DISCUSSION
Our study show that there are great variability in age at first visit to
physiotherapy. The prevalence of CP was similar to figures reported in
other high-income countries,3 and infants born at term
constituted 58% of all CP cases.
Similar to Boychuck and colleagues,12 referral source
and complicated birth history predicted earlier access to physiotherapy.
It is important to acknowledge that children with a complicated birth
history are considered high risk for CP and are routinely enrolled in
neonatal follow-up.7 In this setting, professionals
know they are assessing children at risk for CP. The children may also
have more severe impairments, which may partly explain the finding of
earlier detection.12
However, only slightly more than half of all children with CP are
enrolled in neonatal follow-up.5,10–13 For the
remaining children age at referral varies
considerably,11–13 where the primary healthcare
services including the CHS have the greatest
delays.11–14 Although the CHS is striving to improve
their methods and the infants in our study were identified at an earlier
age than previous studies,11–14 the children are
nevertheless referred later than high-risk infants and with greater
variability. In our study, children referred from CHS had few, if any,
known risk factors for CP and less severe motor impairments, which may
be challenging to detect.10,13,19
Previous research has shown that children with mild motor impairments
and unilateral and bilateral spastic CP have delayed access to early
intervention.13,20 While this was not confirmed in our
study, motor impairment severity and complicated birth history affected
age at referral to habilitation services. As a formal medical diagnosis
is required for referral to habilitation services, our results may imply
that having a known medical history and more severe motor problems makes
diagnosing CP easier.
To meet the requirements of the Health Care Act and the Convention on
the Rights of the Child, evidence-based assessment methods should be an
integrated part of developmental surveillance and health monitoring.
Standardizing care could potentially reduce variability across
organizations and professionals,21 hence increasing
equality and patient safety. Furthermore, using such methods improves
accuracy, enables earlier identification (including mild delays or
suspected deviations) and provides more information compared to clinical
judgement alone.7,10,19,22 Not using such methods will
delay detection of children with CP,11–13consequently depriving children of interventions known to be
beneficial.3,4,6,7 The fact that the rate of CP is
falling and that CP severity is lessening further highlight this
need.3 In our study, the majority of the children had
a high functional level, and of those referred from the CHS, all but one
had mild motor impairment. A recent scoping review suggested that
feasible methods for well-child surveillance are
lacking,23 we have shown, however, that when child
health nurses used SOMP-I in routine well-child surveillance it appeared
to be clinically useful.24
Thus, all professionals performing developmental surveillance and health
monitoring should receive adequate training, use evidence-based
assessment methods when available and be skilled in discriminating
atypical movement from variations in typical
movement.7 However, it is important to remember that
proper assessment of infants using any standardized method is an
acquired skill requiring practice over time. Nurses learning to use the
SOMP-I stressed that becoming a proficient assessor requires training
and practice.25 Furthermore, infants displaying
aberrant motor performance should have access to physiotherapy prior to
any formal medical diagnosis, as mild cases with an uncomplicated birth
history can be particularly difficult to diagnose.10
Only four children were born before gestational week 28, while 75% had
≥1 known risk factors for CP. As one stated aim of the guidelines for
neonatal follow-up is to detect CP,9 all children with
known risk factors should be included in the
follow-up.7 Furthermore, to enable timely
intervention, it should be clearly stated in the guidelines that
infants’ motor performance should be assessed using an evidence-based
assessment method within the first months of life corrected age.