Pediatric Neurology 76 (2017) 66–71

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Pediatric Neurology
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / p n u

Original Article

Implementation of Early Diagnosis and Intervention Guidelines

for Cerebral Palsy in a High-Risk Infant Follow-Up Clinic
Rachel Byrne PT a, Garey Noritz MD b, Nathalie L. Maitre MD, PhD b,c,* on behalf of the
NCH Early Developmental Group b
a
Cerebral Palsy Foundation, New York, New York
b
Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
c
Center for Perinatal Research at Nationwide Children’s Hospital, Columbus, Ohio

ABSTRACT
BACKGROUND: Cerebral palsy is the most common physical disability in childhood, and is mostly diagnosed after
age 2 years. Delays in diagnosis can have negative long-term consequences for children and parents. New guide-
lines for early cerebral palsy diagnosis and intervention were recently published, after systematic review of the
evidence by international multidisciplinary experts aiming to decrease age at diagnosis. The current study tested
the feasibility of implementing these guidelines in an American clinical setting. METHODS: We designed a step-
wise implementation process in a neonatal intensive care follow-up clinic. Efficacy was tested by comparing 10-
month pre- and post-implementation periods. Clinic visit types, cerebral palsy diagnosis, provider competencies
and perspectives, and balancing measures were analyzed. RESULTS: Changes to infrastructure, assessments, sched-
uling algorithms, documentation and supports in diagnosis or counseling were successfully implemented. Number
of three- to four-month screening visits increased (255 to 499, P < 0.001); mean age at diagnosis decreased (18 to
13 months, P < 0.001). Clinic team awareness of early diagnosis and interventions increased (P < 0.001). There was
no decrease in family satisfaction with overall clinic function. Opportunities for improvements included documen-
tation for transitioning patients, generalizabilty across hospital clinics, systematic identification of high-risk status
during hospitalization, and need for cerebral palsy care guidelines for infants under age 2 years. CONCLUSIONS: We
demonstrated for the first time in a US clinical setting the feasibility of implementation of international early di-
agnosis and treatment guidelines for cerebral palsy. This process is adaptable to other settings and underscores
the necessity of future research on cerebral palsy treatments in infancy.
Keywords: infant, cerebral palsy, early intervention, diagnosis
Pediatr Neurol 2017;76:66–71
© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background perinatal period,3 and is associated with a wide range of

Worldwide, cerebral palsy is the most common physical
disability in childhood.1,2 Cerebral palsy is a nonprogressive
disorder of movement originating from neural lesions in the
Conflicts of interest: All the authors declare that they have no competing in-
terests. This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
Article History:
Received July 21, 2017; Accepted in final form August 7, 2017
* Communications should be addressed to: Dr. Maitre; Department of
Pediatrics; Nationwide Children’s Hospital; 700 Children’s Drive, WB6225;
Columbus, OH 43205.
E-mail address: Nathalie.maitre@nationwidechildrens.org
common comorbidities.4 Many of these respond well to in-
terventions in early childhood, when brain plasticity is at its
greatest5 and developmental trajectories can be altered with
maximal benefit into adulthood.6 In large research net-
works, investigators have successfully decreased the age at
cerebral palsy diagnosis to 19 months.7 However, in most
clinical settings the age for diagnosis of cerebral palsy is on
average two years or beyond.8 Delays in diagnosis of cere-
bral palsy are associated with worse long-term function and
participation, parental dissatisfaction, and higher rates of
mental health conditions, including depression.4,9
In response to these concerns, a large working group of
international experts in cerebral palsy-related disciplines and
parent stakeholders published guidelines for early detection

0887-8994/$ — see front matter © 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.pediatrneurol.2017.08.002
 R. Byrne et al. / Pediatric Neurology 76 (2017) 66–71 67

FIGURE 1.
Translation of international guidelines into a clinical practice algorithm in a neonatal intensive care unit follow-up program. Infants referred due
to newborn-attributable risks (e.g., neuroimaging findings consistent with neonatal encephalopathy) most frequently start surveillance according
to the guidelines at the three- to four-month visits. If they are still hospitalized (e.g., extremely preterm infant with white matter injury and lung
disease), the guideline mandated surveillance happens at the bedside with a HINE, a TIMP, and a GMA. Infants referred due to infant-attributable
risks start at closest point on the pathway. For example, an infant referred to the program at nine months by their pediatrician due to inability to
sit would start with a HINE and a Bayley Scales of Infant and Toddler Development. If an MRI has not yet been performed by the three- to four-
month visits when neither sedation nor anesthesia is required, it is deferred until 12 months when anesthesia is no longer required by this particular
setting’s radiology protocols. During the program, infants are referred to services and subspecialists according to needs and established clinical
algorithms. * Select examinations target developmental progression and represent best feasible evidence for specific concern (e.g., Gross Motor
Function Measure-66 at 18 months and 30 months when infant walking to begin establishing trajectory, Infant Toddler Sensory Profile for sensory
processing concerns, Quality of Upper Extremity Skills Test for arm evaluation in hemiplegia, Receptive Expressive Language Test-3 for speech as-
sessment, etc.). ** Neurological examination after 2-year visit includes Amiel-Tison or other. Bayley III, Bayley Scales of Infant and Toddler Development
Third Edition; CBCL, Child Behavior Checklist; CO, cerebral palsy; GMA, General Movements Assessment; HINE, Hammersmith Infant Neurological
Examination; TIMP, Test of Infant Motor Performance. (The color version of this figure is available in the online edition.)

and intervention for cerebral palsy,10 based on a systematic
of evidence for why and how cerebral palsy should be rec-
ognized as early as possible. 11 The guidelines include
recommendations for neuroimaging, neurological exami-
nations, and motor assessments for infants below five months
corrected age and between five and 24 months corrected age.
They define the concept of “high-risk for cerebral palsy” at
three to four months, a category in which infants do not yet
receive a diagnosis, but due to a constellation of clinical factors,
neuroimaging findings and standardized assessments, have
a 95% probability of developing cerebral palsy in the fol-
lowing years. Best current evidence for counseling is based
on published parent surveys and high-quality research. The
guidelines can be translated into clinical practice by adapt-
ing core elements to suit individual clinical settings illustrated
in Fig 1 (setting is a neonatal intensive care unit (NICU) follow-
up program with applied examples of the guidelines).
Although research programs leveraged the evidence base
for early detection of cerebral palsy,12-14 no clinical pro-
grams implemented the guidelines in their entirety as
standard care. NICU follow-up programs routinely follow two
infant populations with common identifiable factors for ce-
rebral palsy: preterm infants and term infants with neonatal
encephalopathy. Many children with less common risk factors
for cerebral palsy also receive care in such programs due to
medical complexity in the perinatal period. The goal of our
study was therefore to test the effectiveness of an imple-
mentation process for clinical use of the early diagnosis
guidelines10 and apply them to a NICU follow-up clinic
setting, where a large population of high-risk infants is rou-
tinely monitored. We hypothesized that comparison of
quantitative metrics for clinic visits, diagnoses, and provid-
er training competency would demonstrate improvements
before and after implementation. We complemented our
study with balancing measures of parent satisfaction and
qualitative data on provider perceptions.
Methods
We analyzed data under an exempt determination from the Nation-
wide Children’s Hospital Institutional Review Board (IRB17-00409) due
to the use of unidentified data.
68 R. Byrne et al. / Pediatric Neurology 76 (2017) 66–71

Part one—baseline conditions

Setting and population

The NICU follow-up clinic in a large referral tertiary care center en-
compassing a network of nine NICUs including levels II, III, and IV units
(a range from special care nurseries to intensive care to surgical refer-
ral centers)15 and geographical region of approximately 200 mi2 was used
as the study setting. Before the implementation of the guidelines, no
specific early cerebral palsy program existed. Suspicion of cerebral palsy
prompted referral at discharge from the clinic (age 2 years) to a devel-
opmental pediatrician or various specialty programs outside the NICU
follow-up program for further evaluation. The exception to this pattern
was for infants who received hypothermia, all of whom were followed
by the pediatric neurologist within the NICU follow-up program. The
clinic saw an average of 5000 high-risk visits per year, mostly referred
from the NICU network, and also from community providers. Referrals
to the clinic were based on established criteria (Supplemental Table S1).

Infrastructure
The electronic medical record was on an Epic platform, commonly
used by large US health systems to access, organize, store, and share
patient medical records. Therapist documentation of Bayley Scales of
Infant and Toddler Development Third Edition16 was standardized with
flow sheets and checklists. Another feature of Epic was the MyChart
option, an online secure portal, allowing parents to communicate with
clinic providers. Pre-implementation, documentation of assessments was
heterogeneous, reflecting personal choice and occasional practice in other
clinics. Clinic scheduling templates were based on therapist schedul-
ing availability and medical practitioners rarely had assigned patients.
Visit schedules, assessments, and referral
Pre-implementation, schedules followed very preterm infants at three
to four months, nine to 12 months, and 22 to 26 months, with interim
visits based on specific therapist- or dietitian-identified needs (Fig 2).
Assessments were guided by participation in the Neonatal Research
Network18 as well as a strong evidence-based practice group in the
therapy department. In addition, specialized providers examined those
patients with high neurological complexity. Therapist assessments often
determined referrals for therapy services, whereas medical providers
made the referrals to subspecialty providers and programs (audiology,
ophthalmology, physical medicine, developmental pediatrics, psychol-
ogy, complex care, cerebral palsy) or for procedures based on their clinical
judgment and a developmental algorithm for the two-year visit.
Providers
The NICU follow-up team was multidisciplinary and diverse.
Supplemental Table S2 lists roles and responsibilities of each provider
in the NICU follow-up clinic pre- and post-implementation.
FIGURE 2.
Schedule of visits prior (A) and after (B) implementation. The journey
in blue represents the schedule before guideline implementation, the
red one after. The cognitive, motor, and language domains of the Bayley
Scales of Infant and Toddler Development Third edition are adminis-
tered. Standardized neurological examinations modified from the
Amiel-Tison17 are performed at 22 to 26 months on research patients
by medical providers trained and certified on an annual basis by a gold-
standard per NRN procedures.18 Bayley III, Bayley Scales of Infant and
Toddler Development Third Edition; CBCL, Child Behavior Checklist; GMA,
General Movements Assessment; HINE, Hammersmith Infant Neuro-
logical Examination; NRN neuro, Neonatal Research Network neurological
examination; OT, occupational therapist; PT, physical therapist; SLP,
speech and language pathologist; TIMP, Test of Infant Motor Perfor-
mance. (The color version of this figure is available in the online edition.)
was accomplished by Prechtl’s Trust certified trainers. Clinical compe-
tency in the Hammersmith Infant Neurological Examination (HINE) was
a novel implementation process published recently.19 Training of medical
providers in scope of practice of various therapy disciplines, available

Research
Clinic personnel were involved in research through Neonatal Re-
search Network studies requiring follow-up of two-year
neurodevelopmental outcomes as a measure of efficacy of NICU-based
interventions. However, interventional studies for infants were not yet
integrated into the workflow of the clinic, making it difficult to incor-
porate new and proven interventions for cerebral palsy and to promote
a culture of change into the setting.

Part two—implementation process

The process followed a predetermined timeline (Fig 3). The plan-

ning phase involved the design of a clinical schedule based on the
guidelines (Fig 1), also respecting the primary mandate of the NICU
follow-up program to follow all high-risk infants, not only those with
cerebral palsy, and to promote effective transition to existing services
after leaving the program. The preparation phase initiated provider culture
change through a series of small moderated workgroups, each charged
with guiding individual aspects of optimal developmental surveillance
for all patients. Training in the General Movements Assessment (GMA)
FIGURE 3.
Implementation timeline and phases. The initial three phases of the im-
plementation process occurred over the course of 12 months. A
consolidation phase with reassessment of strengths and weaknesses
offered the opportunity of a new development phase, planning for pri-
orities of the next implementation cycle.
 R. Byrne et al. / Pediatric Neurology 76 (2017) 66–71 69

services, and best evidence for occupational, physical, speech and feeding TABLE 1.
therapies in infancy was accomplished by a series of self-directed modules Clinic Visit Numbers and Diagnosis Metrics for Implementation
designed by clinical therapy leaders. Dietitians utilized first World Health
7/14 to 5/15 7/16 to 5/17
Organization curves for infants,20 then the cerebral palsy-specific growth
curves21 based on Gross Motor Function Classification System levels. Doc- Total visits in clinic ≤12 2287 1999
months*
umentation in Epic was modified to match the new visit schedule, driven
0 to 2 months 1022 593
by providers practicing regularly in the clinic. Clinic templates were
3 to 4 month visits 255 499§
switched to a provider-based system, allowing continuity of medical care 5 to 12 month visits 1010 907
and neurological trajectories as well as longitudinal perspective from Visits ≤12 months in clinic 2 27
the team leaders who could request specific therapy assessments based with new cerebral palsy
on new knowledge gained in the modules. Visits before three months diagnosis
were scheduled for those with the greatest risk factors and complexi- Mean age at cerebral palsy 18 (SD 7) 13 (SD 4)||
ty. Research was integrated through additional workspace, training of diagnosis in months, range 11 to 32 range 4 to 29
coordinators, improved communication with nursing and social work patients still in clinic
Mean age at cerebral palsy 28 (SD 7) 16 (SD 7)
leaders, and visibility of rehabilitation study materials.22,23
diagnosis in months, any
Parent support was addressed through counseling with the ele- patients seen in clinic†
ments recommended in published literature and the guideline mandates: Total number of patients 70 175
“face-to-face, with both caregivers present if appropriate, private, honest, at NCH with a diagnosis
jargon-free, with empathic communication tailored to the family.”4 Iden- of cerebral palsy under 3
tification of strengths and goals was included, and questions were fostered years‡
by allowing the diagnosing provider to return at conclusion of the visit Abbreviations:
to reassess the emotional context and answer additional questions. NCH = Nationwide Children’s Hospital
MyChart use was explained and encouraged. Referral to services was SD = standard deviation
complemented by a set of written materials (therapist handouts and * Number of visits over a 10-month period in all NICU follow-up clinics with de-
parent educational booklet).24 velopmental testing.
† Includes patients either discharged from clinic before a diagnosis was made
Implementation occurred over one month, during which process im-
or patients referred to other clinics where diagnosis was subsequently made.
provement guides were available to observe, troubleshoot, record ‡ Does not reflect all patients with cerebral palsy at NCH, only those under age
challenges, and provide support if necessary. Written feedback was also
3 years. Incidence unchanged between periods.
solicited. § McNemar test, P < 0.001.
Consolidation involved further observation and support in areas iden- ||
t Test, P < 0.001.
tified as challenges such as knowledge verification, training gaps, hand-
off problems, template and workflow, scheduling difficulties, and referral
difficulties. Development was driven by group identification of new pri-
orities for the next cycle in clinical, operational, and research domains
during regular provider meetings. Intra-hospital and community out-
reach were added as new priorities. point. The number of children in the clinic diagnosed by 12
months increased, with the age at diagnosis decreasing sig-
nificantly. In addition, changes in the clinic were reflected
Part three—evaluation metrics
by a decreased mean age at diagnosis in the overall popu-
lation of children with diagnoses of cerebral palsy at the
Quantitative metrics (Table 1) were obtained in the 10-month periods
from July 1, 2014 to May 30, 2015 and July 1, 2016 to May 30, 2017 to
hospital under age 3 years.
prevent the possibility of crossover effects from early phases of imple-
mentation. Balancing measures were obtained using standard anonymous
feedback clinic questionnaires at the end of each visit from any parent
Provider metrics
in the clinic, not only those of children with cerebral palsy. The goal of
these measures was to determine whether implementation of the Provider metrics (Table 2) demonstrated significant im-
program negatively impacted parent satisfaction through three ques- provement of awareness of best practices around early
tions about overall perception of clinic function. Provider perspectives diagnosis and early interventions for infants less than 12
on cerebral palsy recognition and intervention for those involved in the months. When providers were asked to describe what they
care of infants 12 months and under were obtained through a survey
had learned post-implementation, five major themes
scored on a five-item ranked scale.
emerged: optimizing developmental outcomes for chil-
dren, improvement of support to parents, awareness of
Results assessment tools, effective rehabilitation interventions, and
importance of early detection. Balancing measures of parent
Clinic metrics
satisfaction with clinic processes remained high and un-
changed (Supplemental Table S3).
The proportion of preterm infants seen in the clinic was
not significantly different between the two periods (85.7%
versus 76.6%, P = 0.9). The incidence of cerebral palsy was Statistical analysis
unchanged pre- and post-implementation of the guide- Continuous variables were analyzed using two-tailed t
lines in the hospital system.19 The average age of diagnosis tests. Distributions of visit types pre-implementation versus
of cerebral palsy was decreased from age 18 months to 13 post-implementation were compared using McNemar test
months19 (Table 1). Number of three- to four-month visits with alpha = 0.05. Scores on scales using ranked items were
increased compared with other types of visits (due to the analyzed using two-tailed Wilcoxon matched-pairs signed-
decreased clinic load of new patients and increased focus rank test, with with alpha = 0.05. All calculations were
on three- to four-month visits), resulting in more children performed using SPSS software (IBM Corp. Released 2013,
having GMA and HINE assessments performed at this time IBM SPSS Statistics for MacIntosh, Version 22.0, Armonk, NY)
70 R. Byrne et al. / Pediatric Neurology 76 (2017) 66–71

TABLE 2. certification recorded the GMA on a secure tablet, ex-

Survey Results for Provider Awareness
n 2014 2017
How aware that cerebral palsy 26 1 3
could be frequently
diagnosed by 12 months
How aware of research 22 0 3
interventions targeted to
infants ≤12 months with
cerebral palsy
Therapist and provider: 11 0 4
awareness of GMA and HINE
use
Nurse: awareness of sleep 5 0 2 0.05
importance for infants with
cerebral palsy
Dietitian: awareness of 3 1 3 0.04
cerebral palsy specific
nutrition
Abbreviations:
GMA = General Movements Assessment
HINE = Hammersmith Infant Neurological Examination
Median scores and P value for two-tailed Wilcoxon matched-pairs signed-rank test
significance values are presented.
Ranked items scale was 0 = not at all; 1 = very little; 2 = somewhat; 3 = very much;
4 = always.
Discussion
This study represents the first successful attempt in the
United States to implement the international guidelines for
early detection and intervention for cerebral palsy. Average
age at diagnosis decreased in the clinic program with an in-
crease in provider knowledge base. Overall, parents were not
dissatisfied by the process changes, and qualitative reports
indicated satisfaction from providers and patients on the new
model.
The NICU follow-up program presented a unique oppor-
tunity for success in implementation due to the strong
institution-wide culture of commitment to excellence in clin-
ical care, research, and quality improvement. Institutional
support at the operational level allowed business manag-
ers and clinical leaders to direct the change in vision. For
example, the therapist group already had a funded evidence-
based practice group. The commitment of the NICU follow-
up program team to their high-risk population made a change
in practice relatively easy, as it did not represent a culture
change.
In the consolidation phase, several immediate opportu-
nities for process improvement were identified. In particular,
as previously reported,19 various providers had different
comfort levels with giving the diagnosis of high-risk for or
of cerebral palsy. Establishing confidence in administering
the HINE or reading GMAs was sometimes difficult. For all
these issues, a team-based support system was estab-
lished so that providers could always rely on a more advanced
or experienced provider for assistance. For diagnosis, if the
provider did not feel comfortable or assessed that the family
was not ready (emotional state, lack of support system, other
parent not present, child acutely ill at visit) to receive a di-
agnosis, they explained that findings of an assessment were
not typical. They then scheduled a return visit with a
neurodevelopmental-trained specialist in the clinic. Simi-
larly, for the GMA, therapists with less experience or without
plained that results would be reviewed by an experienced
P Value provider and communicated as soon as available. Experi-
<0.001 enced providers were available either in person or remotely.
Provider confidence in neurological examinations improved.19
On average, providers currently perform five to six HINE ex-
<0.001
aminations per day, leading to increasing clinical competency
and confidence. A year after the initial training program, a
repeat observation of clinical examinations prevented drift
<0.001
and clarified questions. When trained providers left and new
providers were incorporated, a systematic training process
and team-support system helped overcome this new
challenge.
The documentation implementation was overall a success,
with streamlined notes and flow sheets routinely used for
the GMA and HINE. However, a noted failure was lack of com-
pliance with an additional documentation form used in the
Comprehensive Cerebral Palsy program for older children.
The goal of filling out this flow sheet in addition to regular
Epic documentation was to provide data for the Learn from
Every Patient project25 and facilitate transitions. However,
the added burden of repetitive documentation proved un-
sustainable and use of the forms was paused while new
processes were developed to capture the needed informa-
tion without duplication of effort. A streamlined referral
process was devised with the indication of “transition to the
cerebral palsy program,” placed at 30 to 33 months to ensure
continuity between the early and later cerebral palsy
programs.
The success of the program in early identification
prompted troubleshooting questions currently not ad-
dressed in the care of cerebral palsy patients. Partnering with
physical and occupational therapists, orthopedic surgeons
and orthotists specializing in the care of very young chil-
dren and infants allowed a reframing of expectations and
ordering patterns for upper and lower extremity orthotics.
Evidence-base for truncal supports is also being reviewed,
and guidelines for prescription in the clinic are still in de-
velopment. Another area of critical importance to be
addressed was hip surveillance in infants 12 months and
under, in circumstances where the severity of cerebral palsy
is uncertain or unstable at best26 (see Supplemental Table S4).
The development phase highlighted opportunities for
future improvements. Early identification in the NICU of all
infants at risk for cerebral palsy in addition to those already
meeting criteria for follow-up became a priority. Patients re-
ferred to the NICU for reasons that are not commonly
associated with neurological insults are neither routinely
screened using neuroimaging or referred to the follow-up
program (surgical intervention, routine preterm care from
32 to 37 weeks, respiratory distress in term newborns, hy-
perbilirubinemia or sepsis evaluations). Routine use of the
GMA before discharge from the NICU can help screen for
infants meeting the “infant-attributable risk” pathway of the
international guidelines.10 Results of a one-year experi-
ence using the GMA in the NICU for this purpose are
forthcoming.
In addition, several other clinics at the hospital that follow
children at high risk for cerebral palsy have not imple-
mented the guidelines. Many of these children are referred
when pediatricians identify the need for a specialist after
 R. Byrne et al. / Pediatric Neurology 76 (2017) 66–71
age 3 years, whereas others were never cared for in a NICU.
Opportunities and willingness currently exist to adapt the
guidelines to these settings to promote more consistent early
care for high-risk infants. Community outreach and educa-
tion to support pediatric providers through education
materials and care coordination is ongoing.
Finally, this single site experience in implementation pro-
cesses prompted interest at the national level for
implementation of the international guidelines. The Cere-
bral Palsy Foundation therefore initiated the creation of a
structured implementation network across six major US sites
in July 201727 to be expanded over three years in a widen-
ing US-specific network. Knowledge translation, toolkits,
training, and infrastructure will be provided to all partici-
pants, many derived from this single site experience.
Conclusions
This work demonstrates the first successful attempt at
implementing the international early diagnosis and treat-
ment guidelines for cerebral palsy in a clinical setting in the
United States. The process feasibly lends itself to adapta-
tion to other settings. The current experience highlights the
need for new clinical care guidelines and novel interven-
tion research for infants with cerebral palsy diagnosed under
age 2 years.
Authors’ Contributions
NM conceptualized the implementation process and the
research study. RB contributed to the research design and
wrote the first draft of the manuscript. GN contributed to
the implementation process and draft of the manuscript. All
authors in the NCH Early Developmental Group designed and
participated in components of the implementation process
and contributed to the manuscript. All authors read and ap-
proved the final manuscript.
We would like to thank all our patients and their families. In addition, we would
like to thank Ms. Rebecca Lam and Ms. Olena Chorna for their help in preparing
this manuscript and obtaining all regulatory materials. NCH Early Developmental
Group includes Rukhshana Ahmed, Erin Anderson, Nancy Batterson, Lawrence Baylis,
Brooke Bernstein, Teresa Borghese, Regina Bray, Chelsea Britton, Marie Cain, Ilene
Crabtree, Caitlin Cummings, Kelli Dilver, Jaclyn Gray, Jennifer Haase, Andala Hardy,
Megan Harrison, Alyssa Huddleston, Cherie Isler, Cheryl Kokensparger, Beth Kosch,
Joanna Kinner, Jessica Lewis, Ryan Nicoll, Brianne Palay, Audrey Shifflett, Laurel
Slaughter, Michelle Smith, Annie Temple, Kristy Theller, Lindsey Tobias, Jill Tonneman,
Elizabeth Wagner, Kylie Weber.
Appendix: Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.pediatrneurol.2017.08.002.
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