Today, I review, link to, and excerpt from The Cribsiders‘ “#141: Cerebral Palsy from Birth to Adolescence – Some CPs (Clinical Pearls) for CP”.*

*Lidsky H, MacCarthy M, Masur S, Chiu C, Berk J. “#141: Cerebral Palsy from Birth to Adolescence: CP (Clinical Pearls) for CP”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ May 7, 2025.

All that follows is from the above resource.

Summary:

Brace yourself! This week, we’re learning about cerebral palsy from Dr. Matthew MacCarthy, who is both a pediatric physical medicine and rehabilitation (PM&R) specialist at Prisma Health in South Carolina AND a person with cerebral palsy. We’re talking NICU, Botox, and puberty, so get ready to stretch your knowledge with a thoughtful approach to CP diagnosis and management.

Cerebral Palsy Pearls

1. Cerebral palsy is an umbrella term for damage to the developing brain that causes a non-progressive disorder of movement and posture. Each patient’s symptoms will be unique.
2. Care is multidisciplinary and includes primary care, PM&R, orthopedics, neurology, PT, OT, SLP, orthotists, and more.
3. Assume people with CP have normal cognition until proven otherwise.

Cerebral Palsy Notes

What is cerebral palsy?

Cerebral palsy is a broad umbrella term and will look different for different people.

Characteristics of CP

1. It is caused by damage to the developing brain, usually in utero or during birth, but definitely within the first 2 years of life.
2. It doesn’t worsen over time (AKA it’s non-progressive).
3. It affects muscle control, movement, and posture.

What types of brain injury can cause CP?

The most common cause is periventricular leukomalacia (damage to brain tissue surrounding the ventricles), typically from intraventricular hemorrhage. Other causes include other forms of neonatal stroke and hypoxic-ischemic encephalopathy (HIE). HIE typically occurs when infants don’t get enough oxygen at some point in the birth process. Infections, like TORCHES infections or chorioamnionitis, can also cause brain injury. Genetic diagnoses are a little more complex. If an infant has a genetic disorder that causes structural brain malformations and results in a non-progressive movement disorder, some clinicians would diagnose CP and others wouldn’t.

Risk factors

Prematurity is a strong risk factor, and risk increases dramatically with decreasing gestational age.

Gestational age	Hazard ratio for development of CP compared to term infants (39-40 weeks)
35-36 weeks	2-3 times more likely
32-24 weeks	6-9 times more likely
28-31 weeks	16-33 times more likely
25-27 weeks	24-54 times more likely
22-24 weeks	47-84 times more likely

 

However, term infants can still develop CP!

Other risk factors include multiple gestation, maternal infection, coagulopathies (either bleeding or clotting disorders), and maternal chronic disease. Lower socioeconomic status has also been shown to be an independent risk factor, although the exact mechanism is unknown.

What are some common symptoms of CP? 

Symptoms are determined by the location and nature of brain injury, and symptoms vary a lot from person to person. According to Dr. MacCarthy, “there are essentially as many manifestations of CP as there are people with it.”

Spastic CP

Spasticity is the most common motor manifestation of CP. Spasticity is a velocity-dependent increase in muscle tone caused by abnormal motor signaling in the brain and spinal cord. It feels like muscle resistance to passive stretch that is continuous (as opposed to clonus, which is rhythmic). Usually spasticity does not cause pain, so only needs to be treated to improve function or ease of care.

Other motor manifestations

• Dystonic – similar to spasticity but fluctuates over time
• Ataxic – issues with muscle control affecting balance
• Choreiform – nonpurposeful dance-like movements
• Athetoid – small amplitude “writing” movements
• Mixed – any combination of the above

Comorbid conditions

• Visual impairment
• Hearing impairment
• Oral-motor impairment, which can affect speech, feeding, and secretion management (e.g. drooling)
• Epilepsy (about 50% of kids with CP also have seizures)
• Chronic pain related to spasticity and/or contractures
• Voiding issues (urinary retention, incontinence, constipation)
• Cognitive impairment (30-40% of all kids with CP have some degree of cognitive impairment, but different prevalences have been associated with different motor symptom patterns)

Expert tip: Dr. MacCarthy points out that cognitive impairment is common, not universal.  Also, it can be challenging to accurately assess cognition in people who have severe motor symptoms and/or speech challenges, so we may be underestimating cognitive function in those patients. Many people with CP have typical cognition, so assume typical cognition until proven otherwise.

How do you diagnose CP? 

Because symptoms of CP may not develop for months after birth, children are typically diagnosed between 6-18 months of age.

Infants at high risk of CP (e.g. micropremies) should ideally already be connected with services to monitor for early signs of CP, like NICU follow up clinics. Diagnosis can be more challenging and happen later in otherwise-healthy term infants.

Early signs

• Hand preference before 18-24 months
• Unusual crawling patterns (scooting with one side, “commando” crawling with arms only)
• Early developmental milestones (i.e. standing at 6 months due to increased muscle tone)

When Dr. MacCarthy is approaching a later diagnosis of CP, he emphasizes a few things.

1. For otherwise healthy term infants, there typically wasn’t a reason to pursue diagnostics until symptoms developed.
2. While the diagnosis of CP may be a new label or framework for understanding symptoms, often the child may already be connected to the right services (e.g. physical therapy).
3. Diagnosing CP later in life typically means that the child is struggling with more advanced milestones, which often means they have a milder form of CP.

Imaging

Order a brain MRI without contrast, which will show damage in over 80% of cases. Head ultrasound can be used in the NICU to look for a more acute injury, like intraventricular hemorrhage, but MRI is best for detecting remote injury.

Multidisciplinary teams for CP

• Physical medicine and rehabilitation (PM&R) often directs management and administers many of the medications to help manage symptoms, like botulinum toxin.
• Neurology helps with symptom management, especially in cases with comorbid epilepsy or other neurologic conditions.
• Orthopedics helps with symptom management, scoliosis monitoring, orthotics, and procedures, like tendon lengthening.
• Neurosurgery is sometimes involved for children who require intrathecal baclofen pumps.
• Developmental/behavioral pediatrics helps with early monitoring for CP symptoms in high-risk babies (i.e. NICU follow-up clinics) and if there are concerns about cognitive impairment requiring neuropsychological testing.
• Orthotists fit and make braces for children.
• Physical therapy helps with development of gross motor skills and mobility.
• Occupational therapy helps with development of fine motor skills and everyday-life skills (bathing, dressing).
• Speech-language pathology helps with speech, communication, and swallowing.

How do we treat CP?

Medications

Botulinum toxin

Botulinum toxin (one brand name is Botox) causes local neuromuscular blockade by inhibiting the protein complex that facilitates presynaptic fusion of acetylcholine vesicles. It works well for focal spasticity and has no systemic side effects.

Botulinum toxin is dosed up to every 3 months. While its effects may wear off before 3 months, more frequent treatments are associated with antibody formation.

Botulinum toxin can be used in combination with orthotics to help relax a muscle before bracing it in a stretched position.

Baclofen

Baclofen is best for widespread spasticity. The downside of an enteral medication is the systemic side effects, including sedation, worsening central hypotonia, and theoretically lowering seizure threshold (so check with their neurologist if the patient has epilepsy).

Baclofen dosing varies. Dr. MacCarthy typically starts with 0.25 mg/kg given at bedtime for 1 week, then 0.5 mg/kg per day divided into two doses for 1 week. He’ll then increase the dose by approximately 50% of the starting dose per week until symptoms are controlled. A typical therapeutic dose is somewhere around 1-2 mg/kg per day divided into two or three doses. The maximum dose is limited by side effects, mostly sedation.

Intrathecal pumps

If local or enteral medications aren’t sufficient for symptom control, neurosurgery can sometimes place an intrathecal baclofen pump to deliver baclofen directly into the CNS. This is a very specialized procedure that requires very careful patient selection.

Benzodiazepines

Benzodiazepines can be used as an alternative to baclofen in children with epilepsy. Dr. MacCarthy typically doesn’t combine with baclofen due to high chance of sedation.

Orthotics/Braces

Many children with CP benefit from orthotics or braces (those terms are interchangeable) to help stretch areas of spasticity and improve range of motion. Specific orthotics vary based on the child and the affected muscles.

How do we support kids with CP?

Dr. MacCarthy’s step-by-step approach to curious peers

1. Make sure kids have at least one friend! Ask them what barriers they’re experiencing in forming friendships.
2. Talk about how to talk about their diagnosis in an age-appropriate way, like “My brain doesn’t talk to my muscles, so I move differently.”
3. Frame their differences as a positive. Kids love the idea of being a cyborg or having superpowers.

Puberty

Barring any pituitary issues, CP shouldn’t affect pubertal development. You should talk with adolescents with CP about puberty, relationships, and sex, and general anticipatory guidance is usually appropriate. 

Providers often incorrectly assume that people with cerebral palsy (or other disabilities) don’t have romantic or sexual relationships. People with cerebral palsy are also at increased risk of experiencing sexual dysfunction or interpersonal or sexual violence, which makes counseling about healthy relationships even more important.

Transition to adult care

In Dr. MacCarthy’s experience, many adult providers aren’t as familiar with CP and adult care can be more fragmented. He recommends starting the process of transitioning to adult care early. There’s still lots of work to do to spread awareness about CP within internal medicine!

Expert recommendations

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy: A comprehensive systematic review that assesses evidence for all CP treatment modalities.

American Academy of Cerebral Palsy and Developmental Medicine annual conference: A multidisciplinary event great for people interested in learning more about CP.