Therapeutic Strategies for Enhancing Neurodevelopment in Infants with Neurological Risks: A Systematic Review

Abstract

Background: Neurally at-risk infants (prematurity, HIE, IVH, neonatal stroke) experience profound brain plasticity in their first year. The success of therapy is largely dependent on the kind of focus used during attention: internal focus (IFA) caters to the recognition of bodily movements, whereas external focus (EFA) highlights the changes in the surroundings. EFA has been confirmed in older children and adults; however, only a few studies on infants are available.
Purpose: The first goal was to present the evidence base that supports the use of EFA over IFA in the high, risk infants. The second goal was to show a design of a prospective RCT.
Methods: Thorough (PubMed, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, Scopus; registries; grey literature) searches until March 2024, conducted as per PRISMA guidelines. Eligibility criteria: infants <24 months, studies comparing EFA with IFA/usual care. Primary outcomes: motor development (Bayley, AIMS, GMFM, milestones); secondary outcomes: cognition, function, caregiver. RoB2/ROBINS, I, GRADE were used as tools for bias, risk, and certainty assessments.
Results: Out of 3276 records, 24 (16 RCTs, 8 quasi, experimental trials, 2046 infants) studies met the inclusion criteria. The majority of the results pointed out that EFA was associated with faster milestones, higher Bayley and GMFM scores, and that the effects could be prolonged up to 6, 12 months. The neutral results indicated either very severe impairment or low protocol adherence. The risk of bias was at moderate levels; the level of certainty varied from moderate to high for motor outcomes, and lower for cognition and function.
Conclusions: External focus of attention (EFA) leads to better motor skills in the high, risk infants as compared to internal focus of attention (IFA). Still, large, multicenter clinically RCTs are required to become standard practice.