Help Pediatric Patients With Cerebral Palsy

Cerebral palsy (CP) is defined as a group of disorders that affect an individual’s motor function, including a movement, muscle tone and posture.¹

CP is caused by abnormal brain development or damage to the developing brain in early years. This can occur prenatally or during birth, known as congenital CP, or during the first few years of a child’s life as the brain is growing, known as acquired CP.¹ There are 4 major types of CP: ataxic CP, dyskinetic CP (includes athetoid, choreoathetoid, and dystonic), mixed CP (includes spastic-dyskinetic), and spastic CP (includes spastic diplegia, spastic hemiplegia, and spastic quadriplegia).² Classification is based on the clinical features of motor abnormalities.

Patients with CP can have many comorbid conditions. Epilepsy occurs in 25% to 45% of these patients.¹ The brain damage that causes CP typically occurs in 1 part of the brain, so these patients are most susceptible to developing a focal epilepsy. Most patients with CP begin having seizures before aged 2 years.³ Focal seizures start in one part of the brain and either stay in that part or spread to other parts of the brain or the whole brain. The commonly used medication choices for patients with focal-onset epilepsy include: brivaracetam (Briviact), carbamazepine (Tegretol), cenobamate (Xcopri), eslicarbazepine (Aptiom), lacosamide (Vimpat), lamotrigine (Lamictal), oxcarbazepine (Trileptal), topiramate (Topamax), and zonisamide (Zonegran).⁴ Many children with severe CP can have multiple seizure types. For patients with generalized seizures, which affect both sides of the brain, the following medications may be considered: cannabidiol (Epidiolex), clobazam (Onfi), levetiracetam (Keppra), rufinamide (Banzel), and valproic acid (Depakote).⁴ Adverse effects profile, age of patient, comorbidities, formulation, and insurance coverage are all factors when choosing an anti-seizure medication. Other treatment options that may help in reducing seizure burden include the ketogenic or modified Atkins diets.

When a patient with CP continues to have seizures, despite having tried 2 anti-seizure medications, they should quickly be referred to an epileptologist, who is a neurologist with specific training in epilepsy. Epileptologists often work at hospitals with a comprehensive epilepsy program where patients whose seizures are intractable to medications can be evaluated for potential epilepsy surgery. Several pre-surgical tests can help localize where in the brain the seizures are starting. If all the seizures are starting in the same area, a resective surgery, where the epileptogenic tissue is ablated or removed, can be a good option to help decrease the seizure burden or in some cases provide the patient with seizure freedom. Depending on the seizure types and extent of early brain damage, other surgical options include a corpus callosotomy (cutting a band of fibers so that the nerves cannot send signals between the 2 halves of the brain) or functional hemispherectomy (disconnecting the damaged and seizure-causing part of the brain from the normal hemisphere). When the seizure onset zone cannot be determined, implanting a vagus nerve stimulation device under the skin in the chest can decrease the frequency and intensity of seizures.

Children with CP can have many medical problems throughout their lives that are often complicated for caregivers and health care professionals to manage. For the common comorbidity of epilepsy, it is important to recognize and diagnose seizures as early as possible. All medication and surgical options should be considered for these patients to provide them with the best chance of seizure freedom and thus improvement in quality of life.

Sula Gillespie, MSN, PNP; Jennifer Glenn, MSN, PNP; and Mallory Murphy, MSN, PNP are nurse practitioners at Children’s of Alabama Epilepsy Monitoring Unit in Birmingham, Alabama.

References

1. Glader L, Barkoudah E. Cerebral palsy: clinical features and classification. Up to Date. Updated September 21, 2021. Accessed November 2, 2021. https://www.uptodate.com/contents/cerebral-palsy-clinical-features-and-classification

2. What is cerebral palsy. CDC. Updated September 2, 2021. Accessed November 2, 2021. https://www.cdc.gov/ncbddd/cp/facts.html

3. Pavone P, Gulizia C, Le Pira A, et al. Cerebral palsy and epilepsy in children: clinical perspectives on a common comorbidity. Children. 2021;8(1):16. doi:10.3390/children8010016

4. Epilepsy. Epilepsy Foundation. Accessed November 2, 2021. https://www.epilepsy.com/