Botulinum Toxin: Techniques Within Pediatric Physiatry.

BACKGROUND: Intramuscular botulinum toxin injections are used for treatment of focal spasticity in children, particularly in those with a diagnosis of cerebral palsy. There are a variety of techniques used when performing botulinum toxin injections without clear standards for pediatric providers.

OBJECTIVE: To describe current practice techniques for botulinum toxin injections among pediatric physiatrists.

DESIGN: Cross-sectional survey using RedCap Software.

SETTING: Pediatric physiatrists who perform botulinum toxin injections.

PARTICIPANTS: Survey of 307 pediatric physiatrists.

METHODS: Analysis of data from the 2017 practice survey of pediatric physiatrists in the United States.

MAIN OUTCOME MEASUREMENTS: Physicians were asked the primary botulinum toxin used, common dosing information, the role of localization, and the role of sedation and distraction in their practice.

RESULTS: Nearly all pediatric physiatrists use OnabotulinumtoxinA as the primary formulation of botulinum toxin. The maximum dose per body weight used per injection series had a median of 15 units/kilogram and a median maximum total dose of 500 units. Sixty-five percent of pediatric physiatrists report using sedation, of any type, for botulinum toxin injections. When using sedation, the most common primary method was general anesthesia (38.9%), followed by enteral or nasal anxiolytic with the patient awake (26.2%). The most common reported intended injection site for botulinum toxin was "in multiple sites spread throughout the muscle" (67.9%), and then "one site of the muscle at the motor point" (17.1%). Large muscles were injected using primarily anatomic guidance (75.6%) and electromyography (50.8%), and small muscles were primarily completed with electromyography (73.6%) and anatomic guidance (49.2%).

CONCLUSION: There is considerable variability present in one common procedure performed by pediatric physiatrists.

LEVEL OF EVIDENCE: Level IV.