A consensus statement on the use of botulinum toxin in pediatric patients

Abstract

Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.

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“…ETL's arguments offer guidance not only for understanding loneliness but also for treating it. Although loneliness is not a recognized psychopathology [93], it is a common complaint in psychotherapy [94]. In particular, the hypervigilance to threat induced by loneliness-although it may be functional in the service of viability-may also induce maladaptive social cognitions whereby lonely individuals see potential social connections as more threatening than they are.…”

“…It is the binding of acetylcholine to the post-synaptic receptors at the neuromuscular junction that is required to initiate a muscle contraction [93]. BoNT injections are well tolerated with a low risk of adverse events if dosing guidelines are followed [94]. Risks for BoNT include fever, muscle weakness, respiratory difficulties, seizures, swallowing difficulties, bleeding, infections, allergic reaction, generalized muscle weakness, and death.…”

“…Risks for BoNT include fever, muscle weakness, respiratory difficulties, seizures, swallowing difficulties, bleeding, infections, allergic reaction, generalized muscle weakness, and death. On review of the literature, systemic reaction to BoNT-A injections in children occur at a rate of approximately 1-3.6% [94]. Pre-existing medical comorbidities such as orofacial weakness and respiratory weakness may increase a patient's risk of having an adverse event related to BoNT [95,96].…”

Is baclofen the least worst option for spasticity management in children?

“…In children with spastic diplegia or paraparesis and spastic hemiplegia, more focal tone management is often needed to facilitate working toward a particular skill, facilitating or optimizing ambulation, or in response to change in joint range of motion or hip subluxation. For these children, I tend to initiate focal tone management with botulinum toxins and phenol neurolysis [ 18, 19 ]. This permits targeted intervention without concern for sedation that can affect participation in school and other activities or exacerbate constipation.…”

Botulinum toxin for refractory Raynaud's phenomenon: A “how to” guide for pediatric patients

“…BTX‐A has been used for over 30 years to manage other pediatric diseases, including musculoskeletal, neurologic, and pain conditions. BTX‐A is FDA approved to treat limb spasticity in children as young as two 9 . When treating RP, the main adverse effect of BTX‐A is immediate pain from injections.…”