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Panel Advises Early Intervention for Young Kids With Cerebral Palsy

Young children with cerebral palsy or an interim clinical diagnosis of high risk for the disease should be immediately referred for disease-specific and age-specific interventions, according to new international clinical guidelines.

The recommendations apply primarily to children ages 0 to 2 years who are at high risk or have a diagnosis of cerebral palsy, as defined by the 2017 diagnostic international guideline. High risk for the disease was described as evidence of motor dysfunction plus at least one of two additional criteria, namely abnormal neuroimaging or a clinical history indicating a risk for cerebral palsy, noted Iona Novak, PhD, of the University of Sydney in Australia, and co-authors.

“Infants and children have remarkable brain plasticity and aptitude for learning; taking advantage of this window of opportunity with evidence-based intervention for those with early brain injury maximizes functional outcomes and minimizes complications,” they wrote in JAMA Pediatrics.

“Early recognition of cerebral palsy will reduce parental concerns and stress and will ultimately improve the family literacy and the child’s outcome overall,” wrote Abdellah Tebani, PharmD, PhD, and Stéphane Marret, MD, PhD, of Université de Rouen Normandie in France, in an accompanying editorial. “The earlier we intervene, the better the outcome is.”

To develop the guidelines, the authors systematically reviewed best available evidence on cerebral palsy-specific early interventions across nine domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

For the nine domains, 16 systematic reviews and 25 randomized trials met inclusion criteria. The review identified good-quality evidence for parental involvement in intervention programs, as well as task- and context-specific interventions aimed at improving motor and cognitive outcomes in children with cerebral palsy; evidence in other developmental domains was not of high quality, and conditional recommendations were based on other high-risk populations, Novak and team noted.

The panel strongly recommended a comprehensive multidisciplinary approach to care for children, including early screening for comorbidities, since feeding and sleep disorders may be associated with pain, low caloric fuel, and irritability that interferes with development of motor and cognitive skills. “Anticipating secondary impairments enables timely access to interventions, which requires intentional communication among professionals,” they wrote.

To promote eating and drinking in infants and children with dysphagia, evidence supports the use of softer food consistencies and upright supported positioning, they said.

Sleep disorders are five times more likely to affect children with cerebral palsy than children developing typically, and can negatively affect quality of life for the whole family, the team noted.

Clinicians should identify and treat the cause of the disturbance, and educate parents on interventions to establish good sleep hygiene and on training circadian mechanisms, such as a structured bedtime routine that avoids stimulating activities.

Notably, caregiver-provided interventions to promote sleep for children younger than 2 years were ranked by parents of children with cerebral palsy as the most preferable interventions.

Additionally, up to 70% of children with cerebral palsy are affected by some cerebral visual impairment, although it is not often diagnosed in children younger than 2 years. “Early commencement of visual training is recommended to improve attention to visual stimuli and the use of available visual functions,” the authors wrote. “Within the context of parent-child interactions and goal-oriented play, the social and physical environment should be visually adapted to meet the child’s needs.”

Novak and colleagues also recommended that clinicians support parents and caregivers through coaching and education. Parental participation is crucial, given the frequent practice required for skilled movement and functional independence.

Additionally, task- and context-specific goals should be set at appropriate levels, and updated when challenges are met. “Parents’ goals and aspirations must be central to the intervention,” the authors wrote.

Mental health interventions, including those based in cognitive behavioral therapy, were advised for parents and caregivers experiencing stress, anxiety, depression, or trauma. Other conditional recommendations for parent support included attachment support and coaching, musical therapy and interactions, and support to carry out skin-to-skin kangaroo care for preterm/low-birth-weight infants.

“Evidence-based and empathic communication with parents is necessary as new issues and concerns are raised, empowering parents to seek help,” Novak and co-authors noted. “Supporting parents and their relationship with their child is fundamental to comprehensive early intervention; however, it is not always prioritized.”

Disclosures

Novak had no disclosures to report.

Morgan reported grants from the National Health and Medical Research Council during the conduct of the study, and is a trust-certified tutor with General Movements outside the submitted work. Other co-authors also reported grants, consultancy fees, and a patent for provisional application licensed to Enlighten Mobility outside the submitted work.

Tebani and Marret had no disclosures to report.

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