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Pediatric BTX-A Therapy
Management of Spasticity with Botulinum Toxin Type A
05 November 2004
| SUGGESTED PEDIATRIC BOTOX® DOSING |
| Clinical Pattern |
Potential Muscles Involved |
Botox® Dose*
Units/Visit |
Number of
Injection Sites |
| Upper Limbs |
| Adducted/Internally
Rotated Shoulder |
pectoralis complex |
2 |
2-3 |
| latissimus dorsi |
2 |
2 |
| teres major |
2 |
1-2 |
| subscapularis |
1-2 |
1-2 |
| Flexed Elbow |
brachioradialis |
1 |
1 |
| biceps |
2 |
2-3 |
| brachialis |
2 |
1-2 |
| Pronated Forearm |
pronator quadratus |
0.5-1 |
1 |
| pronator teres |
1 |
1 |
| Flexed Wrist |
flexor carpi radialis |
1-2 |
1 |
| flexor carpi ulnaris |
1-2 |
1 |
| Thumb-in-Palm |
flexor pollicis longus |
0.5-1 |
1 |
| adductor pollicis |
0.5-1 |
1 |
| flexor pollicis brevis/opponens |
0.5-1 |
1 |
| Clenched Fist |
flexor digitorum profundus |
1-2 |
1-2 |
| flexor digitorum superficialis |
1-2 |
1-2 |
| Intrinsic Plus Hand |
lumbricales/interossei |
0.5-1 |
1 |
| Lower Limbs |
| Flexed Hip |
iliacus |
1-2 |
1 |
| psoas |
|
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| rectus femoris |
3 |
2 |
| Flexed Knee |
medial hamstrings |
3-6 |
3-4 |
gastrocnemius
(as knee flexor) |
3-6 |
2-4 |
| lateral hamstrings |
2-3 |
1-2 |
| Adducted Thighs |
adductor longus/brevis/magnus |
3-6 |
1-2 |
| Stiff (Extended) Knee |
quadriceps mechanism |
3-6 |
4 |
| Equinovarus Foot |
gastrocnemius medial/lateral |
3-6 |
1-2 |
| soleus |
2-3 |
1-2 |
| tibialis posterior |
1-2 |
1 |
| tibialis anterior |
1-3 |
1 |
| flexor digitorum longus/brevis |
1-2 |
1 |
| flexor hallucis longus |
1-2 |
1 |
| Striatal Toe |
extensor hallucis longus |
1-2 |
1 |
*Adult dosing
recommendations should be substituted for children heavier than 60 kg
| DOSING GUIDELINES FOR CHILDREN |
| Total maximum body dose per visit = lesser of
12 Units per kg or 400 Units |
| Maximum dose per large muscle per visit = 3-6
Units per kg |
| Maximum dose per small muscle per visit = 1-2
Units per kg |
| Maximum dose per injection site = 50 Units |
| Maximum volume per site=0.5 mL, except in
select situations |
| Reinjection >3 months |
Dosing recommendations are based on the consensus opinion of the
Spasticity Study Group. For further discussion, see Mayer NH, Simpson DM,
editors. Spasticity, Etiology, Evaluation, Management, and the Role of
Botulinum Toxin Type A. New York: WE MOVE 2001
| DOSE MODIFIERS |
| CLINICAL SITUATION |
DOSE PER MUSCLE |
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A Decrease in Dose May Be
Indicated if: |
An Increase in Dose May Be
Indicated if: |
| Patient weight |
Low |
High |
| Likely duration of therapy |
Chronic |
Acute |
| Muscle bulk |
Very small |
Very large |
| Number of muscles being injected
simultaneously |
Many |
Few |
| Ashworth score |
Low |
Very High |
| Concern that treatment may result in
excess weakness |
High |
Low |
| Results of previous therapy |
Too much weakness |
Inadequate response |
| KEY POINTS |
| BTX-A rarely causes complications or
significant adverse effects in the pediatric patient |
| Children may benefit from anxiolytics and/or
topical anesthetics before injection |
| Meaningful assessment of treatment outcome
depends on careful definition of objectives beforehand |
| The effects of BTX-A are seen within several
days and last on average for 3-4 months |
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