Network Implementation of Guideline for Early Detection Decreases Age at Cerebral Palsy Diagnosis

The Screening Hand Assessment for Infants for detecting the risk of unilateral cerebral palsy: Item selection and development

AIM

To develop a screening tool (the screening Hand Assessment for Infants [s-HAI]) for infants aged from 3.5 months that can identify a high risk of developing unilateral cerebral palsy (CP) based on a selection of items from the HAI.

METHOD

Receiver operating characteristic curve analysis was performed on previously collected HAI assessments from 212 infants (104 females, 108 males) aged from 3.5 to 8.5 months, to select items suitable for screening. The area under the curve (AUC), sensitivity, specificity, and cut-off values were derived for the suggested item combination. The clinical outcome (unilateral CP yes or no) at 24 months or older served as the external criterion.

RESULTS

About half of the infants developed unilateral CP. The AUC across the items ranged from 0.63 to 0.80, and from 0.85 to 0.87 for different item combinations. Sensitivity for the selected 6-item set was 91% for 8 points or less and 88% for 7 points or less on the contralesional score of each hand, while specificity was 60% and 73% respectively.

INTERPRETATION

The s-HAI, designed from six HAI items, has the potential to be used to screen infants at risk of unilateral CP from 3.5 months of age. It is easy to administer, time-efficient, and can be used in different settings. Its measurement properties and feasibility need to be tested in a new data set.

Evidence-Based Infant Assessment for Cerebral Palsy: Diagnosis Timelines and Intervention Access in a Newborn Follow-up Setting

Evidence-based assessment pathways inform early detection of cerebral palsy and access to intervention. This study investigated the relationships between early evidence-based assessments, diagnosis timeline, and rehabilitation intervention access in a population of children with cerebral palsy who were seen between 2010 and 2022 at the University of Wisconsin Waisman Center Newborn Follow Up Clinic. Cerebral palsy-specific assessments were increasingly integrated after the publication of early detection guidelines by Novak et al. in 2017. Age at cerebral palsy first mention (high risk for cerebral palsy) decreased over time, although age at diagnosis remained similar. Infants who received multiple evidence-based assessments were diagnosed at a younger age. Ninety-nine percent of children were referred to rehabilitation therapies before diagnosis. Infant age at referral to outpatient therapies decreased over time. This study provides novel clinical data on diagnosis timelines and identifies remaining gaps related to implementation feasibility toward improved early diagnosis and intervention access.

BabyOSCAR: Support for measuring underlying coordination of spontaneous movements in infancy

This commentary is on the original articles by Maziero Barbosa et al., Sukal‐Moulton et al., and Peyton et al. on pages 1502–1510, 1511–1520, and 1521–1528 of this issue.

The Current State of Neonatal Neurodevelopmental Follow-up Programs in North America: A Children's Hospitals Neonatal Consortium Report

OBJECTIVE

 This study aimed to determine neonatal neurodevelopmental follow-up (NDFU) practices across academic centers.

STUDY DESIGN

 This study was a cross-sectional survey that addressed center-specific neonatal NDFU practices within the Children's Hospitals Neonatal Consortium (CHNC).

RESULTS

 Survey response rate was 76%, and 97% of respondents had a formal NDFU program. Programs were commonly staffed by neonatologists (80%), physical therapists (77%), and nurse practitioners (74%). Median gestational age at birth identified for follow-up was ≤32 weeks (range 26-36). Median duration was 3 years (range 2-18). Ninety-seven percent of sites used Bayley Scales of Infant and Toddler Development, but instruments used varied across ages. Scores were recorded in discrete electronic data fields at 43% of sites. Social determinants of health data were collected by 63%. Care coordination and telehealth services were not universally available.

CONCLUSION

 NDFU clinics are almost universal within CHNC centers. Commonalities and variances in practice highlight opportunities for data sharing and development of best practices.

KEY POINTS

· Neonatal NDFU clinics help transition high-risk infants home.. · Interdisciplinary neonatal intensive care unit follow-up brings together previously separated outpatient service lines.. · This study reviews the current state of neonatal NDFU in North America..

Unveiling the Immediate Impact of Prechtl's General Movement Assessment Training on Inter-Rater Reliability and Cerebral Palsy Prediction

Prechtl's General Movement Assessment (GMA) is a qualitative video assessment that is an early predictor of cerebral palsy (CP) in infants. GMA raters undergo two levels of training: basic and advanced. Using a retrospective study design, we evaluated the impact of the GMA training level on three key measures: inter-rater reliability (IRR), predictability for a later CP diagnosis, and generalizability for both medically trained and non-medically trained raters. As part of a larger study on former level-IV neonatal intensive care unit (NICU) infants, participants had a GMA video at 3-4 months of corrected age with parental consent. Four GMA raters with basic training interpreted the videos. Subsequently, two raters underwent advanced training and reinterpreted the videos. We evaluated IRR with Gwet's AC1 coefficient, CP prediction with logistic regression, and generalizability with Gwet's Linearization method and McNemar's test. Following basic GMA training, all four raters had moderate to almost perfect agreement. The CP predictability of the raters' individual GMA scores ranged from 73% to 81%. Advanced GMA training significantly improved IRR and enhanced CP predictability. GMA rater proficiency was similar regardless of medical training. Advanced GMA training improved readers' capabilities to correctly identify abnormal movement patterns and aid in early CP diagnosis.

Families as partners in neonatal neuro-critical care programs

Parents of neonates with neurologic conditions face a specific breadth of emotional, logistical, and social challenges, including difficulties coping with prognostic uncertainty, the need to make complex medical decisions, and navigating new hopes and fears. These challenges place parents in a vulnerable position and at risk of developing mental health issues, which can interfere with bonding and caring for their neonate, as well as compromise their neonate's long-term neurodevelopment. To optimize neurologic and developmental outcomes, emerging neonatal neuro-critical care (NNCC) programs must concurrently attend to the unique needs of the developing newborn brain and of his/her parents. This can only be accomplished by embracing a family-centered care environment-one which prioritizes effective parent-clinician communication, longitudinal parent support, and parents as equitable partners in clinical care. NNCC programs offer a multifaceted approach to critical care for neonates at-risk for neurodevelopmental impairments, integrating expertise in neonatology and neurology. This review highlights evidence-based strategies to guide NNCC programs in developing a family-partnered approach to care, including primary staffing models; staff communication, implicit bias, and cultural competency trainings; comprehensive and tailored caregiver training; single-family rooms; flexible visitation policies; colocalized neonatal and maternal care; uniform mental health screenings; follow-up care referrals; and connections to peer support. IMPACT: Parents of neonates with neurologic conditions are at high-risk for experiencing mental health issues, which can adversely impact the parent-neonate relationship and long-term neurodevelopmental outcomes of their neonates. While guidelines to promote families as partners in the neonatal intensive care unit (NICU) have been developed, no protocols integrate the unique needs of parents in neonatal neurologic populations. A holistic approach that makes families true partners in the care of their neonate with a neurologic condition in the NICU has the potential to improve mental and physical well-being for both parents and neonates.

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.

Hybrid developmental follow-up for preterm infants in Brazil: A feasibility study

INTRODUCTION

The low attendance of families in child developmental follow-up programs for at-risk preterm children is a challenge in Brazil.

OBJECTIVE

This study evaluates the feasibility of implementing a developmental follow-up program for Brazilian preterm infants in a hybrid format.

METHODS

This is an observational, prospective cohort study, involving preterm infants. Longitudinal developmental test results, the participation frequency in the program, and the number of referrals to early intervention programs were used to assess feasibility. The General Movements (GMs) assessment, Alberta Infant Motor Scale (AIMS) and, Survey of Wellbeing of Young Children (SWYC) Milestones were administered via telehealth. The Bayley-III was administered in-person.

RESULTS

Thirty-four preterm infants attended the follow-up until 12 months of corrected age and 18 (52.9 %) concluded all follow-up assessments. Twenty-six (76.5 %) attended all assessments via telehealth, and 26 (76.5 %) attended the in-person assessment. Eighteen (52.9 %) infants showed at least one altered result in development tests. Infants exhibiting abnormal results in the GMs assessment, motor developmental delay according to the AIMS, or developmental delay based on Balley-III were promptly referred to early intervention services.

CONCLUSION

This study demonstrated high participation rate and low dropout in a developmental follow-up program employing a hybrid format. The substantial number of identified infants with developmental delay emphasizes the importance of timely detection of motor delays to referral to early intervention services.

Cerebral Palsy and Motor Impairment After Extreme Prematurity: Prediction of Diagnoses at Ages 2 and 10 Years

OBJECTIVE

To identify perinatal factors in children born extremely preterm (EP) that were associated with motor impairment (MI) at 2 and 10 years of age and develop a predictive algorithm to estimate the risk of MI during childhood.

STUDY DESIGN

Participants of the Extremely Low Gestational Age Newborns Study (ELGANS) were classified as: no MI, MI only at 2 years, MI only at 10 years, and MI at both 2 and 10 years, based on a standardized neurological examination at 2 and the Gross Motor Function Classification System (GMFCS) at 10 years of age. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to develop the final predictive model.

RESULTS

Of the 849 study participants, 64 (7.5%) had a diagnosis of MI at both 2 and 10 years and 63 (7.4%) had a diagnosis of MI at 1 visit but not the other. Of 22 total risk factors queried, 4 variables most reliably and accurately predicted MI: gestational age, weight z-score growth trajectory during neonatal intensive care unit (NICU) stay, ventriculomegaly, and cerebral echolucency on head ultrasound. By selecting probability thresholds of 3.5% and 7.0% at ages 2 and 10, respectively, likelihood of developing MI can be predicted with a sensitivity and specificity of 71.2%/72.1% at age 2 and 70.7%/70.7% at age 10.

CONCLUSION

In our cohort, the diagnosis of MI at 2 years did not always predict a diagnosis of MI at 10 years. Specific risk factors are predictive of MI and can estimate an individual infant's risk at NICU discharge of MI at age 10 years.

Automated detection of abnormal general movements from pressure and positional information in hospitalized infants

BACKGROUND

Prechtl's general movements assessment (GMA) allows visual recognition of movement patterns that, when abnormal (cramped synchronized, or CS), have very high sensitivity in predicting later neuromotor disorders; however, training requirements and subjective perceptions from some clinicians may hinder universal adoption of the GMA in the newborn period.

METHODS

To address this, we used a three-phased approach to design a preliminary and clinically-oriented approach to automated CS GMA detection. 335 hospitalized infants were dually recorded on video and a pressure-sensor mat that collected time, spatial, and pressure data. Video recordings were scored by advanced GMA readers. We then conducted a series of unsupervised machine learning and supervised classification modeling with features extracted from clinician- and mat-driven datasets. Finally, the resulting algorithm was converted to a software interface.

RESULTS

A classification model combining normalization, clustering, and decision tree modeling resulted in the highest sensitivity for CS movements (100%). Results were delivered via the software interface within 20 min of data recording.

CONCLUSION

The combination of clinical research, machine learning, and repurposing of existing sensor mat technology produced a feasible preliminary approach to automatically detect abnormal GMA in infants while still in the NICU. Further refinements of software and algorithms are needed.

IMPACT STATEMENT

Machine learning can differentiate cramped synchronized general movement patterns in the neonatal intensive care unit with good sensitivity and specificity. Increasing access to the GMA through automated detection methods may allow for earlier identification of a greater number of children at high risk for movement delay. Large studies leveraging new artificial intelligence approaches could increase the impact of such detection.

Implementation of remote general movement assessment using the in-motion instructions in a high-risk norwegian cohort

BACKGROUND

General Movement Assessment (GMA) is recommended for early detection of risk for cerebral palsy but requires trained clinical experts. We aimed to implement home- and hospital-based filming for remote GMA in a Norwegian high-risk infant cohort, as well as evaluating parents' experiences in filming their infant at home.

METHODS

This knowledge translational study used a prospective cohort design including participants referred to neurodevelopmental follow-up across three sites in the Central Norway Regional Health Authority. Two home films of the fidgety type of general movements were collected between 12+1-14+6 and 15+1-17+6 weeks after term by parents. An additional film was collected at the hospital between 12+1 and 17+6 weeks after term. The instructional guide for all filming was the In-Motion App standards. Videos were transferred to a remote GMA team and classified as either "GMA scorable" or "GMA not scorable" based on Prechtl's GMA standards. Parents responded to an online survey using a 5-point Likert scale to collect information about their perspectives, experiences, and possible worries by filming their infant at home.

RESULTS

One-hundred-and-two infants from 95 families participated. Ninety-two (96.8%) families transferred 177 home-based videos. Eighty-four (92%) of these had 95 videos taken in their local hospital. All 177 home-videos were "GMA scorable" and three (3,1%) out of 95 hospital-based videos were classified as "GMA not scorable". Eight families did not respond to the survey and two families did not receive the survey due to a technical error. Seventy-eight (91.7%) respondents agreed or strongly agreed that it was easy to perform home filming and five (5.9%) agreed that they were more worried about their child`s development after filming at home. Almost 80% of respondents agreed that a video for GMA can be taken at home instead of in hospital.

CONCLUSIONS

This study strengthens the clinical implementation of home filming by parents and remote GMA for early detection of CP in high-risk follow-up programs. The implementation of remote GMA has the potential to facilitate early intervention to improve function in children with CP in line with international recommendations.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04287166 Date of registration: 27/02/2020.

Effectiveness of early diagnosis of cerebral palsy guideline implementation: a systematic review

INTRODUCTION

Tailored implementation interventions are required to overcome the diagnostic research-practice gap for cerebral palsy (CP). Evaluating the impact of interventions on patient outcomes is a priority. This review aimed to summarize the established evidence for the effectiveness of guideline implementations in lowering the age of CP diagnosis.

EVIDENCE ACQUISITION

A systematic review was conducted according to PRISMA. CINAHL, Embase, PubMed and MEDLINE were searched (2017-October 2022). Inclusion criteria were studies that evaluated effect of CP guideline interventions on health professional behaviour or patient outcomes. GRADE was used to determine quality. Studies were coded for use of theory (Theory Coding Scheme). Meta-analysis was performed and a standardized metric used to summarize statistics of intervention effect estimates.

EVIDENCE SYNTHESIS

Of (N.=249) records screened, (N.=7) studies met inclusion, comprising interventions following infants less than 2 years of age with CP risk factors (N.=6280). Guideline feasibility in clinical practice was established through health professional adherence and patient satisfaction. Efficacy of patient outcome of CP diagnosis by 12 months of age was established in all studies. Weighted averages were: (1) high-risk of CP (N.=2) 4.2 months and (2) CP diagnosis (N.=5) at 11.6 months. Meta-analysis of (N.=2) studies found a large, pooled effect size Z = 3.00 (P=0.003) favoring implementation interventions lowering age of diagnosis by 7.50 months, however study heterogeneity was high. A paucity of theoretical frameworks were identified in this review.

CONCLUSIONS

Multifaceted interventions to implement the early diagnosis of CP guideline are effective in improving patient outcomes by lowering the age of CP diagnosis in high-risk infant follow-up clinics. Further targeted health professional interventions including low-risk infant populations are warranted.

Cerebral Palsy: A Current Perspective

Cerebral palsy (CP) is the most common cause of motor disability in children. Insults to the brain at different times lead to diverse injuries. As a result, CP is an extremely heterogeneous clinical diagnosis, presenting differently in each individual and at various ages. With improving survival rates of preterm newborns, increasing active resuscitation of extremely preterm newborns, and widespread availability of extensive genetic testing soon after birth, it is imperative to focus on earlier diagnosis and long-term outcomes of CP. CP is primarily classified into 4 categories based on type of motor impairment, functional ability, distribution, and etiology. As the understanding of CP has evolved significantly in the last 2 decades, the methods of early detection of CP have consequently advanced. Appropriate diagnosis is essential for proper education and counseling of affected families, and introduction of therapeutic interventions as early as possible. In this review, we focus on early brain development and provide an overview of the etiology, classification, diagnosis, early therapeutic options, and prognosis of CP.

Diagnosis and referrals to physical therapy among caregivers of children with genetic disorders: a qualitative inquiry

PURPOSE

Genetic disorders are common in Saudi Arabia. Impaired motor development is one of the major characteristics associated with genetic disorders. Early identifications and referrals are key to receiving physical therapy. This study aims to explore caregivers of children with genetic disorders' experience with early identification and referrals to physical therapy.

MATERIALS AND METHODS

An inductive qualitative design of 16 caregivers of children with genetic disorders was done to investigate the identification and referral process to physical therapy. A thematic analysis was used to analyze the data and multiple coders coded the data to increase the trustworthiness of the analysis.

RESULTS

The analysis led to emergence of four main themes. Caregivers revealed their struggle with the detection process. They struggled with the vague information related to their children's condition. They also expressed a desperate need for guidance to clarify the process for genetic testing, counseling, and rehabilitation. Although their overall experience with physical therapy was satisfactory, they encountered a number of issues related to scheduling appointments, delayed referrals, and unconfirmed diagnoses.

CONCLUSION

The results of this study could indicate that more efforts are required to expedite and elucidate the identification and referral of children with genetic disorders in Saudi Arabia.

Heart Rate and Pulse Oximetry Dynamics in the First Week after Birth in Neonatal Intensive Care Unit Patients and the Risk of Cerebral Palsy

OBJECTIVE

Infants in the neonatal intensive care unit (NICU) are at high risk of adverse neuromotor outcomes. Atypical patterns of heart rate (HR) and pulse oximetry (SpO2) may serve as biomarkers for risk assessment for cerebral palsy (CP). The purpose of this study was to determine whether atypical HR and SpO2 patterns in NICU patients add to clinical variables predicting later diagnosis of CP.

STUDY DESIGN

This was a retrospective study including patients admitted to a level IV NICU from 2009 to 2017 with archived cardiorespiratory data in the first 7 days from birth to follow-up at >2 years of age. The mean, standard deviation (SD), skewness, kurtosis and cross-correlation of HR and SpO2 were calculated. Three predictive models were developed using least absolute shrinkage and selection operator regression (clinical, cardiorespiratory and combined model), and their performance for predicting CP was evaluated.

RESULTS

Seventy infants with CP and 1,733 controls met inclusion criteria for a 3.8% population prevalence. Area under the receiver operating characteristic curve for CP prediction was 0.7524 for the clinical model, 0.7419 for the vital sign model, and 0.7725 for the combined model. Variables included in the combined model were lower maternal age, outborn delivery, lower 5-minute Apgar's score, lower SD of HR, and more negative skewness of HR.

CONCLUSION

In this study including NICU patients of all gestational ages, HR but not SpO2 patterns added to clinical variables to predict the eventual diagnosis of CP. Identification of risk of CP within the first few days of life could result in improved therapy resource allocation and risk stratification in clinical trials of new therapeutics.

KEY POINTS

· SD and skewness of HR have some added predictive value of later diagnosis of CP.. · SpO2 measures do not add to CP prediction.. · Combining clinical variables with early HR measures may improve the prediction of later CP..

Early Neurodevelopmental Assessments for Predicting Long-Term Outcomes in Infants at High Risk of Cerebral Palsy

Importance

Studies suggest that early neurodevelopmental assessments are beneficial for identifying cerebral palsy, yet their effectiveness in practical scenarios and their ability to detect cognitive impairment are limited.

Objective

To assess the effectiveness of early neurodevelopmental assessments in identifying cerebral palsy and cognitive and other neurodevelopmental impairments, including their severity, within a multidisciplinary clinic.

Design, Setting, and Participants

This diagnostic study was conducted at Monash Children's Hospital, Melbourne, Australia. Participants were extremely preterm infants born at less than 28 weeks' gestation or extremely low birth weight infants less than 1000 g and term encephalopathic infants who received therapeutic hypothermia, attending the early neurodevelopmental clinic between January 2019 and July 2021. Data were analyzed from December 2023 to January 2024.

Exposures

Early cerebral palsy or high risk of cerebral palsy, the absence of fidgety movements, and Hammersmith Infant Neurological Examination (HINE) scores at corrected age (CA) 3 to 4 months. Early cerebral palsy or high risk of cerebral palsy diagnosis was based on absent fidgety movements, a low HINE score (<57), and medical neurological examination.

Main Outcome and Measures

The outcomes of interest were cerebral palsy, cognitive and neurodevelopmental impairments and their severity, diagnosed at 24 to 36 months' CA.

Results

A total of 116 infants (median [IQR] gestational age, 27 [25-29] weeks; 65 [56%] male) were included. Diagnosis of early cerebral palsy or high risk of cerebral palsy demonstrated a sensitivity of 92% (95% CI, 63%-99%) and specificity of 84% (95% CI, 76%-90%) for predicting cerebral palsy and 100% (95% CI, 59%-100%) sensitivity and 80% (95% CI, 72%-87%) specificity for predicting moderate to severe cerebral palsy. Additionally, the accuracy of diagnosis of early cerebral palsy or high risk of cerebral palsy was 85% (95% CI, 77%-91%) for predicting cerebral palsy and 81% (95% CI, 73%-88%) for predicting moderate to severe cerebral palsy. Similarly, the absence of fidgety movements had an 81% (95% CI, 73%-88%) accuracy in predicting cerebral palsy, and HINE scores exhibited good discriminatory power with an area under the curve of 0.88 (95% CI, 0.79-0.97) for cerebral palsy prediction. However, for cognitive impairment, the predictive accuracy was 44% (95% CI, 35%-54%) for an early cerebral palsy or high risk of cerebral palsy diagnosis and 45% (95% CI, 36%-55%) for the absence of fidgety movements. Similarly, HINE scores showed poor discriminatory power for predicting cognitive impairment, with an area under the curve of 0.62 (95% CI, 0.51-0.73).

Conclusions and Relevance

In this diagnostic study of infants at high risk for cerebral palsy or other cognitive or neurodevelopmental impairment, early neurodevelopmental assessments at 3 to 4 months' CA reliably predicted cerebral palsy and its severity at 24 to 36 months' CA, signifying its crucial role in facilitating early intervention. However, for cognitive impairment, longer-term assessments are necessary for accurate identification.

Intelligence Sparse Sensor Network for Automatic Early Evaluation of General Movements in Infants

General movements (GMs) have been widely used for the early clinical evaluation of infant brain development, allowing immediate evaluation of potential development disorders and timely rehabilitation. The infants' general movements can be captured digitally, but the lack of quantitative assessment and well-trained clinical pediatricians presents an obstacle for many years to achieve wider deployment, especially in low-resource settings. There is a high potential to explore wearable sensors for movement analysis due to outstanding privacy, low cost, and easy-to-use features. This work presents a sparse sensor network with soft wireless IMU devices (SWDs) for automatic early evaluation of general movements in infants. The sparse network consisting of only five sensor nodes (SWDs) with robust mechanical properties and excellent biocompatibility continuously and stably captures full-body motion data. The proof-of-the-concept clinical testing with 23 infants showcases outstanding performance in recognizing neonatal activities, confirming the reliability of the system. Taken together with a tiny machine learning algorithm, the system can automatically identify risky infants based on the GMs, with an accuracy of up to 100% (99.9%). The wearable sparse sensor network with an artificial intelligence-based algorithm facilitates intelligent evaluation of infant brain development and early diagnosis of development disorders.

Increasing Prevalence of Cerebral Palsy Among Two-Year-Old Children Born at <27 Weeks of Gestation: A Cohort Study

OBJECTIVE

To evaluate changes in prevalence and severity of cerebral palsy (CP) among surviving children born at <27 weeks of gestation over time and to determine associations between CP and other developmental domains, functional impairment, medical morbidities, and resource use among 2-year-old children who were born extremely preterm.

STUDY DESIGN

Retrospective cohort study using prospective registry data, conducted at 25 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Participants were children born at <27 weeks of gestation and followed at 18 through 26 months of corrected age from 2008 through 2019. Outcomes of interest were changes in prevalence of any CP and severity of CP over time and associations between CP and other neurodevelopmental outcomes, functional impairment, and medical comorbidities. Adjusted logistic, linear, multinomial logistic, and robust Poisson regression evaluated the relationships between child characteristics, CP severity, and outcomes.

RESULTS

Among 6927 surviving children with complete follow-up data, 3717 (53.7%) had normal neurologic examinations, 1303 (18.8%) had CP, and the remainder had abnormal neurologic examinations not classified as CP. Adjusted rates of any CP increased each year of the study period (aOR 1.11 per year, 95% CI 1.08-1.14). Cognitive development was significantly associated with severity of CP. Children with CP were more likely to have multiple medical comorbidities, neurosensory problems, and poor growth at follow-up.

CONCLUSIONS

The rate of CP among surviving children who were born extremely preterm increased from 2008 through 2019. At 18 to 26 months of corrected age, neurodevelopmental and medical comorbidities are strongly associated with all severity levels of CP.

The Knowledge Translation of Early Cerebral Palsy (KiTE CP) Study: Implementing Screening Among a High-Risk Prospective Cohort of Australian Infants

OBJECTIVE

To describe the implementation of the international guidelines for the early diagnosis of cerebral palsy (CP) and engagement in the screening process in an Australian cohort of infants with neonatal risk factors for CP.

STUDY DESIGN

Prospective cohort study of infants with neonatal risk factors recruited at <6 months corrected age from 11 sites in the states of Victoria, New South Wales, and Queensland, Australia. First, we implemented a multimodal knowledge translation strategy including barrier identification, technology integration, and special interest groups. Screening was implemented as follows: infants with clinical indications for neuroimaging underwent magnetic resonance imaging and/or cranial ultrasound. The Prechtl General Movements Assessment (GMA) was recorded clinically or using an app (Baby Moves). Infants with absent or abnormal fidgety movements on GMA videos were offered further assessment using the Hammersmith Infant Neurological Examination (HINE). Infants with atypical findings on 2/3 assessments met criteria for high risk of CP.

RESULTS

Of the 597 infants (56% male) recruited, 95% (n = 565) received neuroimaging, 90% (n = 537) had scorable GMA videos (2% unscorable/8% no video), and 25% (n = 149) HINE. Overall, 19% of the cohort (n = 114/597) met criteria for high risk of CP, 57% (340/597) had at least 2 normal assessments (of neuroimaging, GMA or HINE), and 24% (n = 143/597) had insufficient assessments.

CONCLUSIONS

Early CP screening was implemented across participating sites using a multimodal knowledge translation strategy. Although the COVID-19 pandemic affected recruitment rates, there was high engagement in the screening process. Reasons for engagement in early screening from parents and clinicians warrant further contextualization and investigation.

Identifying Opportunities for Early Detection of Cerebral Palsy

This study aimed to evaluate assessment and referral practices for the early detection and diagnosis of children at risk for or with cerebral palsy (CP) by health care and education providers in Maryland and Delaware. A secondary aim was to identify barriers for using early detection tools and identify opportunities for change to support early diagnosis and improve care. Seventy-two participants answered ≥ 50% of the survey questions. Most were occupational or physical therapists (86%) working in early intervention (61%). Eighty-eight percent indicated awareness that CP can be diagnosed by 12 months. Though 86% stated they typically suspect a diagnosis of CP between 0 and 12 months, only 19% reported that their patients received a CP diagnosis < 12 months. The Developmental Assessment of Young Children (73%) and the Peabody Developmental Motor Scales-2 (59%) were used most. Many respondents indicated never using magnetic resonance imaging (70%), the General Movements Assessment (87%), or the Hammersmith Infant Neurological Exam (69%). Participants identified clinical signs and symptoms prompting a referral for the diagnostic assessment of CP, most commonly stiffness in legs (95%), excessive head lag (93%), and persistent fisting (92%). Policy and organizational change, clinician education, and training are needed to support the implementation of CP early detection guidelines.

A prospective assessment of readiness to implement an early detection of cerebral palsy pathway in a neonatal intensive care setting using the PARIHS framework

BACKGROUND

Early detection of cerebral palsy (CP) is possible through targeted use of assessment tools. Changes in practice are needed to facilitate this shift towards earlier diagnosis of CP in New Zealand. The aim of this study was to prospectively evaluate readiness to implement an early detection of CP pathway within a level 3 neonatal intensive care unit (NICU) setting prior to any implementation taking place. The PARIHS (Promoting Action on Research Implementation in Health Services) framework was engaged to assess readiness by highlighting determinants that influence implementation outcomes as either barriers or enablers.

METHODS

A mixed methods approach was used. Firstly, an online staff survey assessed PARIHS sub-elements using Likert scores and free text with the intent to develop a baseline understanding of staff views. Secondly, focus groups were conducted to gain deeper understanding of barriers and enablers to implementation. Participants included health professionals involved in the first 6 months of life. Data were analysed to outline the barriers and enablers of implementation under the Evidence and Context constructs of the PARIHS framework.

RESULTS

Twenty-seven participants completed the survey, and 20 participants participated in eight focus groups and two individual interviews. Quantitative (survey) findings found 65% agreement around the usefulness of research evidence on early CP detection; however, ≤ 45% felt current resources (i.e. human, financial and IT) were sufficient for implementation. Qualitative findings (survey and focus groups) highlighted key staff concerns around resources, family impact (creating unnecessary stress), and equity (barriers to participation). Staff wanted information regarding how international evidence translates to the local context and availability of timely follow-up services. Sub-elements within the Evidence and Context constructs were rated as either mixed or low (except for Evidence - Research, rated as high), overall indicating that Auckland NICU is at the early stages of readiness to implement the early CP detection pathway.

CONCLUSION

This work may resonate with other neonatal services preparing to implement CP early detection pathways. Resourcing has a major role in facilitating implementation of pathways and uncertainty about resources is a barrier to implementation. Ongoing focus on building consensus and funding is required to ensure optimal uptake.

Partnering Early to Provide for Infants At Risk of Cerebral Palsy (PĒPI ARC): protocol for a feasibility study of a regional hub for early detection of cerebral palsy in Aotearoa New Zealand

Introduction

Cerebral palsy (CP) can now be diagnosed in infants with identified CP risk factors as early as three months of age; however, many barriers prevent equitable access to early detection pathways. The "Partnering Early to Provide for Infants At Risk of Cerebral Palsy" feasibility study (PĒPI ARC) seeks to trial a new approach to decrease inequitable health service in Aotearoa New Zealand for high-risk infants and their families. PĒPI ARC incorporates face-to-face clinics, an in-person and virtual Hub, and the use of telehealth to enable flexible access to CP assessments and support for health professionals in early CP detection.

Methods and analysis

A non-randomised feasibility study was conducted from a tertiary Neonatal Intensive Care Unit (NICU) in Wellington and included seven regional referral centres, servicing nearly 30% of the total population in New Zealand (NZ). The families of infants with a high risk of neurodevelopmental impairment and health professionals interacting with the Hub were invited to participate. Mixed methods were used to evaluate the (i) equitable implementation of an early detection pathway, (ii) acceptability, (iii) demand among families and health professionals, (iv) efficacy in relation to reducing the age of receipt of CP diagnosis, and (v) the experiences around communication and information sharing.

Ethics and dissemination

The NZ Health and Disability Ethics Committee approved this study (HDEC: 2022 FULL 13434). The findings will be disseminated in peer-reviewed journals, in conference presentations, and via professional networks.

Clinical trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12623000600640.

Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives

Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.

Reliability, Knowledge Translation, and Implementability of the Spanish Version of the Hammersmith Infant Neurological Examination

Purpose. This study aimed to: (a) translate and cross-culturally adapt the Hammersmith Infant Neurological Examination (HINE) into Spanish; (b) evaluate its intra- and inter-examiner reliability; (c) support a knowledge translation and tool implementation program in early intervention; and (d) evaluate its reliability and implementation for professionals one year after receiving training. Materials and methods. The translation followed the World Health Organization's recommendations. Reliability was assessed in 25 infants aged between 3 and 15 months with identifiable risks of cerebral palsy (CP). The implementation was also evaluated by analyzing the reliability of professionals without previous experience of the tool by using a pre-survey and a follow-up survey one year after training. The survey covered aspects related to the use of early detection tools of CP and the use of HINE, including attitudes, opinions, and perceptions. Results. An excellent intra- and inter-examiner agreement was obtained for the total score of the HINE intra-class correlation coefficient (ICC = 0.98 in both indices). One year after training, the professionals also showed excellent reliability values (ICC = 0.99), as well as an increase in sensitization and skills in evidence-based practices for the early detection of "high risk" of CP. Conclusions. The Spanish version of HINE is a reliable measure for the neurological evaluation of "high risk" of CP and can be administered after standardized training and without costs to acquire the evaluation. This allows its accessible and widespread implementation in the clinical context.

Hammersmith Infant Neurological Examination Subscores Are Predictive of Cerebral Palsy

BACKGROUND

The Hammersmith Infant Neurological Examination (HINE) is a standardized assessment that identifies early signs of cerebral palsy (CP). In practice, the clinician performs this assessment in its entirety, yielding a global score. This study aimed to investigate the individual HINE subscores and "asymmetries" as predictive indicators of CP.

METHODS

In this retrospective nested case-control study, a pediatric neurologist performed the HINE on a cohort of three- to four-month-old former neonatal intensive care unit infants. The infants' neurodevelopmental outcomes were determined by chart review when they were aged two to three years. We performed univariate and multivariable logistic regression analyses to yield the accuracy of the global HINE score, HINE subscores, and "asymmetries" in classifying infants with and without CP.

RESULTS

Of the 108 infants on whom HINE was performed, 50 were either discharged due to normal developmental progress or were lost to follow-up. Of the remaining 58 subjects, 17 had CP and 41 did not. Receiver operator characteristic (ROC) curves of univariate models yielded the following area under the curve (AUC) scores: global HINE score (AUC = 0.75), "reflexes and reactions" (AUC = 0.80), "cranial nerve function" (AUC = 0.76), "asymmetries" (AUC = 0.75), and "movements" (AUC = 0.71). The ROC for our multivariable model (AUC = 0.91) surpassed the global HINE score's predictive value for CP.

CONCLUSIONS

The weighted combination of HINE subscores and "asymmetries" outperforms the global HINE score in predicting CP. These findings suggest the need for revisiting HINE, but further validation with a larger dataset is required.

Managing mothers' and fathers' uncertainty during their journey through early neurodevelopmental follow-up for their high-risk infants-A qualitative account

BACKGROUND

Early diagnosis of cerebral palsy is possible by 5 months corrected age for 'at-risk' infants, using diagnostic tools such as the Hammersmith Infant Neurological Examination (HINE), Prechtl's General Movements Assessment (GMA) and magnetic resonance imaging (MRI). This is an uncertain and stressful time for parents where provision of appropriate information and support is essential.

AIM

To explore parents' views and experiences in relation to the new early neurodevelopmental follow-up of 'at-risk' infants.

METHODS

Thirteen in-depth one-to-one qualitative interviews were conducted by the primary researcher, with eight parents (six mothers and two fathers) of 'at-risk' infants eligible for a follow-up clinic where the GMA and HINE were performed at 12-week corrected age. Interviews used a pre-piloted topic guide and took place before and after the clinic. Interviews were audio-recorded, transcribed verbatim and analysed using inductive coding and thematic analysis using the framework approach.

FINDINGS

Seven themes were identified: (1) attempting to manage uncertainty, (2) taking priority, (3) trusting professionals, (4) independence in the parent role, (5) feeling understood, (6) patterns of care and (7) individuality. Parents reported experiencing uncertainty about their current situation and future. Adequate preparation for and timing of information are vital. When uncertainty is poorly managed, parents' wellbeing suffers. Individual parents' perspectives and infants' developmental trajectories differ, and information should be tailored specifically for this.

CONCLUSION

A parent's understanding of the journey through neurodevelopmental care for their high risk infants is initially very limited. Implementing a counselling service for parents to access psychological support and digital reminder system for clinic appointments, as well as providing more tailored information through trusted professionals, could all improve future parents' experiences.

A Call for Early Detection of Cerebral Palsy

Cerebral palsy (CP) is the most common physical disability across the lifespan, but historically, CP has not been diagnosed before the age of 2 years. Barriers to early diagnosis ranged from lack of available biomarkers, absence of curative treatments, perceived stigma associated with a lifelong diagnosis, and a desire to rule out other diagnoses first. Most importantly, the fundamental question that remained was whether children would benefit from earlier detection and intervention given the paucity of research. However, evidence-based guidelines published in 2017 demonstrated that the General Movements Assessment, the Hammersmith Infant Neurological Examination, and neuroimaging can be combined with other elements such as a clinical history and standardized motor assessments to provide the highest predictive value for diagnosing CP as early as age 3 months in high-risk newborns. Implementation of these guidelines has been successful in decreasing the age at CP diagnosis, particularly in high-risk infant follow-up clinics with expertise in performing these assessments. Early detection of CP allows for clinical and research opportunities investigating earlier interventions during a critical period of neuroplasticity, with the goal of improving developmental trajectories for children and their families. New guidelines and research are now being developed with a focus on early, targeted interventions that continue to be studied, along with global detection initiatives.

Implementing Parent Coaching in Hospital-Based Pediatric Occupational Therapy: A Multisite Quality Improvement Project

IMPORTANCE

Parent coaching (PC) is a best practice for young children with, or at high risk for, cerebral palsy (CP). Occupational therapy practitioners in outpatient settings encounter barriers to implementing PC.

OBJECTIVE

To increase the documented use of PC in outpatient occupational therapy visits for children younger than age 2 yr with, or at high risk for, CP from 0% to 80%.

DESIGN

Multicenter quality improvement (QI) initiative with a time-series design.

SETTING

Three pediatric tertiary-care institutions, each with multiple outpatient occupational therapy clinics.

PARTICIPANTS

Practitioners in the outpatient clinics and patients <2 yr old with, or at high risk for, cerebral palsy.

INTERVENTION

Plan-do-study-act cycles included interventions packaged as a toolkit: education sessions, quick references, electronic medical record (EMR) supports, and site-specific strategies.

OUTCOMES AND MEASURES

The primary outcome measure was the use of PC in outpatient sessions. Process measures included pre- and posteducation practitioner knowledge scores and an EMR checklist. Balancing measures (ensuring that changes do not cause problems in other areas) of parent satisfaction/experience and practitioner productivity were measured pre- and postintervention.

RESULTS

The primary outcome measure goal (80% documented use of PC in sessions) was attained in the seventh month of the study, sustained for 4 mo, and settled at 79.1% for the remaining 6 mo. Practitioner knowledge scores increased from 83.1% to 87.9% after initial education sessions, t[56] = 3.289, p = .001. Parent satisfaction/experience and practitioner productivity scores did not change.

CONCLUSIONS AND RELEVANCE

QI methodology can support PC implementation in pediatric outpatient practice. What This Article Adds: This multisite QI initiative shows that outpatient occupational therapy practitioners can implement PC as a best practice with the use of a toolkit. Results suggest that education alone does not result in changes to practitioner behavior and that QI methods can help when implementing best practices in a clinical setting.

Early detection of neurodevelopmental disorders in paediatric primary care: A scoping review

BACKGROUND

Earlier detection of children at risk for neurodevelopmental disorders is critical and has longstanding repercussions if not addressed early enough.

OBJECTIVES

To explore the supporting or facilitating characteristics of paediatric primary care models of care for early detection in infants and toddlers at risk for neurodevelopmental disorders, identify practitioners involved, and describe how they align with occupational therapy's scope of practice.

METHODS

A scoping review following the Joanna Briggs Institute framework was used. PubMed Central, Cumulative Index to Nursing & Allied Health Literature, and Scopus databases were searched. The search was conducted between January and February 2022. Inclusion criteria were: children aged 0-3 years old; neurodevelopmental disorders including cerebral palsy (CP) and autism spectrum disorder (ASD); models of care used in the paediatric primary care setting and addressing concepts of timing and plasticity; peer-reviewed literature written in English; published between 2010 and 2022. Study protocol registered at https://doi.org/10.17605/OSF.IO/MD4K5.

RESULTS

We identified 1,434 publications, yielding 22 studies that met inclusion criteria. Models of care characteristics included the use of technology, education to parents and staff, funding to utilize innovative models of care, assessment variability, organizational management changes, increased visit length, earlier timeline for neurodevelopmental screening, and collaboration with current office staff or nonphysician practitioners. The top 4 providers were paediatricians, general or family practitioners, nurse/nurse practitioners, and office staff. All studies aligned with occupational therapy health promotion scope of practice and intervention approach yet did not include occupational therapy within the paediatric primary care setting.

CONCLUSIONS

No studies included occupational therapy as a healthcare provider that could be used within the paediatric primary care setting. However, all studies demonstrated models of care facilitating characteristics aligning with occupational therapy practice. Models of care facilitating characteristics identified interdisciplinary staff as a major contributor, which can include occupational therapy, to improve early detection within paediatric primary care.

Early Cerebral Palsy Detection and Intervention

Early identification of cerebral palsy (CP) facilitates optimal care, support, and outcomes for children and their families. Ideally, infants with risk factors or developmental deviations should be evaluated early using standardized assessments of neurodevelopment and brain imaging. If a diagnosis of CP or high risk for CP (HRCP) is established, specialized, evidence-informed therapy and family support should be initiated. With task-specific motor skill training and an enriched environment, infants with CP show greater gross motor and cognitive gains. These enhanced outcomes are only achievable with early diagnosis and subsequent intervention.

Implementation of Early Detection and Intervention for Cerebral Palsy in High-Risk Infant Follow-Up Programs: U.S. and Global Considerations

Early detection and intervention for cerebral palsy is best practice for all high-risk infants according to international guidelines, consensus statements and research-supported evidence. It allows support for families and optimization of developmental trajectories into adulthood. All phases of implementation of CP early detection can be found across the world in high-risk infant follow-up programs, demonstrating feasibility and acceptability through standardized implementation science. The largest clinical network for CP early detection and intervention in the world has now sustained an average age at detection less than 12 months corrected age for more than 5 years. Targeted referrals and interventions for CP can now be offered to patients in optimal periods of neuroplasticity, and new therapies researched as the age of detection decreases. Implementation of guidelines and incorporation of rigorous CP research studies both allow high-risk infant follow-up programs to fulfill their mission of improving outcomes of those with the most vulnerable developmental trajectories from birth.

High-Risk Infant Follow-Up After NICU Discharge: Current Care Models and Future Considerations

Preterm infants are at heightened risk for chronic health problems and developmental delays compared with term-born peers. High-risk infant follow-up programs provide surveillance and support for problems that may emerge during infancy and early childhood. Although considered standard of care, program structure, content, and timing are highly variable. Families face challenges accessing recommended follow-up services. Here, the authors review common models of high-risk infant follow-up, describe novel approaches, and outline considerations for improving the quality, value, and equity of follow-up care.

From guidelines to practice: A retrospective clinical cohort study investigating implementation of the early detection guidelines for cerebral palsy in a state-wide early intervention service

OBJECTIVES

To report on knowledge translation strategies and outcomes from the implementation of the early detection guidelines for cerebral palsy (CP) in a state-wide tertiary early intervention (EI) service and investigate the impact of social determinants on clinical services.

DESIGN

Retrospective longitudinal cohort study.

SETTING

The Western Australia tertiary paediatric EI service.

PARTICIPANTS

EI clinicians, consumers and children using the EI service.

OUTCOME MEASURES

Knowledge translation strategies including consumer perspectives, clinician training and Communities of Practice (CoP) guided implementation. We measured changes in referral number and age, delivery of early detection and intervention following the implementation of the guidelines. Exposure to adverse childhood experiences (ACEs), appointment non-attendance (DNA) rates, remoteness and socioeconomic quintiles were used to measure social determinants of health using negative binomial (Incidence Rate Ratios, IRR) and logistic regression (Odds Ratios, ORs).

RESULTS

Ten consumers participated in Focus Groups, 100 clinicians were trained and 22 clinicians established a monthly CoP. Referrals increased fourfold to 511 children. Corrected gestational age at referral decreased from a median of 16.1 to 5.1 months (p<0.001) and at first appointment from 18.8 to 6.8 months (p<0.001). Children living in social disadvantage had the highest DNA risk (quintile 1 vs 5: IRR 2.2, 95% CI 1.1 to 4.6, p=0.037). Children exposed to ACEs had higher odds of living in social disadvantage (quintile 1 vs 5, OR=3.8, 95% CI 1.4 to 10.0, p=0.007). No significant association was found between remoteness and DNA rate or ACE score.

CONCLUSIONS

Implementation strategies reduced referral age and improved the delivery of early detection assessments. Further investigation of the association between social disadvantage, DNA risk and ACE score is required in the development of a state-wide early detection network.

Trihexyphenidyl in young children with dystonic cerebral palsy: A single arm study

PURPOSE

The incidence of dystonic cerebral palsy causing significant morbidity is on the rise. There is a paucity of evidence for the management of dystonia in children.

METHODS

Forty-one children aged 6 months-5 years with predominantly dystonic cerebral palsy were started on a predetermined protocol of trihexyphenidyl (0.25-0.52 mg/kg) and followed up at 3, 6 and 12 weeks. Dystonia severity, motor function and developmental age at baseline and 12 weeks were compared using the Global Dystonia Scale (GDS), the Gross Motor Function Measure (GMFM), and Fine Motor/Perceptual Subscale of the Early Developmental Profile-2. Thirty-four children completed the entire 12 weeks of intervention.

RESULTS

The mean age of participants was 25±11 months. A significant decrease in median total dystonia scores on the GDS was observed post-intervention (74.5 to 59, p <  0.0001), and 64% of participants gained motor milestones. GMFM scores increased significantly from a median of 19.8% pre-intervention to 26.5% post-intervention (p <  0.0001). There was improvement in the fine motor domain as compared to the baseline (p <  0.0001). The number of children classified at Gross Motor Function Classification System levels 1 and 2 increased to 47.05% from 5.88% in the pre-intervention group.

CONCLUSION

Trihexyphenidyl significantly improved dystonia, motor function and development in children with dystonic cerebral palsy in this study. Additional studies are needed to clarify its role in larger numbers of children with this condition.

Motor Optimality Scores are significantly lower in a population of high-risk infants than in infants born moderate-late preterm

BACKGROUND

The Motor Optimality Score-Revised (MOS-R) is a detailed scoring of the General Movement Assessment (GMA), measuring the spontaneous behaviors of infants. Infants born moderate-late preterm are not traditionally followed in high-risk clinics, but have increased risk of neurodevelopmental disability.

AIMS

Compare MOS-R at 3 months corrected age (CA) in high-risk (HR; very preterm or abnormal neuroimaging) infants to infants born moderate-late preterm (MLP).

STUDY DESIGN

In this prospective cohort study, parents of enrolled infants created video recordings using an app at 3 months CA. Videos were scored with the General Movement Assessment (GMA) and MOS-R. MOS-R scores were divided into "higher-risk" (≤19) and "lower-risk" (≥20).

SUBJECTS

181 infants born MLP or categorized as HR.

RESULTS

Among enrolled infants, 68 (38 %) were in the MLP group, and 113 infants were in the HR group. The HR group had 3.8 increased odds of having an aberrant GMA score compared to the MLP group (p < 0.01, 95 % CI 1.38-10.52). The HR group had significantly lower MOS-R scores (mean 20) than the MLP group (mean 24; p < 0.001; 95%CI 3.3-7.3). The HR group had 11.2 increased odds of having a higher-risk MOS-R score (95%CI 2.5-47.6, p < 0.001) than MLP group. Infants were most likely to have a lower MOS-R score if they had any of the following: VP shunt placement, periventricular leukomalacia, or bronchopulmonary dysplasia.

CONCLUSIONS

Aberrant GMA and higher-risk MOS-R scores were more common in infants at high-risk, reflecting history of brain lesions and younger gestational age at birth.

Predictive value of the test of infant motor performance and the Hammersmith infant neurological examination for cerebral palsy in infants

BACKGROUND

Current recommendations for early detection tools for cerebral palsy (CP) include assessments that vary in feasibility and resource requirements. The predictive value of less resource-intensive tools has not been fully explored.

AIMS

To determine the predictive value of the Test of Infant Motor Performance (TIMP) at 3-4 months corrected age (CA) for CP, and whether administration of both the TIMP and the Hammersmith Infant Neurological Exam (HINE) improves early CP detection.

STUDY DESIGN

Five-year retrospective observational study of infants who received the TIMP and the HINE at 3-4 months CA in a high-risk follow-up clinic. TIMP and HINE cut-off scores (alone and in combination) were compared for CP discriminatory ability.

SUBJECTS

Of patients with HINE scores (n = 1389; 676 [48.7 %] female; median gestational age at birth 31 weeks [interquartile range 29-34 weeks]), 1343 had concurrent TIMP scores available.

OUTCOME MEASURES

Clinical diagnosis of CP.

RESULTS

HINE total score <57 had optimal CP predictive value (AUC = 0.815; 77 % sensitivity; 91 % specificity) compared to optimal TIMP cut-off (1 SD below the mean, AUC = 0.71; 52 % sensitivity; 94 % specificity) and all tested TIMP and HINE combinations (all p < 0.001).

CONCLUSIONS

HINE total score <57 at 3-4 months CA had the best CP predictive value, confirming its value absent first-line detection tools. Concurrent administration of TIMP did not improve predictive value.

Le suivi de l'extrême prématuré après le congé des soins intensifs néonatals

La survie des extrêmes prématurés (moins de 28 semaines d'âge gestationnel) s'est améliorée au fil du temps. Bon nombre s'en sortent bien et ont une bonne qualité de vie. Ils demeurent toutefois vulnérables à des problèmes de santé, y compris des difficultés neurosensorielles et neurodéveloppementales, que les médecins de première ligne, les pédiatres et les cliniques spécialisées doivent surveiller. Le présent document de principes passe en revue les conséquences médicales et neurodéveloppementales potentielles pour les extrêmes prématurés dans les deux ans suivant leur congé et fournit des stratégies de counseling, de dépistage précoce et d'intervention. Parce qu'ils sont tous liés à l'extrême prématurité, la dysplasie bronchopulmonaire ou les troubles respiratoires, les problèmes d'alimentation et de croissance, le développement neurosensoriel (vision et audition), la paralysie cérébrale et le trouble du spectre de l'autisme doivent faire rapidement l'objet d'une évaluation. Pour évaluer la croissance et le développement, il faut corriger l'âge chronologique en fonction de l'âge gestationnel jusqu'à 36 mois de vie. Par ailleurs, l'attention au bien-être émotionnel des parents et des proches fait partie intégrante des soins de qualité de l'extrême prématuré.

Follow-up care of the extremely preterm infant after discharge from the neonatal intensive care unit

The survival of babies born extremely preterm (EP, <28 weeks gestation) has improved over time, and many have good outcomes and quality of life. They remain at risk for health issues, including neurosensory and neurodevelopmental difficulties requiring monitoring by primary physicians, paediatricians, and specialty clinics. This statement reviews potential medical and neurodevelopmental consequences for EP infants in the first 2 years after discharge and provides strategies for counselling, early detection, and intervention. EP-related conditions to assess for early include bronchopulmonary dysplasia or respiratory morbidity, feeding and growth concerns, neurosensory development (vision and hearing), cerebral palsy, and autism spectrum disorder. Correction for gestational age should be used for growth and development until 36 months of age. Integral to quality care of the child born EP is attention to the emotional well-being of parents and caregivers.

Accuracy of the Hammersmith infant neurological examination for the early detection of neurological changes in infants exposed to Zika virus: A case-cohort study

The Hammersmith infant neurological examination (HINE) is a highly predictive tool for the easy and low-cost detection of cerebral palsy. Between 2015 and 2016, the rapid spread of the Zika virus (ZIKV) in Brazil was responsible for an increase in microcephaly cases. This study aimed to verify the accuracy of the HINE for the early detection of neurological problems in Brazilian babies exposed to ZIKV.This was a cross sectional case-control study of children exposed to ZIKV. This study was part of the Jundiaí ZIKV Cohort. Of a total sample of 782 children, 98 were evaluated (26 in the exposed group and 63 in the control group). We included late preterm infants and term infants who were exposed to the ZIKV and were participants in the ZIKV Cohort study. Student's t-test and stepwise multivariate logistic regression were used to compare groups.Of the 26 items evaluated in the five scored categories of the HINE (cranial nerve function, posture, movements, tone, reflexes, and reactions), only the difference in ankle dorsiflexion between the exposed and the control groups was statistically significant. However, some items showed a significant trend in relation to the control group.Our results demonstrated the importance of early neurological assessment of infants exposed to ZIKV, even in those without a microcephaly diagnosis.

Early Diagnosis of Cerebral Palsy in Low- and Middle-Income Countries

Cerebral palsy describes a group of permanent disorders of movement, motor function and posture that occur due to non-progressive insults to the developing brain. Most of the information concerning the early diagnosis of cerebral palsy originates from studies conducted in high-income countries. In this scoping review, we aimed to explore the tools used in low- and middle-income countries for the early diagnosis of cerebral palsy. A systematic search was conducted using OVID Medline and PubMed databases. “Early diagnosis” was defined as diagnosis prior to 12 months of age, and low- and middle-income countries were classified according to the World Bank classification system. We identified nine studies on the early diagnosis of cerebral palsy from low- and middle-income countries. The tools featured (n = number of studies) were: General Movement Assessment (6), neonatal magnetic resonance imaging (3), Hammersmith Neonatal Neurological Examination (2), Hammersmith Infant Neurological Examination (1) and cranial ultrasound (1). We found a paucity of published literature on the early diagnosis of cerebral palsy from low- and middle-income countries. Further research is needed to determine the tools that are accurate and feasible for use in low-resource settings, particularly since cerebral palsy is more prevalent in these areas.

Tool Use for Early Detection of Cerebral Palsy: A Survey of Spanish Pediatric Physical Therapists

PURPOSE

The purpose of this study was to assess the use of diagnostic assessment tools in pediatric physical therapy practice in Spain. Best practice recommendations indicate the timely use of key assessment tools to reduce the age of diagnosis of cerebral palsy (CP).

METHODS

Pediatric physical therapists currently working in Spain in early intervention were recruited through targeted physical therapy entities. They were invited to complete the purpose-developed electronic survey, consisting of 45 multiple-choice questions, with 5 thematic blocks.

RESULTS

Results from 140 anonymous respondents were analyzed. The average reported age when CP was suspected was 12.6 months. Most used the child's clinical history (88.1%), the Alberta Infant Motor Scale (41.3%), and Vojta Assessment Procedure (32.1%) to assess and detect CP. General Movements Assessment (25.7%) and Hammersmith Infant Neurological Examination (28.4%) were used infrequently.

CONCLUSIONS

Currently, pediatric physical therapists in Spain rely on clinical history and outdated tools to identify children with CP.Digital Abstract available at: http://links.lww.com/PPT/A361 (English).Digital Abstract available at: http://links.lww.com/PPT/A362 (Spanish).

Neonatal Neuroimaging in Neonatal Intensive Care Graduates Who Subsequently Develop Cerebral Palsy

Cerebral palsy is a common cause of physical disability. The New Zealand Cerebral Palsy Register (NZCPR) was established in 2015 and reports national data. Internationally, an early CP diagnosis has been a focus, with imaging and clinical tools used to enable early accurate detection. Accordingly, guidelines are being developed for New Zealand, including a specific pathway for high-risk neonatal intensive care (NICU) graduates, reflecting the high rate of CP in this group. To inform this work, we reviewed imaging data from a retrospective NICU cohort identified from the NZCPR. In these 140 individuals with CP and a confirmed NICU admission during 2000–2019 inclusive, imaging frequency, modality, and rate of abnormality was determined. Overall, 114 (81.4%) had imaging performed in the NICU, but the frequency and modality used varied by gestational subgroup. For infants born at less than 32 weeks gestation, 53/55 had routine imaging with ultrasound, and IVH was graded as none or mild (grade 1–2) in 35 or severe (grade 3–4) in 18 infants. For the 34 infants born between 32–36 weeks gestation, only 13/19 imaged in the NICU were reported as abnormal. For 51 term-born infants, 41/42 imaged in the NICU with MRI had abnormal results.

Constraint-Induced Movement Therapy for Infants With or at Risk for Cerebral Palsy: A Scoping Review

IMPORTANCE

Although research shows that older children with hemiplegic cerebral palsy (CP) benefit from constraint-induced movement therapy (CIMT), the efficacy of CIMT among the infant population is unknown.

OBJECTIVE

To explore the existing evidence on CIMT for infants age 24 mo and younger with CP or at risk for CP.

DATA SOURCES

PubMed, CINAHL, Cochrane, and ProQuest were searched. Study Selection and Data Collection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and American Occupational Therapy Association guidelines were used for abstracting data and assessing data quality. Two frameworks guided this scoping review. Studies met the following criteria: infants with hemiplegic CP, published in English between 2000 and 2020, peer reviewed, and addressed changes in upper limb function of the hemiplegic upper limb.

FINDINGS

Eight articles met the inclusion criteria: 2 randomized controlled trials, 1 retrospective cohort design, 1 pretest-posttest study, 2 single-subject studies, and 2 case studies. In this scoping review, we examined CIMT protocols for an overview of dosage, constraint, administration, parent training and education, and objective outcome measures.

CONCLUSIONS AND RELEVANCE

Existing literature supports CIMT protocols for infants with CP. However, much variability exists in protocol design and appropriate outcome measures among studies. Higher level research is needed to support the efficacy of CIMT among infants with CP. What This Article Adds: This scoping review summarizes the existing literature on CIMT for infants with hemiplegic CP. This information can help guide therapists to implement CIMT protocols in the clinical setting and to identify additional research to establish practice standards.

A neonatal neuroNICU collaborative approach to neuromonitoring of posthemorrhagic ventricular dilation in preterm infants

Morbidity and mortality in prematurely born infants have significantly improved due to advancement in perinatal care, development of NeuroNICU collaborative multidisciplinary approaches, and evidence-based management protocols that have resulted from a better understanding of perinatal risk factors and neuroprotective treatments. In premature infants with intraventricular hemorrhage (IVH), the detrimental secondary effect of posthemorrhagic ventricular dilation (PHVD) on the neurodevelopmental outcome can be mitigated by surgical intervention, though management varies considerably across institutions. Any benefit derived from the use of neuromonitoring to optimize surgical timing and technique stands to improve neurodevelopmental outcome. In this review, we summarize (1) the approaches to surgical management of PHVD in preterm infants and outcome data; (2) neuromonitoring modalities and the effect of neurosurgical intervention on this data; (3) our resultant protocol for the monitoring and management of PHVD. In particular, our protocol incorporates cerebral near-infrared spectroscopy (NIRS) and transcranial doppler ultrasound (TCD) to better understand cerebral physiology and to enable the hypothesis-driven study of the management of PHVD. IMPACT: Review of the published literature concerning the use of near-infrared spectroscopy (NIRS) and a cerebral Doppler ultrasound to study the effect of cerebrospinal fluid drainage on infants with posthemorrhagic ventricular dilation. Presentation of our institution's evidence-based protocol for the use of NIRS and cerebral Doppler ultrasound to study the optimal neurosurgical treatment of posthemorrhagic ventricular dilation, an as yet inadequately studied area.