Global prevalence of cerebral palsy: A systematic analysis

Multicenter Improvement in Screening for Dystonia in Young People With Cerebral Palsy

Background and Objectives

Dystonia is a common, debilitating, and often treatment-refractory motor symptom of cerebral palsy (CP), affecting 70%-80% of this population based on research assessments. However, routine clinical evaluation for dystonia in CP has failed to match these expected numbers. Addressing this diagnostic gap is a medical imperative because the presence of dystonia rules in or out certain treatments for motor symptoms in CP. Therefore, our objective was to optimize rates of clinical dystonia screening to improve rates of clinical dystonia diagnosis.

Methods

Using the quality improvement (QI) infrastructure of the Cerebral Palsy Research Network (CPRN), we developed and implemented interventions to increase the documentation percentage of 5 features of dystonia in young people with CP, aged 3-21 years. This QI initiative was implemented by 7 physiatry and pediatric movement disorders physicians at 4 tertiary-care pediatric hospitals between October 10, 2021, and July 1, 2023. Using a prospective cohort study design, we collected visit data across all participating sites every 2 weeks and tracked our progress using control charts.

Results

We assessed 847 unique visits, mostly for established patients (719/847, 85%) who were 9.2 years old on average (95% CI 8.8-9.5). By April 10, 2022, the mean percentage of dystonia screening elements documented across all sites increased from 39% to 90% and the mean percentage of visits explicitly documenting the presence or absence of dystonia increased from 65% to 94%. By October 23, 2022, the percentage of visits diagnosing dystonia increased from 57% to 74%. These increases were all sustained through the end of the study period on July 1, 2023.

Discussion

Using a rigorous QI-driven process across 4 member sites of a North American learning health network (CPRN), we demonstrated that we could increase screening for dystonia and that this was associated with increased clinical dystonia diagnosis, matching expected research-based rates. We propose that similar screening should take place across all sites caring for people with CP.

Failure of Split Posterior Tibial Tendon Transfer in Cerebral Palsy Complex Foot Deformities: A Review of Failure Definitions and Risk Factors for Failure

PURPOSE OF REVIEW

This review examines variability in failure and recurrence rates following split posterior tibial tendon transfer (SPOTT) for spastic equinovarus deformity (SED) in children with cerebral palsy (CP). It evaluates patient-specific and surgical risk factors contributing to poor outcomes and assesses the inconsistent definitions of failure across the literature.

RECENT FINDINGS

Across the seven included studies, failure was more common in patients under the age of 8, non-ambulatory individuals, and those with quadriplegic CP. Surgical contributors included poor tendon tensioning, residual spasticity, over- or under-correction, and untreated bony deformities. Although modified techniques demonstrated improved outcomes, the risk of recurrence was not completely eliminated. All studies consistently lacked standardized definitions of surgical failure and recurrence, limiting cross-study comparability. Postoperative management strategies-particularly structured bracing protocols and delaying surgery until after age 8-were associated with more favorable outcomes. SPOTT remains a viable surgical option for dynamic SED in children with CP, but long-term success is highly dependent on careful patient selection, surgical expertise, and consistent postoperative care. Inconsistent definitions of recurrence and failure remain a major barrier to improving clinical outcomes and conducting meaningful comparative research. To enhance clinical decision-making and guide future studies, a standardized grading system should be urgently developed and adopted in the field.

Transcutaneous Spinal Stimulation and Short-Burst Interval Treadmill Training in Children With Cerebral Palsy: A Pilot Study

OBJECTIVE

The purpose of this pilot study was to evaluate the effects of transcutaneous spinal cord stimulation (tSCS) and short-burst interval locomotor treadmill training (SBLTT) on spasticity and mobility in children with cerebral palsy (CP).

METHODS

We employed a single-arm design with two interventions: SBLTT only, and tSCS + SBLTT, in four children with CP. Children received 24-sessions each of SBLTT only and tSCS + SBLTT. Spasticity, neuromuscular coordination, and walking function were evaluated before, immediately after, and 8-weeks following each intervention.

RESULTS

Spasticity, measured via the Modified Ashworth Scale (MAS), reduced in four lower-extremity muscles after tSCS + SBLTT (1.40 ± 0.22), more than following SBLTT only (0.43 ± 0.39). One-minute walk test (1-MWT) distance was maintained during both interventions. tSCS + SBLTT led to improvements in peak hip and knee extension (4.9 ± 7.3° and 6.5 ± 7.7°), that drove increases in joint dynamic range of 4.3 ± 2.4° and 3.8 ± 8.7° at the hip and knee, respectively. Children and parents reported reduction in fatigue and improved gait outcomes after tSCS + SBLTT. Improvements in spasticity and walking function were sustained for 8-weeks after tSCS + SBLTT.

CONCLUSION

These preliminary results suggest that tSCS + SBLTT may improve spasticity while simultaneously maintaining neuromuscular coordination and walking function in ambulatory children with CP.

SIGNIFICANCE

This work provides preliminary evidence on the effects of tSCS and the combination of tSCS + SBLTT in children with CP.

Mobility device use in children with cerebral palsy

AIMS

To quantify the number and types of mobility devices used by children with cerebral palsy (CP) and explore the relationships between Gross Motor Functional Classification System (GMFCS) level, age, insurance, income, and number and types of devices.

METHOD

This was a secondary analysis of a cohort from a larger randomized controlled trial. Data from 89 children with CP (56.2% male and 43.8% female; mean = 4 years 11 months; SD = 2 years 0 months; range 2 years 0 months-8 years 10 months) were collected from electronic medical records, parent-completed medical history questionnaires, and the Hollingshead Four-Factor Index. The analysis included quasi-Poisson and logistical regressions.

RESULTS

Most children had Medicaid insurance (83.2%). All income and GMFCS levels were represented. The most common mobility devices were lower-extremity orthoses (75.3%). The number of devices used increased by 8.2% for each 1-year increase in age. Children classified in GMFCS level V used 5.1, 2.9, and 1.6 times more mobility devices than children classified in GMFCS levels I, II, and III respectively. GMFCS level also predicted the use of wheelchairs, bath chairs, and standers. Income and insurance were not significant.

INTERPRETATION

Children used more devices as age and GMFCS level increased. Device access is an important public health initiative.

Tissue Engineering and Regenerative Medicine: Perspectives and Challenges

From the pioneering days of cell therapy to the achievement of bioprinting organs, tissue engineering, and regenerative medicine have seen tremendous technological advancements, offering solutions for restoring damaged tissues and organs. However, only a few products and technologies have received United States Food and Drug Administration approval. This review highlights significant progress in cell therapy, extracellular vesicle-based therapy, and tissue engineering. Hematopoietic stem cell transplantation is a powerful tool for treating many diseases, especially hematological malignancies. Mesenchymal stem cells have been extensively studied. The discovery of induced pluripotent stem cells has revolutionized disease modeling and regenerative applications, paving the way for personalized medicine. Gene therapy represents an innovative approach to the treatment of genetic disorders. Additionally, extracellular vesicle-based therapies have emerged as rising stars, offering promising solutions in diagnostics, cell-free therapeutics, drug delivery, and targeted therapy. Advances in tissue engineering enable complex tissue constructs, further transforming the field. Despite these advancements, many technical, ethical, and regulatory challenges remain. This review addresses the current bottlenecks, emphasizing novel technologies and interdisciplinary research to overcome these hurdles. Standardizing practices and conducting clinical trials will balance innovation and regulation, improving patient outcomes and quality of life.

A qualitative study investigating the experiences of unmet social needs for children with cerebral palsy and their families: perspectives of parents and clinicians

PURPOSE

To explore (i) the impact of unmet social needs on children with cerebral palsy and their families; (ii) enablers-, and (iii) barriers to addressing unmet social needs.

MATERIAL AND METHODS

Eligible participants attended or worked at one of the three Paediatric Rehabilitation Departments including: children with a diagnosis of cerebral palsy; parents/carers; and clinicians. One-on-one interviews were conducted with parents/carers and focus groups with clinicians. Interview and focus group transcripts were deductively thematically analysed according to the social model of disability.

RESULTS

A total of 44 participants (8 parents and 36 clinicians) took part. No children consented to participate. Analysis of the qualitative data identified four main themes and 14 sub-themes. The main themes were: Unmet social needs are pervasive; An inequitable health system with no roadmap; Everyone suffers as a result of unmet social needs; and It takes a village to raise a child.

CONCLUSION

Unmet social needs have profound impacts on families. The experiences of unmet social needs are intensified by the extra complexities of raising a child with disability. Societal barriers including inequitable systems and the fragmented services are barriers impeding on families receiving support and ultimately limiting their wellbeing.

Characteristics of children with ataxic cerebral palsy

BACKGROUND

To compare the characteristics, functional levels, and comorbidities of children with ataxic cerebral palsy (CP), with those of children with other CP subtypes.

METHODS

A cross-sectional study of children with CP born between 2000 and 2019 as reported in the Scandinavian national CP follow-up programmes and quality registries. Data for age, sex, levels of the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), the Communication Function Classification System (CFCS), epilepsy, intellectual disability, and pain were extracted.

RESULTS

There were 302 children (3.9%) with ataxic CP and 7336 children (96.1%) with other subtypes. Children with ataxic CP differed significantly from other subtypes, with a greater proportion classified in GMFCS II (37.7% vs. 15%), MACS II (41.4% vs. 24.8%), and CFCS II (24.7% vs. 10.5%), more girls (50.7% vs. 41.7%), school-aged (47% vs. 41.6%), adolescents (33.4% vs. 25.4%), or had an intellectual disability (51.2% vs. 38.4%), but the prevalence of pain and epilepsy was similar between the subtypes.

CONCLUSIONS

Children with ataxic CP have different characteristics and functional levels than children with other subtypes. We recommend a thorough examination of motor performance, communication, and intellectual disability to meet the individual needs of children with ataxic CP.

Predictors of community participation from preschool to school age in children with cerebral palsy

AIM

To investigate participation frequency patterns and child and family predictors of community participation in young children with cerebral palsy (CP).

METHOD

We prospectively assessed participation frequency at preschool (Young Children's Participation and Environment Measure) and again at school age (Participation and Environment Measure-Children and Youth). Linear regressions examined preschool predictors of community school-age participation: preschool child age; sex; gross motor function (Gross Motor Function Classification System [GMFCS]); manual function (Manual Ability Classification System); pain; prosocial behaviour; conduct; family ethnicity; income; and residence type.

RESULTS

Children with CP (n = 155, 44% females, 64% classified in GMFCS level I or II), mean baseline age = 4 years 4 months (SD = 1 year 1 month) and at school age = 6 years 7 months (SD = 7 months) had a median community participation frequency at preschool age of 2.8 (interquartile range [IQR] = 1.3) and 2.8 (IQR = 1.6) at school age. Preschool community participation was 2.02 (confidence interval [CI] = -2.20 to -1.83) units lower than at home; at school age, it was 2.40 (CI = -2.59 to -2.22) units lower. Greater prosocial behaviour (child model: R2 = 0.26, p = 0.001) predicted higher school age community participation.

INTERPRETATION

In young children with CP, community participation was infrequent at preschool age (a few times in the last 4 months) and this persisted into school age. Higher preschool prosocial behaviour predicted community participation at school age. Enhanced awareness of infrequent community participation of preschool children with CP and supporting a child's social behaviours may help facilitate community participation.

Quality of cerebral palsy videos on Chinese social media platforms

A significant research gap exists in evaluating the prevalence and quality of Chinese videos depicting CP on domestic social media platforms. In contrast to studies that focus on online video content concerning CP on YouTube, CP videos on YouTube are largely inaccessible to average citizens in mainland China. This disparity underscores the need for further investigation into the availability and nature of CP videos specifically on Chinese social media platforms. To assess the reliability and quality of short videos related to cerebral palsy (CP) on Chinese social media platforms. The present cross-sectional study examined 344 videos about CP from popular Chinese social media platforms, including TikTok, Kwai, Weibo, Bilibili, and RED. The analysis of these videos involved a detailed assessment of their sources, content, and characteristics. Additionally, quantitative scoring tools such as journal of the American medical association (JAMA) benchmarks, gobal quality score (GQS), and DISCERN were utilized to evaluate video quality. Furthermore, the potential relationship between video quality and various attributes such as duration, number of likes, and comments was explored and their impact on the quality of information presented in the videos was analyzed. The average duration of the 344 videos was 92.12 s (SD 105.69). CP rehabilitation training videos comprised 45.64% of the total, followed by expert-contributed videos at 40.70%. Mean scores for JAMA, GQS, and DISCERN were 1.62 (SD 0.60), 2.05 (SD 0.99), and 1.26 (SD 1.26) respectively. RED had the lowest average scores. Videos focusing on disease knowledge scored highest on JAMA and GQS scales. Experts achieved significantly higher GQS and DISCERN scores compared to health-related institutions and amateurs. Spearman correlation analysis revealed a strong positive correlation between likes and comments (r = .0.87, P < .0.001). Enhancing the management of medical content is crucial to address the compromised reliability of Chinese online short videos providing information to families of CP patients. Improving content professionalism and accuracy ensures users access genuinely valuable information.

Anxious Dads and Depressed Moms: Child Disability and the Mental Health of Parents

Having a child with a disability undoubtedly affects parents in many ways, including their well-being. However, the specific mental health trajectories of parents, differentiated by the severity of impairments and parental roles, remain under-explored. We investigate the mental-health effects of having a child with a disability. Using individual-level register data from Sweden, we exploit the epidemiological features of Cerebral Palsy (CP) to estimate causal effects. Results show that prescriptions for mental-health disorders increase after the birth of a child with CP. While fathers are more likely to be dispensed anti-anxiety medications, dispensed medications for anti-depressants increase for mothers. Further, the effects are larger for parents of children with severe impairments but do not differ across parental characteristics. Our findings highlight the need for support and assistance for families with children with disabilities.

Childhood muscle growth: Reference curves for lower leg muscle volumes and their clinical application in cerebral palsy

Skeletal muscles grow substantially during childhood. However, quantitative information about the size of typically developing children's muscles is sparse. Here, the objective was to construct muscle-specific reference curves for lower leg muscle volumes in children aged 5 to 15 y. Volumes of 10 lower leg muscles were measured from magnetic resonance images of 208 typically developing children and 78 ambulant children with cerebral palsy. Deep learning was used to automatically segment the images. Reference curves for typical childhood muscle volumes were constructed with quantile regression. The median total leg muscle volume of a 15-y-old child is nearly five times that of a 5-y-old child. Between the ages of 5 and 15, boys typically have larger muscles than girls, both in absolute terms (medians are greater by 5 to 20%) and per unit of body weight (1 to 13%). Muscle volumes vary widely between children of a particular age: the range of volumes for the central 80% of the distribution (i.e., between the 10th and 90th centiles) is more than 40% of the median volume. Reference curves for individual muscle volumes have a similar shape to reference curves for total lower leg muscle volume. Confidence bands about the centile curves were wide, especially at the youngest and oldest ages. Nonetheless, the reference curves can be used with confidence to identify small-for-age muscles (centile < 10). We show that 56% of children with cerebral palsy in our cohort had total lower leg muscle volumes that were small-for-age and that 80% had at least one lower leg muscle that was small-for-age.

Facilitators and barriers to implementation of early intensive manual therapies for young children with cerebral palsy across Canada

BACKGROUND

Cerebral Palsy (CP) is the most common childhood-onset motor disability. Play-based early intensive manual therapies (EIMT) is an evidence-based practice to improve long-term hand function particularly for children with asymmetric hand use due to CP. For children under two years old, this therapy is often delivered by caregivers who are coached by occupational therapists (OTs). However, why only a few Canadian sites implement this therapy is unclear. There is a need to identify strategies to support implementation of EIMT. The primary objective of this study was to identify the facilitators and barriers to EIMT implementation from the perspectives of (1) caregivers of children with CP (2), OTs and (3) healthcare administrators for paediatric therapy programs.

METHODS

The Consolidated Framework for Implementation Research (CFIR) was used to guide development of an online 5-point Likert scale survey to identify facilitators (scores of 4 and 5) and barriers (scores of 1 and 2) to implementation of EIMT. Three survey versions were co-designed with knowledge user partners for distribution to caregivers, OTs, and healthcare administrators across Canada. The five most frequently endorsed facilitators and barriers were identified for each respondent group.

RESULTS

Fifteen caregivers, 54 OTs, and 11 healthcare administrators from ten Canadian provinces and one territory participated in the survey. The majority of the identified facilitators and barriers were within the 'Inner Setting' CFIR domain, with 'Structural Characteristics' emerging as the most reported CFIR construct. Based on the categorization of the most frequently endorsed facilitators and barriers within the CFIR domains, the key facilitators to EIMT implementation included the characteristics of the intervention and establishing positive workplace relationships and culture. The key barriers included having workplace restrictions on EIMT delivery models and external influences (e.g., funding) on EIMT uptake.

CONCLUSIONS

We identified key facilitators and barriers to implementing EIMT from a multi-level Canadian context. These findings will inform the next steps of designing evidence-informed and theory-driven implementation strategies to support increased delivery of EIMT for children under two years old with asymmetric hand use due to CP across Canada.

Neurodevelopmental screening for neonates less than 44 weeks gestation in low-income and middle-income countries: a systematic review

INTRODUCTION

With global improvements in neonatal survival, more small and sick newborns in low-income and middle-income countries (LMICs) are at increased risk of neurodevelopmental disability and delay. While there is increased recognition of the importance of early identification of neurodevelopmental differences and timely initiation of therapy, little is known about standardised neonatal neurodevelopmental screening tools in these settings.

METHODS

We performed a systematic review to determine what standardised neurodevelopmental assessments had been used in LMICs for neonates before 44 weeks corrected gestational age and published in the literature. We excluded short-term clinical assessments designed for specific pathologies. We performed the search across seven databases, screened studies for eligibility and inclusion and extracted bibliographic data, country, patient characteristics, assessments and study aims. Results were summarised in tabular and graphical presentation.

RESULTS

There were 2477 records screened, yielding 67 studies for inclusion. Studies in Asian countries made up 65.7%, while Latin America and Africa made up 19.4% and 16.4%, respectively. Physicians and paramedical staff performed the screening assessments in only 16.4% of studies, and 92.5% of studies used inpatient recruitment. The Neonatal Behavioural Neurological Assessment (25.4%) was the most frequently used screening tool followed by the General Movements Assessment (22.4%), the Hammersmith Neonatal Neurological Examination/Dubowitz (16.4%) and the Neonatal Behavioural Assessment Scale (10.4%).

CONCLUSIONS

We did not identify any one neonatal neurodevelopmental screening assessment that is rapid, globally validated, identifies targets for intervention, has high predictive prognostic value and does not require neonatal or kinesiologic expertise or uncommon equipment. Such an assessment, in concert with evidence-based intervention, therapeutic delivery platforms, established referral pathways and trained personnel would improve functional outcomes for high-risk small and sick neonates in LMICs.

A 6-Week Modified Physical Therapy Intensive Program for a Child With Cerebral Palsy

PURPOSE

This case report assesses the outcomes of a 6-week modified intensive program for a 4-year-old boy with cerebral palsy (CP), Gross Motor Function Classification System Level IV.

SUMMARY OF KEY POINTS

The modified intensive program included the practice of developmental gross motor skills, standing/gait training in adaptive equipment, constraint-induced movement therapy, and whole body vibration.

CONCLUSIONS

The child improved in 4 of the 5 outcomes, including timed sitting balance and modified versions of the 5 Times Sit-to-Stand Test and 9-Hole Peg Test. His ability to assist with transfers, sit independently, and use both hands for play and self-help skills also improved.

RECOMMENDATIONS FOR CLINICAL PRACTICE

This case report adds to the body of evidence supporting the use of intensive program models of physical therapy for children with CP and highlights the need for additional research in this emerging area of clinical practice.

Caregivers' experiences of feeding children with cerebral palsy: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to investigate the feeding experiences of caregivers of children with cerebral palsy, in any setting, by identifying, critically appraising, and synthesizing the relevant literature.

INTRODUCTION

Feeding difficulties in children with cerebral palsy are common and affect both children and caregivers. Difficulties include dysphagia and risk of aspiration, which can result in poor growth and development. Caregivers find feeding challenging and stressful due to the time involved, fear of aspiration, and the pressure of meeting other family demands. Finding ways to support caregivers effectively in feeding will have important health and quality-of-life outcomes for caregivers and their children with cerebral palsy.

INCLUSION CRITERIA

Studies with qualitative data exploring informal caregivers' experiences (eg, perspectives, challenges, feelings) of feeding children with cerebral palsy, in any country or setting, were included. Informal caregivers (eg, parents, foster carers, grandparents) could be of any age, gender, or cultural background. Children with cerebral palsy of any severity level were included. Formal caregivers, such as health professionals, were ineligible. The feeding method could include oral feeding, tube feeding, or both.

METHODS

The JBI methodology for systematic reviews of qualitative evidence was followed. The databases searched on June 27, 2023, included CINAHL (EBSCOhost), APA PsycINFO (Ovid), MEDLINE (Ovid), ProQuest Central, Scopus, and ProQuest Dissertations and Theses. Two members of the review team independently screened titles and abstracts, and full texts of eligible studies. Three members of the review team independently appraised selected studies for methodological quality. The meta-aggregation approach was used for data synthesis to pool findings from included studies to form categories and synthesized findings. Finally, the ConQual approach was used to establish confidence in the synthesized findings based on their dependability and credibility.

RESULTS

From the literature search and citation searching, 619 records were screened, from which 10 studies were included in the review. A total of 196 findings were extracted for analysis, which resulted in 19 categories and 5 synthesized findings. The synthesized findings were "Feeding and feeding difficulties," "Caregiver emotions and burden around feeding a child with cerebral palsy," "Caregiver support and feeding," "Feeding, social interaction, and mothering," and "Gastrostomy tube decisions and perceptions." The overall ConQual score for each synthesized finding was rated as low.

CONCLUSIONS

Feeding a child with CP was a difficult experience for caregivers. Caregivers were able to problem-solve feeding issues, but they often felt unsupported by health professionals and services. Feeding negatively impacted caregivers' and children's social interactions outside the home, where caregivers sought to achieve normalcy for their child and family. However, feeding was described as an essential part of mothering, and caregivers felt like a failure if they could not feed their child orally. Caregivers struggled with the decision to allow their child to have a gastrostomy tube, but most viewed it positively once it was inserted. More research into other cultures and research into fathers' experiences of feeding children with cerebral palsy is recommended.

Prevalence and Types of Strabismus in Cerebral Palsy: A Global and Historical Perspective Based on a Systematic Review and Meta-Analysis

PURPOSE

Strabismus is more frequent in cerebral palsy (CP) than in the normal population, but reports differ how much it is increased. We here examined the global prevalence and types of strabismus in CP, whether esotropia or exotropia is more frequent, and whether the prevalence differs between ethnicities and/or country income levels, and between generations.

METHODS

We compiled in a systematic review and meta-analysis the results of 147 CP studies that report the prevalence of strabismus or the ratio of esotropia to exotropia, and we conducted subgroup analyses for region (income level) and ethnicity. We performed a pooled analysis for the CP strabismus prevalence, and estimated the global number of CP cases with strabismus.

RESULTS

The pooled prevalence of strabismus in CP is 49.8% in high-income countries and 39.8% in lower-income countries. We estimate the global number of strabismus cases in CP as 12.2 million, with 7.6 million males and 4.6 million females, based on current estimates of 29.6 million global CP cases. Esotropia is more frequent than exotropia in Caucasians, while exotropia is more frequent than esotropia in Hispanic and in some Asian and African populations. The strabismus prevalence in CP increases with increasing country income levels.

CONCLUSION

Generational changes in strabismus prevalence appear to reflect a transition of CP types and an increase in prevalence as countries attain higher income and more effective maternal health care. The distribution of esotropia and exotropia in CP patients largely reflects the horizontal strabismus type that is predominant in the subject's ethnicity.

Upper limb training for young children with unilateral cerebral palsy using video coaching: An explorative retrospective clinical study

INTRODUCTION

Young children with unilateral cerebral palsy (CP) received a home-based training program using video coaching for parents. The primary aim of our study was to evaluate the effectiveness of unilateral training on the use of the affected arm and hand during bimanual activities and to explore factors that affect treatment response. Secondary, we evaluated whether effects were retained after an 8-week break, and if data were available, we explored the effects of a second uni- or bimanual training block. Furthermore, adherence was evaluated.

METHODS

Explorative retrospective clinical study evaluating the effectiveness of the first 8-week training block on the (Mini-) Assisting Hand Assessment ((Mini-) AHA) unit score in 81 children aged 8-36 months. Pre- and post-intervention (T0-T1) and 8-week follow-up measurements (T2) were evaluated, and factors influencing treatment response were explored, using linear mixed models (LMM). Additionally, effects of a second training block were explored in 31 of the original 81 children, contingent upon data availability, with T3-T4 measurements included. Adherence, measured as percentage of treatment duration, was explored.

RESULTS

Mini-AHA and AHA unit scores significantly improved between T0 and T1, but did not change between T1 and T2. In children aged 18 months and older, baseline AHA scores were related to change scores. In children aged <18 months, no predictors of treatment response were identified. LMM showed significant improvement between T1-T3 and T1-T4 in Mini-AHA scores in children with a second training block. Adherence rates were 85% in the first and 81% in the second block.

CONCLUSIONS

Our data suggest that upper limb training using video coaching can improve hand use in infants and toddlers with unilateral CP, with retained effects after an 8-week break and further enhancement following a second training block. Individual results differed, and controlled studies are needed to strengthen the evidence. High adherence rates suggest the program's feasibility.

CONSUMER AND COMMUNITY INVOLVEMENT STATEMENT

There was no direct consumer and community involvement in the study design.

PLAIN LANGUAGE SUMMARY

Cerebral palsy is caused by a brain injury around birth and is the most common physical disability in children, affecting their movement. Children with one side of the body affected often use that side less, making daily activities harder. Training the affected arm in the first 2 years of life is important because the brain is still very adaptable. In our study, we evaluated a home-based training program for young children with cerebral palsy, with blocks of 8 weeks of therapy using video coaching for parents. We looked at how well the first training block improved the use of the affected arm and hand. We also looked at whether the effects lasted after an 8-week break and whether a second training block further improved hand use. Lastly, we looked at how well families continued to train. We found an improvement of the use of the affected hand after the first training block. Children older than 18 months with poorer hand use at the start made more progress, while especially children younger than 18 months demonstrated further improvement after the second training block. Most parents and children were able to continue the training program using video coaching. Early upper limb home-based training with video coaching can help young children with cerebral palsy to improve the use of their affected arm and hand. Video coaching seems effective to motivate parents to continue with the program. Individual results varied. There is a need for larger studies.

Transferability of an executive function intervention in children with cerebral palsy: A randomized controlled trial

AIM

To evaluate the transfer effects of a home-based computerized executive function intervention on non-targeted cognitive functions (visual perception and memory), quality of life (QoL), and participation in children with cerebral palsy (CP), and to determine whether any improvements were maintained 9 months after the intervention.

METHOD

Sixty children with CP (aged 8-12 years) were randomly allocated to the intervention (15 females/15 males, mean age 10 years 4 months [SD = 1 years 8 months], age range 8-12 years) or waitlist (control) (15 females/15 males, mean age 10 years [SD = 1 years 9 months], age range 8-12 years) group. The intervention group underwent a home-based executive function intervention programme for 30 minutes per day, 5 days a week, for 12 weeks. All participants were assessed before the intervention, immediately after and 9 months after the intervention was completed.

RESULTS

After the intervention was completed, performance in immediate verbal memory, verbal learning, and visual perception (object and picture recognition) was significantly better in the intervention group than in the waitlist (control) group. No improvements were found in visual memory, visuospatial perception, QoL, or participation after the intervention. Scores at the follow-up showed that any beneficial effects were not maintained 9 months after the intervention was completed.

INTERPRETATION

A home-based computerized executive function intervention produced transfer effects on memory and visual perception immediately after the intervention in children with CP, although any beneficial effects were not sustained at the 9-month follow-up.

Natural history of gait patterns in untreated children with bilateral cerebral palsy in a low-income country setting

AIM

To assess a group of ambulant, untreated children with bilateral spastic cerebral palsy, in a resource-poor setting, who had never been assessed by a health care professional or received any treatment, to help establish the natural history of gait patterns in this condition.

METHOD

At CURE Children's Hospital of Ethiopia, 46 children with no prior health care contact were assessed in a cross-sectional cohort study, through a detailed history, clinical examination, and instrumented gait analysis using a motion capture system.

RESULTS

There was a large spread in the data reflecting the high natural heterogeneity in this population. The severity of gait pathology did not correlate with age; however, a small but significant reduction in sagittal hip and knee range of motion with increasing age was observed. There was also a trend towards reduced passive knee extension with age.

INTERPRETATION

Improved understanding of the aspects of gait that are likely to naturally improve, deteriorate, or remain stable over time helps guide treatment decisions in this population.

Cerebral palsy characteristics in term-born children with and without detectable perinatal risk factors: A cross-sectional study

AIM

To compare, in term-born children with cerebral palsy (CP), the characteristics of those who exhibit detectable risk factors for CP at birth with those who do not.

METHOD

This was a cross-sectional study of term-born children using the Canadian Cerebral Palsy Registry comparing those with and without perinatal risk factors and/or neonatal symptoms for pregnancy, birth and neonatal characteristics, magnetic resonance imaging (MRI) findings, CP subtype, and impairment severity. Risk factors were quantified with a CP risk calculator. Multivariable and multinomial regressions were expressed as odds ratios (OR) and relative risk ratios.

RESULTS

Of 1333 term-born children, 781 (58.6%) had complete variables for the CP risk calculator, of whom 195 (25%) had 'undetectable' newborn infant CP risk, and they did not have greater postneonatal brain injury. Focal injury on MRI was more common (OR 2.0, 95% confidence interval [CI] 1.3-3.1) than in the 'detectable' group. The 'undetectable' group had more unilateral CP (OR 1.8, 95% CI 1.3-2.6), less severe motor impairment (OR 0.76, 95% CI 0.67-0.86), and were more verbal (OR 2.3, 95% CI 1.5-3.6).

INTERPRETATION

In the Canadian CP Registry, one-quarter of term-born children lacked neonatal encephalopathy, seizures, or perinatal risk factors. They were more likely to have unilateral CP, focal MRI findings, and communicate with words than children with risk factors or neonatal symptoms.

How does the environmental inadequacy mediate the effect of functional limitations on participation restrictions in young adults with cerebral palsy?

BACKGROUND

Adults with cerebral palsy (CP) face various functional limitations and comorbidities, that prevent them from participating fully in social life. Disability models suggest that an environment not tailored to their needs could partly explain the link between functional limitations and participation restrictions. However, there is still insufficient knowledge about how the environment hinders participation.

OBJECTIVE

To investigate the mediating role of environmental inadequacy in the relationship between functional limitations and participation restrictions in young adults with CP.

METHODS

Cross-sectional study, which included 310 young adults with CP, aged 22-27 years at interview (2018-2020) and recruited in well-defined geographical areas in France, Germany, Italy, Portugal and Sweden. Environmental inadequacy was assessed using the EAEQ and participation restrictions using the QYPP-YA. A theorical model was tested with a partial least squares structural equation model.

RESULTS

Functional limitations had a significant direct effect on participation restrictions (β = 0.62, p < 0.001). A small part of the total effect was mediated by the "inadequacy of services, systems and policies" environmental latent variable (β = 0.10, p < 0.001). "Inadequacy of support and relationships" and "inadequacy of attitudes" environments demonstrated no mediating effect. Unexpectedly, a higher "inadequacy of products and technology" environmental score appeared to reduce participation restrictions (β = -0.10, p = 0.025).

CONCLUSIONS

The environment considered as suggested by the ICF had only a minimal mediating effect in our study. However, public health policies must give priority to improvements at the macro-environmental level, particularly in terms of availability and access to the "services, systems and policies".

Longitudinal relationship between hip displacement and hip function in children and adolescents with cerebral palsy: A scoping review

AIM

To identify, describe, and synthesize available evidence on the longitudinal relationship between hip displacement and hip function, using the International Classification of Functioning, Disability and Health (ICF) framework, in children and adolescents with cerebral palsy (CP) aged up to 18 years.

METHOD

Five databases were searched systematically from inception to May 2022. Study and sample characteristics, and hip displacement and hip function measures, mapped to the ICF domains, were extracted for narrative synthesis.

RESULTS

Twenty-nine studies were included: four longitudinal registry-based studies; 12 prospective studies; 12 retrospective studies; and one randomized controlled trial. Sample size ranged from 11 to 267. Twenty-seven (93%) studies entailed an intervention: surgery (n = 16); rehabilitation (n = 2); nerve block or botulinum neurotoxin A injection (n = 4); and combined surgery and injection (n = 2). Twenty-six studies (90%) reported outcomes at the body structure and function and impairment domain of the ICF; 17 (59%) reported outcomes in the activity domain; and three (10%) included participation measures. The most common hip displacement measure was Reimers' migration percentage (79%).

INTERPRETATION

Because of the inclusion of interventions in most studies, and the preponderance of retrospective studies, the relationship between hip displacement and hip function in CP is unclear. More high-quality prospective evidence on the natural history of hip displacement, and its effect on function, is needed to improve population-wide screening of children with CP.

Zebrafish in neurodevelopmental disorders studies: Genetic models and pathological involvement of microglia

Neurodevelopmental disorders (NDDs) are a group of brain disorders with a neonatal or early childhood onset and are lifelong. Various factors including genetics, and environmental and immune-related risk factors have been associated with NDDs. Given the complex nature of these disorders, multiple animal models have been used to investigate their aetiology and underlying cellular and molecular mechanisms. Recently, zebrafish have attracted great attention as an emerging model for studying NDDs. In addition to their easy maintenance, short developmental cycle, ex utero embryonic evolution, and optical clarity, zebrafish have successfully recapitulated phenotypes seen in human genetic disorders. This review explores the growing role of zebrafish in NDD research, by summarizing recently developed zebrafish genetic models for autism spectrum disorder, schizophrenia, and cerebral palsy. We then explore the potential of zebrafish as a model for studying NDDs linked to immune system dysfunction.

Genetic Alterations in Atypical Cerebral Palsy Identified Through Chromosomal Microarray and Exome Sequencing

This study investigated the genetic causes of atypical cerebral palsy (CP) through chromosomal microarray (CMA) and exome sequencing (ES) in a cohort of 10 Korean patients to identify variants and expand the spectrum of mutations associated with atypical cerebral palsy. Whole ES and/or genome sequencing (GS) after routine karyotyping and CMA was performed to identify causative variants and expand the spectrum of mutations associated with atypical CP. In cases of atypical CP, scoliosis and/or kyphosis, ranging from mild to severe, were present in all patients. Epilepsy was a comorbidity in seven patients (70%), and intellectual disability (ID) was observed in varying degrees. This study identified three copy number variations (CNVs), including 15q11.2 microdeletion (n = 1), 17p11.2 duplication (n = 1), and 12p13.33p11.23 duplication/18p11.32 microdeletion (n = 1), and six likely pathogenic variants (LPVs) or pathogenic variants (PVs) detected in the SLC2A1, PLAA, CDC42BPB, CACNA1D, ALG12, and SACS genes (n = 6). These findings emphasize the significance of incorporating genetic testing into the diagnostic process for atypical CP to improve our understanding of its molecular basis and inform personalized treatment strategies. To further advance this research, future studies should focus on exploring genotype-phenotype correlations, assessing the functional impact of identified variants, and increasing the sample size to validate the observed patterns.

Effectiveness of Physiotherapy for Improving Participation, Gross Motor Function, Gait and Balance in Children and Adolescents with Cerebral Palsy: Study Protocol for a Randomized Controlled Trial

Background: People with cerebral palsy (CP) present with limitations in gait and functionality, with a great impact on participation. Physiotherapy interventions based on goal-directed training (GDT), treadmill gait training (TGT), and action observation treatment (AOT) showed to be effective for improving functionality, gait and balance in children and adolescents with CP. On the other hand, since COVID-19 lockdown, telecare has an increased role in physiotherapy interventions. The aim of this randomized controlled trial (RTC) is to analyze the effectiveness of a multimodal intervention that combines face-to-face PT sessions of GDT and TGT and online PT sessions of a family-centered education program, which includes AOT activities and is effective to improve participation, gross motor function, gait and balance in children and adolescents with CP. Methods: A single-blinded RCT is proposed for 48 children and adolescents with CP (6-17 years old) who will be randomly allocated into two groups: the experimental group will receive six weeks of a multimodal PT intervention with 12 face-to-face sessions (GDT and TGT) and 6 online sessions of a family-centered telecare EP, which includes AOT activities. Participants in the control group will carry on with their regular PT treatment plus the EP as the experimental group. The outcome variables of participation (CAPE); gait speed and endurance (10 mm/6 mm); gross motor function (GMFM-88-SP); and dynamic and static balance (PBS) will be collected at baseline, after group interventions and 12 weeks from baseline and will be compared following standard principles for RCTs. Conclusions: The implementation of a multimodal PT intervention that combines face-to-face sessions of GDT and TGT and online sessions of a family-centered EP, which includes AOT activities, may be effective to improve participation, gross motor function, gait and balance in children and adolescents with CP. Trial registration: ClinicalTrials.gov with ID: NCT04778930.

Stakeholder's perspective on brain-computer interfaces for children and young adults with cerebral palsy

Communication Brain-Computer Interfaces (cBCIs) are a promising tool for people with motor and speech impairment, in particular for children and young adults with communication impairments, for example due to cerebral palsy (CP). Here we aimed to create a solid basis for the user-centered design of cBCIs for children and young adults with severe CP by investigating the perspectives of their parents/caregivers and health care professionals on communication and cBCIs. We conducted an online survey on 1) current communication problems and usability of used aids, 2) interest in cBCIs, and 3) preference for specific types of cBCIs. A total of 19 parents/caregivers and 36 health care professionals who interacted directly with children and young adults (8-25 years old) with severe CP, corresponding to Gross Motor Function Classification System level IV or V, participated. Both groups of respondents indicated that motor impairment occurred the most frequently and had the greatest impact on communication. The currently used communication aids included mainly no/low-tech aids and high-tech aids. The majority of health care professionals and parents/caregivers reported an interest in cBCIs, with a slight preference for implanted electrodes over non-implanted ones, and no preference for either of the two proposed mental BCI control strategies. Results indicate that cBCIs should be considered for a subpopulation of children and young adults with severe CP, and that in the development of cBCIs for this group both visual stimuli and sensorimotor rhythms, as well as the use of implanted electrodes, should be considered.

Acupuncture combined with language training for aphasia in children with cerebral palsy: a systematic review with meta-analysis and trial sequential analysis

Objective

The aim of this study was to comprehensively evaluate the efficacy of acupuncture combined with language training in the treatment of aphasia in children with cerebral palsy (CP).

Methods

We searched eight electronic databases from their inceptions to July 1, 2024 for randomized controlled trials (RCTs) of acupuncture for aphasia in children with CP. The evaluation of methodological quality for RCTs incorporated in this study adhered to the guidelines provided by the Cochrane risk-of-bias tool (ROB2). The Grading of Recommendations Assessment, Development and Evaluation Approach (GRADE) was used to evaluate the certainty of evidence of each outcome. The heterogeneity of the included literature was tested using Review Manager 5.4 software, while publication bias was estimated using funnel plots and Egger's tests by STATA15.1. A trial sequential analysis (TSA) was performed to test the robustness of the conclusiveness of our results.

Results

In this study, we encompassed a total of 56 randomised controlled trials encompassing 4,683 participants. The majority of these trials were characterized by either a high or uncertain risk of bias, predominantly due to the omission of blinding within their experimental setups. Meta-analysis showed that acupuncture combined with language training was significantly better than language training alone in improving the clinical efficiency (RR: 1.25; 95% CI: 1.21, 1.29; p < 0.00001). A subgroup analysis of the different types of acupuncture revealed that acupuncture, electroacupuncture, scalp acupuncture, and auricular point seed-pressing all showed a significant improvement in aphasia in children with CP. Acupuncture combined with language training could significantly improve the adaptive behaviour (MD: 7.46; 95% CI: 3.67, 11.26; p = 0.0001), verbal behaviour (MD: 7.79; 95% CI: 5.66, 9.92; p < 0.00001), fine motor behaviour (MD: 4.66; 95% CI: 1.28, 8.03; p = 0.007), and personal social behaviour (MD: 6.47; 95% CI: 2.38, 10.55; p = 0.002); it was also significantly more effective in improving the language comprehension developmental quotient (SMD: 2.02; 95% CI: 1.54, 2.50; p < 0.00001), the expressive language development quotient (SMD: 2.40; 95% CI: 1.76, 3.03; p < 0.00001), assessment of dysarthria (MD: 0.40; 95% CI: 0.11, 0.69; p = 0.007), and oral motor function (SMD: 2.63; 95% CI: 1.36, 3.90; p < 0.0001).

Conclusion

Acupuncture combined with language training could be an effective treatment for aphasia in children with CP. Due to low or very low certainty of evidence and high heterogeneity, more rigorous RCTs are needed to verify the effect of acupuncture in the management of CP.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024501328, identifier CRD42024501328.

The Use of Novel Therapies in the Management of Haemolytic Disease of the Fetus and Newborn (HDFN): Scientific Impact Paper No. 75

Haemolytic disease of the fetus and newborn (HDFN) is a rare condition that causes a baby to develop anaemia while growing inside the woman; or after birth. Left untreated, this may lead to stillbirth or neonatal death. HDFN is caused when the pregnant woman's antibodies cross the placenta, enter the baby's circulation, and attach to proteins called antigens (inherited from the father) on the baby's haemoglobin containing red blood cells, and cause them to break apart, causing fetal anaemia. Women routinely have their blood tested at the start of pregnancy to assess their ABO blood group and Rh antigens. There are five main Rhesus antigens: D, C, c, E, e; with anti-D being responsible for most cases of HDFN. If a woman is found to be Rh D negative; a 'non-invasive' blood test is performed to assess if the fetal blood group is the same as the woman's. If a woman is found to be Rh D negative, and the baby is found to be D positive, the baby is at risk. This is because the baby has inherited the D antigen from the father; so-called Rhesus incompatibility. Other red blood cell antibodies such as anti-Kell or anti-Duffy can also cause fetal anaemia. Women at highest risk of developing HDFN are those who have had at least one previous birth or a sensitising event (such as abdominal trauma) in a current or previous pregnancy, causing the woman and baby's blood to mix. Current treatment for haemolytic disease of the fetus involves giving fetal blood transfusions, with a small risk of early labour or pregnancy loss. If anaemia develops later in pregnancy, early delivery of the baby may be recommended; which could lead to complications of prematurity. In cases of mild HDFN, the baby may only require light therapy for neonatal jaundice. However, if the anaemia occurs earlier in pregnancy and is severe, the baby may need blood transfusions while still in the womb - and after birth may require an exchange transfusion, to remove the woman's antibodies from their circulation and to treat the anaemia. Intravenous immunoglobulin (IVIG) is a potential non-invasive method to prevent or delay the onset of severe anaemia. It is a blood product given intravenously every week to women who have been deemed at very high risk of early onset HDFN. It can be started at the end of the first trimester until birth, or until anaemia develops. This paper will discuss the evidence behind IVIG and other novel therapies during pregnancy, including the risks and the benefits. The developers of the paper include obstetricians, neonatologists and haematologists to provide different opinions on this topic.

Cause-Specific Secular Trends and Prevention Measures of Post-Neonatally Acquired Cerebral Palsy in Victoria and Western Australia 1975-2014: A Population-Based Observational Study

AIM

To describe the timing and causes of post-neonatally acquired cerebral palsy (PNN-CP) and map the implementation of relevant preventive strategies against cause-specific temporal trends in prevalence.

METHODS

Data for a 1975-2014 birth cohort of children with PNN-CP (brain injury between 28 days and 2 years of age) were drawn from the Victorian and Western Australian CP Registers. Descriptive statistics were used to report causal events and timing. Poisson regression models were used to investigate the strength of evidence for cause-specific temporal trends in prevalence. Preventive strategies were mapped alongside cause-specific trends.

RESULTS

Amongst 512 children, causes of PNN-CP included infections (31%, n = 157), head injuries (24%, n = 121) and cerebrovascular accidents (CVAs) (23%, n = 119). Infections were the only main causal group of PNN-CP that declined significantly (p = 0.014). Fifty two percent (n = 267) of the PNN-CP cohort acquired their brain injury before 6 months of age, the majority having an infectious cause (57%, n = 90). Improved clinical care and a range of preventive strategies, including childhood vaccination programs, occurred during this period.

CONCLUSION

Infants under 6 months are a priority group for preventive strategies for PNN-CP. Declining temporal trends were observed for PNN-CP caused by infection, and the causal subgroup of CVAs associated with surgery. Interventions aimed at further reducing the risk of head injury, CVAs and infections, are needed to reduce the prevalence of PNN-CP.

Outpatient Management of Clinical Comorbidities in Children With Cerebral Palsy in Low- and Middle-Income Countries

BACKGROUND

Cerebral palsy (CP) is the most common physical disability of childhood. Its prevalence in low-and middle-income countries (LMICs) is over 3/1000 live births, about double the 1.6/1000 in high income countries (HICs). Multimorbidity is highly prevalent in CP. In LMICs, there are higher rates of prevalence, severity, comorbidities and mortality in children with CP. The evidence base for the recommendations in CP emanates overwhelmingly from studies conducted in HICs. Research conducted in LMICs settings, involving local clinicians, considering local context and investigating local solutions are urgently needed.

METHODS

This scoping review aimed to identify and synthesise current evidence on management of clinical comorbidities in children with CP in LMICs. The Joanna Briggs Institute guidelines were followed for the data extraction and analysis phases. The following questions guided the scoping review: What are the main clinical comorbidities in children with CP? What are the gold standards for diagnosis and treatment of these comorbidities? What options do we have to diagnose and treat these comorbidities in LMICs when gold standards are not available?

RESULTS

A total of 22 188 citations were identified by our search strategy, with 21 380 remaining after the removal of 808 duplicates. After screening titles and abstracts, 1918 citations progressed to full text review. A total of 194 articles met the eligibility criteria and were included in the review. The guiding questions of the review were answered for the following morbidities: respiratory impairments, dysphagia and aspiration, gastroesophageal reflux disease, drooling, obstructive sleep apnea syndrome, malnutrition, constipation, epilepsy, sleep disorders, spasticity, dystonia, pain, hip disorders, scoliosis and osteoporosis.

CONCLUSION

This article highlights the need for interventions adapted to the realities of LMICs. Empowering paediatricians and healthcare professionals in LMICs is crucial for early diagnosis and proactive interventions. Specific guidelines for LMICs can better guide professionals in managing these complex conditions.

The 24-Hour Activity Checklist for Cerebral Palsy: Translation, Content Validity and Test-Retest Reliability of Portuguese Versions

BACKGROUND

The importance of 24-h movement behaviour, including sleep, physical activity (PA) and sedentary behaviour (SB), has gained prominence due to its significant impact on the health and development of children, including those with cerebral palsy (CP). The 24-h activity checklist for CP, a tool developed in the Netherlands to monitor the activity in CP paediatric population, requires translation and cultural adaptation to Portuguese for use in Brazil and Portugal.

METHODS

This cross-sectional methodological study involved translating and culturally adapting the 24-h activity checklist for CP into Brazilian Portuguese (BP) and European Portuguese (EP) languages. The process included forward translation, synthesis and backward translation, expert panel evaluation and pretesting. Brazilian and Portuguese experts appraised content validity, assessed by the individual item (I-CVI) and scale level content validity index scores (S-CVI/Ave). Sixty parents of children with CP participated in the test-retest analysis, reported with the Intraclass Correlation Coefficients (ICCs).

RESULTS

I-CVI scores were higher than 0.78 for both versions. S-CVI/Ave scores were considered excellent for BP (0.91) and EP version (1.0). Expert's appraisal results in the inclusion of a question about sleep-related time indicators and the split of sleep, PA, and screen time questions for weekdays and weekends. Brazilian and Portuguese parents of children with CP reported understanding on instructions, questions, and answer options. The ICC values range from 0.81 to 0.99 and 0.6 to 0.98, for BP and EP, respectively.

CONCLUSIONS

The BP and EP versions of 24-h activity checklist for CP demonstrated good content validity and test-retest reliability, supporting its use in Brazil and Portugal. This tool can contribute to improving communication between families and healthcare professionals to monitor and develop tailored interventions for healthy movement behaviours in children with CP.

Postneonatal Cerebral Palsy in Europe: Prevalence and Clinical Characteristics According to Contributory Events: An SCPE Study

BACKGROUND

Postneonatal cerebral palsy (PNCP) is rare and requires large databases to be studied over time.

OBJECTIVES

To study the time trend of prevalence of PNCP overall and by cause, and to describe the clinical characteristics of children with PNCP according to cause and compared with children with pre/peri/neonatal CP (PPNCP).

METHODS

The Surveillance of Cerebral Palsy in Europe (SCPE) database was used. Primary events (the first known chronological event in the causal chain) were classified according to the SCPE classification (six main and 19 sub-categories). Prevalence trends for children born during 1976-2012 were modelled using multilevel generalised linear models. The clinical characteristics of PNCP and PPNCP cases born after 1998 were reported as proportions.

RESULTS

The prevalence rates of PNCP were 1.76 (95% confidence interval (CI) 1.37, 2.23) and 0.82 per 10,000 live births (95% CI 0.73, 0.92) in children born during 1976-1980 and 2006-2012, respectively. The models showed a 2% annual decline in overall prevalence (prevalence rate multiplied by 0.98 each year) and a 10% decline for infectious causes for every 5-year change. The prevalence rate in children born during 2006-2012 was 0.26 per 10,000 (95% CI 0.21, 0.32) for infectious causes, which remained the most frequent. No trend emerged for other causes. Unilateral spastic CP, associated impairments and severe gross motor dysfunction were more frequent in PNCP than in PPNCP, and PNCP showed predominantly grey matter injury (55.6%). Seventeen percent were born preterm. PNCP differed by cause, with cerebrovascular accidents presenting the least severe and hypoxic causes the most severe forms.

CONCLUSION

Our study confirms the decrease in the prevalence of PNCP in children born up to 2012, particularly for CP, due to infectious causes, which remain the most frequent. Children with PNCP had more severe presentation overall than those with PPNCP, with severity depending on the cause.

Can External Neuromodulation Garments Improve Gait and Function in Children With Cerebral Palsy? A Prospective Single-Arm Study

Introduction

The Exopulse Mollii Suit is an external electrical stimulation garment that is designed to reduce spasticity through electrical stimulation of targeted muscles. Our aims were to study the impact of the garment in improving gait and function in children with cerebral palsy (CP).

Methods

Individuals aged 4-18 years with spastic CP, Gross Motor Function Classification System level I-III were included for a prospective single-arm study from January 2021 to January 2022. Participants wore the suit for 4 weeks 60 min a day. Outcome measures taken pre, post and 1-month-post intervention included: 3D gait analysis (gait profile score, gait deviation index and temporo-spatial parameters), gross motor function measure-88 (GMFM-88), EQ-5D-Y, compliance rate, adverse event and satisfaction. Paired t-test was used for data analysis to compare measurement time points.

Results

Twenty children (median age 7 [range: 4-16; interquartile range: 3.1] years, 55% female, 45% male were recruited. Post-intervention results showed there was no improvement in the gait profile but there was an improving trend in temporo-spatial parameters GMFM Domain C crawling and kneeling improved significantly (p = 0.03). Improvement in EQ-5D- Y usual activity was significant (p = 0.04). Compliance rate was 95% and nil major adverse event was reported. The majority (75%, n = 15) of parents and participants perceived overall positive experience.

Conclusion

The positive changes in gait profile and function were no longer significant at 1-month post-intervention. Further studies with a longer intervention period and concurrent strengthening program are required.

Implications for Physiotherapy Practice

Using the Molli Suit for 60 min a day for 4 weeks, may be useful in improving:(1) Gait cadence in children with CP. (2) Gross motor function in terms of crawling and kneeling in children with CP.

ChMER: an exoskeleton robot with active body weight support walker based on compliant actuation for children with cerebral palsy

Introduction

Lower limb exoskeleton robots for young children with cerebral palsy (CP) are crucial to support earlier rehabilitation that is more beneficial than later. For safety reasons, pediatric exoskeletons are usually equipped with body weight support (BWS) devices to help young patients maintain balance. However, existing pediatric exoskeletons tend to use stiff joint actuation and passive BWS with limited compliance.

Method

This paper proposes a novel mobile exoskeleton robot for young children (3- ∼ 6-years-old) with CP based on intrinsically compliant actuation. A compact kinematic chain that integrates an exoskeleton, an active BWS system, and a walker is proposed. Furthermore, with the actuation design optimization of the kinematic chain, the robot can walk alone stably in passive rehabilitation and provide high compliance in active rehabilitation. The exoskeleton adopts actuation similar to the quasi-direct drive paradigm to acquire high mechanical compliance and uses a secondary planetary reducer to ensure high output torque. Assistive torque control is achieved through proprioceptive sensing instead of torque sensors. The BWS system uses a series elastic actuator to accurately generate the weight support force and significantly reduce the fluctuation of the support force compared to the passive BWS.

Results and discussion

Finally, control frameworks for passive and active rehabilitation are implemented to validate the robot performance. The experimental results demonstrate that our robot can support safe and compliant rehabilitation.

Chinese herbal medicine for the treatment of children with cerebral palsy: a meta-analysis of randomized controlled trials with core herbs exploration

Introduction

Chinese herbal medicine (CHM) taken orally is frequently utilized to enhance functional ability and independence in cerebral palsy (CP); nonetheless, there is a lack of current evidence regarding the efficacy of oral CHM in treating CP. Additionally, the general complexities of CHM prescriptions often obscure the underlying mechanisms. Our study aims to assess the efficacy of oral CHM in treating CP, a meta-analysis will be conducted on randomized clinical trials (RCTs).

Materials and methods

We searched Cochrane Library, PubMed, Embase, Scopus, PubMed Central, ClinicalTrials.gov, and China National Knowledge Infrastructure (CNKI), from 1990 to 2022. The primary outcome was the improvement in Effectiveness rate (ER). The secondary outcome was the improvement of motor function (GMFM). Subgroup analysis and trial sequential analysis (TSA) were conducted to confirm results consistency. Core CHMs were investigated through system pharmacology analysis.

Results

Seventeen RCTs were analyzed, in which CHMs with Standard treatment (ST) were compared to ST alone. All participants were aged <11 years. More participants in the CHM group achieved prominent improvement in ER (RR: 1.21, 95% CI: 1.13-1.30, p-value < 0.001, I2 = 32%) and higher GMFM improvement (SMD: 1.49; 95% CI: 1.33-1.65, p-value < 0.001, I2 = 92%). TSA also showed similar results with proper statistical power. Core CHMs, such as Glycyrrhiza uralensis Fisch. Ex DC., Poria cocos (Schw.) Wolf, Paeonia lactiflora Pall., processed Rehmannia glutinosa (Gaertn.) DC., Astragalus mongholicus Bunge, and Angelica sinensis (Oliv.) Diels, exerted effects on immune modulation and metabolism systems. The subgroup analysis showed participants using core CHMs or longer CHM treatment duration, and studies enrolling CP with spastic or mixed type, or mild-to-moderate severity had better outcomes in CHM groups with less heterogeneity.

Conclusion

CHMs may have a positive impact on managing pediatric CP; however, the potential bias in study design should be improved.

Systematic Review Registration

Identifier CRD42023424754.

Longitudinal Hammersmith Infant Neurological Examination (HINE) Trajectories in Children with Cerebral Palsy Identified in High-Risk Follow-Up

Background/Objectives: The Hammersmith Infant Neurological Examination (HINE) is a standardized neurologic exam for infants between 2 and 24 months. Scores can be compared to optimality cutoffs as one component to support an early diagnosis of cerebral palsy (CP). Some prognosis is also possible for infants diagnosed with CP. We aimed to understand the longitudinal trajectories of HINE scores in infants who were ultimately diagnosed with CP. Methods: Clinical records were reviewed for children who were diagnosed with CP in two high-risk infant follow-up clinics with HINE scores from at least two visits between the corrected ages of 3 months and 2 years. Trajectories were calculated individually and by group for infants in four categories-term neonatal hypoxic ischemic encephalopathy (HIE), term perinatal arterial ischemic stroke (PAIS), premature infants with brain injury, and "Other" (term infants with congenital malformations and/or congenital hydrocephalus). The changes in HINE scores between clinic visits were compared using linear mixed-effect models with a random intercept, pulling data by diagnostic group across visits and accounting for within-child correlations of scores over the follow-up time. Results: The changes in HINE scores for sixty children (twenty-five with prematurity, eighteen with HIE, seven with PAIS, and ten in the other category) were assessed. The linear mixed-effect models indicated that the infants with PAIS had an estimated 10.8-point increase in total HINE scores after 9 months of age compared to earlier assessments (95% CI [2.5, 19.2]. There was no statistically significant improvement in the scores among the infants in the other brain injury groups. The infants with PAIS had an estimated 2.9-point increase in HINE asymmetry scores after 9 months of age compared to prior visits (95% CI [0.7, 5.1]). None of the other diagnostic categories had statistically significant increases in asymmetry scores over time. Conclusions: The children with PAIS with resultant hemiplegia showed increasing HINE scores throughout the first two years of life. In contrast, the HINE scores remained stable for those children with term HIE, prematurity-associated brain injury, and congenital malformations and/or congenital hydrocephalus diagnosed with CP. Tracking individual changes (or stability) in HINE scores can aid diagnosis, inform prognosis, and guide the design of clinical trials targeting neurologic injury.

General Movements Assessment and Hammersmith Infant Neurological Examination for early diagnosis of cerebral palsy in infants born at term treated with therapeutic hypothermia

AIM

To establish if the General Movements Assessment (GMA) and Hammersmith Infant Neurological Examination (HINE) support the early diagnosis of cerebral palsy (CP) in a cohort of infants who have undergone therapeutic hypothermia.

METHOD

This was a retrospective cohort study from a large single center between 2018 and 2022. Sample size included surviving 112 infants with follow-up (68 males, 44 females) with a mean gestational age of 39 weeks (interquartile range 38-40), diagnosed with moderate or severe neonatal encephalopathy who underwent therapeutic hypothermia. Groups were compared using Fisher's exact and Mann-Whitney U tests.

RESULTS

The absence of normal fidgety movements at the 3-month GMA was highly associated with CP (p < 0.001, sensitivity 89%, specificity 89%). HINE scores were associated with CP at 3 months, 6 months, and 9 months (p < 0.001; sensitivity 82%-90%, specificity 95%-100%). The HINE scores, which optimally differentiated those with and without CP, were less than 47 at 3 months, less than 51 at 6 months, and less than 64 at the 9-month follow-up.

INTERPRETATION

The GMA and HINE were predictive of CP in infants born at term with neonatal encephalopathy who had undergone therapeutic hypothermia. Atypical (absent or abnormal) fidgety movements on the GMA at 3 months and the HINE score at 3 months, 6 months, and 9 months were all highly associated with CP diagnosis with more than 80% sensitivity and more than 90% specificity. The optimal HINE cutoff score for predicting CP may differ from infants born preterm and will benefit from further analysis.

Improving Register Ascertainment of Children With Post-Neonatally Acquired Cerebral Palsy Through Health Service Partnerships

BACKGROUND

The New South Wales (NSW) and Australian Capital Territory (ACT) Cerebral Palsy (CP) Register is a database of clinical and demographic information from children with CP. A child with CP resulting from an insult to the developing brain sustained between 29 days and 2 years of age is classified as having post-neonatally acquired CP (PNN-CP). In clinical services, children may meet the criteria and timing for PNN-CP but have a singular diagnosis of acquired/traumatic brain injury.

OBJECTIVES

To implement and evaluate a new CP register ascertainment strategy focused on identifying children with PNN-CP attending acquired brain injury rehabilitation services.

METHODS

Electronic medical records of children with an acquired brain injury attending the Sydney Children's Hospitals Network and John Hunter Hospital rehabilitation departments 2019-2024 were reviewed by researchers and rehabilitation paediatricians to identify children with PNN-CP. Children who fulfilled the criteria for CP were invited to participate in the CP Register. To evaluate this ascertainment strategy, we (i) ran descriptive statistics to analyse proportional changes of children with PNN-CP on the register and (ii) calculated temporal trends in prevalence per 10,000 live births for birth years 2003-2016, before and after the record ascertainment period.

RESULTS

Of 1051 children with an acquired brain injury, 46 had PNN-CP (2003-2019) and had not previously been included on the register. This ascertainment strategy resulted in increased prevalence of PNN-CP in all 2-year time points between 2003 and 2016 and equated to a 31% improvement in ascertainment of children with PNN-CP on the register.

CONCLUSIONS

Ascertainment of children with PNN-CP for the NSW/ACT CP Register has been improved by systematically reviewing children with an acquired brain injury. This is now part of standard practice, and other registers should consider whether this strategy may improve ascertainment of PNN-CP in their regions.

From eligibility to diagnosis: candidacy and the complex journey of cerebral palsy diagnosis within primary care

BACKGROUND

Cerebral Palsy (CP) is an umbrella term for a group of permanent postural and movement conditions caused by non-progressive damage to the developing brain. Infants not identified with risk factors for CP around the time of birth are usually referred on from primary care after six months of age, essentially precluding early therapy. Candidacy, a seven-step dynamic theory, describes how individuals negotiate their eligibility for medical attention with themselves, others, and health services. This study aims to explore the CP diagnostic journey for community identified infants using the concept of candidacy.

METHODS

Data was combined from two studies: an online survey of caregivers of children with CP about their earliest concerns and diagnosis journeys (n=255), and a series of interviews to support the development of a new tool to facilitate earlier identification of infants with emerging motor difficulties (11 parents, 11 health care professionals [HCPs]). A deductive thematic analysis was used with a semantic, critical realist approach. An initial analysis was framed by the Andersen Model of Total Patient delay, and then conceptualised using Candidacy.

RESULTS

Participants had difficulties identifying whether their child needed medical attention, prompting online searches, and seeking advice from family and friends. HCP adjudications led to immediate or delayed referral, in which families continued their searches, reappearing at services until a referral was made. Once referred, families faced poor operating conditions, such as long waiting times. After learning the diagnosis criteria, participants began making requests for referral and navigated to private services if requests were denied. Participants felt that more information on infant development from a reliable source was needed to support new parents in raising their concerns to aid earlier identification.

CONCLUSION

Participants identified personal lack of infant development knowledge as being the limiting factor to earlier referral. Further research is needed to develop materials relevant for the UK and to understand General Practitioner perspectives regarding provision of such materials.

Data-Driven Early Prediction of Cerebral Palsy Using AutoML and interpretable kinematic features

Early identification of cerebral palsy (CP) remains a major challenge due to the reliance on expert assessments that are time-intensive and not scalable. Consequently, a range of studies have aimed at using machine learning to predict CP scores based on motion tracking,e.g. from video data. These studies generally predict clinical scores which are a proxy for CP risk. However, clinicians do not REALLY want to estimate scores, they want to estimate the patients' risk of developing clinical symptoms. Here we present a data-driven machine-learning (ML) pipeline that extracts movement features from infant video based motion tracking and estimates CP risk using AutoML. Using AutoSklearn, our framework minimizes risk of overfitting by abstracting away researcher-driver hyperparameter optimization. Trained on movement data from 3- to 4-month-old infants, our classifier predicts a highly indicative clinical score (General Movements Assessment [GMA]) with an ROC-AUC of 0.78 on a held-out test set, indicating that kinematic movement features capture clinically relevant variability. Without retraining, the same model predicts the risk of cerebral palsy outcomes at later clinical follow-ups with an ROC-AUC of 0.74, demonstrating that early motor representations generalize to long-term neurodevelopmental risk. We employ pre-registered lock-box validation to ensure rig-orous performance evaluation. This study highlights the potential of AutoML-powered movement analytics for neurodevelopmental screening, demonstrating that data-driven feature extraction from movement trajectories can provide an interpretable and scalable approach to early risk assessment. By integrating pre-trained vision transformers, AutoML-driven model selection, and rigorous validation protocols, this work advances the use of video-derived movement features for scalable, data-driven clinical assessment, demonstrating how computational methods based on readily available data like infant videos can enhance early risk detection in neurodevelopmental disorders.

CCS Concepts

Computing methodologies → Machine learning approaches ; Applied computing → Health informatics .

ACM Reference Format

Melanie Segado, Laura Prosser, Andrea F. Duncan, Michelle J. Johnson, and Konrad P. Kording.. Data-Driven Early Prediction of Cerebral Palsy Using AutoML and interpretable kinematic features. In. ACM, New York, NY, USA, 8 pages.

The effect of constraint-induced movement therapy for children with hemiplegic cerebral palsy in Vietnam

PURPOSE

Pediatric constraint-induced movement therapy (CIMT) is an evidence-based treatment that has a long history of demonstrating efficacy for children with hemiparesis. The purpose of this study is to determine the effectiveness of a culturally responsive CIMT program for children with hemiplegic cerebral palsy (CP) developed for the Vietnam healthcare system.

METHODS

Thirty children with hemiplegic CP (mean age = 2.88 years, age range: 1 to 8 yrs, 60% male) were recruited to a CIMT program (7.5 h/week, 4 weeks) developed for the cultural context of Vietnam. Motor abilities of the affected arm and participation in daily activities were evaluated at 3 time points (one-week prior to CIMT (baseline), one-week before (pre) and after (post) CIMT) using the Quality of Upper Extremity Skill Test (QUEST) and Pediatric Motor Activity Log-Revised (PMAL-R). Individual goals were measured using the Goal Attainment Scale (GAS).

RESULTS

There were significant increases in the "How often scale" and "How Well" scales of the PMAL-R (0.75 and 0.75, p < 0.00)). Score of Grasp and Dissociated Movement items on the QUEST increased significantly (6.47 and 7.63, p < 0.001). Group GAS T-Scores were 52.19 indicating that children met individual goals.

CONCLUSIONS

A model of CIMT was successfully developed and delivered within the Vietnamese healthcare system. Future studies should explore the optimal model for CIMT in various regions of world where the delivery of rehabilitation services may vary.

Sleep Characteristics of Children and Youth with Cerebral Palsy

Background: Children with cerebral palsy are considered to be a population at risk for the occurrence of sleep difficulties. However, existing literature has been limited by subjective measures of sleep and has failed to examine contributing factors. Methods: Forty-five youth with cerebral palsy participated. Both youth and caregivers completed sleep-related questionnaires, while youth completed daily actigraphy for objective sleep assessments. Results: Sleep patterns, including sleep duration, wake after sleep onset, and sleep efficiency, are generally aligned with existing sleep recommendations. However, the number of awakenings was significantly higher in youth with cerebral palsy compared to these recommendations. Most youth experienced poor sleep quality, and approximately a quarter experienced insomnia. Being a boy and having a preexisting mental health diagnosis was associated with poor sleep quality and greater insomnia symptoms. Conclusions: Most youth with cerebral palsy experience a range of sleep difficulties. This study provides new information on sleep patterns in youth with cerebral palsy, highlighting the importance of addressing sleep issues in this population to improve their well-being and ultimately limit the negative impacts on overall health and quality of life.

Transition and Life-Long Care for Adults With Cerebral Palsy: A Patient Group 'Too Hard to Impact!' Are We Still Sending Young People 'Off a Cliff'?

OBJECTIVES

At Evelina London Children's Hospital, tertiary care is provided for children with Cerebral Palsy (CP) across the South East of England. An increasing number of adults with CP remain under the care of the children's hospital due to a lack of appropriate adult neurodisability services. This quality improvement project as part of a gap analysis regarding transition pathways for young adults with CP, aimed to explore the lived experience of young adults within our service, with respect to transition and care in adulthood.

METHODS

This was a multi-methods design. Firstly, a bespoke questionnaire to young adults with CP and their families evaluated their experience of transition, access to services, challenges with care, and their needs from healthcare professionals (n = 46). Then, a focus group with parents of adults with CP (n = 4) and interviews with adults with CP (n = 5) informed design of an ideal transition pathway and adult service. The qualitative data were thematically analysed.

RESULTS

Framework analysis of the questionnaire data was mapped against the International Classification of Functioning (ICF) with the following themes identified: Body structure and function: pain and anxiety; Activity: equality; accessibility and relationships; Participation: need for friendship and social opportunities, employment and education; Environmental factors: health services and providers; home environment and wider community; Personal factors: independence. Analysis of the focus group and interviews identified five main themes: Gradual and co-ordinated transition process; Co-ordination of care in adult services; Knowledge, skills and experience of professionals; Communication; and Worrying about the future.

CONCLUSIONS

Participants identified significant challenges with transition pathways and adult care. Annual reviews from healthcare professionals with expertise in CP should be offered to young adults to ensure early identification of health needs. Further research is needed to support business planning in development of appropriate adult services for adults with CP and ensure successful transition pathways.

Nutritional risk screening and nutritional assessment for children with cerebral palsy: A review of the current research status and future directions

BACKGROUND

Although the primary impairment involved in Cerebral palsy (CP) is motor function, malnutrition is also common. However, there is a lack of tool recommendations for early malnutrition risk screening in children with CP, and the means of nutritional intervention for children with CP are also limited.

METHODS

This study systematically searched the literature about clinical nutrition related content of cerebral palsy in Pubmed, MEDLINE, Embase, and the Cochrane Library in Jan 2024 and by hand searching, and we checked reference lists and citations to identify additional studies. Search terms include cerebral palsy, children, diagnosis, prediction, malnutrition, nutritional risk screening, nutritional assessment, nutritional support. Additions are marked in red in the modified version.

RESULTS

The timing of diagnosis of CP has been moving forward, and some new diagnostic tools have been developed. Nutritional status is correlated with regional economic level, but there is still a malnutrition rate of nearly 30 % in developed countries. Severe restrictions in terms of gross motor function, swallowing dysfunction, feeding difficulties, cognitive impairment, and insufficient energy intake are common risk factors for malnutrition in children with CP. Z-score should be calculated in combination with measurement indicators in the assessment of physical development of children with CP. The nutritional outcomes of children with CP can be improved by various means, including diversified a Nutrition Support Team (NST) interventions.

CONCLUSIONS

The incidence of malnutrition in children with CP is high, which needs to be paid more attention. More effective malnutrition risk screening tools need to be developed for children with CP to guide the implementation of comprehensive and personalized nutritional interventions and improve malnutrient-related outcomes.

Family expectations and demand for home-based videogaming therapy in children with cerebral palsy in Costa Rica: a mixed methods study

PURPOSE

To understand the expectations and demand for a movement-tracking videogame (Bootle Blast) for home-based, upper limb (UL) rehabilitation among Costa Rican children with cerebral palsy (CP).

METHODS

Data were collected via telephone screening (demand) and child-parent dyads Zoom interviews (expectations). Descriptive statistics and data transformation were used to report on demand success criteria (i.e., recruitment rate, having an appropriate screen and space to play, setting a weekly play time goal (PTG) ≥45 min, identifying one UL therapy goal). The DEPICT model for collaborative qualitative analysis was used in the thematic analysis of interview data.

RESULTS

Fifteen dyads participated (1.6 ± 1 recruited/month). All had a flat-screen TV in a suitable location to play, were able to set a UL therapy goal, and established PTGs ranging from 45-120 min per week. Identified themes were: 1) Socio-cultural factors heighten demand, 2) Feelings of hope prevail for the intervention, and 3) Collaborative goal setting supports realistic expectations for Bootle Blast.

CONCLUSIONS

Dyads had positive and realistic expectations about implementing the proposed videogaming intervention. This study provides insights on tailoring a family-centered, therapy gaming intervention to improve access to motor rehabilitation for children with CP in rural/remote settings and low-middle income countries.

Identificação de ingredientes de intervenções não invasivas para crianças deambuladoras com paralisia cerebral usando as minhas palavras favoritas: uma revisão de escopo

Objetivo

Mapear os ingredientes das intervenções não invasivas fornecidas às crianças deambuladoras com Paralisia Cerebral (PC).

Método

Os artigos foram selecionados e as características dos estudos extraídas. Os ingredientes das intervenções foram descritos em termos do Sistema de Especificação de Taxonomia de Reabilitação (RTSS) e vinculados às minhas palavras favoritas. Os resultados foram interpretados e validados por meio da abordagem de Envolvimento de pacientes e do Publico em Pesquisa (EPP).

Resultados

Sessenta e um artigos foram incluídos, dos quais 55,5% foram classificados como ensaios clínicos randomizados. Os estudos selecionados incluíram um total de 2187 crianças (a idade média variou de 3 meses a 5,9 anos), a maioria de países desenvolvidos. Os estudos incluídos investigaram um total de 27 intervenções, que juntas apresentaram ingredientes representando todas as minhas palavras favoritas, na seguinte ordem de frequência: “Saúde” (ex., treinamento de força e resistência), “Funcionalidade” (ex., prática ativa e repetitiva de uma tarefa), “Família” (ex., terapia focada no contexto), “Diversão” (ex., inclusão de atividades amistosas para crianças), “Amigos” (ex., atividades em grupo) e “Futuro” (ex., compartilhamento de informações didáticas). Assim, os ingredientes relacionados à palavra “Futuro” foram os relatados com menos frequência.

Interpretação

Terapeutas e famílias precisam estar cientes da correspondência mais apropriada entre as metas elencadas por meio das minhas palavras favoritas e os objetivos, ingredientes e alvos das intervenções. Finalmente, “Diversão”, “Amigos” e “Futuro” devem ser abordadas como desfechos potenciais em estudos futuros.

F-words ingredients of non-invasive interventions for young ambulant children with cerebral palsy: A scoping review

AIM

To map the ingredients of non-invasive interventions provided to young ambulant children with cerebral palsy.

METHOD

Articles were screened and each study's characteristics extracted. The intervention ingredients were described in terms of the Rehabilitation Treatment Specification System and linked to the 'F-words'. Results were interpreted and validated by a patient and public involvement group.

RESULTS

Sixty-one papers were included, of which 55.5% were classified as randomized controlled trial design studies. The selected studies included a total of 2187 children (mean age range 3 months to 5 years 11 months), most from high-income countries. The included studies investigated a total of 27 interventions, which together presented ingredients representing all F-words, in the following order of frequency: 'fitness' (e.g. strength and endurance training), 'functioning' (e.g. active and repetitive practice of a task), 'family' (e.g. context-focused therapy), 'fun' (e.g. inclusion of child-friendly activities), 'friends' (e.g. group activities), and 'future' (e.g. didactic information sharing). Thus, ingredients related to the F-word 'future' were the most infrequently reported.

INTERPRETATION

Therapists and families need to be aware of the most appropriate match between the F-word goals, ingredients, and targets. Finally, 'fun', 'friends', and 'future' should be addressed as potential outcomes in future studies.