What treatments are available for the associated medical problems

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1. Epilepsy. Our knowledge of epilepsy has increased  substantially in the past few years. There are many types
of epilepsy, and medication is prescribed following  a careful diagnosis of the type of epilepsy. Doctorsattempt to prescribe medications with the fewest side effects whilst providing good seizure control. The two
most commonly used anticonvulsants are:
• Carbamazepine (“Tegretol”). Side effects are unusual but include nausea (in young children this can be manifested as loss of appetite), and skin rash which usually develops shortly after commencing the drug. If the drug is commenced too rapidly initial drowsiness may occur. A controlled release preparation is now available which may be advantageous for those
children able to swallow tablets.
• Sodium valproate (“Epilim”). Side effects are unusual, but include nausea, bowel disturbance and hair loss. Liver damage has been reported but is extremely rare. Several older anticonvulsants are sometimes used because they may suit individual children or lead  to better seizure control. These include:

• Phenytoin (“Dilantin”). This drug has a number of unwanted side effects including gum overgrowth, the
development of abnormal body hair and occasionally coarsening of facial features. Because the margin
between a therapeutic and toxic dose is narrow, signs of overdose – nausea, unsteadiness and drowsiness – do sometimes occur, necessitating regular blood tests.
• Phenobarbitone. This drug can occasionally causeirritability and aggravate constipation.
• Primidone (“Mysoline”). This drug has some of the side effects of phenobarbitone.
• Nitrazepam (“Mogadon”). This drug may cause drowsiness and increased bronchial secretions. It is also used as an hypnotic occasionally in children but more commonly in adults.
• Clonazepam (“Rivotril”). This drug can cause irritability, drowsiness and disruptive behaviour.  It can also worsen drooling.
• Clobazam (“Frisium”). This drug is from the same family as clonazepam. Drowsiness or dizziness may
occur but is usually mild. This drug is one of the more recent anticonvulsants and is similar to clonazepam and nitrazepam in chemical structure.

There are a number of newer anticonvulsants:

• Vigabatrin (“Sabril”). Side effects may include drowsiness, irritability and agitation. There have been reports that this drug may cause problems with vision.
• Lamotrigine (“Lamictal”). This is the most useful of the new drugs, but is usually used as an “add on” to drugs in the previous groups. It is said to cause an increase in alertness which can be a positive effect. The most worrying unwanted effect is a severe skin rash. If a skin rash develops, the drug should be ceased. It may also cause gastro-intestinal disturbance
(for example, nausea or diarrhoea).
• Topiramate (“Topimax”) and gabapentin (“Neurontin”) are more recent drugs. Their place  in the management of childhood epilepsy is beingevaluated.

2. Gastro-oesophageal reflux. Conservative measures,

such as ensuring that the infant or child is propped upright after a meal and thickening liquids, may be helpful. Two medications are frequently used, par-ticularly when there is evidence of oesophagitis or gastritis (inflammation of the oesophagus or stomach):

• Cisapride (“Prepulsid”) enhances stomach movements and may accelerate gastric emptying and shorten intestinal transit time. Diarrhoea may occur. Rare cases of cardiac arrythmias have been reported. Patients experiencing arrythmias have usually been  on multiple medications.
• Ranitidine (“Zantac”) reduces gastric acidity.  Very occasionally surgery for reflux is necessary when medications have failed to control the problem. The  surgical procedure is called a fundoplication.

3. Saliva control.

 The speech pathologist plays a central role and can provide strategies and programs to improve dribbling problems. For children where these strategies
are not effective, medication is occasionally used, particularly in children over the age of six years. These medications are as follows:
• Benzhexol hydrochloride (“Artane”) reduces salivary secretions. Occasionally irritability or even
hallucinations may occur. Blurring of vision, constipation and difficulty with urination are also  potential side effects.
• Glycopyrrolate (“Robinul”) is similar to benzhexol hydrochloride but seems to produce fewer side effects.  It is not widely available at present in Australia.  For older children with persistent dribbling problems, surgical treatment can be offered. The plastic surgeon redirects the submandibular ducts and removes the sublingual glands. This operation usually reduces
drooling but does not lead to an unduly dry mouth. It is important that children undergoing this procedure have regular dental follow up as there is an increased risk of dental cavities.

4. Constipation.

 Children with cerebral palsy often have problems with constipation. A high fibre diet and increased fluid intake can help with this problem. This may not be easily achieved in some children with cerebral palsy. Careful use of laxatives is preferable to
severe constipation.

5. Nutrition.

 A dietitian can provide useful advice about adequate nutrition. Excessive weight gain can  be very disadvantageous for children learning to walk. Undernutrition and failure to make adequate weight gains may be related to feeding difficulties. In a small proportion of children, the use of tube feeding can be helpful. A separate booklet about this is available.

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