Speech and language interventions for infants aged 0 to 2 years at high risk for cerebral palsy: a systematic review

Potential clinical applications of advanced genomic analysis in cerebral palsy

Cerebral palsy (CP) has historically been attributed to acquired insults, but emerging research suggests that genetic variations are also important causes of CP. While microarray and whole-exome sequencing based studies have been the primary methods for establishing new CP-gene relationships and providing a genetic etiology for individual patients, the cause of their condition remains unknown for many patients with CP. Recent advancements in genomic technologies offer additional opportunities to uncover variations in human genomes, transcriptomes, and epigenomes that have previously escaped detection. In this review, we outline the use of these state-of-the-art technologies to address the molecular diagnostic challenges experienced by individuals with CP. We also explore the importance of identifying a molecular etiology whenever possible, given the potential for genomic medicine to provide opportunities to treat patients with CP in new and more precise ways.

Depth and Quality of Recommendations in Popular Sources About How to Play with Infants: Content Analysis

AIM

Systematically evaluate the depth and quality of play recommendations provided in popular sources for parents of infants in the first year of life.

METHODS

This represents the second stage of a larger analysis of educational content available to parents. Two coders (>90% agreement) extracted and coded play activities from popular websites, applications, and books screened from a systematic online search. Depth of instruction variables were extracted. Activity quality was rated based on opportunities for child-initiated movement, problem-solving with objects, and responsive communication.

RESULTS

4370 play activities from 214 sources were analyzed. Activities were likely to suggest specific ages for infants and that a caregiver be present. Less than half of the activities incorporated toys or provided guidance about how to position or physically support infants. Activity quality was low; most activities did not explicitly encourage parents to provide opportunities for child-initiated movement, problem-solving with objects, or quality communication.

CONCLUSIONS

Parents may encounter a large number of play activities in popular sources, but the depth of instruction and quality of those activities could be improved. Provision of higher-quality education to parents may enhance parent-child play interactions to positively impact parent and child outcomes, especially for children at risk for delays.

Current approach to cerebral palsy

This teaching review aims to provide an overview of the current approach to children with cerebral palsy (CP), retrieving the best available evidence and summarizing existing knowledge in the field of CP in children. We also highlight areas where more research is needed and novel strategies for diagnosing and treating cerebral palsy. CP includes a group of permanent disorders of movement and posture that cause activity limitation. Multiple risk factors, occurring preconceptionally, prenatally, perinatally, or postneonatally, are involved in the pathogenesis of CP, with the prenatal ones accounting for 80-90 % of cases. Due to its heterogeneity, CP has various classifications, but usually is classified based on clinical findings and motor impairment. Standardized function classification systems have been developed to address inconsistencies in previous classifications. The combination of clinical assessment and validated predictive tools is recommended for an early diagnosis, which is important for early intervention and prevention of secondary impairments. The therapeutic regimen in CP involves prevention and management of the motor and associated problems. It includes the enhancement of motor performance, the enrichment of cognition and communication skills, the prevention of secondary impairments, and the support of parents and caregivers. The care of CP children demands a multidisciplinary approach focused on improving motor skills, reducing comorbidities, enhancing the quality of life, and prolonging survival.

Brain injury and long-term outcome after neonatal surgery for non-cardiac congenital anomalies

BACKGROUND

There is growing evidence that neonatal surgery for non-cardiac congenital anomalies (NCCAs) in the neonatal period adversely affects long-term neurodevelopmental outcome. However, less is known about acquired brain injury after surgery for NCCA and abnormal brain maturation leading to these impairments.

METHODS

A systematic search was performed in PubMed, Embase, and The Cochrane Library on May 6, 2022 on brain injury and maturation abnormalities seen on magnetic resonance imaging (MRI) and its associations with neurodevelopment in neonates undergoing NCCA surgery the first month postpartum. Rayyan was used for article screening and ROBINS-I for risk of bias assessment. Data on the studies, infants, surgery, MRI, and outcome were extracted.

RESULTS

Three eligible studies were included, reporting 197 infants. Brain injury was found in n = 120 (50%) patients after NCCA surgery. Sixty (30%) were diagnosed with white matter injury. Cortical folding was delayed in the majority of cases. Brain injury and delayed brain maturation was associated with a decrease in neurodevelopmental outcome at 2 years of age.

CONCLUSIONS

Surgery for NCCA was associated with high risk of brain injury and delay in maturation leading to delay in neurocognitive and motor development. However, more research is recommended for strong conclusions in this group of patients.

IMPACT

Brain injury was found in 50% of neonates who underwent NCCA surgery. NCCA surgery is associated with a delay in cortical folding. There is an important research gap regarding perioperative brain injury and NCCA surgery.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Clinical utilisation of the Infant Monitor of vocal Production (IMP) for early identification of communication impairment in young infants at-risk of cerebral palsy: a prospective cohort study

AIM

To report prospective longitudinal data of early vocaliszations of infants identified "at-risk" of cerebral palsy (CP) for early identification of communication impairment.

METHOD

This case-control longitudinal prospective cohort study reports on the assessment of 36 infants, 18 identified as at-risk of CP at the time of enrolment and 18 typically developing (TD) children, at three time points: 6 months, 9 months and 12 months of age, Data were obtained through criterion and norm referenced assessments of vocaliszation behaviors.

RESULTS

Early vocal behaviors of infants identified as at-risk of CP did not differ from their age matched peers at 6 months of age, however, significant group differences emerged at 9 and 12 months when pre-canonical and canonical babble typically emerge. Generalized linear mixed models analysis showed that the rate of development of early language ability and more complex speech-related vocal behaviors was slower for infants at risk of CP when compared to TD infants, with over 75% of infants with CP showing below normal vocal production and impaired language by 12 months of age.

INTERPRETATION

Our data suggest characteristics of infant vocalizations associated with pre-canonical and canonical babbling provide a strong evidence base for predicting communication outcomes in infants at risk of CP.

Prediction of Communication Impairment in Children With Bilateral Cerebral Palsy Using Multivariate Lesion- and Connectome-Based Approaches: Protocol for a Multicenter Prospective Cohort Study

BACKGROUND

Bilateral cerebral palsy (BCP) is the most common type of CP in children and is often accompanied by different degrees of communication impairment. Several studies have attempted to identify children at high risk for communication impairment. However, most prediction factors are qualitative and subjective and may be influenced by rater bias. Individualized objective diagnostic and/or prediction methods are still lacking, and an effective method is urgently needed to guide clinical diagnosis and treatment. The aim of this study is to develop and validate an objective, individual-based model for the prediction of communication impairment in children with BCP by the time they enter school.

METHODS

A multicenter prospective cohort study will be conducted in four Chinese hospitals. A total of 178 children with BCP will undergo advanced brain magnetic resonance imaging (MRI) at baseline (corrected age, before the age of 2 years). At school entry, communication performance will be assessed by a communication function classification system (CFCS). Three-quarters of children with BCP will be allocated as a training cohort, whereas the remaining children will be allocated as a test cohort. Multivariate lesion- and connectome-based approaches, which have shown good predictive ability of language performance in stroke patients, will be applied to extract features from MR images for each child with BCP. Multiple machine learning models using extracted features to predict communication impairment for each child with BCP will be constructed using data from the training cohort and externally validated using data from the test cohort. Prediction accuracy across models in the test cohort will be statistically compared.

DISCUSSION

The findings of the study may lead to the development of several translational tools that can individually predict communication impairment in children newly diagnosed with BCP to ensure that these children receive early, targeted therapeutic intervention before they begin school.

TRIAL REGISTRATION

The study has been registered with the Chinese Clinical Trial Registry (ChiCTR2100049497).

Neurological and developmental outcomes following neonatal encephalopathy treated with therapeutic hypothermia

In randomized trials, therapeutic hypothermia (TH) is associated with reduced prevalence of the composite outcome mortality or neurodevelopmental morbidity in infants with neonatal encephalopathy (NE). Following systematic review, the reduction in prevalence of both mortality and infant neuromorbidity is clear. Among three trials reporting school age outcomes, the effects of NE and TH suggest that such benefit persists into middle childhood, but none of the major trials were powered to detect differences in these outcomes. Cognitive, educational and behavioural outcomes are all adversely affected by NE in children without moderate or severe neuromorbidity. High-quality longitudinal studies of neurocognitive and educational outcomes following NE in the era of TH, including studies incorporating multimodal neuroimaging assessments, are required to characterise deficits more precisely so that robust interventional targets may be developed, and resource planning can occur. Understanding the impact of NE on families and important educational, social, and behavioural outcomes in childhood is critical to attempts to optimise outcomes through interventions.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews

IMPORTANCE

Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years.

OBJECTIVE

To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

EVIDENCE REVIEW

The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument.

FINDINGS

Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5).

CONCLUSIONS AND RELEVANCE

When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy

PURPOSE OF REVIEW

Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019.

RECENT FINDINGS

Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

A Research on Developmental Characteristics of Children With Language Delay in Zhejiang Province, China

Study Design: We used Sign-significant relations (S-S) to assess the developmental characteristics of 1- to 4-year-old children with language delays in Zhejiang Province and to provide scientific basis for early clinical detection and comprehensive intervention. Methods: A total of 1,113 children among the ages of 1 and 4 who complained of poor language skills were assessed in language competence using S-S. These children diagnosed with language delays were divided into six groups, with each group having an age difference of 6 months. The developmental characteristics of each group were described and analyzed. Results: (1) Children from the age of 18 to 36 months were most likely to be affected by language problems, while boys were more susceptible than girls in each group. (2) There was no significant difference in the proportion of children with poor communication attitude among the groups. (3) The older the group, the higher the proportion of basic learning ability abnormality. The cutoff age for qualitative leap in the proportion of basic learning abilities was 2 years old. (4) With the increase of age, the proportion of abnormal language comprehension in each group increased gradually. The cutoff age for qualitative leap in the proportion of language comprehension was 1.5 and 2 years old. Conclusion: Language delays usually occur in children around the age of two, and as the children get older, in addition to expression of language abilities, they are more likely to have abnormal language comprehensive abilities and abnormal basic learning abilities. Based on the clinical research, we must take seriously the early screenings for this age group and conduct intervention training as soon as possible.

Efficacy of the Small Step Program in a Randomized Controlled Trial for Infants under 12 Months Old at Risk of Cerebral Palsy (CP) and Other Neurological Disorders

The objective was to evaluate the effects of the Small Step Program on general development in children at risk of cerebral palsy (CP) or other neurodevelopmental disorders. A randomized controlled trial compared Small Step with Standard Care in infants recruited at 4–9 months of corrected age (CA). The 35-week intervention targeted mobility, hand use, and communication during distinct periods. The Peabody Developmental Motor Scales^2ed (PDMS-2) was the primary outcome measure. For statistical analysis, a general linear model used PDMS-2 as the main outcome variable, together with a set of independent variables. Thirty-nine infants were randomized to Small Step (n = 19, age 6.3 months CA (1.62 SD)) or Standard Care (n = 20, age 6.7 months CA (1.96 SD)). Administering PDMS-2 at end of treatment identified no group effect, but an interaction between group and PDMS-2 at baseline was found (p < 0.02). Development was associated with baseline assessments in the Standard Care group, while infants in the Small Step group developed independent of the baseline level, implying that Small Step helped the most affected children to catch up by the end of treatment. This result was sustained at 2 years of age for PDMS-2 and the PEDI mobility scale.

Parent-mediated communication interventions for improving the communication skills of preschool children with non-progressive motor disorders

BACKGROUND

Children with motor disorders can have difficulties in producing accurate and consistent movements for speech, gesture or facial expression (or a combination of these), making their communication difficult to understand. Parents may be offered training to help recognise and interpret their child's signals and to stimulate their children's development of new communication skills.

OBJECTIVES

To assess the effectiveness of parent-mediated communication interventions, compared to no intervention, treatment as usual or clinician-mediated interventions, for improving the communication skills of preschool children up to five years of age who have non-progressive motor disorders.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, 12 other databases and three trials registers in July 2017. We also searched the reference lists of relevant papers and reviews, and contacted experts working in the field to find unpublished studies.

SELECTION CRITERIA

We included studies that used randomised or quasi-randomised designs; compared a parent-mediated communication intervention with no treatment, treatment as usual or clinician-mediated therapy; and included children with non-progressive motor disorders up to five years of age.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review included two randomised controlled trials involving 38 children (20 boys, 18 girls), aged 15 to 96 months, and their mothers. All children had developmental disabilities; 10 had motor disorders, but it was unclear if these motor disorders affected their gestural, vocal or verbal communication. Mothers attended eight group training sessions over 11 to 12 weeks and received two or three home visits. Outcomes were assessed immediately after training. We found no report of longer-term follow-up. One study took place at an intervention centre in Canada and the other in South Korea.Both studies recruited small numbers of participants from single centres. Since it is not possible to blind participants attending or therapists providing training to group allocation, we considered both studies to be at high risk of performance bias. We also rated one study at high risk of attrition bias, and both studies at low risk of reporting bias.There was very low-quality evidence for all outcomes assessed. There was no evidence of an effect of training for children's initiation of conversation or engagement in joint attention during interaction with their mothers. Mothers who received training became more responsive to their children's communication, but there were no differences in the extent to which they controlled conversation by directing their children. Missing data meant that we were unable to evaluate the effects of training on children's frequency of communication, frequency of spoken language in conversation, speech production, or receptive or expressive language development. There were no effects on maternal stress. We found no reports of the effects of parent training on children's use of individual communication skills, such as asking questions or providing information, on their generic participation or adverse outcomes. Neither did we find reports of mothers' satisfaction with treatment, its acceptability or their compliance with it.

AUTHORS' CONCLUSIONS

There is only limited, very low quality evidence that parent-mediated communication interventions may be associated with improvements in interaction between mothers and their preschool children who have motor disorders. The indirectness of the study samples and high risk of bias in the included the studies significantly limits our confidence in the evidence, as do issues with study design and lack of detail in results. It is not clear if training has been tested with children whose motor disorders limit the consistency and accuracy of movements underpinning spoken or gestural communication. Some speech and language therapists currently provide communication training for parents. Further research, with larger numbers of children whose movement disorders affect their speech and gestures, coupled with detailed reporting of children's baseline skills, is needed to test whether communication training for parents can help them to promote the communication development of their young children with movement disorders.

Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment

IMPORTANCE

Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months' corrected age.

OBJECTIVES

To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy-specific early intervention that should follow early diagnosis to optimize neuroplasticity and function.

EVIDENCE REVIEW

This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument.

FINDINGS

Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months' corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months' corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence.

CONCLUSIONS AND RELEVANCE

Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.