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May 17, 2021

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

Author Affiliations
  • 1Cerebral Palsy Alliance Research Institute, Brain Mind Centre, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
  • 2University of Southern California, Los Angeles
  • 3Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
  • 4Clinic and Clinical Services, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
  • 5Grace Centre for Newborn Care, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
  • 6IRCCS Fondazione Stella Maris, Pisa, Italy
  • 7The University of Queensland, St Lucia, Queensland, Australia
  • 8University of Pisa, Pisa, Italy
  • 9National Institutes’ of Health, Bethesda, Maryland
  • 10Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
  • 11University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
  • 12Division of Phoniatrics, Medical University of Graz, Austria
  • 13Karolinska Institutet, Stockholm, Sweden
  • 14University of California, San Francisco, San Francisco
  • 15Holland Bloorview Kids Rehabilitation Hospital, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
  • 16Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
  • 17Teachers College, Columbia University, New York, New York
  • 18The Royal Children’s Hospital, Melbourne, Australia
  • 19Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
  • 20Duquesne University, Pittsburgh, Pennsylvania
  • 21University Children’s Hospital Zurich, Zurich, Switzerland
  • 22Nationwide Children’s Hospital, The Ohio State University, Columbus
  • 23Orygen, Parkville, Victoria, Australia
  • 24University of Melbourne, Parkville, Victoria, Australia
  • 25Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
  • 26Makerere University, Kampala, Uganda
  • 27Pediatric Neurology Unit, Fondazione Policlinico Universitario A. Gemelli, Universitá Cattolica del Sacro Cuore, Rome, Italy
  • 28Department of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia
  • 29The University of Sydney, Sydney, Australia
  • 30Perth Children’s Hospital, Nedlands, Western Australia, Australia
  • 31Curtin University, Perth, Australia
  • 32Eugene Child Development and Rehabilitation Center, Oregon Health and Science University, Eugene
JAMA Pediatr. 2021;175(8):846-858. doi:10.1001/jamapediatrics.2021.0878
Key Points

Question  What are the evidence-based recommendations to guide early intervention in children aged 0 to 2 years who have or are at high risk of cerebral palsy?

Findings  In this systematic review, there was good-quality evidence for involvement of parents in intervention programs and task-specific and context-specific interventions to improve motor and cognitive outcomes in children with cerebral palsy. The evidence in other developmental domains is not as strong, and conditional recommendations are based on other high-risk populations.

Meaning  It is critical that early intervention for cerebral palsy starts at diagnosis and the associated impairments are monitored and treated according to recommendations.


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.

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