We carefully read the letter we received from Hidalgo et al.1 in relation to the publication of our study. In this letter, the writers underscored the “urgent need” in Spain of implementing international guidelines for the early diagnosis of cerebral palsy (CP) and even population-wide screening.
Our prospective study with follow-up of a cohort of patients with neonatal hypoxic-ischemic encephalopathy in a Spanish region evinced a decrease in the prevalence of CP in this population relative to previous years, in agreement with the findings of similar studies conducted in other countries, while identifying the presence of other neurodevelopmental abnormalities that may have been overlooked more frequently in the past.
These results cannot be extrapolated to other risk groups, not to mention the general population. Furthermore, they should not be used to guide decision-making in public health policy, as would be the case of screening programs.
The implementation of a screening program is a long and complex process that requires assessment by expert groups and health care authorities of its usefulness, feasibility, affordability, efficiency, cost-benefit ratio and potential harms, among other widely used criteria.2
The Sociedad Española de Neurología Pediátrica (Spanish Society of Pediatric Neurology) publishes and periodically updates protocols for the diagnosis and treatment of CP adapted to the particular circumstances of Spain,3 so we do not think it necessary to implement additional guidelines. On the other hand, we do not know of nor have found evidence of existing population-wide CP screening programs in any country, quite probably because this disease presents significant limitations for the purpose of screening. Current efforts are focused on the identification and follow-up of patients at high neurologic risk. Most high-income countries have established follow-up programs up to at least age 2 years for affected newborns, and Spain is not an exception.
In addition, and in contrast to other countries, nearly the entire healthy, low-risk pediatric population in Spain is managed and followed up by pediatricians and pediatric nurses in primary care centers through the Healthy Child program. This program consists of a schedule of systematic check-ups over the first years of life, including neurodevelopmental assessments. This specialized care delivered by providers with accredited education and practical training in the field of pediatrics is an essential factor in the optimization of the detection of neurodevelopmental red flags. Any child in whom a developmental disorder may be suspected (not limited to CP) is referred to specialized pediatric neurology or early intervention services. Although there is always room for improvement, we believe that the primary care services currently available to the Spanish pediatric population are of high enough quality to ensure the early detection of these problems, and there is no evidence of delayed diagnosis of CP with this approach.
follow-up plans should be personalized to the extent possible according to the individual risk factors of the patient. As the authors highlighted, it is important to be rigorous in the assessment and identification of risk factors during pregnancy and delivery as well as individual risk factors in the patient; however, while we consider it necessary to have specialized follow-up programs for children with known neurodevelopmental risk, we do not think it necessary to extend these programs to cover any child with potential risk. The goal of this strategy is to achieve maximum effectiveness while avoiding the diversion of resources (which are always finite) from those who need them most, as well as, to the extent possible, reducing the “overpathologization” of patients and their families, which in itself constitutes a socioemotional burden.
