PEARLS OR PERILS

1. Although prematurity is a major risk factor for CP, most children with CP were not premature infants.

2. Hand preference prior to the age of 18 months may be an indication of hemiparetic CP.

3. Additional workup for an etiology other than CP should be undertaken in any child who has lost developmental milestones.

4. Sensory impairments, especially in hemiparesis, can be an important contributing factor to decreased functional hand use.

5. Children with severe motor impairments related to CP can have normal cognition.

6. Periods of rapid growth in children with CP may be associated with worsening contractures because spastic muscles fail to grow as quickly as bones.

7. Children who have a sudden increase in spastic­ity should be evaluated for constipation, urinary tract infection, esophagitis, musculoskeletal pain, or other potential sources of noxious stimulation.

8. Oral baclofen should be titrated up slowly to min­imize sedation and titrated off slowly to minimize the likelihood of withdrawal symptoms, including increased tone and seizures.

9. When evaluating toe walking due to equinus, always evaluate and address spasticity and con­tractures of more proximal muscles, in particular, the iliopsoas and the hamstrings.

10. Not all children who walk on their toes have CP. Toe walking can also be idiopathic or due to proximal muscle weakness, as is the case with Duchenne muscular dystrophy.

11. Children with CP who sit independently by age 2 years are likely to be functional ambulators, while those who fail to walk by age 4 years are unlikely to be a functional ambulatory (223).

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