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Improving the Outlook for Cerebral Palsy Children

Despite the incidence of cerebral palsy decreasing, it is still Australia’s most common cause of physical disability in childhood, experts say.

And with the condition affecting over two in every 1000 live births, it is more than likely a GP will be caring for these patients in their clinical practice.

The authors of a review in the latest Medical Journal of Australia highlight areas where the treating health professional, including the GP can play a role in improving these children’s health outcomes as well as their quality of life.

“While there is currently a limited range of evidence-based treatments that change the underlying pathology of cerebral palsy, there are many areas in which health care professionals can change the natural history of cerebral palsy and improve participation and quality of life for children with this condition,” they said.

They refer to a framework for management of patients with cerebral palsy, known as the six Fs. These Fs help both clinicians and families of the affected child set realistic goals and develop appropriate pathways to meet them. The six Fs are:

Function – encourage the child to try activities and celebrate not only what they can achieve but the attempt.

Family –  the family environment is vitally important to the child’s health outcomes both physically and psychologically. Significant attention, support and resources need to be directed to this.

Fitness – Overall physical fitness is at least as important as exercises directed at helping overcome the particular physical disability of a child with cerebral palsy.

Fun – Caregivers need to ensure the child with cerebral palsy does not miss out on this key component of childhood.

Friends – Social interaction and the development of quality relationships need to be incorporated as a management goal.

Future – This is all about setting realistic goals and expectations and the mapping out plans of how to achieve them, keeping in mind the other five Fs.

In addition to this very grounding framework of management, the review authors went on to describe the current state of play of treatment for the various physical manifestations of cerebral palsy.

Spasticity and dystonia are the most common signs of the disease and along with physical therapies such as physiotherapy, occupational therapy, splints and orthotics there are a number of medications and even some surgical options for treatment.

Baclofen, diazepam and Botulinum toxin A are well-known options to treat the spasticity and dystonia. But apparently there is emerging evidence for the use of other medications such as gabapentin and clonidine. There are also some highly specialised surgeries being performed for subsets of cerebral palsy children such as deep brain stimulation for children with dystonic and dyskinetic movement, selective dorsal rhizotomy for severe spasticity in the lower limbs and even intrathecal baclofen to avoid the side effects of oral baclofen.

The review also highlights three potential problem areas for children with cerebral palsy that are of particular relevance for GPs caring for children with this condition.

Hip displacement is more of a risk in children with cerebral palsy, and if it is missed it can result in hip dislocation. Regular clinical and radiographic assessment is recommended.

“The pelvic x-ray is taken in a standardised supine position and is usually repeated between six and 12 months, depending on the severity of cerebral palsy and the rate of progression of migration of the femoral head out of the acetabulum,” they said.

Referral is recommended once migration approaches 30%

Another major issue to check for in children with cerebral palsy is pain, with evidence suggesting up to 75% of young patients are regularly experiencing this. The review authors recommend carers ask about this directly, as children may not volunteer this information despite chronic pain’s well-known effect on quality of life. Pain treatment is generally fairly standard, however specific treatments are available for pain arising from unique symptoms such as dystonia or spasticity.

Finally, the review authors advise treating clinicians to watch out for feeding and swallowing problems, and as a consequence of these, deficiencies in nutrition.

There is a wide range of potential issues concerning eating and drinking that can affect children with cerebral palsy, including swallowing difficulty, managing utensils, posture, risk of aspiration, sensory difficulties and even excessive drooling. All of these can be managed, but the key first step is identifying there is an issue before nutritional deficiencies manifest in comorbidities such as osteoporosis.

Unfortunately, as yet, we still cannot cure cerebral palsy. However, with early interventions, close monitoring and targeted therapies the natural history of cerebral palsy is being altered for the better.

Reference

Graham D, Paget SP, Wimalasundera N. Current thinking in the health care management of children with cerebral palsy. Med J Aust. 2019 Feb; 210(3): 129-35. DOI: 10.5694/mja2.12106