Paediatric medicine - Cerebral palsy

Diagnosis and management of cerebral palsy, including recognising signs in infants that are suggestive of cerebral palsy and how to monitor these patients for complications.

Cerebral palsy (CP) encompasses a group of neurological disorders characterised by abnormal motor function, such as abnormal tone, posture, and/or movement, resulting from a non-progressive but permanent insult to the developing brain.

In the UK, the prevalence of CP is 3.33 per 1000 live births in the poorest quintile, compared with 2.08 in the most affluent. The prevalence of cerebral palsy in children born at term is fairly static, but its prevalence in those with low birth weight has more recently plateaued.

Due to the increased survival of more preterm and severely affected children, the overall prevalence of cerebral palsy has not changed significantly with time.

Risk factors

Insult to the developing brain could occur at any time in the prenatal, perinatal, or postnatal period (see box below). Around 70-80% of CP is caused by prenatal or perinatal risk factors, and prematurity is the most important risk factor.

Causes/risk factors

Prenatal brain injury

  • Congenital infections (TORCH syndrome [toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex] and HIV)
  • Chorioamnionitis

Perinatal brain injury

  • Birth asphyxia
  • Perinatal arterial and venous stroke
  • Intracranial and intraventricular haemorrhage
  • Kernicterus
  • Birth injury related to prematurity and periventricular leukomalacia
  • Neonatal hypoglycaemia

Brain injury

  • Stroke


The topographical classification of CP depends on the predominant motor abnormality - that is, whether it is spastic, dyskinetic, ataxic, or mixed - and also on whether the distribution of these abnormalities is unilateral or bilateral.

About 85-90% of all CP is spastic and this may be hemiplegic, diplegic, or quadriplegic. Developmental delay, with abnormalities of tone, posture, and/or movement, is the most common presentation. Persistent neonatal reflexes and early hand preference in infancy are very suggestive of CP.

Other features suggestive of spastic CP include brisk tendon reflexes, pyramidal signs, scissoring gait, and toe-walking. More severely affected children may have microcephaly.

The use of functional classification for cerebral palsy is very useful in understanding the level of functional activity and participation.

The gross motor functional classification system (GMFCS) is age dependent and describes five groups from level 1 to level 5, depending on the level of mobility. Similar classification is also available for upper limb function.

Neuroimaging in children with CP is often abnormal and may to help determine the aetiology. MRI is the imaging modality of choice.

Progressive decline, loss of skills, or atypical features, such as dysmorphism, macrocephaly, consanguinity, diurnal variation, or a strong family history, suggest another diagnosis. These children must be investigated for genetic or neurometabolic disorders, as these have implications for treatment and allow genetic counselling about recurrence risk.

The incidence of co-morbidities is high, especially in children with spastic quadriplegia (see box below).



Children with CP affected

Learning difficulties




Visual difficulties


Speech and language problems


Hearing impairment



There is no cure for cerebral palsy. The main goal of treatment is to improve function and maximise developmental potential with physiotherapy, occupational therapy, and medications.

Medications, such as botulinum toxin, baclofen, and diazepam, can be used in conjunction with orthoses for spasticity. Anticholinergic drugs, such as trihexiphenidyl, can be used for dyskinetic CP. Selective dorsal rhizotomy and deep brain stimulation may be beneficial in certain types of cerebral palsy.


In severe spasticity, children develop contractures and can have hip dislocations. An X-ray should be considered for any unexplained pain. Non-ambulatory children with CP should be monitored for osteoporosis and vitamin D deficiency.

Almost half of children have symptomatic epilepsy and this may be refractory to medication. Oromotor dysfunction may lead to feeding difficulties and problems with communication. Constipation is a common symptom and may require regular laxatives.

This population also has psychosocial difficulties, affecting their overall quality of life and participation in society.


Factors affecting prognosis include the type of CP, comorbidities, and the degree of developmental delay. Children with hemiplegic CP with no other deficit almost always walk by 2 years of age, while 50% of those with spastic diplegia walk by the age of 3 years.

Of children with spastic quadriplegia, 25% need help with care and all activities of daily living, and only 33% eventually walk. A child’s motor ability at 2 years of age can be used as a rough guide to future ambulation.

Adult morbidity and mortality from ischemic heart disease, cerebrovascular disease, cancer, and trauma are higher in patients with CP, although this is still debatable as we learn more about long-term survivors.

  • Dr Pinki Munot and Dr Sophia Varadkar are consultant paediatric neurologists at Great Ormond Street Hospital for Children NHS Trust, London

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  1. Wimalasundera N, Stevenson VL. Review: cerebral palsy. Pract Neurol (2016); 0: 1–11. doi:10.1136/practneurol-2015-001184
  2. Russman BS, Ashwal S. Evaluation of the child with cerebral palsy. Semin Pediatr Neurol (2004); 11(1): 47-57.
  3. McManus V, Guillem P, Surman G, Cans C. SCPE work, standardization and definition - an overview of the activities of SCPE: a collaboration of European CP registers. Zhongguo Dang Dai Er Ke Za Zhi (2006 Aug); 8(4): 261-5.
  4. Turk MA. Health, mortality, and wellness issues in adults with cerebral palsy. Dev Med Child Neurol (2009); 51 Suppl 4: 24-9.
  5. Liptak GS, Accardo PJ. Health and social outcomes of children with cerebral palsy. J Pediatr 2004 Aug; 145(2 Suppl): S36-41. Review.

This is an updated version of an article first published in June 2010.

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