Please reply to the following discussion with one reference. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite resources in your responses to other classmates.  

KN Discussion:

 What is the most likely diagnosis? Why?

Cerebral palsy (CP) is a congenital disorder of movement, muscle tone, or posture (Bunik et al., 2020). The common symptoms are hyper reflexes, floppy or rigid limbs, and involuntary movement. (Garfinkle et al., 2020). Usually, first manifestations are recognized by early childhood; however, in some cases, the condition may be disguised until 3-4 years of age (Garfinkle et al., 2020).  According to Bunik et al. (2020), the term CP has a wide spectrum of clinical symptoms, and can be described as a nonprogressive, chronic, static impairment of muscle tone, strength, coordination, or movements. It typically originates from some cerebral insult or injury in the perinatal period. Spastic CP is the most common form of CP accounting for 75% of all cases (Bunik et al., 2020). In this case, the patient is highly suspicious for paraplegic CP – both legs affected with arms functioning normally (Garfinkle et al., 2020).

• What would be three differentials in this case? Why?

To begin, it is important to differentiate central from peripheral disorders. CP is always a disorder of the central nervous system (Garfinkle et al., 2020). Several other conditions present with similar symptoms of motor impairment. Some to name are fetal alcohol syndrome, hydrocephalus, tumors, agenesis of the corpus callosum or other brain malformations, Tay-Sachs disease, phenylketonuria, Lesch-Nyhan syndrome, spinal cord injury, hypothyroidism, seizures, and many genetic and metabolic disorders (Bunik et al., 2020). For initial assessment, I would select the following differential diagnoses:

1. Unspecified lack of expected normal physiological development in childhood. R62. 50 
2. Specific developmental disorder of motor function F82
3. Hydrocephalus, unspecified G91. 9

• What developmental milestones are expected at this age?

These are the physical and mental milestones a provider should expect in 11 months old baby (Sheldrick et al., 2019):

Motor function:

• Crawls
• Stands up unassisted
• Walks and/or takes steps
• Points or goes for items they want
• Grabs finger foods and feeds themselves
• Babbles and imitates words
• Waves “bye-bye”
• Starts to say simple words like “Mama” and “Dada”
• “Scooches” butt
• Rolls from back to front and front to back
• Can stack play items, cups, or bowls

Cognitive function:

• Sees colors well now
• Develops specific preferences for tastes and textures
• Shows curiosity and explores how things work
• Expresses separation anxiety
• Shows personality traits
• Attaches meaning to words, like going to get shoes when you say you’re going “bye-bye”
• Understands simple one-word phrases or requests
• Loves music and dancing
• Mimics animal sounds
• What do you believe is your best course of action/treatment plan for this appointment? Why?

CP is a complex disease that requires multidisciplinary team involvement (Bunik et al., 2020). First and foremost, the diagnosis must be confirmed prior to treatment initiation. Therefore, a referral to a pediatric neurologist with additional diagnostic is granted at this point of care.  If the diagnosis is confirmed, a care plan should be guided with accounting for specific patient clinical manifestation and may involve gastroenterology, orthopedics, neurology, pathology, physical and occupational therapy, psychology, and social work (Patel et al., 2020).  Care may also involve an ophthalmologist, feeding clinic and nutritionist services, and genetic counseling (Garfinkle et al., 2020).

It is imperative to educate caregivers on CP. The key point is that CP is nonprogressive, but requires intervention nevertheless (Garfinkle et al., 2020). Lack of appropriate management may result in progressive worsening of motor function (Garfinkle et al., 2020). Research shows that children who receive special services—physical therapy, occupational therapy, speech therapy, and other interventions—have better outcomes than children who do not, and early intervention typically leads to better outcomes (Patel et al., 2020). Support groups or opportunities to meet other families with affected children are often helpful (Patel et al., 2020).  A social worker can be instrumental in coping with complex health problems and utilization of available resources (Bunik et al., 2020). Many patients are eligible for Supplemental Security Income or state program benefits for the severely handicapped (Bunik et al., 2020).

References

Bunik, W.H.L. A. (2020). CURRENT Diagnosis and Treatment Pediatrics (25th Edition). McGraw-Hill Learning Solutions. https://digitalbookshelf.southuniversity.edu/books/9781264258390

Garfinkle, J., Li, P., Boychuck, Z., Bussières, A., & Majnemer, A. (2020). Early clinical features of cerebral palsy in children without perinatal risk factors: a scoping review. Pediatric neurology, 102, 56-61.

Goolsby, M. J., & Grubbs, L. (2018). Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses (4th Edition). F. A. Davis Company. https://digitalbookshelf.southuniversity.edu/books/9780803695443

Patel, D. R., Neelakantan, M., Pandher, K., & Merrick, J. (2020). Cerebral palsy in children: a clinical overview. Translational pediatrics, 9(Suppl 1), S125.

Sheldrick, R. C., Schlichting, L. E., Berger, B., Clyne, A., Ni, P., Perrin, E. C., & Vivier, P. M. (2019). Establishing new norms for developmental milestones. Pediatrics, 144(6).