Recent studies have provided methods to detect infants and young children with cerebral palsy (CP) early. For infants who are high-risk, such as those born very premature, there are international guidelines to detect CP early using a range of sophisticated assessment tools (magnetic resonance imaging, General Movements Assessment using videos, standardized neurodevelopmental assessments). These tools are being used in Neonatal Follow-up programs that follow high-risk newborns systematically over the first years of life.
Many children with CP are not born early and did not have a high-risk delivery. A different strategy is needed for these children so that we can diagnose CP early. We developed a toolkit to help community physicians detect CP in infants as part of their well-baby care visits.
Early Detection Tools: Prompts for Referral
Clinical features
If “YES” to any ONE of these ATYPICAL SIGNS (if premature, use corrected age), refer to a developmental pediatrician or a child neurologist for diagnostic assessment.
Typical development
Atypical development
Clinical feature
The child consistently demonstrates a hand preference before 12 months of age
Typical development
Atypical development
Clinical feature
The child consistently keeps 1 or 2 hands fisted (closed/clenched) after the age of 4 months
Typical development
Atypical development
Clinical feature
The child demonstrates a persistent head lag beyond 4 months of age
Typical development
Atypical development
Clinical feature
The child demonstrates consistent asymmetry of posture and movements after the age of 4 months
Typical development
Atypical development
Clinical feature
The child is not able to sit without support beyond 9 months of age
Typical development
Atypical development
Clinical feature
The child demonstrates stiffness or tightness in the legs between 6–12 months of age (e.g. unable to bring
their toes to mouth when having their diaper/nappy changed)
Warning signs
If “YES” to EITHER of these signs, monitor and plan for a follow-up visit with your patient rather than immediately refer for diagnostic assessment
The child demonstrates a persistent Moro reflex beyond 6 months of age
The child demonstrates consistent toe-walking or asymmetric-walking beyond 12 months of age
Referral recommendations
When referring to a medical specialist for diagnostic assessment, also refer to:
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All children should be referred to a motor intervention specialist (e.g. pediatric occupational therapist and/or pediatric physical therapist)
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If the child manifests a delay in communication, they should be referred to a speech-language pathologist
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If the child manifests hearing concerns, a referral should be made to an audiologist
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If the child manifests vision difficulties (e.g. not fixating, following, and/or tracking), a referral should be made to an optometrist or an ophthalmologist, and to a functional vision specialist (e.g. occupational therapist with expertise in pediatric vision; early childhood vision consultants)
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If the child manifests feeding difficulties (e.g. poor sucking, swallowing, choking, not gaining weight), a referral should be made to a feeding specialist (e.g. occupational therapist or speech-language pathologist or nutritionist)
Reference PDFs
Overview of the toolkit
- Early identification, leading to timely diagnosis and early rehabilitation interventions are considered best practice for children with cerebral palsy.
- About half of children with CP are either born full term after an uneventful pregnancy and delivery or are born preterm but are more than 29 weeks gestational age; these children don’t usually qualify for Neonatal Follow-up surveillance by specialists, but rather, are followed in their community by community doctors (e.g. pediatricians, family physicians).
- These clinicians are uniquely positioned to identify and refer children suspected of having CP to medical specialists (e.g. child neurologists, developmental pediatricians) for diagnostic assessment and to rehabilitation specialists for intervention.
- However, community physicians often do not have the advanced training in atypical child development that medical specialists receive and may not recognize the early features of CP during their developmental surveillance visits.
- A ‘wait-and-see’ approach to referral for diagnostic assessment has traditionally been favored, and parents have reported dissatisfaction with delays in the diagnostic process.
- With a critical window of optimizing early brain development, using novel medical and rehabilitation interventions, it is essential to
diagnose young children with CP as early as possible. - We have developed tools for community physicians to assist them in the early detection of CP, as part of well-baby care visits
- Identified a knowledge gap in the literature related to age at referral for CP
- Documented population-based evidence on current physician referral practices and identified factors associated with delayed referral2
- Generated the knowledge deemed essential to share with primary care practitioners to enhance their detection efforts3
- Informed and validated the generalizability and appropriateness of these results through consultation with a panel of international experts
This resulted in the establishment of the following:
- 6 clinical features that should prompt referral for diagnostic assessment;
- 2 warning signs that warrant monitoring rather than immediate referral for diagnosis; and
- 5 referral recommendations to other healthcare professionals to occur simultaneously with referral for diagnosis.
Early Detection Tools: Prompts for Referral
- This knowledge is being tailored to the primary care context through collaboration with relevant stakeholders, and will be disseminated in whatever format(s) are determined to be optimal to increase awareness and enhance early detection in the primary care context of children suspected of having CP.
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