Early targeted intervention 'critical' for improving outcomes in cerebral palsy
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Early intervention for children with or at high risk for cerebral palsy should begin “as soon as possible” in order to build on “a critical developmental time,” according to results of a systematic review published in JAMA Pediatrics.
Researchers conducted the review to develop clinical guidelines for early intervention among children at high risk for cerebral palsy (CP) and their families.
“These guideline recommendations apply to children aged 0 to 2 years who are at high risk [for] or have a diagnosis of CP, as defined in the 2017 diagnostic international guideline, but not infants born preterm without identifiable brain injury, since many of these infants will not have CP,” Catherine Morgan, PhD, a research fellow at the Cerebral Palsy Alliance Research Institute in Australia, and colleagues wrote. “To assign the interim clinical diagnosis of high risk [for] CP, the infant must have motor dysfunction (an essential criterion) and at least [one] of [two] additional criteria, namely abnormal neuroimaging or a clinical history indicating a risk for CP. We refer readers to the 2017 guideline for more detailed information regarding early and accurate diagnosis of CP.”
Specifically, the researchers searched six databases for “the best available evidence” regarding early interventions tailored for CP across nine domains related to motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health and parental support among children aged 0 to 2 years at high risk for or with CP. They included 16 systematic reviews and 27 randomized clinical trials.
Results showed support for three best-practice principles related to the nine domains:
- immediate referral for intervention following a diagnosis of, or high risk for, CP;
- building parental capacity for attachment; and
- parental goal-setting at intervention’s start.
The strongest evidence supported 28 recommendations, of which 24 were for and four were against, related to the nine domains, with the most recommendations in the domains of sleep and communication at seven each and the fewest in the domain of muscle tone at one. For sleep, the researchers recommended implementation of sleep hygiene, such as structuring a bedtime routine in a dark and quiet environment, among children with or at high risk for CP of all motor types. The researchers recommended “transactional speech-language and communication interventions” that showed parents and caregivers how to build connections and engage in “reciprocal communication exchanges” to encourage active communication with infants. The single recommendation regarding muscle tone suggested the start of “comprehensive, goal-directed hypertonia management” for hypertonia that results in pain or negatively impacts motor development.
In the motor domain, one recommendation the researchers offered included “beginning intervention at the time of suspected diagnosis to harness neuroplasticity through specific training and respecting parent requests for early intervention” among children with or at high risk for unilateral or bilateral CP.
Overall, the researchers emphasized the importance of a comprehensive, multidisciplinary approach, with comprehensive screening for comorbidities in an infant diagnosed with or at high risk for CP. They noted potential interference with motor and cognitive skills related to feeding and sleep disorders, as well as the need for anticipation of secondary impairments to allow for timely access to intervention. They also underscored the necessity of evidence-based and empathic communication between health care providers and parents, which would empower them to seek help.
“Early targeted intervention builds on a critical developmental time for plasticity of developing systems,” Morgan and colleagues wrote. “Intervention referrals for each domain should be specific to the recommendations.”
In a related editorial, Abdellah Tebani, PharmD, PhD, associate professor and clinical biochemist from the department of metabolic biochemistry, and Stéphane Marret, MD, PhD, of the department of neonatal pediatrics, intensive care and neuropediatrics, both at the University of Rouen Normandy in France, highlighted modes of technology that may aid future research in the management of CP.
“Given the complex clinical and biological management of CP, there is an urgent need for a detailed, systematic understanding of how such neurological disease complexity unfolds in the nervous system at both time and space scales,” Tebani and Marret wrote. “This includes morphological, physiological, molecular and connectivity dissection of neural circuits. To do so, high-throughput technologies, including multimodal imaging and single-cell panomic molecular profiling, with an increasing resolution and automation, offer a great opportunity to study the human brain at an unprecedented depth and scope.”
Reference:
Tebani A and Marret S. JAMA Pediatr. 2021;doi:10.1001/jamapediatrics.2021.0884.
Perspective
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Darrah Haffner, MD, MHS
Cerebral palsy is the most common motor disability in childhood, with 1 in 345 children affected. The 2017 international guidelines detailed the early and accurate diagnosis of CP and the clinical classification of high risk for CP. This systematic review extends the prior recommendations by supporting immediate referral to early intervention after diagnosis. These guidelines emphasize the multidisciplinary needs of young children with or at high risk for CP, providing important recommendations for targeted interventions and parent support. When infants are diagnosed with CP, the stakes are high. These guidelines provide a strong framework for evidence-based interventions in a critical developmental window.
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