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"In Case You Missed It" from Pediatric Passages

Summer 2018

This was a prospective study that examined the effect painful procedures and glucose exposure had on structural brain development and general development in neonates born prior to 30 weeks gestational age, specifically the differences between males and females. Neonates chosen had limited exposure to narcotic and sedative medications and attempt was made to match the number of painful procedures between groups. To determine differences in brain structure, MRI imaging was performed at three predetermined time points after birth. Investigators were specifically looking at differences in size and structure of the basal ganglia and thalamus based on literature that suggests these areas are involved in pain perception. To measure development, the Bayley Scales of Infant Development was used at 18 months corrected gestational age. The medical chart was used to determine total doses of analgesia and oral glucose neonates received as well as the number and type of painful procedures the neonate experienced.

The results showed that female neonates exposed to higher number of painful procedures had decreased brain growth, specifically in the thalamus, when compared to females who were exposed to fewer painful procedures. This was also true when female neonates were compared to equally paired male neonates. Female neonates who received larger total doses of glucose also had decreased brain growth, showing that giving glucose instead of opioids does not mitigate the negative effects of the painful procedure. Rather, exposure to greater amounts of glucose may be detrimental to structural brain development. Similar results were seen when the neonates underwent developmental assessment at 18 months – females who were exposed to more pain and higher glucose doses had significantly lower scores on the Bayley Scales compared to males.

It is already known that the premature brain does not develop normally and that premature babies often undergo many painful procedures. To reduce exposure to opioids, oral glucose was thought to be an acceptable alternative to pain management. Unfortunately, this study determined glucose has almost the same negative effect on brain development as exposure to opioid medications. Equally as surprising, female neonates had worse outcomes when compared to males, which is in opposition to most outcomes regarding premature babies. This study addresses the importance for further investigation of acute interventions in neonates and their long-term effects. While it is important to ensure premature babies are comfortable while undergoing painful procedures, more studies need to be performed to determine the best way to control pain without affecting long term brain development.  

This study evaluated the change in gait kinematics of twenty-one children with spastic diplegic (n=14) and hemiplegic (n=7) cerebral palsy at baseline after 18 months of use of either a solid AFO (sAFO), a hinged AFO (hAFO), or SMO.  All orthotics were constructed by a pedorthotist.  All AFOs were set at neutral or 1-5 degrees of dorsiflexion based on the clinical judgement of the pedorthotist.   Data were collected with participants walking at a self-selected pace, with and without orthotics.  Motion between the following segments were measured during all stages of the gait cycle: tibia-calcaneus, calcaneus-cuboid, navicular-first metatarsal bone, and first metatarsal-hallux.  Range of motion and angle of rotation data were also recorded for all joints.  When comparing kinematic data from the initial and final visits in the three groups, the only significant difference was increased ankle eversion during barefoot gait in the group who wore solid AFOs at the final visit.  There was no significant change in range of motion between the initial and final visits in any of the groups.  Children in the hAFO group had improved dorsiflexion and decreased sagittal movement when wearing hAFOs compared to barefoot gait at the initial visit.  However, there was no significant difference in these measures between hAFOs and barefoot gait at the final visit.  From this data, the authors concluded that wear of orthotics have the potential to maintain foot position and prevent future deformity.  The SMO group showed significant improvement in sagittal forefoot motion between gait with SMOs and barefoot gait after 18 months of use, suggesting that SMOs continue to have immediate effects on foot alignment, even after prolonged periods of wear.

Adolescents and young adults with chronic health care needs are at risk for poor health outcomes when transitioning from pediatric to adult health care.  Multiple physician organizations issued a consensus statement, outlining six core elements for care transition:  transition policy, planning, readiness, tracking, monitoring, transfer of care, and transfer connection.  The researchers implemented a transition plan using these recommendations, which employed a nurse coordinator to facilitate the transition between pediatric and adult care, and to compiled comprehensive portable medical summary, a checklist, and an action plan for each patient.  They performed a randomized controlled trial comparing the guideline-based transition plan to usual care.  A total of 209 participants with chronic medical problems were recruited from an academic pediatric practice.  The ages of the subjects were between 16 and 22, and all had the same Medicaid-managed care organization insurance plan. Diagnoses of the participants included cerebral palsy, autism, Down syndrome, and learning disabilities.  Participants were stratified into two groups by age (16-18 years and 19-22 years), and into three complexity tiers based on diagnosis and need for coordination with additional care teams.  The Patient Assessment of Chronic Illness Care (PACIC) and the Client Perceptions of Coordination Questionnaire (CPCQ), which measure the patient’s perception of healthcare delivery, quality, and coordination, were collected at baseline, and at 6 and 12 months post-enrollment.  The intervention group had significantly higher PACIC scores compared to the control group at 6 and 12 months post-enrollment, particularly in the domains of problem solving, coordination of care and follow-up, and patient activation.  The patients with high complexity had higher PACIC scores, however, there was no significant difference between control and intervention in the moderate and low complexity groups.  Participants in the intervention group also reported less confusion about the role of providers, and at 12 months post-enrollment, reported more frequent discussions about future care, and were more likely to report that they were receiving the services they needed.  The data from this study suggest that using an approach to transition based on the consensus guidelines may facilitate a more streamlined transition to adult health care, particularly for the most complex patients.

A previous study on baclofen pharmacokinetics in children with cerebral palsy showed that a single-nucleotide polymorphism (SNP) in the ABCC9 gene is associated with increased clearance of oral baclofen.  The ABCC9 gene belongs to the multi-drug resistance protein group, whose substrate profile is not well-characterized.  In this study, DNA was collected from 53 children, ages 2 to 17 years, using whole blood or saliva and genotyped for 4535 SNPs involving 307 genes associated with baclofen absorption, distribution, metabolism, and excretion.  Outcome measures included the estimated baclofen clearance and estimated oral baclofen clearance corrected for body weight, and improvement hamstring spasticity as measured by the modified Tardieu scale between baseline and follow-up visits.  Of the top 20 SNPs with statistically significant difference in apparent oral clearance corrected for body weight, only one SNP, rs11046232, on the ABCC9 gene remained statistically significant after adjustment for false-discovery rate.  The TT homozygous genotype had a corrected clearance of 0.25 ± 0.07 L/h/Kg (present in 48/53 children) and the AT heterozygous genotype (present in 3/53 children) had a higher corrected clearance of 0.51 ± 0.05 L/h/Kg. Children with the AT heterozygous genotype still had higher corrected clearances when controlled for age.  The AT heterozygotes also had more spasticity as measured by a higher mean hamstring R1 angle.  While the small total sample size and presence of only three of AT heterozygotes is a significant limiting factor of this study, the relationship between ABCC9 SNPs and baclofen clearance in children warrants further study.

Rehabilitation services are a crucial component in the recovery from traumatic brain injury (TBI).  To assess unmet need in the pediatric TBI population, the authors enrolled 170 children with traumatic brain injury between the ages of 8 and 18 admitted to six children’s hospitals in a prospective study.  Forty-seven children had moderate to severe TBI, and 123 children had complex mild TBI (cmTBI), defined as having radiologic evidence of intracranial injury and intial GCS of 13-15 with return to baseline within 24 hours.  Baseline data was collected within 30 days of injury, and follow-up data was collected via interview at 6, 12, and 24 months post-injury.  At each follow-up, parents reported any new evaluation by special education services, rehabilitation professionals, or a physiatrist.  Need was defined as the presence of impairment that could be addressed by these services.  The authors found that children with moderate to severe TBI had the highest needs for physiatry and educational needs, and their need for services increased with time since injury. However, children with cmTBI had proportionally more unmet needs in all areas, except for speech therapy.  Factors associated with having needs for services met included admission to an inpatient rehabilitation unit, household income over $50,000, and the presence of premorbid conditions affecting the brain. Based on this data, the authors concluded that children with TBI should be assessed for rehabilitation and educational needs into the chronic phase of recovery.

It is well accepted that children with congenital heart disease (CHD) are at risk for neurodevelopmental and behavioral disabilities, but there is wide variability in outcomes in the CHD population making it challenging to predict which children will be most affected. This cohort study attempts to understand individual neurobehavioral performance to help provide an opportunity for parental and caregiver education, and early referral to neurodevelopmental support services. By assessing specific behaviors using Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS), targeted areas of concern can be identified and a behavioral profile can be developed that provides insight into at-risk areas to better guide intervention. The study found compared to typically developing controls born at term, neonates with CHD demonstrate different neurobehavioral performance in multiple subdomains both before and after undergoing surgical intervention.

In addition to looking at each child’s results individually, the study suggests that there are neurobehavioral patterns unique to neonates with CHD. Neonates with CHD tend to interact less with their environment, demonstrate decreased arousal, attention, and excitability compared with typically developing neonates. This pattern of behavior is also different from other hospitalized high- risk populations, such as drug-exposed neonates, who tend to have a more highly excitable pattern. This study is important because it supports routinely performing targeted neonatal evaluations may be useful in both guiding standardized therapies and neonatal handling practices and identifying patients at risk. It also highlights areas for future investigation focusing on how to develop individualized therapies to improve neurodevelopmental outcomes in the population with CHD as a whole and individually.

The use of power mobility devices may profoundly impact the development, function, and participation of children who have mobility limitations yet it is an under-researched area of interest. While it is unclear exactly how many children use power mobility, studies suggest use is increasing. This qualitative study explored the experiences of children learning to use a power mobility device from the perspective of parents, pediatric occupational therapists, and physical therapists. Three themes were identified: (1) ‘Power in mobility’ which described how learning to use powered mobility changed more than just a child’s locomotor abilities and was transformative on multiple levels; (2) ‘There isn’t a cookbook’ revealed how learning to use powered mobility occurred along an individualized continuum of skills that often unfolded over time in a cyclical process; (3) ‘Emotional journey’ explored how the process of learning to use powered mobility was an emotionally charged undertaking for children, families, and therapists. This study highlights the need to individualize power mobility training, and emphasizes the need to be mindful of the emotional aspects and the potentially life-altering changes that can occur with powered mobility use.

Metachromatic leukodystrophy (MLD) is a rare progressive neurological disorder, often accompanied by motor impairments that are challenging to treat. In this case series, authors report the course of treatment with intrathecal baclofen (ITB), aimed at improving daily care and comfort in children and young adults with MLD. All patients with MLD in a regional center on ITB treatment for a minimum of 6 months were included (10 patients in total). Eight patients had MLD with a predominant spastic movement disorder (sMLD) and two were mainly dyskinetic. Patients with sMLD were compared with matched patients with spastic cerebral palsy (CP). Complication rates related to ITB treatment were similar in both groups. ITB treatment course in the first 6 months after pump implantation appears to show more dose increase in most patients MLD, compared to patients with spastic CP. This may be due to the progressive disease in MLD. ITB is a feasible therapy to improve daily care and comfort in patients with MLD and should therefore be considered early.

This review discusses changes in paradigms of treatment for neonatal brachial plexus injury. Specifically, the authors discuss that irreversible changes occur at the neuromuscular junction within 12-24 months after nerve injury without reinnervation, and prolonged axotomy results in decreased axonal sprouting following nerve repair, suggesting that monitoring for one year prior to intervention for neonatal brachial plexus injury may worsen outcomes. Clinical exam is essential in early diagnosis, and early assessment and grading of severity of injury using tools such as the active movement scale allows detection of small but clinically meaningful improvement in function. They suggest that a 3 month test score helps predict benefit from surgical evaluation. They review new techniques that have been developed for management, such as nerve transfer, and evidence that early OT involvement and ROM at the arm do not worsen subluxation. Early therapy may instead preserve passive ROM, strengthen affected muscles, promote functional use of the extremity as well as teach compensatory techniques. It is also important to identify associated conditions requiring management early on, such as torticollis or speech delay, or pain that may indicate underlying skeletal injury. The authors recommend that a child that has not had recovery by 1 month of age be referred to a multidisciplinary neonatal brachial plexus program.

An important goal for the specialty center is to predict whether or not the child will have satisfactory spontaneous recovery or require additional management. Algorithms include the University of Michigan NBPP (Neonatal Brachial Plexus Palsy) Treatment Pathway, in which if the child has not regained adequate biceps strength to bring their hand to mouth by 6 months, they are a surgical candidate. 1 study does suggest that using biceps strength to predict arm flexion in recovery may be wrong 12% of the time. The University of Toronto test score is applied at 3 months and evaluates elbow flexion, elbow extension, and wrist, finger and thumb extension. A subthreshold score on the Toronto Test Score (<3.5) predicts poor spontaneous recovery with conservative management and is associated with a 5% risk of an inaccurate prediction. A failing test score at 3 months is considered to be an indication for surgical management, and a higher score leads to reevaluation at 6 and 9 months, with the cookie test of biceps strength at 9 months to determine if primary nerve reconstruction is indicated. A decision tree developed by the authors using the Narakas grade, presence of clavicle fracture at birth, Horner syndrome, pseudomeningocoele on imaging, birth weight, and history of induction or augmentation of labor had a positive predictive value of 94% and negative predictive value of 79% for failure to improve spontaneously after the time of surgical candidacy. These algorithms support the importance of early identification and possible surgical referral before 1 year of age.

Additional studies support improvement in movements including shoulder abduction to at least 90 degrees after nerve graft repair, and nerve transfers have been shown to be an effective option for improving biceps strength to 6 or more on the AMS, or Medical Research Council grade 3 or more. Outcomes for shoulder abduction and external rotation still appear limited currently. As only 3.3% of children with NBPP underwent primary nerve surgery and 20-30% of patients have persistent deficit based on a large database study, the authors argue this is an underutilization of surgical management. They recommend increasing awareness and early referral by primary care physicians in order to improve outcomes for children with NBPP.

Relevance: Pediatric physiatrists play an important role in the multidisciplinary team managing NBPP, and can assist in educating primary care physicians about the current evidence and outcomes with early evaluation and management before 1 year of age. It is important to be aware of the current literature regarding management of NBPP.

This epidemiology study looked at 10 years of cervical spine injury data captured by the High School Reporting Information Online injury surveillance system.  Injuries included any injury to the cervical spinal cord, bones, nerves, or supporting structures of the cervical spine including muscles, ligaments, and tendons.  They found an injury rate of 3.04 per 100,000 athlete exposures with highest rates in football, wrestling, and girls gymnastics.  This data is helpful in educating both families and ATCs on the importance of proper technique and strengthening in injury prevention.

In this point/counterpoint discussion Dr Louise Spierre and Dr Robert Rinaldi make arguments for and against opening Pediatric Rehabilitation Medicine fellowship training programs to general pediatricians.  This is simply a good read that further emphasizes the growing needs of our field and a way that we could potentially increase access for the children we care for.

Authors at the Kennedy Krieger Institute developed this study to evaluate the effectiveness of the Physical and Neurological Examination of Subtle Signs (PANESS) in monitoring for residual motor changes after Sports Related Concussion (SRC) in a cohort of adolescents. The PANESS examines subtle signs of motor impairment during gait, balance, and timed basic motor functions. It is a bedside assessment, requires no technology, and contains two subscores, Gait and Stations, and Total Timed, which are combined for a Total Score, in which higher values indicate poorer outcomes. The PANESS has been found to have greater sensitivity than traditional clinical measures to residual deficits one year after mild to moderate pediatric TBI. While the PANESS is a widely used in pediatric populations when evaluating for attention deficit hyperactivity disorder and TBI, it has never been utilized in the concussion population. The researchers recruited 20 patients, ages 13-17 years old, with witnessed sports-related concussion. Fifteen of the athletes (5 female) met inclusion/exclusion criteria and participated for the entirety of the study. These athletes were matched with healthy control subjects, accounting for age, sex, socioeconomic status, and race. Concussed subjects were initially evaluated within 14 days of the injury, and repeat testing was performed one month later. In 6 of the SRC subjects, they had ongoing concussion related symptoms at their second visit, and underwent a third visit after clinical recovery. Control subjects were evaluated in two visits, roughly one month apart. Data analysis revealed that the SRC group had higher (poorer) PANESS scores in the Gait & Stations, Total Timed, and Total Score when compared to control subjects at the initial visit. SRC subjects improved their scores in the Gait & Stations subset in subsequent testing, becoming equivalent with non-concussed controls. The SRC subjects continued to demonstrate higher (poorer) scores in the Total Timed subset of the PANESS even after “clinical recovery” and symptom resolution, in which they had been returned to sports. All of the subjects were also given the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), where composite scores for Verbal Memory, Visual Memory, Visuomotor Speed, and Reaction Time were examined. At the first visit, SRC subjects performed worse on Visual Memory, Visuomotor Speed, and Reaction Time, but not on Verbal Memory when compared to the control group. At their last visit, the SRC group showed no significant differences compared with controls on any of the testing. The authors argue that the persistence of relative deficits on the PANESS despite clinical recovery could account for increased rate of injury and repeated concussion in the adolescent athlete, though the small sample size makes extrapolation difficult.

Authors working in Ajou University Medical Center in South Korea performed a retrospective cohort study analyzing 996 children who were seen in a torticollis specialty clinic between 2010 and 2012 in an attempt to identify the incidence of clavicular fracture in infants with Congenital Muscular Torticollis (CMT). Of the 996 infants with CMT, 20 subjects (2.01%) were found to have concurrent clavicular fractures. Comparison of characteristics of the subjects showed that there was no significant difference in gender, birth weight, and gestational age between the subjects with concurrence of CMT and clavicular fracture and the subjects with CMT alone. Of the 20 subjects, 18 of the infants had a contralateral clavicular fracture. Right CMT with left clavicular fracture was the most common combination. All 20 of the CMT + Fracture subjects were delivered via vaginal delivery, while in subjects with isolated CMT, 25% were born via c-section. The authors hypothesize that the usual delivery presentation of Left Occiput Anterior (LOA) predisposes the infant to either ischemic damage, compartment syndrome, or traumatic stretching of the right sternocleidomastoid (SCM), and if assisted delivery maneuvers are required, the left anterior shoulder and clavicle will bear the brunt of the trauma required at the time of delivery. The authors feel that the 2% clinical incidence of clavicular fracture warrants screening in all infants being assessed for CMT, as a diagnosis of fracture will limit therapeutic interventions including range of motion, while the limb is fixated to promote bone healing.

The purpose of this study was to examine the efficacy of Armeo robotic therapy, compared to conventional therapy, on upper limb function in children with hemiplegic cerebral palsy. The authors conducted a double-blinded study of thirty children from a single center in Saudi Arabia, ages 6-8 years old, half of whom received robotic therapy, while the other half participated in conventional therapies focusing on range of motion, weight bearing, and functional tasks. Both groups received three 45-minute therapy sessions per week, for a total of 12 weeks. Outcome measures were the Modified Ashworth Scale and the Quality of Upper Extremity Skills Test (QUEST), which were measured pre- and post-treatment. Pretreatment measurements detected no significant difference in MAS or QUEST between the two groups of children. Children in the robotics group had statistically significant improvements in both their spasticity measures, and in their ability to perform on the QUEST. The MAS scores for the robotics group decreased by 0.4 more than the conventional group, while the QUEST scores in the robotics group increased by 5.9 points more than the conventional group. There was no long term follow up to demonstrate retention of improvements.

Spring 2018

Multilevel surgery (MLS), which is also referred to as single-event multilevel surgery (SEMLS), is when 4 or more orthopedic surgical procedures are performed in 1 session in an operating room. There is then one extended period of rehabilitation time after this, rather than the surgeries being performed individually with their own rehabilitation/recovery time after each procedure. MLS has become the standard approach to orthopedic surgery in children with bilateral spastic cerebral palsy. The objective of this study was to examine the effects of MLS on long-term gait outcomes at skeletal maturity in ambulatory individuals with bilateral spastic cerebral palsy. Secondarily, this study also sought to examine the safety of MLS. This was a retrospective study of individuals from 3 centers. Clinical evaluations and follow-ups and standardized gait data were evaluated. Results demonstrated that 94% of children did not have any change in their Gross Motor Function Classification System (GMFCS) score. The authors reported that among the 231 children in this study, 77% showed a clinically-significant improvement in long term (with a mean of approximately 9 years after MLS) improvement in Gait Profile Score (GPS). They note a limitation that there was no non-MLS group in the study to compare outcomes in a group without surgery. Surgical adverse events were recorded in 47% of the individuals in this study. 7/231 individuals had a grade III adverse event and 1/231 had a permanent grade IV adverse event, without any grade V complications recorded. This study is noted to be the largest outcome study with the longest follow-up after MLS. The authors conclude that MLS is safe and effective for ambulatory children with bilateral spastic cerebral palsy. This study can be a helpful reference when talking to families about the risks and benefits of MLS.


While consensus papers on intrathecal baclofen (ITB) have addressed treatment of both spasticity and dystonia, most research on the topic focuses on spasticity rather than dystonia. The aim of this study was to examine the effect of intrathecal baclofen on function and activity of individuals with dyskinetic cerebral palsy. This was a retrospective chart review of individuals with dyskinetic cerebral palsy who were treated with intrathecal baclofen at a single site between 2004 and 2013. Parental grading of activities of daily living and pain and provider grading of dystonia, spasticity, and passive range of motion before and after intrathecal baclofen were collected. Data from 25 individuals was included in the study. Functional follow-up occurred at a mean of 1.5 years after intrathecal baclofen implantation.  20/25 individuals were reported to have improved activities of daily living (with 16/22 having improved sitting and 17/25 having improved communication) and 13/25 having improved pain scores. Using the Barry-Albright Dystonia Scale, dystonia improved from a mean of 7.1 (SD 5.2) to 1.5 (SD 1.8) at rest and improved from a mean of 19.2 (SD 3.4) to 9.9 (SD 3.7) with activity. Spasticity (using the Modified Ashworth Scale) improved in 19/25 individuals. Only small changes were seen in passive range of motion after intrathecal baclofen (increased in some individuals and decreased in others). 5/25 participants required catheter revisions during the study period. One individual required intrathecal baclofen pump explanation due to an infection, with a new pump implanted at a later time. There was subcutaneous leakage of cerebrospinal fluid post-operatively, which was treated with compression only, in 10/25 individuals. This study demonstrated that intrathecal baclofen can have a positive impact on activities of daily living and dystonia in individuals with dyskinetic cerebral palsy. The authors acknowledged that a randomized control trial would be valuable for studying this topic further and noted that one is currently underway. This study can be a helpful reference when discussing the risks and benefits of intrathecal baclofen for individuals with dyskinetic cerebral palsy.  


Early botulinum toxin injections may be considered in cases of cerebral palsy, obstetric brachial plexus palsy, clubfoot, or congenital torticollis. Botulinum toxin has a grade A level of evidence for reduction of focal spasticity in CP, and is recommended for treatment of lower limb muscles in CP. It is considered to be safe for children with CP >2 years of age, but there are limited recommendations for children < 2 years of age. This study reviews the current literature regarding the safety of intramuscular botulinum toxin injections in children with orthopedic and neurologic-related musculoskeletal disorders who are under 2 years of age. The authors also reviewed the evidence on the effectiveness of early Botox injections in different pathologies and different protocols used. Inclusion criteria for articles included at least 1 child under 2 years of age, safety-related or effectiveness outcome of botulinum toxin injections (BTI), BTI in the striated muscles of the neck, trunk, or limb, and articles must have been in English.

Results/Conclusions: 104 articles were selected for review, 17 of which had individual data on children under 2 years of age that could be extracted. 11 articles exclusively included children under 2 years of age. 3 included children with CP, 6 included children with OBPP, 4 included children with clubfoot, and 2 children with congenital torticollis. One study described a child with myelomeningocele with lower limb deformities, and 1 a child with zone II finger flexor tendon repair. A total of 473 children under 2 years of age received BTI in the striated muscles of the limbs and neck; 55 children with CP, 112 with obstetric brachial plexus palsy, 257 with clubfoot, and 44 with congenital torticollis. Two studies were RCTs, 1 with level 1 evidence and 1 with level 2. Four studies were prospective with level 3 and 4 evidence, 8 studies were retrospective with level 4 evidence, and 3 studies were case reports with level 5 evidence according to the modified Sackett scale. Three studies including 328 of the 473 infants included a systematic evaluation of adverse effects. One severe adverse effect of transverse myelitis after BTI for clubfoot was reported, but a link between the myelitis and BTI was excluded. The most frequently-reported adverse events were all mild, including pain at the point of injection, weakness in the injected muscle, asthenia, hematoma at injection point, and dysesthesia at the injection point. These were reported at rates varying between 3.7% and 25% in the various studies. In 1 study, 1 moderate adverse event of mild dysphagia after injection was reported out of 27 infants (3.7%). No relations were reported between age to time of injection, gender, protocol used, and frequency of events in any study.

One RCT with level 2 evidence including 15 children with CP, GMFCS I-II, with repeat BTI in the hamstrings at a mean age of 16 months described a significant increase in popliteal angle and decrease in spasticity 1 and 3.5 years later compared to control receiving daily stretching. No significant differences were seen in passive ankle dorsiflexion or spasticity of the ankle plantar flexors. Another study with level 4 evidence found no significant effect on the prevention of hip subluxation after BTI in a sample of 7 children ages 13-45 months. However, if adjusted for age and severity, the subgroup <2 years of age with a Reimers index <30% there was a statistically-significant mean improvement of 3% in the Reimers index after injection. Two studies evaluating motor function found no statistically-significant improvement in motor function on the PEDI or GMFM-66 at 1 and 3.5-year follow-up for children with CP. 

In obstetric brachial plexus palsy, 1 study with level 4 evidence found BTI improved passive external rotation by a mean 26 degrees in 8 children, another showed improvement by 10.1 points of active ER on the active movement scale in 8 children, and another study with level 5 evidence found an increase in antagonist muscle strength after BTI in 4 infants on the Medical Research Council scale. A study with level 4 evidence showed 58.35 of infants with surgical indications had surgeries cancelled, modified or postponed after BTI. Another study with level 4 evidence had 24/35 infants injected for glen humeral subluxation had no recurrence at 1 year.

One RCT with level 1 evidence found no change in time in plaster or number or percutaneous tenotomies after BTI for children with clubfoot. One study with level 4 evidence and 2 with level 5 evidence found a significant increase of 30 to 50 degrees in ankle dorsiflexion in infants with combined treatment with casting and physiotherapy. Two studies with level 4 evidence found an increase in active and passive cervical motion in 75% of infants with congenital torticollis, and mean improvement of 11.9 degrees lateral rotation.

Botox was used more frequently than disport, with total doses ranging from 6 to 12 U/kg Botox or 30U/kg for Dysport for CP. For brachial plexus, the total maximum dose used was 10U/kg. In children with clubfoot, doses ranged from 5 to 11.6U/kg Botox. Pain management varied between topicals, general anesthesia, no anesthesia, or unspecified. Guidance varied between palpation, e-stim or EMG, or unspecified.

Based on these studies, the authors conclude that the safety of BTI in children under 2 appears similar to older children, though rates may vary based on pathology and injection site. There is not yet a high enough level of evidence to conclude effectiveness of BTI in these populations. More studies are needed.

Relevance: As providers managing these conditions and considering these interventions, it is important to be aware of the current state of the literature, and to consider how we can perform better studies to determine whether these interventions are both safe and effective for our patients.


The purpose of this study is to examine the prevalence of development of secondary attention deficit/hyperactivity disorder (SADHD) within 5-10 years after TBI, and associated risk factors. The authors conducted a prospective cohort study of 187 children (81 with TBI, 106 controls) ages 3-7 years who were hospitalized for either TBI, or orthopedic injuries for a control group. Study sites included 3 tertiary children’s hospitals and 1 general hospital in Ohio, and patients were enrolled between January 2003 to June 2008. Inclusion criteria included an accidental cause of injury, no preinjury neurologic problems or delays, and English as the primary language. Outcome assessments were the DSM-Oriented Attention-Deficit/Hyperactivity Problems Scale on a parent-reported Child Behavior Checklist, report of an ADHD diagnosis, and/or treatment eith stimulant medication not present at baseline assessment. Surveys were completed at baseline, 6 months, 12 months, 18 months, 3.4 years and 6.8 years after injury.  The final assessment was completed after middle school transition with the expectation that deficits in executive function and attention would emerge at that time. ADHD was defined as Tscores greater than 65 on the DSM-Oriented Attention Deficit/Hyperactivity Problems Scale, parent-reported history of ADHD diagnosis or prescribed stimulant medication.


Of the original cohort of 221, 15 were excluded with uncomplicated mild TBI, 16 children with primary ADHD were excluded, and 3 children were missing parent rating scales at the baseline assessment, resulting in the cohort of 187 children. Mean age of injury was 5.1 years, 57.8% were male, and 26.7% were nonwhite race/ethnicity. Retention rates didn’t differ across injury groups. 48 children without preinjury ADHD met the definition of SADHD. 61.5% of those with severe TBI developed SADHD within the first year after injury, while 50.0% of those with moderate TBI and 53.8% with complicated mild TBI who developed SADHD developed it later than the first year after injury. Children with severe TBI had increased risk for development of SADHD compared to control, while mild and moderate TBI groups did not differ significantly. Although the risk of SADHD developing after complicated mild TBI and moderate TBI did not meet the threshold for statistical significance, all TBI severity groups demonstrated almost twice the risk for SADHD compared with controls. Lower maternal educational level and greater family dysfunction were significantly associated with risk for SADHD. The interaction of male sex and lower levels of maternal education were also associated with increased risk of SADHD.

Relevance: As providers managing children with TBI and the subsequent cognitive effects of TBI, this study provides important information on risk factors for SADHD that may help guide monitoring and expectations for symptoms, as well as for counseling of families. The study supports post-injury clinical monitoring.


The authors of this study sought to assess self-determination of adolescents with neonatal brachial plexus palsy (NBPP) compared with their typically-developing peers via self-reported measures of function due to the importance of self-determination on enhancing learning and improving postschool outcomes. Via a case-control design, they studied 20 adolescents with NBPP along with 20 age/gender-matched typically developing adolescents by measuring the American Institutes for Research (AIR) Self-Determination Scale and a physical assessment (AROM, Grip/pinch strength, MRC muscle strength, 9-Hole Peg Test, and Mallet scale). Parents of each participant completed a demographic survey. The authors found similar self-determination levels in adolescents with NBPP to those of typically-developing adolescents; however, all adolescents rated their opportunities to engage in self-determined behaviors at school significantly lower than at home. Given the results of this study, one would require further assessment of opportunities at school to gauge if self-determination is a factor that is limiting for adolescents with neonatal brachial plexus palsy in a school setting.


This cross-sectional designed study compared femoral cartilage thickness via ultrasound measurement in 40 patients with diplegic cerebral palsy to 51 healthy controls. They found a significant difference in the mean cartilage thickness measurements of the medial condyle and intercondylar area of knees in the cerebral palsy group with those patients classified as GMFCS V having the thinnest cartilage in all measured areas. They also found a moderate negative correlation between age and thickness measurements that did not exist in the healthy group. These findings support routine surveillance, as well as consideration of joint health problems in the assessment of pain of unknown etiology in children with cerebral palsy.