A new care pathway for the diagnosis of cerebral palsy among community pediatricians

Early diagnosis of cerebral palsy (CP) has long been recommended and is essential to access CP-specific supports and interventions, which in turn improve long-term function (1–3). According to a recent review of the Canadian Cerebral Palsy Registry, children have been diagnosed with CP on average at 19 months in Canada (4) and 25 months in British Columbia (BC) (5)—much later than what clinical guidelines enable and missing the optimal window for early interventions (3,6). Age of diagnosis has been shown to be associated with Gross Motor Function Classification System (GMFCS) level, and children with a function level of I-II are being diagnosed particularly late (5). There is now persuasive evidence linking a timely diagnosis to improved access to CP-specific interventions, better long-term health and functional outcomes, satisfaction with the health care system, and overall quality of life for the child and family members (3,7). The BC Cerebral Palsy Advisory Committee (BCCPAC) in 2021 echoed the many calls for urgent clinical practice change to provide an early diagnosis of CP (7–9). In two survey studies from 2018 to 2022, BC pediatricians reported limited experience with—and consistent barriers to—diagnosing CP related to knowledge, skills, and confidence, with a notable gap being insufficient understanding of how to make an accurate diagnosis (10). To address these gaps, respondents indicated that a comprehensive clinical pathway for diagnosing CP in the community would be most beneficial. In response, a new CP diagnostic care pathway was developed in 2024 to be used as a clinical support tool for community-based pediatricians and other pediatric primary care providers (Figure 1). The pathway aims to be a clinical support tool that operationalizes evidence into a point-of-care reference. Although the pathway is tailored to BC’s provincial health care system, it can be adapted and applied to other jurisdictions, which follow a similar health care model. British Columbia Cerebral Palsy Community Diagnostic Care Pathway. Children with medical risk factors (e.g., prematurity, low birth weight) are typically closely followed by neonatal follow-up clinics or early development programs and are detected in this manner. However, this care pathway expands on current detection and diagnostic guidelines (11) to focus on children who are being assessed in the community, tend to have a higher function level, and be identified later through clinical findings. These are known as clinical/developmental “red flags” for CP (Table 1). This list builds on previous CPS statements and clinical guidelines (11–14) to add new red flag features, all of which are supported by robust evidence reviews and have been adopted by the BCCPAC (7). A comprehensive assessment is recommended following the detection of any of these findings. Clinical/developmental red flags for CP Detection of any of these findings should prompt further assessment. CP, cerebral palsy. Clinical/developmental red flags for CP Detection of any of these findings should prompt further assessment. CP, cerebral palsy. The three criteria of CP (Figure 1) are required and sufficient to make this diagnosis in accordance with the accepted definition of CP (15). These criteria can be met with findings from a complete history and neurological examination. Standardized assessments such as the Hammersmith Infant Neurological Exam (HINE) and General Movements Assessment (GMA) may be used to support the diagnosis. The GMA is less relevant for this subpopulation as it is used up to 5 months of age, before the development of the majority of the clinical/developmental red flags. However, pediatricians may partner with their local community Occupational Therapist (OT)/ Physiotherapist (PT) who are trained in the HINE to have this assessment completed, as it is used up to age 2 years. Brain imaging such as Magnetic resonance imaging (MRI) also informs diagnosis. Benefits include identifying an etiology thereby providing parents with a clearer answer, facilitating discussions with families, and enhancing diagnostic confidence for physicians and families, therefore it is recommended in the investigation of a child with CP. However, the major drawback is that obtaining an MRI may lead to diagnostic delays thereby delaying referrals to early interventions. Brain imaging is not mandatory for diagnosis in the presence of clinical signs. Engage parents on the appropriateness of an MRI for their child. Physicians may consider delaying brain MRI until age 2, when myelination is completed, and results are therefore more definitive (16). Like any new diagnosis, disclosure can be daunting. Clear and direct communication about a CP diagnosis is associated with better long-term parental mental health (3,17,18). Novak et al. (19) explain how to adapt the SPIKES protocol to deliver a new diagnosis of a disability, using CP as an example. This valuable resource also includes a list of topics that parents will want to hear about in diagnostic discussions. We emphasize function, with several classification systems available, the most widely used being the GMFCS (20). Levels are typically stable after age 2 and can be used to guide a discussion on prognosis. Use neutral language and focus on what the child can do; be realistic but optimistic. An interim clinical diagnosis of “high risk/ probability of CP” can be given when a diagnosis is suspected but cannot be made with certainty (11). The next most important step is providing CP-informed intervention as early as possible. If the child is not already connected, refer immediately to their closest therapy service provider including physiotherapy and occupational therapy. This can be performed at Child Development Centres or equivalent programs. The type of intervention may depend on the subtype and functional level, and therefore it is optimal to include this information in the referral. For example, Constraint-Induced Movement Therapy is a recommended intervention with strong evidence for unilateral CP, which can be initiated by the pediatrician in the clinic and continued at home. For more information on the effectiveness of interventions, please see the systematic review by Novak et al. (21). The authors are grateful to members of the Cerebral Palsy Early Diagnosis Program Team at Sunny Hill Health Centre, BC Children’s Hospital, and collaborators: community pediatrician Dr Anamaria Richardson and implementation scientist Dr Stephanie Glegg from the University of British Columbia. The BC Cerebral Palsy Community Diagnostic Care Pathway was developed as a resource to support a BC Children’s Hospital knowledge translation project to change cerebral palsy diagnostic practices with pediatricians in British Columbia. Support for the project and development of this care pathway was generously funded by the BC Children’s Hospital Foundation and Michael Smith Health Research BC through the 2023 Reach grant. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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