Cerebral palsy (CP) is an umbrella term covering disorders of movement and posture, leading to activity limitations, caused by non-progressive lesions or malformations in the immature brain . Accompanying disturbances of sensation, perception, cognition, communication and behaviour are frequent, as are secondary musculoskeletal problems and epilepsy . The brain lesion is non-progressive, but its consequences do change over time, and can be barriers to activity and participation in different life arenas .
In all children the most rapid maturation and development of both the musculoskeletal and central nervous systems occurs during preschool age, and this development forms the basis for future function . Among clinicians in paediatric rehabilitation, a general consensus is that children with lesions of the central nervous system should receive rehabilitation interventions as soon as possible, due to the rapid brain development during early life .
Clinicians and researchers therefore share a common goal to enhance development of function and prevent known secondary complications in as many developmental areas as possible in children at risk of CP, or already diagnosed with CP. These services are called early intervention (EI). EI is differently defined across countries, and there is no consensus regarding age. The Early Intervention Handbook  defines it as “multidisciplinary services provided to children from birth to five years of age to promote child health and well-being, enhance emerging competencies, minimise developmental delays, remediate existing or emerging disabilities, prevent functional deterioration and promote adaptive parenting and overall family function”.
EI includes several rehabilitation services targeting five developmental areas (cognitive, physical, communication, adaptive and social–emotional). Early life is the period of the highest developmental potential due to the high plasticity of the immature brain . A review by De Graaf-Peters and Hadders-Algra  suggested that intervention prior to 40–44 weeks post menstrual age (PMA) should be restricted to interventions aiming to mimic the intrauterine environment, such as the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). However, after 40-44 weeks, the intervention should include active stimulation of the child’s development. Continuous neurobiological development occurs during both pre- and postnatal life, which should guide our clinical work.
De Graaf-Peters and Hadders-Algra  highlighted five important clinical consequences. First, the child’s age-specific nervous system calls for age-specific neurological assessments. Second, visible neural dysfunction is affected by age-dependent characteristics. Third, prediction of developmental disorders at an early age is dependent on specific neurodevelopmental changes of the brain, which can cause either disappearance of earlier dysfunctions or the opposite. Fourth, there are periods in the child’s early life that are specifically vulnerable to adverse events, due to specific neurodevelopment events in these periods. Fifth, age-specific neurodevelopment might be important for the timing of EI . Recent research has documented that the period of dendritic outgrowth and active synapse formation is the best period for the repair of brain damage. This indicates that the period between 28 weeks PMA and 15 months postnatally would be best for EI .
However, a recent systematic review by Morgan et al. concluded that the evidence for early motor intervention is limited by the lack of high‐quality trials . Due to small sample sizes and the heterogeneity of the interventions, both in content and duration, as well as ages of evaluations and outcome measures, clinical recommendations are weak and inconclusive. The most promising intervention included child-initiated movement, task specificity and environmental modification . This systematic review showed the importance of family-centred activities as well as specific environmental changes. EI programs are directed toward family and caregivers to cope with the stress of having a child with a complex disability such as CP. Further, the effective interventions may enhance the mothers’ attitudes toward their children, and thereby contribute to empowerment of caregivers.
Guralnic  also described the positive effect on mother–child interaction of an EI program for both preterm and term-born children. Another study showed a positive effect of a Mother–Infant Transaction Program (MITP) on important qualities of social interaction between mothers of moderately and late preterm infants at 12 months. Being a first-time mother seems to be a mediator that enhances the effects of the intervention .
A recent Cochrane review by Spittle et al.  concluded that EI in infants born preterm (<37 gestational weeks) is associated with improved cognitive development during infancy and preschool age, and a minor positive effect on infant motor development.
Interestingly, the general positive effects of EI occur in the presence of a large variety of theoretical concepts and actual program content. Parent–infant relationships have a greater impact on cognitive outcomes at infancy and preschool age than intervention programs that focus on either infant development or parent support .
Fewer studies examine the effect of EI on children born at term with CP. The available results among children with CP born at term showed a large variation in intervention approaches, similar to EI in infants born preterm . Studies conducted after term age indicated that intervention programs using the principles of neurodevelopmental treatment or Vojta, namely programs in which passive handling techniques have a prominent role, did not have a clear beneficial effect on motor development, and are not recommended . According to Novak, the preferable interventions are child-active approaches that induce maximal neuroplasticity . Moreover, specific motor training programs, such as training locomotor movements on a treadmill and general developmental programs, targeting the child’s exploration of active motor behaviour, showed a positive effect on motor development .
Early detection of children with CP or at high risk of developing CP is crucial to including them as soon as possible in EI programs. Predictive tools for CP are now available, such as the Hammersmith Infant Neurological Evaluation (HINE), the General Movement Assessment (PRECHTL GMA) tool, and cerebral MRI classifications .
High-quality evidence to support EI in improving neurodevelopmental outcomes is sparse. The existing evidence for infants with CP or at high risk of CP recommends interventions based on motor learning principles, active involvement of the parents and enrichment of the environment [4, 7, 10]. Best practice is considered to be diagnosis-specific intervention as early as possible, during periods of high brain plasticity and before compensatory maladaptation of the musculoskeletal and central nervous system [4, 7, 10].
Setting – the situation in Moldova
In 2003, the first Centre of Early Intervention Services (CEI) Voinicel was founded in Chisinau, Moldova, with the help of the Norwegian non-governmental organisation Ahead-Moldova. The need for family-based intervention was identified in order to address the high rate of abandoned children resulting from a lack of services for families with children at risk of developmental disorders, as well as those with identified disabilities.
The National Agency of Public Health has reported that neurological disability is the second most frequent paediatric disability in Moldova, and that 60% of those with a neurological disability are children with CP . Therefore, some early-stage interventions had to be implemented as soon as possible. Moldova has four orphanages for children 0–18 years old, housing a total of 1300 children with disabilities born before 2003.
In 2008, a study of the model of EI services for children with disabilities in Moldova was performed . Based on the results of this study, an approach was developed that focused on providing multidisciplinary services to families with children at risk of developing or already diagnosed with a disability. The eligible age for inclusion is 0–3 years.
Around the same time that CEI Voinicel began providing EI services, neonatal mortality and morbidity prevention strategies in Moldova were established in three national programs: ‘Strengthening perinatal healthcare in the Republic of Moldova’, consolidated by Government Decision no. 1171 of 18 October 1997 and Ministry of Health no. 58 of 25 February 1998 (1998–2002); ‘Promotion of quality perinatal services’ (2003–2007) approved by Ministry of Health no. 185 of 18 June 2003; and ‘Modernization of the perinatal system of the Republic of Moldova’ (2006–2014) .
The Concept of Neonatal Diagnosis and Surveillance Service  was elaborated and implemented during 2008 for the care of very low birthweight children (<1500 g), based on the same decision of Ministry of Health no. 118 of 20 February 2009 .
In 2008, the Institute of Mother and Child (the main Republican hospital for children in Moldova), with support from the Swiss Cooperation Office, implemented the follow-up (FU) program for children with special needs from the entire country. CEI Voinicel provides EI for children and their families in the area of the capital, Chisinau.
The primary aim of this study was to explore whether EI and FU programs influence function and associated impairment outcomes in children with CP, by comparing those enrolled and those not enrolled in EI and FU programs.