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

Efficacy of Early Intervention for Infants With Cerebral Palsy in an LMIC: An RCT

OBJECTIVE

To test efficacy of a parent-delivered multidomain early intervention (Learning through Everyday Activities with Parents [LEAP-CP]) for infants with cerebral palsy (CP) compared with equal-dose of health advice (HA), on (1) infant development; and (2) caregiver mental health. It was hypothesized that infants receiving LEAP-CP would have better motor function, and caregivers better mental health.

METHODS

This was a multisite single-blind randomized control trial of infants aged 12 to 40 weeks corrected age (CA) at risk for CP (General Movements or Hammersmith Infant Neurologic Examination). Both LEAP-CP and HA groups received 15 fortnightly home-visits by a peer trainer. LEAP-CP is a multidomain active goal-directed intervention. HA is based on Key Family Practices, World Health Organization. Primary outcomes: (1) infants at 18 months CA: Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT mobility); and (2) caregiver: Depression Anxiety and Stress Scale.

RESULTS

Of eligible infants, 153 of 165 (92.7%) were recruited (86 males, mean age 7.1±2.7 months CA, Gross Motor Function Classification System at 18 m CA: I = 12, II = 25, III = 9, IV = 18, V = 32). Final data were available for 118 (77.1%). Primary (PEDI-CAT mobility mean difference = 0.8 (95% CI -1.9 to 3.6) P = .54) and secondary outcomes were similar between-groups. Modified-Intention-To-Treat analysis on n = 96 infants with confirmed CP showed Gross Motor Function Classification System I and IIs allocated to LEAP-CP had significantly better scores on PEDI-CAT mobility domain (mean difference 4.0 (95% CI = 1.4 to 6.5), P = .003) compared with HA.

CONCLUSIONS

Although there was no overall effect of LEAP-CP compared with dose-matched HA, LEAP-CP lead to superior improvements in motor skills in ambulant children with CP, consistent with what is known about targeted goal-directed training.

Outcomes of a Parent-Delivered Baby-mCIMT Model for Infants at High Risk of Unilateral Cerebral Palsy Using Remote Coaching in Telerehabilitation

There is growing evidence of the positive effects of constraint-induced movement therapy (CIMT) for infants at high risk of unilateral cerebral palsy (UCP) when provided by parents with in-person coaching/supervision from occupational therapists during home visits. The aim of this study is to investigate whether Baby-mCIMT (modifiedCIMT) can be as effective if parents are coached/supervised remotely. In this case-control study, we recruited 20 infants and re-used 18 controls, 4-8-month-old infants in both groups at high risk of UCP. The same protocol regarding inclusion criteria, data collection, and training volume was used in both groups. The training was conducted for two 6-week periods, separated by a 6-week break, consisting of daily 30 min sessions conducted by parents, supported by therapist coaching once a week. The primary outcome was measured using the Hand Assessment for Infants (HAI). There was no difference in the change of HAI units (p = 0.803) or that of the affected-hand raw score (p = 0.942) between the two groups. The remote coaching method was well received by parents. In conclusion, this demonstrates that remote coaching/supervision is as effective as the in-person approach, requiring less time and effort for both families and healthcare providers.

Factors influencing caregiver buy-in to early intervention physical therapy

OBJECTIVE

The family-centered care framework of Early Intervention (EI) has shifted the focus toward caregiver engagement, but the underlying processes that build this are unknown. The aims of this study were 1) to describe the process of caregiver engagement in therapy and (2) to identify factors perceived to influence caregiver buy-in, confidence, and engagement in EI.

METHODS

This preliminary descriptive study utilized quantitative questionnaires and qualitative semi-structured interviews of EI participants (23 caregivers and four physical therapists). Interviews were transcribed and theme coded until saturation was achieved and a concept map was developed.

RESULTS

All caregivers believed that their children benefited from EI, that they were empowered and confident in caring for their children, and their quality of life improved based on the quantitative data. The qualitative data revealed that building a rapport and therapeutic relationship is the foundation to developing buy-in. Reciprocal communication is critical to the relationship and the buy-in. Caregiver knowledge and awareness of progress foster caregiver buy-in and confidence once the relationship is established.

CONCLUSION

Improved understanding of the factors influencing the development of buy-in will provide a framework for the clinician to enhance caregiver buy-in. Enhanced buy-in may promote parental engagement and improved outcomes for the child and family.

Early Intensive Bimanual Stimulation Program (BB-Bim) for Infants at Risk of Unilateral Cerebral Palsy: A Randomized, Multiple-Baseline, Single-Case Study

IMPORTANCE

Clinical practice guidelines for infants at high risk of cerebral palsy (CP) emphasize the importance of very early and intensive intervention.

OBJECTIVE

To determine the feasibility of a new, home-based, early intensive bimanual stimulation program (BB-Bim) and its impact on hand function in infants at risk of unilateral CP.

DESIGN

Single case experimental design, multiple baseline across subjects, lasting from 12 to 15 wk, including a 4- to 7-wk randomized baseline, followed by 8 wk of BB-Bim.

SETTING

Home.

PARTICIPANTS

Infants (ages 3-12 mo) with suspected unilateral CP, whose parents agreed to participate in the stimulation program.

INTERVENTION

Parent-provided bimanual stimulation 20 min/day, 6×/wk, with weekly occupational therapist coaching visits.

MEASURES

Weekly repeated measures were the Hand Assessment in Infants (HAI) and Goal Attainment Scaling (GAS). Feasibility and relevance were assessed with a logbook and a parental report, including 10 continuous 0-10 scaled questions.

RESULTS

Six infants were included (2 with left and 4 with right brain lesions). Parents provided a mean 3.4 to 6.2 stimulation sessions/wk. Feasibility and relevance were highly rated (Ms = 8.2-9.6, SDs = 0.2-1.3). Stimulation significantly improved HAI bimanual and total scores for all infants, with no impact on HAI unilateral scores. GAS scores improved with stimulation (significant for 3 infants).

CONCLUSIONS AND RELEVANCE

BB-Bim was feasible and tended to improve bimanual function in infants at risk of unilateral CP. What This Article Adds: Parent-provided daily bimanual stimulation at home is feasible when parents are coached weekly by an occupational therapist. Bimanual stimulation seems to improve functional interactions between the hands among infants at high risk of unilateral CP.

Engaging the Lower Extremity via Active Therapy Early (ELEVATE) Is Feasible and May Improve Gross Motor Function in Children with Spastic Bilateral Cerebral Palsy: A Case Series

Purpose

The feasibility of ELEVATE with respect to adherence and preliminary efficacy was determined for children with spastic bilateral cerebral palsy (CP) from encephalopathy of prematurity.

Methods

A case series was used. Participants were randomized to receive ELEVATE immediately or delay the intervention by 3 months before receiving the intervention. The outcomes included feasibility measures of (1) number of children recruited, (2) percentage of sessions attended, (3) stride counts during the intervention, and preliminary efficacy measures of change over the intervention period in (4) Gross Motor Function Measure-66 (GMFM-66), and (5) kinematics and weight-bearing during treadmill walking.

Results

Four boys under 3 years of age participated. All participants tolerated 60-minute intervention sessions four times/week for 12 weeks, and attended 75%-94% (min-max) of the targeted sessions. The median step count per session ranged from 833 to 2484 steps (min-max) during the final week of training. Participants showed an increase in GMFM-66 score of 2.4-7.5 points (min-max) over the 3-month intervention phase, as compared to a decrease of 1.7 for one participant and an increase of 1.3 for another over the delay period. Three participants demonstrated small improvements in their gait with the intervention.

Conclusions

Engaging young children with bilateral CP in intensive rehabilitation targeting gross motor function was feasible and demonstrated preliminary efficacy. The results have guided the design of a larger clinical trial to assess efficacy of early, active interventions for children with spastic bilateral CP.

Parental Coping, Representations, and Interactions with Their Infants at High Risk of Cerebral Palsy

The aim of this study is to describe parental coping, representations, and interactions during the time of inclusion in the Small Step early intervention program for infants at high risk of cerebral palsy (CP) in Norway (ClinicalTrials.gov: NCT03264339). Altogether, 11 infants (mean age 4.8 months, SD: 1.5) and their parents (mothers: n = 10, fathers: n = 9) were included. Parental coping was assessed using the Parenting Stress Index-Short Form (PSI-SF) and the Hospital Anxiety and Depression Scale (HADS). Parental representations and parent-infant interactions were assessed using the Working Model of the Child Interview (WMCI) and the Parent-Child Early Relational Assessment (PCERA). Parents' PSI-SF and HADS scores were within normal range; however, 26.7% showed symptoms of stress, 52.6% showed symptoms of anxiety, and 31.6% showed symptoms of depression above the cut-off. WMCI results indicate that 73.7% of the parents had balanced representations. For PCERA, the subscale Dyadic Mutuality and Reciprocity was of concern, while two other subscales were in areas of strength and three subscales in some concern areas. There were no differences between mothers and fathers. Most of the parents had balanced representations, some had mental or stress symptoms and many were struggling with aspects of the parent-infant interaction. This knowledge could be useful when developing more family-centered interventions.

Effect of Motor Intervention for Infants and Toddlers With Cerebral Palsy: A Systematic Review and Meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis on the effect of motor intervention on motor function of infants and toddlers with cerebral palsy (CP).

METHODS

Four databases were searched for randomized controlled trials (RCTs) of motor interventions for children with or at high risk of CP younger than 36 months. Studies were excluded if less than 50% of children developed CP.

RESULTS

Eleven RCTs included 363 children; 85% diagnosed with CP. Very low-quality evidence supports that: (1) task-specific motor training was more effective than standard care for improving motor function (small effect), (2) constraint-induced movement therapy (CIMT) may be more effective than bimanual play or massage for improving function of the more affected hand (moderate effect), and high-intensity treadmill training is no more effective than low-intensity for improving walking.

CONCLUSIONS

Very low-quality evidence supports that task-specific motor training and CIMT may improve motor function of infants and toddlers with CP.The Supplemental Digital Content Video Abstract is available at: http://links.lww.com/PPT/A382 .

Parental engagement in early intervention for infants with cerebral palsy-A realist synthesis

BACKGROUND

Emphasis on parental engagement strategies within occupational therapy and physiotherapy early intervention (EI) programmes for infants at high risk of cerebral palsy (CP) has increased. This reflects consensus that increasing parent participation enhances treatment efficacy, potentially improving infant and parent outcomes. However, evaluation of parental engagement in EI is complex. Despite the growing application of parental engagement strategies, aligned with family-centred care practice, theoretical evaluation is currently lacking within the literature. This realist synthesis aimed to identify component theories underlying EI strategies to support parental engagement and to use empirical findings to evaluate how these work in practice.

METHODS

Realist synthesis: Databases Medline, Embase, Amed, CINAHL and PsychInfo were searched (from February 1985 - February 2020); further articles were sourced from reference lists. A data extraction form was used, and a Critical Appraisal Skills Programme tool was used to assess study rigour.

RESULTS

Twenty-six articles were included. Quality of relationships, parent education and intervention co-design were the key themes related to parental engagement strategies. Findings indicate that constructive parent reasoning mechanisms of trust, belief, sense of control, perceived feasibility of home programme delivery and ultimately motivation are linked to the underlying intervention resources afforded by specific strategies (e.g., coaching pedagogy). These responses are precursors to engagement outcomes that include increased parental self-efficacy and adherence. Importantly, parental self-efficacy can initiate a process of change leading to improved parental confidence and anxiety.

CONCLUSIONS

Sensitively designed programme strategies, centred on relational quality between parent, infant and therapist, are fundamental for effective parent connection, involvement and investment within EI for infants with CP.

Early, Intensive, Lower Extremity Rehabilitation Shows Preliminary Efficacy After Perinatal Stroke: Results of a Pilot Randomized Controlled Trial

Background

Perinatal stroke injures motor regions of the brain, compromising movement for life. Early, intensive, active interventions for the upper extremity are efficacious, but interventions for the lower extremity remain understudied.

Objective

To determine the feasibility and potential efficacy of ELEVATE—Engaging the Lower Extremity Via Active Therapy Early—on gross motor function.

Methods

We conducted a single-blind, two-arm, randomized controlled trial (RCT), with the Immediate Group receiving the intervention while the Delay Group served as a 3-month waitlist control. A separate cohort living beyond commuting distance was trained by their parents with guidance from physical therapists. Participants were 8 months to 3 years old, with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis. The intervention was play-based, focused on weight-bearing, balance and walking for 1 hour/day, 4 days/week for 12 weeks. The primary outcome was the Gross Motor Function Measure-66 (GMFM-66). Secondary outcomes included steps and gait analyses. Final follow-up occurred at age 4.

Results

Thirty-four children participated (25 RCT, 9 Parent-trained). The improvement in GMFM-66 over 12 weeks was greater for the Immediate than the Delay Group in the RCT (average change 3.4 units higher) and greater in younger children. Average step counts reached 1370-3750 steps/session in the last week of training for all children. Parent-trained children also improved but with greater variability.

Conclusions

Early, activity-intensive lower extremity therapy for young children with perinatal stroke is feasible and improves gross motor function in the short term. Longer term improvement may require additional bouts of intervention.

Clinical trial registration

This study was registered at ClinicalTrials.gov (NCT01773369).

From Hemispheric Asymmetry through Sensorimotor Experiences to Cognitive Outcomes in Children with Cerebral Palsy

Recent neuroimaging studies allowed us to explore abnormal brain structures and interhemispheric connectivity in children with cerebral palsy (CP). Behavioral researchers have long reported that children with CP exhibit suboptimal performance in different cognitive domains (e.g., receptive and expressive language skills, reading, mental imagery, spatial processing, subitizing, math, and executive functions). However, there has been very limited cross-domain research involving these two areas of scientific inquiry. To stimulate such research, this perspective paper proposes some possible neurological mechanisms involved in the cognitive delays and impairments in children with CP. Additionally, the paper examines the ways motor and sensorimotor experience during the development of these neural substrates could enable more optimal development for children with CP. Understanding these developmental mechanisms could guide more effective interventions to promote the development of both sensorimotor and cognitive skills in children with CP.

The developing brain: Challenges and opportunities to promote school readiness in young children at risk of neurodevelopmental disorders in low- and middle-income countries

This paper discusses possibilities for early detection and early intervention in infants with or at increased risk of neurodevelopmental disorders in low- and middle-income countries (LMICs). The brain's high rate of developmental activity in the early years post-term challenges early detection. It also offers opportunities for early intervention and facilitation of school readiness. The paper proposes that in the first year post-term two early detection options are feasible for LMICs: (a) caregiver screening questionnaires that carry little costs but predict neurodevelopmental disorders only moderately well; (b) the Hammersmith Infant Neurological Examination and Standardized Infant NeuroDevelopmental Assessment (SINDA) which are easy tools that predict neurodisability well but require assessment by health professionals. The young brain's neuroplasticity offers great opportunities for early intervention. Ample evidence indicates that families play a critical role in early intervention of infants at increased risk of neurodevelopmental disorders. Other interventional key elements are responsive parenting and stimulation of infant development. The intervention's composition and delivery mode depend on the infant's risk profile. For instance, in infants with moderately increased risk (e.g., preterm infants) lay community health workers may provide major parts of intervention, whereas in children with neurodisability (e.g., cerebral palsy) health professionals play a larger role.

GMFCS level improvement in children with cerebral palsy treated with repeat botulinum toxin injections and intensive rehabilitation: A retrospective study

PURPOSE

The Gross Motor Functional Classification System (GMFCS) provides a standardized classification of motor disability in children with cerebral palsy (CP) that is typically considered longitudinally stable. Here, changes in GMFCS levels of children with CP who received repeated botulinum toxin A (BoNT-A) injections within an intensive rehabilitation approach were evaluated.

METHODS

This retrospective, observational study included 503 children with CP (GMFCS I-V) treated in a single university rehabilitation clinic. Individualized treatment plans and a variety of rehabilitation techniques were incorporated within an integrated model of care. Each child received≥2 repeated BoNT-A injections as well as an intensive rehabilitation program.

RESULTS

GMFCS level following repeat treatment improved in 42.1% of the patients and worsened in 3 patients; 14.9% of children showed improvement after 1 treatment cycle, 12.3% after 2 cycles, 7.6% after 3 cycles, 3.6% after 4 cycles, and 3.8% after≥5 cycles. Type of involvement (p < 0.001), baseline GMFCS (p = 0.001), number of treatment cycles (p < 0.001) and presence of severe dystonia (p = 0.032) were significant predictors of GMFCS improvement, but age and gender were not.

CONCLUSION

Children with CP may change GMFCS level when intensive rehabilitation programs are combined with repeated BoNT-A injections.

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.

Early intervention evidence for infants with or at risk for cerebral palsy: an overview of systematic reviews

AIM

To perform an overview of systematic reviews and more recent randomized controlled trials (RCTs) on early motor interventions in infants aged 0 to 3 years with or at risk of cerebral palsy to inform current clinical and research efforts and provide a benchmark to assess future interventions ideally initiated within the first 6 months.

METHOD

Standardized searches of the PubMed, Embase, Scopus, and Web of Science databases were conducted for systematic reviews (2009-2020) and RCTs (2015-2020).

RESULTS

From 840 unique records, 31 full texts were reviewed, yielding three systematic reviews encompassing 46 studies, 16 with comparison groups, and six additional RCTs that met the criteria. Two enrichment- and activity-based approaches had medium effect sizes on motor development, only one with low risk of bias; two others had large task-specific effect sizes but some bias concerns; and three enriched environment studies with some bias concerns had medium effect sizes on cognitive development. Most had small or no effect sizes, bias concerns, and uncertain diagnostic determinations.

INTERPRETATION

Data synthesis revealed limited data quantity and quality, and suggest, although not yet confirmed, greater benefit from early versus later intervention. Research efforts with greater early diagnostic precision and earlier intervention are accelerating, which may transform future outcomes and practices. What this paper adds For over 50% of trials within the reviews, the intervention was compared to standard care with only two showing efficacy. Similar to results in older children, constraint-induced movement therapy (CIMT) emerged as efficacious with high effect sizes. CIMT was not superior to similarly intense bimanual training or occupational therapy. Goals-Activity-Motor Enrichment intervention initiated before 5 months of age was superior to equally intense standard care. Several other enriched environment strategies promoted cognitive and/or motor development.

Perinatal stroke: mapping and modulating developmental plasticity

Most cases of hemiparetic cerebral palsy are caused by perinatal stroke, resulting in lifelong disability for millions of people. However, our understanding of how the motor system develops following such early unilateral brain injury is increasing. Tools such as neuroimaging and brain stimulation are generating informed maps of the unique motor networks that emerge following perinatal stroke. As a focal injury of defined timing in an otherwise healthy brain, perinatal stroke represents an ideal human model of developmental plasticity. Here, we provide an introduction to perinatal stroke epidemiology and outcomes, before reviewing models of developmental plasticity after perinatal stroke. We then examine existing therapeutic approaches, including constraint, bimanual and other occupational therapies, and their potential synergy with non-invasive neurostimulation. We end by discussing the promise of exciting new therapies, including novel neurostimulation, brain-computer interfaces and robotics, all focused on improving outcomes after perinatal stroke.

Peabody Developmental Motor Scales - Second Edition (PDMS-2): Reliability, content and construct validity evidence for Brazilian children

BACKGROUND

The Peabody Developmental Motor Scales - Second Edition (PDMS-2) has been used by health and educational professionals to assess the gross and fine motor skills of children with typical development, motor and/or cognitive delays, and disabilities.

AIM

Investigate the validity and reliability of PDMS-2 for use in Brazil.

METHODS

For content validity, 13 professionals participated in the study. For construct validity, a sample of 637 children from birth until 71 months (0-23 months: n = 399; 24-71 months: n = 238) was assessed with the PDMS-2.

RESULTS

The PDMS-2 administered to the Brazilian population has psychometric characteristics equivalent to the original version.

CONCLUSION

PDMS-2 is a valid and reliable tool for evaluating Brazilian children's motor development and providing appropriate support for clinical and educational intervention plans and follow-ups.

Early Diagnostics and Early Intervention in Neurodevelopmental Disorders-Age-Dependent Challenges and Opportunities

This review discusses early diagnostics and early intervention in developmental disorders in the light of brain development. The best instruments for early detection of cerebral palsy (CP) with or without intellectual disability are neonatal magnetic resonance imaging, general movements assessment at 2-4 months and from 2-4 months onwards, the Hammersmith Infant Neurological Examination and Standardized Infant NeuroDevelopmental Assessment. Early detection of autism spectrum disorders (ASD) is difficult; its first signs emerge at the end of the first year. Prediction with the Modified Checklist for Autism in Toddlers and Infant Toddler Checklist is possible to some extent and improves during the second year, especially in children at familial risk of ASD. Thus, prediction improves substantially when transient brain structures have been replaced by permanent circuitries. At around 3 months the cortical subplate has dissolved in primary motor and sensory cortices; around 12 months the cortical subplate in prefrontal and parieto-temporal cortices and cerebellar external granular layer have disappeared. This review stresses that families are pivotal in early intervention. It summarizes evidence on the effectiveness of early intervention in medically fragile neonates, infants at low to moderate risk, infants with or at high risk of CP and with or at high risk of ASD.

Feeding modifications and additional primary caregiver support for infants exposed to Zika virus or diagnosed with congenital Zika syndrome: a rapid review of the evidence

OBJECTIVE

Infants exposed to Zika virus (ZIKV) or diagnosed with congenital Zika syndrome (CZVS) may present dysphagia, regurgitation and other feeding difficulties. They may require special feeding practices to minimise the risk of mortality, morbidity and developmental problems. Improving knowledge, skills and behaviours of caregivers may preserve health, maximise development and promote quality of life among affected infants. We reviewed intervention studies of modified feeding practices and additional primary caregiver support to improve outcomes among infants 0 to 12 months of age exposed to ZIKV or diagnosed with CZVS.

METHODS

Rapid review and meta-analysis. We searched PubMed/MEDLINE and contacted experts. The search is current to 18 July 2020. We planned a meta-analysis using fixed-effect models; if unfeasible, we intended to summarise studies narratively. We planned to assess risk of bias of included studies and quality of evidence using Cochrane guidance.

RESULTS

We identified 42 records for title and abstract screening; 14 were eligible for full-text assessment. Among these, no intervention studies were found. Eight observational studies reported on the nutritional status, feeding practices and outcomes among infants affected by ZIKV or diagnosed with CZVS. They are presented and discussed to provide a basis for future research.

CONCLUSIONS

While no intervention studies were found, evidence from eight observational studies highlights the need for early nutrition interventions and caregiver support among infants affected by ZIKV or diagnosed with CZSV. More research is needed to assess whether modifications of feeding practices and provision of additional primary caregiver support will impact outcomes of interest.

Do Infants at Risk of Developing Cerebral Palsy or Other Neurodevelopmental Disorders Learn What They Practice?

Through secondary analyses of the Small Step. Randomized Control Trial, we tested the hypothesis that children at risk of developing cerebral palsy (CP) or other neurodevelopmental disorders would learn what they practice, i.e., that they would have a more rapid development within the specifically trained foci (hand use or mobility) of each time period compared to the development rate within the foci not trained at that time. Nineteen infants (6.3 (1.62) months corrected age) included in the Small Step program were assessed at six time points during the intervention. For statistical analysis, general and mixed linear models were used, and the independent variables were the Peabody Developmental Motor scale (stationary, locomotion, grasping and visuomotor sub scales), the Gross Motor Function Measure-66 and the Hand Assessment for Infants. Outcomes related to gross motor function improved significantly more after mobility training than after hand use training, while fine motor function was improved to the same extent following both training types. Significantly higher improvements after the first training period were seen in one out of three outcome measures in both gross and fine motor assessments. The improvements observed were all independent of diagnosis at two years. The concept “you learn what you practice” was most clearly confirmed in the case of gross motor development.

Coaching approaches in early intervention and paediatric rehabilitation

Currently, coaching is increasingly applied to foster the involvement of families with an infant or young child with special needs in early intervention and paediatric rehabilitation. Coaching practices are included in many forms of intervention and are regarded as essential to reach beneficial outcomes for the child and family. There are, however, many ambiguities that blur the concept of coaching and hamper its understanding and integration as an evidence-based approach in early intervention and paediatric rehabilitation: lack of differentiation between coaching and training of families, for example. Challenges to incorporate coaching into professional practice relate to adult learning processes and knowledge acquisition, and transformation of attitudes, beliefs, and treatment habits. In this paper, we review the barriers encountered and the possibilities available to promote successful implementation of coaching in early childhood interventions. WHAT THIS PAPER ADDS: Literature defines coaching ambiguously, which hampers its implementation in early intervention. The term 'coaching' should be reserved for relationship-directed, family-centred intervention.

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.