Botox Injections.

When a child first visits in preparation for Botox injections, we review her history--previous medical, surgical, and radiological evaluations--and ask who thought she might be a candidate for Botox injections--and why?

Most diagnosis procedures of children with movement disorders can be painful or distressing. Visiting a doctor's office is often an anxiety-laden event. But on this visit, nothing threatening is done. The physical exam consists of observing the child's movements and gentle handling, to assess the degree of spasticity, range of motion, and abnormal neurologic findings. Other than that, we just talk.

Discussing goals

Discussing what the family expects to achieve is vital. Goals can be functional (better use of a hand or less toe-walking), management (easier care), or cosmetic (the bent up crooked arm being able to swing more freely in walking). Injections should not be done unless everyone agrees to which goals can be--and want to be--achieved.

We also discuss whether or not to sedate the child. Since as many as eight injections may be done at one session, young children do better and have less fear of returning for subsequent injections if they are sedated. We use oral Versed, which tends to not only sedate, but also make the child forgetful of the event.

We also review the time--course of action of Botox--one to three days to onset of effect, peak effect at two to four weeks, and expected duration of effect of three to six months.

Opting for Botox injections usually comes when more conservative measures--therapeutic handling, use of orthotics or other positioning devices, etc.--have not produced the desired results, or if the child has hit a plateau in development. It is preferable for Botox injections to be done in concert with the child's orthopedist.

The injection process during a subsequent appointment is surprisingly simple. Low intensity electrical stimulation identifies an "electroactive" point in the target muscle(s). It may take only five minutes to inject multiple muscles. A local anesthetic cream is used on the skin to numb the area beforehand.

Possible results

While the effect of Botox lasts only three to six months, lasting improvement is possible, since therapy may be more effective during that time. In that case, the child will not revert to the preinjection status. Repeat injections may be appropriate to see if that "step-wise" improvement can be continued.

Botox injections tend to mimic the effects of surgical tendon lengthenings. They can buy time until the child is old enough to have a surgical procedure (generally after 5 years old), or, in the older child, to see how the child will respond to tendon lengthenings. It also allows time to see how well the child responds to therapy, and whether or not families are capable of performing the necessary home exercise program.

Dr. Diamond is the Director of Out-Patient Services at Children's Specialized Hospital, New Jersey. Double-boarded in Pediatrics and PM&R, he has a particular interest in multi-modality medical treatment of pediatric spasticity.