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Ongoing AssessmentOverviewEvery child with CP should have routine well-child visits and most will benefit from additional routine visits for chronic care assessment and management. See Parent Concerns Questionnaire - CP.Diagnostic CriteriaBasic diagnostic criteria include the presence of a non-progressive neurologic deficit secondary to a brain maldevelopment or injury to the developing brain.Pearls And AlertsBecause new causes for apparent CP are being recognized, [Hoon: 1997] the diagnosis of CP should be reaffirmed mentally at every visit in any child with CP but without an obvious historical cause, even in older children. If there is any question about the diagnosis, the child should be referred to neurology or genetics. History And ExaminationQuestions regarding interim history are organized by system for completeness.
Interim HistoryMobility: Does the child have age appropriate mobility (rolling, crawling, walking)? Have they made progress in activities of daily living? Any changes in the therapies the child is receiving? Any changes in spasticity treatments, equipment, orthopedic surgeries, contractures, stander? Any change in exercise tolerance?Growth and nutrition: Is nutritional status or growth a concern? See Nutrition and growth in children with CP. Is the child fed orally or by feeding tube? (See Feeding tube issues (general)). Is the child receiving any therapy to improve oral feeding skills? What is the child's usual calcium intake? GI: New or ongoing issues with constipation? Is he/she toilet trained? Also see Constipation treatment (general) and Toilet Training (general). Problems with gastroesophageal reflux? Swallowing and drooling: Does the child cough and/or choke during eating and drinking? How long does it take for the child to eat or be fed? Is swallowing or drooling a problem? Pulmonary: Are there respiratory concerns? Has the child had pneumonia? Does the child have difficulty sleeping? Frequent snoring? Neurology: Has there been developmental regression Has the child had seizures or concerning episodes? See the Seizure module for more information. Does the child have a ventriculo-peritoneal shunt in place? Any signs of shunt malfunction (e.g., headache, mood or activity change, emesis)? Sleep Problems: Ask about sleeping problems. Does the child snore? Does the child have excessive daytime sleepiness? Musculoskeletal/Bone: Has the child had fractures? Fractures without clinical explanation prompt concerns for osteopenia/osteoporosis, especially in the child on antiepileptic medications, or abuse. Do they have a standing program? Are joint contractures limiting mobility? Urinary: Does the child have urinary frequency, urgency, or dribbling? Is he/she toilet trained? Also see Neurogenic Bladder (general). Other: Is there evidence of chronic pain? Developmental and Educational ProgressWhat are the child's abilities? At what age level does the child understand language? Parents' estimate of the child's mental age? How does the child communicate (e.g., differential cries, eye gaze, verbal, signing, augmentative device). Describe the child's early intervention or school program. Are there new concerns about school or early intervention?Social and Family FunctioningHow is the family coping? Are there siblings of the child with CP? Is the child functioning well at school? Does the child have recreational activities and opportunities for friendships? Are there behavioral problems or depression? Is the family accessing available financial resources? Respite? What about the extended family?Physical ExamGeneralFollow general appearance and interaction of the child with the environment. Mobility aids, hearing aids, glasses? General appearance of head, shunt palpable? Nutritional status?Growth ParametersHeight | weight | head circumference (HC) Children who were born prematurely may need to be followed on preterm growth charts; if standard growth charts are used, prematurity should be corrected for until 18-24 months of age.Weight should be followed for obesity or, more likely, malnutrition. See Nutrition and growth in children with CP. Children who have low weight, height and head circumference for age may have an underlying genetic syndrome. HC is particularly important to track; a HC crossing percentile lines in the upward direction may signal hydrocephalus whereas a HC crossing percentile lines in the downward direction may reflect microcephaly. Neurologic ExamWatch for new focal findings that might signify a progressive course and for signs of increasing spasticity or dystonia that might need new therapeutic interventions.MusculoskeletalCheck for scoliosis and joint contractures. See Musculoskeletal Assessment in the Primary Care Setting.HEENTCheck for strabismus, dental problems, drooling, and swallowing problems. Middle ear fluid should be treated aggressively as it might contribute to hearing loss.SkinLook for pressure sores in children with decreased mobility, including under ankle-foot orthotics.TestingSensory TestingChildren with CP frequently have problems with vision and hearing and need regular screening.Imaging and EEGMRI should be considered if there is a change in the child's clinical course. EEG is only necessary if seizures are clinically suspected.Genetic TestingIf suspicion arises about a genetic etiology for a child's CP, either directed genetic testing or a referral to genetics should be considered.Other TestingModified barium swallow (sometimes called a cookie swallow or video swallow) - performed in collaboration with a speech therapist to assess swallowing function and whether the child is aspirating.DEXA scan - consider if bones look hypodense on X-ray, if the child is non-mobile, on antiepileptic medication, or has a history of fractures. If osteoporosis is confirmed, further evaluation should focus on diet and vitamin adequacy, weight-bearing potential (ie., standing program), and exclusion of other potential causes of osteoporosis. DEXA scans are of limited value before age three years due to lack of normative data. Sleep study - A sleep study should be considered if the child has difficulty sleeping, disrupted sleep, or signs of obstructive sleep apnea (e.g., snoring, day time sleepiness, etc). Subspecialist EvaluationsChildren with CP often need access to a number of subspecialists. The Medical Home should be the initiator and coordinator of these referrals with input from the family. The goal is to have the child see needed subspecialists and to avoid duplication of services or unnecessary appointments. Developmental Pediatrics (see Services below for relevant providers)Developmental pediatric specialists provide neurodevelopmental consultation for the ongoing evaluation of children with CP. Pediatric Neurology (see Services below for relevant providers)Neurology should evaluate the child's clinical status yearly, or more often if indicated. A neurology consultant can offer expertise in management of seizure disorder or evaluation of new neurological changes. A child with ataxia should be followed closely by neurology to watch for progression. Pediatric Physical Medicine & Rehab (see Services below for relevant providers)Pediatric physiatry will assist in improving functional quality of life using assistive devices, medications, and guiding physical, occupational, and speech therapy. Pediatric Neurosurgery (see Services below for relevant providers)Neurosurgery should follow children with ventriculo-peritoneal shunts approximately yearly, with additional visits as needed for shunt problems. Pediatric Orthopedics (see Services below for relevant providers)Most children with CP and significant tonal abnormalities should be followed by an orthopedic specialist to monitor for contractures, scoliosis, hip subluxation, and to guide interventions to optimize gait efficiency. Pediatric Gastroenterology (see Services below for relevant providers)Children with difficulty gaining weight, feeding problems, GERD, and severe constipation may need referral to gastroenterology. General Pediatric Surgery (see Services below for relevant providers)Referral may be indicated for placement of a feeding tube. Pediatric Dentistry (see Services below for relevant providers)Children with CP should be seen by pediatric dentists if possible as they may be more prone to caries and may need anesthesia for some dental procedures. Caries may lead to food refusal and systemic disease if untreated. Pediatric Otolaryngology (see Services below for relevant providers)To evaluate and treat drooling and swallowing difficulties as well as to consider PE tubes, if there are frequent ear infections, to optimize hearing. Pediatric Pulmonology (see Services below for relevant providers)To assess difficulties the child may be having with cough, breathing during sleep, frequent respiratory infections. Pediatric Ophthalmology (see Services below for relevant providers)Children with CP may need ongoing care by a pediatric ophthalmologist if they have strabismus, acuity loss, or cortical visual impairment. ResourcesPractice GuidelinesGuidelines from the American Academy of Pediatrics, the American Academy of Neurology, and the Child Neurology Society for
the assessment of the child with cerebral palsy.
Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M, Stevenson R. ToolsMusculoskeletal Assessment in the Primary Care Setting Parent Concerns Questionnaire - CP ServicesPediatric GastroenterologySee all Pediatric Gastroenterology services providers (2) in our database. Pediatric NeurologyPediatric Neurology,
more info...
See all Pediatric Neurology services providers (2) in our database. Pediatric Physical Medicine & RehabPrimary Children's Rehabilitation Salt Lake,
more info...
See all Pediatric Physical Medicine & Rehab services providers (2) in our database. For other services related to this condition, browse our Services categories or search our database. Page BibliographyHoon AH Jr, Reinhardt EM, Kelley RI, Breiter SN, Morton DH, Naidu SB, Johnston MV. |
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