)
  • Scores <50: likely bilateral CP
  • Scores 40-60: likely GMFCS I-II
  • Scores <40: likely GMFCS III-V
• MRI patterns predict ambulatory status: 1
  • Nonambulant CP more likely with bilateral parenchymal hemorrhages (grade IV), bilateral cystic periventricular leukomalacia (grade III), brain maldevelopment, or basal ganglia injury
  • Ambulant CP more likely with unilateral lesions or noncystic periventricular leukomalacia

Mandatory Comorbidity Screening

Screen systematically for these conditions at initial diagnosis and ongoing surveillance: 1, 2, 3

Neurological

• Epilepsy (affects 35%): standard antiepileptic management 1, 2
• Intellectual disability (affects 49%): cognitive assessment 1, 2

Musculoskeletal

• Hip surveillance: anteroposterior pelvic radiographs every 6-12 months starting at age 12 months (28% develop hip displacement) 1, 2, 4
• Scoliosis and contracture monitoring 1

Sensory

• Vision assessment in first 48 hours of life using early assessment protocols; reassess at 3 months if abnormal (11% have functional blindness) 1, 2, 3
• Hearing screening with standard accommodations (4% have hearing impairment) 1, 2, 3

Pain

• Chronic pain screening at every visit (75% experience chronic pain): may manifest as irritability, sleep disturbance, or behavioral changes 1, 2, 3
• Pharmacological therapy and environmental interventions for ongoing pain 1, 4
• Preemptive analgesia for procedural pain 1

Feeding and Nutrition

• Swallowing safety assessment if pneumonia history exists (aspiration pneumonia is the leading cause of death) 1, 2
• Weight monitoring regularly (severe physical disability elevates malnutrition risk) 1, 4
• Consider tube feeding if swallowing dysfunction confirmed 1

Sleep

• Sleep disorder screening (23% affected): treat before secondary academic and behavioral problems emerge 1, 2
• Management: sleep hygiene, parental education, spasticity management, melatonin (2.5-10 mg), gabapentin (5 mg/kg) 1, 4

Other

• Behavioral disorders (26%): screening and mental health support 1, 2, 4
• Sialorrhea management: botulinum toxin A, benztropine mesylate, or glycopyrrolate 1
• Bladder function: medical investigations (anatomical abnormalities common); standard toilet training over longer duration 1

CP-Specific Early Intervention Strategies

Intervention must begin immediately upon diagnosis or interim high-risk diagnosis to capitalize on neuroplasticity—waiting for definitive diagnosis delays critical developmental windows. 1, 2

Motor and Cognitive Interventions

• For unilateral CP (hemiplegia): Constraint-Induced Movement Therapy (CIMT) or bimanual therapy produces better hand function short-term and substantially better long-term 1
• For bilateral CP (diplegia): Learning Games Curriculum 1
• For all CP subtypes: Goals-Activity-Motor Enrichment (GAME) intervention at home produces better motor and cognitive skills at 1 year than usual care 1
• Use child-initiated movement, task-specific practice, and environmental adaptations 1

Communication Interventions

• Speech language pathology: Hanen "It Takes Two to Talk" and "More Than Words" programs 1
• Alternative and augmentative communication when speech inadequate or impossible 1

Orthopedic Interventions

• Hip surveillance program: prevents displacement, contracture, and scoliosis through regular monitoring and early intervention 1

Critical Clinical Pitfalls to Avoid

Never Assume Static Course

• Any acute neurological deterioration requires urgent neuroimaging to exclude stroke, hemorrhage, spinal cord compression, or hydrocephalus (CP is non-progressive by definition) 3
• Loss of motor milestones suggests neurodegenerative process, not CP 2

Don't Wait for Certainty

• Use interim diagnosis of "high risk of CP" if definitive diagnosis cannot yet be made with certainty—this enables immediate intervention referral 1, 2
• False negatives resulting in late diagnosis and late intervention are detrimental to parents and infants 1
• Parent concern is a valid reason to trigger formal diagnostic investigations and referral 1

Don't Miss Atypical Presentations

• Absence of spasticity does not exclude CP: motor types evolve during first 2 years; dyskinetic (4-7%) and ataxic (4-6%) forms exist without spasticity 1, 3
• Hypotonia (2%) is an underrecognized motor type 1

Communication with Families

• Diagnosis communication should be a series of well-planned conversations (not a single event) as parents experience grief and loss 1
• Early referral fosters acceptance and increases confidence in the medical team 2
• Delaying diagnosis can lead to lasting parental anger and depression 2

Prognosis Counseling

Provide realistic expectations based on evidence: 1, 2

• 2 in 3 individuals will walk
• 3 in 4 will talk
• 1 in 2 will have normal intelligence