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ANALYSIS
Objectives
1. Know the definition of CP.
2. Recognize the classifications of CP.
3. Know the basic therapeutic approach to CP.
Considerations
The spasticity of the baby’s lower extremities described is abnormal and
is sug- gestive of CP. He has gross motor delay. A complete
developmental and neu- rologic assessment is crucial for initiating
therapies that will help him achieve maximal functional outcome.
Although often of low yield, an attempt should be made to identify the
etiology of the child’s CP. Knowing the etiology can aid in developing a
treatment plan, in family planning (especially if the eti- ology is
inherited), and in assuaging parental guilt for this child’s condition.
APPROACH TO
Cerebral Palsy
DEFINITIONS
CEREBRAL PALSY (CP): A disorder of movement and posture that
results from an insult to or anomaly of the immature central nervous
system (CNS). This definition recognizes the central origin of the
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dysfunction, thus distin- guishing it from neuropathies and myopathies.
132 CASE FILES: Pediatrics
CLINICAL APPROACH
With a prevalence of at least 1 to 2 cases per 1000 live births, CP is
the most common childhood movement disorder. Approximately one-
third of CP patients also have seizures, and approximately 60% are
mentally retarded. Deafness, visual impairments, swallowing difficulty
with concomitant aspira- tion, limb sensory impairments, and
behavioral disturbances are common comorbidities. The effect of
aggressive neonatal medical therapies on CP prevalence is unclear;
improved premature infant outcomes may mitigate the impact of
increased survival of very low-birth-weight infants.
Most children with CP have no identifiable risk factors. Current
research indicates that CP most likely is the result of antenatal insults.
Difficulties during the pregnancy, delivery, and the perinatal period are
thought to reflect these insults and are probably not the primary cause
of CP.
Cerebral palsy, or “static” encephalopathy, is the result of a one-time
CNS insult. In contrast, progressive encephalopathies destroy brain function
with time. The term static is misleading, however, because the
manifestations of CP change with age. Contractures and postural
deformities may become more severe with time or may improve with
therapy. Also, a child’s changing developmental stages early in life can
alter the expression of his or her neurologic deficits.
Immaturity of the CNS at birth makes diagnosis of CP nearly
impossible in a neonate. If a CNS insult is suspected, head imaging (by
ultrasound or MRI) can be helpful in recognizing CP early. Possible
imaging findings include periventricular leukomalacia, atrophy, or focal
infarctions. Beyond infancy, CP is suspected when a child fails to meet
anticipated developmental milestones.
Examples of concerning findings are
• A stepping response after age 3 months
• A Moro reflex beyond 6 months
• An asymmetrical tonic neck reflex beyond 6 months
Cerebral palsy can be classified in terms of physiologic,
topographic, or functional categories. Physiologic descriptors identify the
major motor abnor- mality and are divided into pyramidal (spastic) and
extrapyramidal (nonspastic) categories. Extrapyramidal types can be
subdivided further into choreoathetoid, ataxic, dystonic, or rigid types.
The topographic classification categorizes CP types according to
limb involvement. Hemiplegia refers to involvement of a single lateral
side of the body, with greater impairment of the upper extremities than
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the lower extrem- ities. Diplegia describes four-limb involvement, with
greater impairment of the
134 CASE FILES: Pediatrics
Comprehension Questions
ANSWERS
15.1 D. The Apgar score at 1 minute reflects the neonatal environment
immediately prior to birth; the 5-minute score correlates the
infant’s response to resuscitation. The Apgar scores are not an
accurate reflection of morbidity. An examination is a better
indicator of the child’s outcome, but CP cannot be ruled out on the
basis of a normal neonatal physical examination. A discussion of
the events of deliv- ery is best left to the obstetrician; the majority
of difficult deliveries are the result of a previously unidentified
antenatal insult. However, avoidance of the parents will likely only
further their anxiety and may impede your efforts to provide care
for the child.
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Clinical Pearls
Cerebral palsy is a disorder of movement or posture resulting from an insult to, or an anomaly of, the ce
Most children with cerebral palsy have no identifiable risk factors for the disorder.
Optimal treatment plans for cerebral palsy use a multidisciplinary approach.
REFERENCES
American Academy of Pediatrics. Use and abuse of the Apgar score. Available at:
http://www.aap.org.
Johnson MV. Cerebral palsy. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF,
eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: WB Saunders;
2007:2494-2495.
Shapiro BK, Capute AJ. Cerebral palsy. In: McMillan JA, Feigin RD, DeAngelis CD,
Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2006:2251-2258.
Wollack JB, Nichter CA. Cerebral palsy. In: Rudolph CD, Rudolph AM, Hostetter
MK, Lister G, Siegel NJ, eds. Rudolph’s Pediatrics. 21st ed. New York, NY:
McGraw- Hill; 2003:2197-2202.