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: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

Trends in Outcomes for Neonates Born Very Preterm and Very Low Birth Weight in 11 High-Income Countries

Objective To evaluate outcome trends of neonates born very preterm in 11 high-income countries participating in the International Network for Evaluating Outcomes of neonates. Study design In a retrospective cohort study, we included 154 233 neonates admitted to 529 neonatal units between January 1, 2007, and December 31, 2015, at 24(0/7) to 31(6/7) weeks of gestational age and birth weight <1500 g. Composite outcomes were in-hospital mortality or any of severe neurologic injury, treated retinopathy of prematurity, and bronchopulmonary dysplasia (BPD); and same composite outcome excluding BPD. Secondary outcomes were mortality and individual morbidities. For each country, annual outcome trends and adjusted relative risks comparing epoch 2 (2012-2015) to epoch 1 (2007-2011) were analyzed. Results For composite outcome including BPD, the trend decreased in Canada and Israel but increased in Australia and New Zealand, Japan, Spain, Sweden, and the United Kingdom. For composite outcome excluding BPD, the trend decreased in all countries except Spain, Sweden, Tuscany, and the United Kingdom. The risk of composite outcome was lower in epoch 2 than epoch 1 in Canada (adjusted relative risks 0.78; 95% CI 0.74-0.82) only. The risk of composite outcome excluding BPD was significantly lower in epoch 2 compared with epoch 1 in Australia and New Zealand, Canada, Finland, Japan, and Switzerland. Mortality rates reduced in most countries in epoch 2. BPD rates increased significantly in all countries except Canada, Israel, Finland, and Tuscany. Conclusions In most countries, mortality decreased whereas BPD increased for neonates born very preterm

Use of the General Movements Assessment for the Early Detection of Cerebral Palsy in Infants with Congenital Anomalies Requiring Surgery

The general movements (GMs) assessment is recognised as one of the most important tools in the early detection of cerebral palsy (CP). However, there remains a paucity of data on its application to infants with congenital anomalies requiring surgery. This was a prospective study of 202 infants (mean gestation 38 weeks, SD 2.2) who had undergone major surgery for congenital anomalies in the neonatal period. Infants were assessed at three months of age (mean 12 weeks, SD 1.6) and GMs videos were independently rated by three clinicians, two blinded to clinical details. Developmental follow-up was at three years of age. Of the twenty-five infants (9%) rated as having an absence of fidgety movements, 22 were seen at 3 years, and 17 had an abnormal outcome: 11 with CP, and 6 with a developmental disability. Infants with absent fidgety movements were 21.5 (95% CI 7.3&ndash;63.8) times more likely to have an abnormal outcome including CP. None of the infants with normal fidgety movements had a diagnosis of CP and 86% were assessed to be developing normally. The GMs assessment has predictive value for cerebral palsy and neurodevelopment for infants with congenital anomalies, and should be incorporated into routine follow-up to facilitate early referral

Clara cell secretory protein and inflammatory mediators in newborn infants at risk of bronchopulmonary dysplasia

The incidence of bronchopulmonary dysplasia (BPD) remains unchanged despite improved perinatal care. Measuring lung fluid inflammatory markers is a widely-used technique, but is invasive and difficult to collect in non-intubated newborn infants. Examining serum concentrations of inflammatory mediators is a less invasive investigation of lung inflammation. The primary aim was to determine early post-natal serum concentrations of anti-inflammatory Clara Cell Secretory Protein (CCSP) in relationship to newborn lung diseases and development of BPD. This included comparison of serum ([CCSP](serum)) and tracheal CCSP ([CCSP](TAF)), serum surfactant proteins A (SP-A) and B (SP-B), pro- and anti-inflammatory cytokines and S100A12; additionally whether measuring [CCSP](serum) and other markers is useful in predicting later BPD development, and finally whether CCSP can suppress inflammation in vitro. Blood was collected from infants during the first week and analysed for [CCSP](serum), surfactant proteins, S100A12 and cytokines using &#145;in-house&#146; and commercial assays, plus tracheal aspirates for CCSP. Recombinant CCSP (rhCC10) was used to assess suppression of lipopolysaccharide (LPS) and hyperoxia-induced inflammation in BEAS-2B cells in vitro. This unique research has confirmed a gestationally-influenced increase of [CCSP](serum) in the first day of life, correlating to [CCSP](TAF). The pattern of [CCSP](serum) differed to SP-A and -B which increased over the first week, and cytokines which showed no clear pattern. Full term infants had the highest day 1 [CCSP](serum) concentrations whilst BPD-prone preterm infants had the lowest concentrations of [CCSP](serum), and low anti-inflammatory interleukin-10 and -13 on day 7. Mechanical ventilation caused increased [CCSP](serum) in moderately preterm infants. In contrast, serum pro-inflammatory cytokine concentrations were not good predictors of later BPD development. Recombinant CCSP minimally suppressed LPS-induced inflammation but not with additional hyperoxia. A novel finding was that S100A12 was supressed in preterm infants with respiratory distress syndrome (a precursor of BPD), either due to altered neutrophil response or antenatal corticosteroid exposure. These findings suggest that an early increase in CCSP production is under gestational influence and may confer more pulmonary protection to term infants. Measuring [CCSP](serum) and other markers in the early post-natal period can provide a less-invasive and adjunctive measurement in monitoring BPD

Individualised developmental care for babies and parents in the NICU : evidence-based best practice guideline recommendations

Advances in neonatal care have improved survival of premature and critically ill infants; and while rates of some long-term neurodevelopmental problems in survivors have improved, such as cerebral palsy, there are others such as learning and behavioural difficulties that have not. The goal of improving long term neurodevelopmental morbidity has led to an increased focus on improving developmental care not only in neonatal long term follow- up clinics but within the NICU itself to capture the period of earliest brain neuroplasticity. The application of a systematic approach to improve practice is considered the most effective strategy for implementing neuroprotective developmentally supportive care. The content of this paper incorporates evidence-based systematic reviews to guide clinicians in the application of developmentally supportive interventions

The evolution of an interdisciplinary developmental round in a surgical neonatal intensive care unit

Background: Developmentally supportive environments are known to improve medical outcomes for hospitalized neonates and are considered the overarching philosophy for practice in the neonatal setting. Developmental rounds are a strategy incorporated by multidisciplinary teams to support development within and beyond the neonatal unit. Typically, they consist of bedside consultations and individualized developmentally supportive recommendations for families and clinicians. Globally, the use of developmental rounds has been described since the early 1990s. They are viewed as a measure to counter some of the barriers to developmental care implementation while buffering against the effect of an intensive care admission. To date, their use in the surgical neonatal intensive care unit (sNICU) has been minimally reported in literature. Purpose: This article describes the focus and work of a developmental round team and strategy in the sNICU. Method: A retrospective audit of developmental round key performance criteria undertaken over a 4-year period (2015-2018). Findings/Results: More than 300 developmental consults and 2000 individualized developmental recommendations occurred annually. Parental presence during the developmental round increased by 10%, from 48% to 58%, during the audit period. Implications for Practice/Implications for Research: Literature has supported the use of developmental round interventions; however, minimal data have been reported to date. This article provides retrospective audit data of a developmental round intervention in the sNICU with a focus on data over 4 years to highlight key areas, including the structure and process, recommended educational standards for team members, and parental engagement, as key markers for developmental round efficacy. Future research should focus on the link between the developmental round intervention and long-term neonatal outcomes

Are boys and girls just different? Gender differences in the Movement Assessment Battery for Children, 2nd edition (M ABC-2) suggests that they are

Introduction The second edition of the Movement Assessment Battery for Children (M ABC‐2) is a standardised, norm referenced assessment that is frequently used by therapists to identify children with motor difficulties. The norms for the M ABC‐2 were derived from a sample of children in the United Kingdom (UK) and are combined across the age groups for boys and girls. The aims of this research were to investigate gender differences in the performance of 8‐ and 9‐year‐old Australian children and if the norms in our cohort differed from UK‐based M ABC‐2 norms. Methods Children aged 8 or 9 years of age who underwent major neonatal cardiac or non‐cardiac surgery and healthy controls were assessed using the M ABC‐2 as part of the Development After Infant Surgery (DAISy) study. Results There were statistically significant differences in the scores for boys and girls aged 8‐ and 9‐years old on the M ABC‐2. Girls performed better than boys in manual dexterity and on total standard scores. Our control group compared to the assessment norms scored significantly poorer in manual dexterity, aiming and catching and total standard scores. Conclusion Caution should be used when interpreting the results of the M ABC‐2 for Australian 8‐ and 9‐year olds. Contemporary Australian, gender‐specific M ABC‐2 norms should be considered. Further research is required to investigate gender differences and differences in performance of Australian children compared to the assessment norms in other age groups on the M ABC‐2

'Big issues' in neurodevelopment for children and adults with congenital heart disease

It is established that neurodevelopmental disability (NDD) is common in neonates undergoing complex surgery for congenital heart disease (CHD); however, the trajectory of disability over the lifetime of individuals with CHD is unknown. Several â € big issues' remain undetermined and further research is needed in order to optimise patient care and service delivery, to assess the efficacy of intervention strategies and to promote best outcomes in individuals of all ages with CHD. This review article discusses â € gaps' in our knowledge of NDD in CHD and proposes future directions