Best Clinical Practice in Botulinum Toxin Treatment for Children with Cerebral Palsy.

Botulinum toxin A (BoNT-A) is considered a safe and effective therapy for children with cerebral palsy (CP), especially in the hands of experienced injectors and for the majority of children. Recently, some risks have been noted for children with Gross Motor Classification Scale (GMFCS) of IV and the risks are substantial for level V. Recommendations for treatment with BoNT-A have been published since 1993, with continuous optimisation and development of new treatment concepts. This leads to modifications in the clinical decision making process, indications, injection techniques, assessments, and evaluations. This article summarises the state of the art of BoNT-A treatment in children with CP, based mainly on the literature and expert opinions by an international paediatric orthopaedic user group. BoNT-A is an important part of multimodal management, to support motor development and improve function when the targeted management of spasticity in specific muscle groups is clinically indicated. Individualised assessment and treatment are essential, and should be part of an integrated approach chosen to support the achievement of motor milestones. To this end, goals should be set for both the long term and for each injection cycle. The correct choice of target muscles is also important; not all spastic muscles need to be injected. A more focused approach needs to be established to improve function and motor development, and to prevent adverse compensations and contractures. Furthermore, the timeline of BoNT-A treatment extends from infancy to adulthood, and treatment should take into account the change in indications with age.

Author information
1Department of Paediatric- and Neuro-Orthopaedics, Orthopaedic Hospital Rummelsberg, 90592 Schwarzenbruck, Germany and MOTIO, 1080 Vienna, Austria.
2Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road Headington, Oxford OX3 7LD, Oxfordshire, UK.
3Department of Paediatric- and Neuro-Orthopaedics, University Children’s Hospital Basel (UKBB), Spitalstrasse 33, 4056 Basel, Switzerland.
4Centre de Réadaptation de COUBERT (Ugecam) 77170, France and ROMATEM, Etiler Istanbul 34337, Turkey.
5Pediatric Orthopaedics and Institue of Motion Sciences Department, Aix-Marseille Université, Boulevard Jean Moulin, Marseille 13885, France.
6Department of Paediatrics, Hospital Infantil La Paz, Universidad Autonóma de Madrid, Madrid, Spain.
7Orthopedic Department, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany.

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