Swedish Study Finds Differences, Potential Bias, in Treatment of Children with CP

Swedish Study Finds Differences, Potential Bias, in Treatment of Children with CP

Among children with cerebral palsy (CP) in Sweden, differences in treatment are evident based on sex and place of birth, a new study shows.

While some of these differences may have underlying biological causes — such as differing rates of scoliosis in the sexes leading to discrepancies in the use of back braces — others may be due to bias or other factors. Further research is needed to ensure that every child receives the best possible care, its researchers said.

The study, “Gender differences in treatments and interventions received by children and adolescents with cerebral palsy,” was published in BMC Pediatrics.

Whether a person with a condition like CP is given a particular treatment or not depends on a myriad of factors, from national healthcare policies to available resources. Biases may also affect who is given which treatments.

“Humans operate in accordance with their preconceived notions, opinions and biases—conscious or unconscious —which may affect who is offered certain treatments,” the researchers wrote. “This may result in unwarranted differences in the treatment strategies endorsed, and, by extension, health disparities.”

The researchers looked for differences in treatment based on sex. “Importantly,” they wrote, “the aim was not to determine if boys or girls received better treatment (more is not per definition better, and in some cases, treatments may even be harmful) but to assess and explain differences in treatments received between genders, if applicable.”

They analyzed data from Sweden’s Cerebral Palsy Follow-Up Program (CPUP), which collects information for about 95% of people with CP who were born after 2000 and living in Sweden.

Specifically, physical therapy and occupational therapy treatments were analyzed, with 2,635 and 3,480 people included for each respective type of therapy. Both groups had a slight preponderance of boys relative to girls (58% vs. 42%), and the average age was just under 10 years old. Slightly more than 80% of children in both groups were born in Nordic countries (Sweden, Norway, Denmark, and Finland).

Girls were significantly more likely than boys to have spinal braces. This finding is in line with previous research that suggested scoliosis is more common in females with CP than in males, suggesting this difference in treatment may reflect underlying biological differences.

Sex-based differences were also observed for the frequency of the surgical procedure selective dorsal rhizotomy (SDR; used to treat spastic CP), with girls about half as likely to receive it compared to boys. No data in this study support a direct biological reason for this difference.

The researchers speculated that differences in CP subtype — which are known to vary based on sex — may account for this SDR difference. But since subtypes were not assessed in this study, more research will be needed to know for sure.

Children born outside of the Nordic countries were about five times less likely to have spinal braces than those born in Nordic countries. Unlike the difference in sex for spinal braces, no obvious biological reason existed for this discrepancy. The researchers speculated that some children may have recently emigrated, so they may be prescribed spinal braces in the future — but, again, data to support this possibility are lacking.

Children born outside of the Nordic countries were also about four times less likely to be given intrathecal baclofen (ITB). A possible reason here is not biological but may be a systemic: ITB pumps need to be refilled every few months, and failure to do so can lead to severe, even life-threatening withdrawal. It is possible that some children included in the Cerebral Palsy Follow-Up Program, though currently living in Sweden, are not permanent residents.

“Consequently,” the researchers wrote, “providers might be hesitant to recommend ITB for children if there is no guarantee that they will be able to stay in the country or be able to refill the medication.” Again, no data from this study directly supports or discredits this speculation.

Other assessed treatments, such as botulinum toxin injections, did not vary significantly based on sex or place of birth.

Overall, this study highlights a need for further research into why certain children with CP are more or less likely to be given particular treatments. Such research could allow for a minimization of bias and help ensure that all get the most appropriate treatment.