PERSPECTIVES

A Call for Early Detection of Cerebral

Palsy
Faith Kim, MD,* Nathalie Maitre, MD, PhD,† on behalf of the Cerebral Palsy Foundation
*Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian Children’s Hospital of New York, New York, NY
†
Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA.

PRACTICE GAPS

Clinicians caring for infants who are at risk of developing cerebral palsy
(CP) should be familiar with standardized assessment tools including the
General Movements Assessment and the Hammersmith Infant Neurological AUTHOR DISCLOSURES Dr Maitre has
worked under grants from the National
Examination. Clinicians trained in these tools can use them to make an
Institutes of Health and the Cerebral
early, accurate diagnosis of CP to allow for earlier intervention and Palsy Foundation; owns a patent, care of
improved outcomes. Enlighten Mobility and Thrive
Neuromedical; and is a cofounder of
Thrive Neuromedical. Dr Kim receives
support as a principal investigator for the
OBJECTIVES After completing this article, readers should be able to: Cerebral Palsy Foundation Early Detection
Initiative and has received honoraria for
being a guest speaker, courtesy of
1. Describe the changing spectrum of cerebral palsy (CP) diagnosis in Hackensack University and Morristown
infants treated in NICUs. Medical Center. This commentary does
not contain a discussion of an
2. Describe the development and implementation of clinical guidelines for unapproved/investigative use of a
early detection of CP. commercial product/device.

3. Recognize the utility of General Movements Assessment, Hammersmith

Infant Neurological Examination, and neuroimaging in the early ABBREVIATIONS

detection of CP. AIMS Alberta Infant Motor Scale

ASD autism spectrum disorder
CP cerebral palsy

ABSTRACT CS
cUS
cramped synchronized
cranial ultrasound
Cerebral palsy (CP) is the most common physical disability across the DAYC Developmental Assessment of
Young Children
lifespan, but historically, CP has not been diagnosed before the age of 2
EDI Early Detection and
years. Barriers to early diagnosis ranged from lack of available biomarkers, Implementation
absence of curative treatments, perceived stigma associated with a lifelong ELGAN Extremely Low Gestational Age
Newborn Study
diagnosis, and a desire to rule out other diagnoses first. Most importantly,
FM fidgety movement
the fundamental question that remained was whether children would GMA General Movements
benefit from earlier detection and intervention given the paucity of Assessment
research. However, evidence-based guidelines published in 2017 GMFCS Gross Motor Function
Classification System
demonstrated that the General Movements Assessment, the Hammersmith HIE hypoxic-ischemic
Infant Neurological Examination, and neuroimaging can be combined with encephalopathy
other elements such as a clinical history and standardized motor HINE Hammersmith Infant
Neurological Examination
assessments to provide the highest predictive value for diagnosing CP as
HRIF high-risk infant follow-up
early as age 3 months in high-risk newborns. Implementation of these IVH intraventricular hemorrhage
guidelines has been successful in decreasing the age at CP diagnosis, MRI magnetic resonance imaging
PVL periventricular leukomalacia
particularly in high-risk infant follow-up clinics with expertise in performing
TIMP Test of Infant Motor
these assessments. Early detection of CP allows for clinical and research Performance

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 opportunities investigating earlier interventions during a critical period of neuroplasticity, with the goal of
improving developmental trajectories for children and their families. New guidelines and research are now being
developed with a focus on early, targeted interventions that continue to be studied, along with global detection
initiatives.
INTRODUCTION
Cerebral palsy (CP) is the most common physical disabil-
ity across the lifespan, with approximately 10,000 infants
with a new diagnosis of CP every year in the United
States. (1)(2)(3)(4)(5)(6) Although the prevalence of severe
forms of CP has declined, the overall prevalence of the dis-
order has remained unchanged despite advances in obstet-
ric and neonatal care. (7)(8)(9) Children with CP can be
broadly categorized into groups based on their level of risk
at birth:
1. Term infants with hypoxic-ischemic encephalopathy
(HIE)
2. Preterm infants
3. Infants with identifiable and diverse risk factors such
as stroke, intrauterine drug exposure, cytomegalovirus,
and other infectious diseases
4. Infants with no identifiable risk factors (10)(11)(12)(13)
Among infants with moderate to severe HIE, 19% de-
veloped CP by 2 years of age despite therapeutic hypother-
mia, compared with 31% of nontreated infants. (14)(15)
(16)(17)(18)(19)(20)(21) Furthermore, it is well-established
that the risk of CP increases with decreasing gestational
age. (7)(22)(23)(24) A large systematic review demonstrated
a pooled prevalence of CP of 59 in 1,000 live births in in-
fants weighing 1,000 to 1,499 g at birth and 112 in 1,000
live births in infants born at less than 28 weeks’ gestation.
(9) Approximately 15% of preterm infants born between 24
and 27 weeks’ gestation develop CP, and as more infants at
younger gestational ages (22–23 weeks’ gestation) are sur-
viving, the rates of CP have increased to more than 20% in
the most premature infants. (23)(25)(26)(27) However, even
late preterm (34 to <37 weeks’ gestation) and moderately
preterm (32 to <34 weeks’ gestation) infants who comprise
the majority of infants born prematurely have higher odds
of developing CP compared with term infants, with white
matter injury representing the predominant type of abnor-
mal neuroimaging found in this subgroup of patients. (28)
Although the American Academy of Pediatrics recom-
mends motor development surveillance at ages 9, 18, 30,
and 48 months, a large proportion of term newborns who
develop CP may be undetected initially. (2)(29)(30)(31) A
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recent Canadian study used a prognostic bedside tool inte-
grating risk factors in the neonate and pregnant person
(eg, tobacco use, diabetes, preeclampsia, intra-amniotic in-
fection) and identified twice as many children with CP in
low-risk term infants compared with those who presented
with neonatal encephalopathy; however, this algorithm
has not yet been proven to be generalizable across popula-
tions. (32)
Standardizing practices to facilitate early detection of
CP across all groups of infants based on scientific evi-
dence will optimize identification and support the develop-
ment of additional effective interventions for affected
infants. In this article, we review the definition and risk
factors for CP as well as the history of early detection, in-
troducing readers to the basic elements and principles be-
hind assessment tools being implemented in high-risk
infant programs across the world.
OVERVIEW OF CP
The definition of CP has been debated dating back to 1861
when William Little first described a condition as “cerebral
paresis” that started in childhood and persisted across a
person’s lifespan. (33) The most cited definition in the lit-
erature reflects a large international consensus and reads
as follows: “[CP] describes a group of disorders of the develop-
ment of movement and posture, causing activity limitation that
is attributed to non-progressive disturbances that occurred in
the developing fetal or infant brain. The motor disorders of
[CP] are often accompanied by disturbances of sensation, cogni-
tion, communication, perception, and/or behavior, and/or by a
seizure disorder.”(34) This definition does not imply a single
etiology or discrete lesion but rather describes a spectrum of
disease with a common phenotype but possible broad origins,
or “disturbances.”(33) Mechanisms underlying the development
of CP are often attributed to 1) intrauterine factors (eg, placental
pathology, congenital anomalies, fetal growth restriction, drug
exposure), 2) peripartum events (eg, HIE, stroke, or intra-amni-
otic infection), 3) postnatal complications, most commonly due
to prematurity-related morbidities (eg, intraventricular hemor-
rhage [IVH] or periventricular leukomalacia [PVL]), or 4) identi-
fiable genetic factors. (35) However, the etiology of CP remains
unknown in half of affected children. Recent studies have
highlighted a more prominent role for genetic factors in the
 development of CP. Among 250 parent-offspring trios, of
which the majority (63%) were classified as having no identifi-
able cause associated with CP, whole-exome sequencing identi-
fied newly implicated genes in those with CP and estimated
that 14% of cases were related to a causative genomic mutation.
(36) A meta-analysis that included exome or genome sequenc-
ing in individuals with CP found an overall diagnostic yield of
8% to 16% in those with risk factors for CP versus 14% to
48% in those without risk factors; this finding is similar in pa-
tients with an intellectual disability or autism spectrum disorder
(ASD). (37) Thus, a genetic assessment is now included in a
systematic approach to an evaluation of CP.
The definition of CP acknowledges the complexity of
this disease beyond that of a physical disability. Almost
75% of children with CP experience another comorbidity,
which may worsen the impact of the disorder on func-
tional limitations and quality of life. (10)(38)(39) A meta-
analysis using data from CP registers found that most
children with CP experienced pain, 1 in 2 had an intellec-
tual disability, 1 in 3 could not walk or had a hip displace-
ment, and 1 in 4 could not talk; epilepsy and other
neurosensory impairments were common. (39) Children
with CP are also at high risk of developing behavioral dis-
orders. One study found that 7% of children with CP had
ASD compared with 1% of the general population; ASD
was most prevalent in children with nonspastic forms of
CP. (6) The added burdens of comorbidities are further
unevenly distributed amongst different subtypes of CP, of-
ten lesser in those with spastic hemiplegic or diplegic var-
iants. (39) Despite CP being a life-long disability, almost
all affected children are expected to have a normal life ex-
pectancy. The lowest survival rates are reported in those
with more severe disabilities, particularly if they have
other disorders such as epilepsy, severe cognitive disabil-
ity, or gastrostomy-tube dependence. (40)(41)(42)
CP can be conceptualized in different frameworks, but
the most globally accepted is the World Health Organiza-
tion’s International Classification of Function, which places
disability and functioning as outcomes of interactions be-
tween health conditions and contextual factors. (43) Evalua-
tion of CP then encompasses medical, individual, social,
and environmental factors, which all contribute to health
and activity. Neonatologists are most familiar with the
Gross Motor Function Classification System (GMFCS), ini-
tially developed and validated for patients with CP aged 2 to
12 years, but sometimes used in neonatal research studies
for children without CP. (44) The GMFCS categorizes chil-
dren with CP into 1 of 5 levels (levels I–V depending on
support needed for ambulation and mobility, with level V
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requiring the most support) based on self-initiated move-
ment; the emphasis is on sitting, walking, and wheelchair
mobility, with the expectation that the classification remains
stable even into early adulthood. (44) One previous study
examining the validity of the GMFCS tool in children with
CP ranging from 16 months to 13 years old found that chil-
dren younger than 6 years who were initially classified as
level II to IV were more likely to be reclassified, often to a
lower functional level when they were older compared with
children who were first classified as level I or V. (45) This
was particularly true in children younger than 4 years, indi-
cating less reliability of this tool in predicting functional
abilities later in life for younger children. (45) Although the
GMFCS now contains a descriptive category for infants
with CP aged 0 to 2 years, it should be used with caution
as a valid indicator of functional abilities in early childhood.
In one small study including 77 children with CP younger
than 2 years, 42% required reclassification by the age of 4
years—two-thirds of them were reclassified to a better func-
tional GMFCS level. (46)
Description of CP type and distribution in the first 2
years can be challenging, especially for preterm infants.
The classification algorithms developed by Dr Kuban for
the Extremely Low Gestational Age Newborn Study (EL-
GAN) study are helpful for neonatologists as they acknowl-
edge the difficulties in tone assessment resulting from
prolonged medical stays and interrupted development.
(47) In general, hemiplegia involving 1 side of the body,
and diplegia involving bilateral lower limbs are the most
common subtypes of CP affecting more than 75% of chil-
dren; they are associated with lower GMFCS levels. (48)
Quadriplegia involves all 4 limbs and can manifest as
spasticity with more severe functional limitations. (48)
There are 3 main types of abnormal tone including spastic
(87%), dyskinetic (7.5%), and ataxic (4%) CP but different
types can coexist and are difficult to differentiate in the
first 2 years of age. (7)(49) Spastic CP often manifests af-
ter damage to the periventricular white matter, (44) dyski-
netic CP after damage to the subcortical gray matter (eg,
basal ganglia and thalamus), and ataxic CP is most often
due to cerebellar injury or malformations. (49)
HISTORY BEHIND EARLY DETECTION
Historically, CP was thought of as an “unseen handicap,”
not diagnosed due to the emerging nature of voluntary
movements in infancy and the delayed evolution of abnor-
mal tone. (50) The notion that CP was preceded by a neu-
rologically silent period prevailed, and clinicians adopted a
wait-and-see approach until recently, when the advent of
Vol. 25 No. 1 JANUARY 2024 e3
 diagnostic tools and international consensus backed by
mounting evidence has favored early detection.
BASIC PRINCIPLES AND EVIDENCE OF TOOLS
USED FOR EARLY DETECTION
In 2017, a set of clinical guidelines based on systematic re-
views and evidence-based guidelines was published, which
delineated an algorithm that used a combination of vali-
dated tools to provide an early, accurate diagnosis of CP as
early as 3 months in specific cases. (51) The guidelines in-
corporate several high-evidence assessment tools (the Gen-
eral Movements Assessment [GMA], the Hammersmith
Infant Neurological Examination [HINE], the Developmen-
tal Assessment of Young Children (DAYC)-2, and brain
magnetic resonance imaging [MRI]) that measure differ-
ent but complementary constructs in addition to a clinical
history and other standardized motor assessments. (51)
The GMA
General movements are part of a spontaneous motor rep-
ertoire that are endogenously generated and are present
from fetal life until about 5 months’ corrected age. In the
early 1990s, Dr. Prechtl first described the GMA, a novel
visual approach to characterize an infant’s pattern of spon-
taneous movements. (52) He observed that the quality of
these movements were altered in both preterm and term
infants who had an underlying brain injury compared
with healthy controls. (52) He described 2 distinct general
movement patterns that comprise the GMA and can be
Contorneo seen in both term and preterm infants: 1) writhing move-
Ajetreo ments and 2) fidgety movements (FMs). (53) During the
writhing period, which begins around 36 weeks’ postmenst-
rual age and persists until 9 weeks’ corrected age, general
movements are categorized as normal writhing, poor reper-
toire, chaotic, or cramped synchronized (CS). (53) Normal
writhing movements involve the whole body in a variable,
complex sequence with fluent movements that start and
end gradually, occurring frequently while the infant is
awake or sleeping with no external stimuli whereas poor
repertoire movements are more monotonous in nature. (53)
The most significant abnormal general movements to rec-
ognize during this period are CS patterns, which are char-
acterized by synchronous contractions of all limbs followed
by a relaxation phase and are highly predictive of the devel-
opment of spastic CP, most notably if they are present at
term-postmenstrual age. (53) At about 7 to 8 weeks’ cor-
rected age, FMs start to emerge and replace writhing move-
ments, persisting until 5 months’ corrected age when they
are then replaced by goal-directed, voluntary movements in
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healthy infants. (53) FMs are small, circular, and multiplanar
rapid and continuous movements that involve all parts of
the body including the extremities, head, neck, and trunk.
The presence of FMs represents a normal finding whereas the
absence of FMs at 3 to 4 months’ corrected age is highly
predictive of CP. (53)
Given the need to rely on gestalt or perception of move-
ment pattern quality, the GMA involves short video re-
cordings lasting 3 to 5 minutes that are then interpreted
after filming at 2 different time points: at term postmenst-
rual age during the writhing period and 3 to 4 months’
corrected age during the fidgety period. Because the GMA
has become a standardized qualitative tool with high inter-
observer reliability and validity, clinicians can become cer-
tified as GMA basic and/or advanced readers after taking
a 31=2-day course offered by the General Movements Trust.
(54)(55)
The first study describing the predictive value of the
GMA was published by Dr. Prechtl when he evaluated gen-
eral movements during the writhing and fidgety periods in
130 preterm and term infants with both low-risk cranial ul-
trasound (cUS) findings (eg, grade 1 IVH) and high-risk
cUS deficits (eg, grade 2–4 IVH, PVL) and examined their
neurologic outcomes by age 2 years. (55) FMs had a higher
sensitivity and specificity of 95% and 96%, respectively, in
predicting neurologic outcomes compared with cUS, which
had a sensitivity and specificity of 80% and 83%, respec-
tively. (55) Most infants with CS movements during the
writhing period developed absent FMs, and all but 1 infant
(43/44) with absent FMs developed CP. (55) Several studies
replicated these findings, demonstrating that trajectories of
CS movements followed by absent FMs were highly predic-
tive of CP. (53)(54)(55)(56)(57)(58)(59) A systematic review
of 19 studies on high-risk populations including preterm
and low-birthweight infants demonstrated a pooled sensitiv-
ity of 98% and specificity of 91% of the GMA for CP, most
predictive during the fidgety period around 3 to 4 months’
corrected age, which was better than the use of cUS or
term-postmenstrual age brain MRI. (60)
The HINE
The HINE is a scorable neurologic examination consisting
of 26 items that assess cranial nerves, tone, posture,
movements, reflexes, and reactions. It can be administered
in infants between 2 months and 2 years of age. (61) It
was first described in 1999 by Dr Haataja and validated
for use in a cohort of 119 healthy term infants followed
until age 18 months, providing a distribution of scores
across each domain. (62) It allows trained examiners to
 derive global optimality scores ranging from 0 to 78 and a
separate asymmetry score. It can be performed in 5 to 10 mi-
nutes and has good interobserver reliability after training. (62)
Longitudinal assessments allow examiners to differentiate be-
tween transient versus permanent abnormalities. The HINE
can provide both diagnostic and prognostic information in
high-risk infants. In the largest single study to date of 1,541 in-
fants discharged from the NICU, Romeo et al performed the
HINE at different time points during the first 2 years of age
and reported cutoff scores for each age window from 3 to 12
months that had high prognostic value for later CP diagnoses.
(63) In those who had documented brain insults, HINE scores
could assist with severity prognostication. (63)
Since then, numerous studies have evaluated the HINE’s
predictive value in various populations. (61)(64)(65)(66)(67)
Romeo et al recently demonstrated that 50% of low-risk
preterm infants with a HINE score less than 73 at 12
months’ corrected age had normal neurologic outcomes by
age 2 years, thus providing more appropriate cutoff scores
for these patients. (68) The HINE may help assess the se-
verity of CP at 2 years of age in infants with documented
brain insults, and combinations of global and asymmetry
scores on the HINE may help categorize hemiplegic CP.
(61)(69)(70)
Other Standardized Motor Assessments
Several standardized motor assessments are available, which
can be performed in both preterm and term infants and
have been studied for their predictive value for CP, namely
the Alberta Infant Motor Scale (AIMS), the Test of Infant
Motor Performance (TIMP), and the DAYC. The AIMS is a
58-item standardized tool that evaluates gross motor develop-
ment from birth until 18 months of age or when indepen-
dent ambulation is achieved and requires direct observation
of the infant in prone, supine, sitting, and standing posi-
tions. (71) The TIMP is a 42-item standardized tool that can
be performed as early as 34 weeks’ gestational age until 4
months’ corrected gestational age and requires both direct
observation and items elicited such as cranial nerve function
and evaluation of antigravity control. (72) Both evaluations
can take from 20 to 30 minutes to administer, and the
AIMS can be administered over telehealth but the TIMP
should be conducted in person. The TIMP should be admin-
istered by clinicians such as physical and occupational thera-
pists in the NICU or early intervention programs who have
undergone training through workshops and online modules;
however, the AIMS has been shown to have good reliability
between both experienced and novice examiners because
it relies on direct observation. (71) The DAYC is a
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standardized assessment tool that evaluates development
from birth through age 5 years using an interactive ques-
tionnaire for parents that can also be administered over
telehealth. The physical development domain in the most
updated version measures both gross motor and fine mo-
tor skills based on parental report, direct observation, or
assessment and takes about 10 minutes to administer
with good reliability reported. (73)(74) Although the
AIMS, TIMP, and DAYC do not require highly special-
ized training and/or additional resources compared to
the GMA, clinicians should not use any tool in isolation
for the purpose of predicting or diagnosing CP; rather
these tools should be used to help identify at-risk infants
and follow the trajectory of motor development while
screening those who may require closer surveillance.
(51)(75)
Neuroimaging
Although neuroimaging is helpful in early identification
of CP, 10% to 15% of infants with CP have normal neuro-
imaging; therefore, similar to the other assessment tools
mentioned in this review, it should not be used in isola-
tion when making or excluding a diagnosis of CP. (51)(76)
In a systematic review with over 2,400 infants and a CP
prevalence of 9.4%, sequential cUS in the NICU had a
pooled sensitivity of 74% (95% confidence interval [CI],
63%–83%) and specificity of 92% (95% CI, 81%–96%) to
predict CP in both preterm and high-risk term infants, es-
pecially in cases of grade 3 or 4 IVH, cerebellar injury,
and cystic PVL. (60)(77)(78)(79) Periventricular hemor-
rhagic infarction, a more accurate term for grade 4 IVH,
confers a high risk for CP, and white matter injury confers
a 20-fold increased odds of developing CP. (80)(81)
Evidence to support the routine use of MRI in preterm
infants to predict CP is mixed, with poor sensitivity
(65%–71%) and good to excellent specificity (84%–95%).
(81)(82)(83) The Choosing Wisely campaign endorsed by
the American Academy of Pediatrics recommends avoid-
ing routine screening MRIs at term-equivalent age in pre-
term infants given the lack of data to suggest improved
prediction of long-term outcomes; however, MRI should
be considered in infants with HIE, stroke, brain malfor-
mations, PVL, or severe IVH. (84) Notably, the Kidokoro
scoring (MRI scoring system of abnormalities that is spe-
cific for preterm infants with IVH) performed in preterm
infants at term-equivalent age is used in Australia and pro-
vides strong evidence of predicting outcomes accurately.
(85) Newer imaging techniques and modalities may allow
more accurate prognostication of diagnosis, topography,
Vol. 25 No. 1 JANUARY 2024 e5
 and severity in the future. (86) Certainly, if CP is suspected,
clinicians should consider MRI as part of the diagnostic
evaluation in a term infant without risk factors, for cortical
or vascular malformations among possible etiologies. (87)
Evidence to Support the Combination of Multiple
Tools
None of the assessment tools described herein (GMA,
HINE, standardized motor assessments, and neuroimag-
ing) should be used in isolation for detection of CP as
they each offer a complementary construct:
1. The GMA evaluates the quality of spontaneous move-
ments and provides information on neural function and
integrity.
2. The HINE is a standardized neurologic examination.
3. Standardized motor assessments (eg, AIMS, TIMP, and
physical domain of the DAYC) are tools to evaluate fine
and gross motor impairment.
4. Neuroimaging (eg, brain MRI or cUS) detects brain ab-
normalities or injury associated with CP.
Serial HINEs between 3 and 24 months’ corrected age
and the GMA at 3 to 4 months’ corrected age in infants
with newborn-detectable risk factors have shown promise
in predicting CP, especially the combination of absent
FMs and HINE score of less than 50. (88) The pooled pre-
dictive power of HINE, GMA, and cUS or MRI in high-
risk term and preterm infants has shown sensitivity, spe-
cificity, and positive and negative predictive values greater
than 98% in predicting the development of CP by 2 years
compared to each tool alone. (76) The caveat in this study,
however, was that HINE examiners, GMA readers, and
neuroimaging readers were all experts in the field of CP.
Use of CP Early Detection Tools in Neonatal
Follow-Up
The international clinical practice guidelines published in
2017 were developed by a multidisciplinary panel of scien-
tific and clinical experts in CP and parent stakeholders,
and outlined 12 recommendations based on best evidence-
based assessments with an algorithm for early detection of
CP (Fig). (51) Early detection is feasible and accurate and
can lead to earlier CP-specific interventions whereas an in-
terim designation of “high risk of CP” should be used if
the clinician is concerned but cannot be certain of the di-
agnosis. (51) In general, infants younger than 5 months'
corrected age who have identifiable risks such as the neu-
ral insults previously mentioned, but also others such as
intrauterine growth restriction, intrauterine drug exposure,
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and cytomegalovirus infection, should have a GMA, HINE,
thorough medical history conducted including review of
any detectable risk factors for CP or parent-identified con-
cerns, review of imaging, and a standardized motor assess-
ment performed starting at 3 to 4 months’ corrected age; in
infants older than 5 months, the HINE, MRI, and standard-
ized motor assessments are recommended. (12)(13)(51)
IMPLEMENTATION OF CLINICAL GUIDELINES
Because of the inconsistent ways in which neurologic ex-
aminations were performed and documented in high-risk
infant follow-up (HRIF) clinics, the neonatal neurodeve-
lopmental team at Nationwide Children’s Hospital, which
has over 5,000 yearly visits, was trained in the HINE with
the help of a Hammersmith trained neurologist and by de-
veloping a preparation course work and on-site practice.
(89) Following the implementation of the HINE, which
was administered at the 3- to 4-month, 9- to 12-month,
and 22- to 26-month visits up until 2 years’ corrected age,
the age at diagnosis of CP was reduced from 28 months
to 15.7 months without an increase in the number of new
diagnoses while maintaining adequate inter-rater reliabil-
ity. (89) By successfully learning and implementing the
HINE and the GMA into clinical practice at a single site
while standardizing documentation in the electronic medi-
cal record, the team was able to demonstrate a reduction
in age at CP diagnosis, demonstrating the feasibility of us-
ing this tool in clinical practice. (90)
Following the publication of the clinical guidelines for
early detection in 2017, single centers started implement-
ing these recommendations, reducing the age at diagnosis
to 8.5 months in one cohort with 98% of those diagnosed
with CP being referred to CP-specific early intervention
programs. (89)(91)(92) The largest implementation study
to date included the formation of an Early Detection and
Implementation (EDI) Network composed of 5 diverse US-
based HRIF clinics. The network reduced the age at CP di-
agnosis using quality improvement methodology and im-
plementation science on a large scale by transitioning to
an earlier visit at 3 to 4 months and incorporating the
GMA, HINE, medical history, and standardized motor
function assessment. (93) Within 1 year, the network low-
ered the age at diagnosis from 19.5 months’ corrected age
to 9.5 months’ corrected age with no increase in the num-
ber of CP diagnoses. (93) Recent publications show that
they sustained their change 5 years later, even through the
addition of new sites and the challenges related to the
COVID-19 pandemic. (94)
 Figure. Pathway to early detection. A represents the best available evidence pathway per the international clinical guidelines published by Novak et al
in 201751; B is next best if some tools in A are not available. AIMS5Alberta Infant Motor Scale, CP5cerebral palsy, DAYC5Developmental Assessment of
Young Children, GMs5Prechtl Qualitative Assessment of General Movements, HINE5Hammersmith Infant Neurological Examination, IUGR5intrauterine
growth restriction, MAI5Motor Assessment of Infants, NSMDA5Neuro-Sensory Motor Development Assessment, TIMP5Test of Infant Motor Perfor-
mance. (Modified from “Early Recognition of Cerebral Palsy: A Pathway to Referral” published online in 2018. Reprinted with permission from the Cerebral
Palsy Foundation in New York, NY.)

CAREGIVER PERCEPTION OF EARLY DIAGNOSIS
Population data support the notion that delaying conversations
surrounding even the suspicion of CP can be detrimental to
parental well-being. The vast majority of caregivers already
suspect the diagnosis before being told, and in 1 study, more
than 40% of caregivers experienced dissatisfaction and resent-
ment about a delayed diagnosis, which correlated with later
depression. (95) On a large scale, the US-based implementa-
tion network found that 90% of parents reported receiving
empathy and support at the diagnosis visit. (95) This positive
perception of early CP diagnosis has been confirmed, with pa-
rents generally wanting more information on the next steps.
(81)(96)(97) Parents of children with CP have stated that ear-
lier diagnosis or use of a high-risk designation was beneficial
to their family and their child and was a priority in an honest
yet positive conversation with diagnosis-related education and
resources. (97)
To address starting conversations earlier, a consensus
statement was put forth by the EDI network and the Cana-
dian Neonatal Follow-Up Network in 2022 to adopt a “high-
risk for CP” designation when a diagnosis is suspected but
there is a missing diagnostic component or a negative result
(Table). (94)(97) During a focus group involving caregivers
of children with CP describing their experiences surround-
ing CP diagnosis and the concept of using a designation
early on, parents expressed that a designation was an accept-
able alternative to start these conversations and could be re-
visited even if a diagnosis was ultimately not made. (98)
Globally, clinicians who have shifted their practice toward
early detection of CP have adopted this designation to pro-
vide a framework for shared decision-making and establish-
ing a common language between families and high-risk
follow-up clinicians. Importantly, this shift to early detection
has allowed for the study of earlier interventions in children
with CP even younger than 2 years. The results are promis-
ing, and an increasing pipeline of studies testing new inter-
ventional approaches is actively underway. (99)(100)
CONCLUSIONS
Across NICUs and HRIF clinics around the world, a shift
toward early detection of CP to drive new early interven-
tions has evolved from decades of historical challenges

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 Table. Proposed criteria for diagnosis of cerebral palsy (CP) versus high-risk clinical designation.
Basic elements of diagnosis of CP
High risk for CP clinical designation
Adapted from Maitre NL, Byrne R, Duncan A, et al; CP EDI Consensus Group; Canadian Neonatal Follow-up Network. “High-risk for cerebral palsy”
designation: A clinical consensus statement. J Pediatr Rehabil Med. 2022;15(1):165–174.
and advances. The feasibility of decreasing the age at CP diag-
nosis on a large scale has been proven, starting with practices
in the NICU and followed by an HRIF visit at 3 to 4 months’
corrected age. (84) Early diagnosis and high-risk designation
are well-accepted by caregivers, and these conversations can
and should start early, even while in the NICU when a fu-
ture diagnosis of CP is suspected. Through the implementa-
tion of evidence-based international clinical guidelines, after
receiving training in the use of these new assessment tools,
we can optimize the developmental trajectories of children
with CP. We can refer these children earlier to interventions
during a critical period of neuroplasticity to reduce motor
deficits and secondary impairments. All this can happen
while promoting better support, education, and well-being
for former NICU families—a goal that has always been cen-
tral to NICU follow-up programs.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Know the evolution of neurodevelopmental
impairments during development and the
difference between transient and permanent
impairments in NICU graduates (eg,
developmental delay vs. intellectual disability;
tone abnormalities vs. cerebral palsy).
• Know the significance of persistent neuromotor
abnormalities in infancy (including asymmetries).
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