The Importance of Diagnosing Cerebral Palsy Early
It is very important to diagnose cerebral palsy (CP) as soon as possible because early treatment leads to better outcomes in children. In fact, identifying brain damage soon after birth is crucial because there are treatments that can prevent the brain damage from causing cerebral palsy.
Cerebral palsy is a group of disorders that cause a child to have problems with motor skills. This affects movement, posture, coordination and balance, and it sometimes leads to a child spending most of her time in a wheelchair. Cerebral palsy is caused by an injury to the brain while it is still developing, which means a child can get CP until approximately 3 years of age. Sometimes, however, a child is not diagnosed with cerebral palsy until 4 or 5 years of age, when certain developmental milestones are missed.
Before discussing developmental milestones, we’ll examine the early signs of cerebral palsy, including signs noticed at the hospital.
Which Tests Are Used for Diagnosing Cerebral Palsy?
Recognizing cerebral palsy at young age can be a challenge. However, there are some procedures that can help the medical team identify this type of disability. Tests include:
- Blood test
- Vision testing
All babies and children should have a detailed history taken and a thorough physical exam performed by the physician. The brain injury that causes cerebral palsy is a static one (although the initial injury will evolve), meaning it won’t change over time. When a child is suspected of having brain damage, repeated examinations are usually required to determine if the condition is static or progressive. Another reason it is important for the physician to take a detailed history, perform a thorough exam and do proper testing is because it is not only important to determine if the child has cerebral palsy, but also to classify which type of cerebral palsy the child has (spastic, ataxic, dyskinetic, etc.).
Magnetic resonance imaging (MRI) is a test that uses a magnetic field and pulses of radio wave energy to make pictures of the brain. MRI often gives different information about structures in the brain than can be seen with an X-ray, ultrasound, or computed tomography (CT) scan. MRI can also show problems that cannot be seen with other imaging methods.
MRI of the baby’s brain can identify a brain injury, such as a lesion in the brain, in the majority of cases of cerebral palsy. In addition, MRI may provide information regarding the timing of the brain insult. MRI abnormalities in babies with cerebral palsy include hypoxic ischemic lesions, such as those associated with hypoxic ischemic encephalopathy (HIE) and periventricular leukomalacia (PVL). MRI gives such important information about the brain that clinicians should make every effort to have this test performed on the baby, in most cases.
A computed tomography (CT) scan uses X-rays to make detailed pictures of structures inside the brain. Typically, exposure to radiation should be avoided or minimized in babies. While CT scans can identify brain abnormalities in many babies and children with cerebral palsy, MRI is preferred because it has a better capacity for detecting brain injury. Furthermore, research shows that MRI is much better at helping to detect the timing of the insult that caused the cerebral palsy, and it is better at helping to determine the actual cause of the cerebral palsy.
Screening for Problems Associated with Cerebral Palsy
Screening for intellectual disability, eye and hearing problems, speech and language disorders, and disorders of mouth muscle function must be performed as part of the initial assessment for cerebral palsy because these problems are commonly associated with cerebral palsy.
An electroencephalogram (EEG) must be performed when there are features that suggest the child has a seizure disorder, such as epilepsy. The reason for this is because seizures occur in at least a third of children who have cerebral palsy. Epilepsy and seizure disorders must be promptly diagnosed and treated because seizures can worsen brain damage, which can cause the cerebral palsy to be more severe. Furthermore, seizure activity can cause additional brain injuries.
Screening for Blood Clotting Problems
Some children with hemiplegic cerebral palsy or MRI findings that show cerebral infarction (brain tissue death caused by restricted blood flow/oxygen deprivation) may have a blood clotting disorder called prothrombotic coagulation disorder. It is standard practice to screen for coagulation abnormalities in children suspected of having cerebral palsy so that this disorder can be properly managed. Children with hemiparesis, which is less severe than hemiplegia, should be tested for HIE.
In babies who are developing normally, most developmental reflexes pertaining to posture disappear when the baby is between 3 and 6 months of age. These reflexes do not properly function or properly disappear when a child has cerebral palsy. Therefore, delay in the disappearance of a developmental reflex may be an early indication of cerebral palsy, and an exaggeration of a developmental reflex is also an early sign of CP.
Testing the tonic labyrinthine reflex (TLR) is very important. The TLR is a primitive reflex found in newborns. With this reflex, tilting the head back while lying on the back (supine) causes the back to stiffen and arch backwards, the legs to straighten, stiffen and push together, the toes to point, the arms to bend at the elbows and wrists, and the hands to become fisted or the fingers to curl. The presence of the TLR past the first 6 months of life may indicate that the child has cerebral palsy. In children with CP, the TLR may even be more pronounced.
A diagnosis of cerebral palsy involves assessment by medical and therapeutic specialists from a variety of fields. The most commonly consulted specialists include pediatric neurologists, developmental specialists, neuroradiologists, orthopedic surgeons, and ophthalmologists. It is crucial that cerebral palsy be diagnosed as soon as possible so that treatment and therapy can begin. Research shows that aggressive and consistent treatment and therapy are associated with better long-term outcomes.
Missed Developmental Milestones Are a Common Diagnostic Tool
Impairments caused by cerebral palsy range in severity, usually in relation to the amount of injury to the brain. The most common early signs of cerebral palsy are developmental delays. A parent should be concerned if the child is delayed in reaching key growth milestones, such as rolling over, crawling, sitting and walking. The physician will look for signs such as abnormal muscle tone, unusual posture, persistent infant reflexes (such as looking for a nipple), and early development of a hand preference. Spastic cerebral palsy may not be diagnosed until the baby is 6 months of age, and dyskinetic cerebral palsy is typically not apparent until the child is 18 months old. Ataxic cerebral palsy may take even longer to diagnose.
The primary problems caused by cerebral palsy is impairment of muscle tone, gross and fine motor functions, balance, control, posture and reflexes. A baby can have problems with his or her face and mouth muscles, so parents may notice that the baby has problems swallowing and feeding, as well as poor muscle tone in the face.
Some of the earliest specific signs of cerebral palsy in a baby include the following:
- The baby’s head lags when they are picked up while lying on their back
- When he or she is picked up, his or her legs get stiff and cross like scissors
- The baby is irritable, has difficulty sleeping, and is difficult to handle or cuddle
- The baby has poor visual attention and may be overly docile (body doesn’t appropriately tense or stiff)
- The baby has difficulty feeding and frequently vomits
- The baby doesn’t roll over in either direction
- The baby feels either really stiff or floppy, or has shaky arms and legs
- The baby reaches out with one hand only, while keeping the other one in a fist, or keeps both hands in fists continuously
- The baby cannot birng his or her hands together
- The baby is not able to push up with their hands while lying on their stomach
- The baby has difficulty bringing their hands to their mouth
- The baby’s crawling is lopsided; they push off with one hand and leg while dragging the opposite hand and leg
- The baby is not able to sit independently
- The baby is unable to stand while holding onto support
General signs of cerebral palsy in babies and young children include the following:
- The baby’s primitive reflexes, such as rooting, may continue well past the age in which they should stop
- The baby or child is stiff and has increased reflexes and clonus, which is involuntary, rhythmic, muscular contractions and relaxations; it is a series of very quick movements (bending and straightening) of the arm or leg
- The baby’s postural reactions may be delayed. Postural reactions are motor skills that develop during the first year of life and form the basis of functional motor skills. These reactions automatically maintain the body in an upright position through changes in muscle tone, in response to the position of the body and its parts
The three types of postural reactions are:
- Righting reactions, which maintain the head in alignment with the body, and maintain upper body alignment with the lower body.
- Equilibrium reactions, which are reactive reactions that return the body to a vertical position after displacement.
- Protective reactions, which are reactive and protect the body from falling if the body has been displaced beyond a certain point–beyond the point whereby postural correction can bring the body back to a vertical position.
- The tone in extremities may be very stiff
- The baby has abnormal mouth and tongue patterns, such as retracting and thrusting the tongue, biting really hard and not letting go, an overly sensitive mouth, and frequent grimacing
Signs of cerebral palsy are usually noticed by parents first. In fact, 70-80% of all disabilities in children are initially noticed by parents. Nonetheless, physicians must do regular examinations of all babies and young children. In addition, if there is any suspicion that a baby’s brain suffered an oxygen depriving insult, which can be caused by umbilical cord, placenta or uterine problems, as well as brain bleeds, an MRI should be performed soon after birth to assess any potential brain damage, and MRI scans must be performed at regular intervals thereafter so physicians can see the brain injury as it evolves.
A cerebral palsy diagnosis is sometimes difficult to make since there is no single test that confirms or rules it out. In the most severe cases, early signs of brain damage are apparent and a diagnosis can be made. However, in mild to moderate cases, a diagnosis may not be made until the child’s brain is fully developed.
Detecting Brain Injuries Helps with Diagnosing Cerebral Palsy
Hypothermia (brain cooling) treatment is an incredible therapy that halts almost every injurious process associated with hypoxic ischemic encephalopathy (HIE). Research shows that hypothermia treatment decreases the likelihood that HIE will cause death or cerebral palsy in a baby, and it can decrease the severity of the CP. This treatment must be given within 6 hours of the insult that caused the HIE, which often means it should be started 6 hours after birth.
Postponement of hypothermia treatment should not occur while assessment for brain injury is taking place. Most hospitals have a quick method of determining if a child has HIE and qualifies for hypothermia treatment.
Brain injuries must also be diagnosed early because brain injury is a progression. If intracranial pressure, brain bleeds and brain swelling are not recognized and properly managed, the brain injury can become a lot worse than it otherwise would have been. Sometimes the medical team uses the ventilator (breathing machine) to help control the intracranial pressure. But this can actually cause overventilation injuries due to carbon dioxide levels that are too low for too long. Overventilation injuries can cause brain damage. Thus, all factors must be considered in managing a baby with a brain injury. The key is to minimize further brain injury, and this includes recognition and treatment of seizure activity.
Research Update: Signs of Cerebral Palsy Emerge Around Six Months of Corrected Age
Children are often not diagnosed with cerebral palsy until about one to two years of age, when it becomes clear that they are missing milestones. However, research by Novak et al. (2017), published in JAMA Pediatrics, suggests that it is possible to diagnose cerebral palsy before six months corrected age. Corrected age takes into account an infant’s due date; if they were born early, the number of months they were premature is subtracted from their age. For example, if an infant is seven months old but was born two months prematurely, the corrected age would be five months.
Novak et al. did a literature review of published papers on cerebral palsy, and concluded that the following tools are especially useful in early diagnosis and risk assessment:
- Neonatal MRI
- Prechtl Qualitative Assessment of General Movements
- Hammersmith Infant Neurological Examination
- Developmental Assessment of Young Children
In certain cases, making an absolute diagnosis at such a young age may not be feasible. However, the authors stress that the ability to identify infants in a high-risk category is extremely beneficial because they may be given certain forms of early intervention that can optimize cognitive and motor abilities and prevent secondary complications from developing.
Legal Help for Children with Seizures, Hypoxic Ischemic Encephalopathy (HIE) and Cerebral Palsy
If your child has seizures, hypoxic ischemic encephalopathy (HIE) and/or cerebral palsy, contact the award winning birth injury lawyers at Reiter & Walsh ABC Law Centers. Reiter & Walsh is a national birth injury law firm that has been helping children for decades. Attorney Jesse Reiter, president of the firm, has been focusing solely on birth injury cases for over 28 years, and most of his cases involve hypoxic ischemic encephalopathy (HIE) and cerebral palsy.
Jesse is currently recognized as one of the best medical malpractice attorneys in America by U.S. News and World Report 2014, which also recognized ABC Law Centers as one of the best medical malpractice law firms in the nation. The lawyers at ABC Law Centers have won numerous awards for their advocacy of children and are members of the Birth Trauma Litigation Group (BTLG) and the Michigan Association for Justice (MAJ).
The nationally recognized birth injury lawyers at Reiter & Walsh have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and they give personal attention to each child and family they represent. The award winning firm has numerous multi-million dollar verdicts and settlements that attest to its success and no fees are ever paid to the firm until your case is won. Email or call Reiter & Walsh ABC Law Centers at 888-419-2229 for a free case evaluation. The firm’s award winning lawyers are available 24 / 7 to speak with you.