Consensus recommendations for botulinum toxin injections in the spasticity management of children with cerebral palsy during COVID-19 outbreak

Ebru Yılmaz Yalçinkaya ,Afitap İçağasıoğlu ,Nalan Çapan,Resa Aydın ,Birkan Sonel Tur,Canan Tıkız ,Ece Ünlü Akyüz,Demet Ofluoğlu,Süda Tekin ,Melek Sezgin ,Kadriye Öneş,Murat Zinnuroğlu ,Özden Özyemişçi Taşkıran ,Evrim Karadağ Saygı ,Şehim Kutlay,Özlem El,Sibel Çağlar,Tuğçe Özekli Mısırlıoğlu ,Hakan Nur,Pınar Akpinar ,Berrin Hüner

doi:10.3906/sag-2009-5

Abstract

Spasticity is the most common motor disturbance in cerebral palsy (CP). Lockdown in the COVID-19 outbreak has profoundly changed daily routines, and similarly caused the suspension of spasticity treatment plans. Besides, the delay in botulinum toxin (BoNT) injection, which is important in the management of focal spasticity, led to some problems in children. This consensus report includes BoNT injection recommendations in the management of spasticity during the COVID-19 pandemic in children with CP. In order to develop the consensus report, physical medicine and rehabilitation (PMR) specialists experienced in the field of pediatric rehabilitation and BoNT injections were invited by Pediatric Rehabilitation Association. Items were prepared and adapted to the Delphi technique by PMR specialists. Then they were asked to the physicians experienced in BoNT injections (PMR specialist, pediatric orthopedists, and pediatric neurologists) or COVID-19 (pediatric infectious disease, adult infectious disease). In conclusion, the experts agree that conservative management approaches for spasticity may be the initial steps before BoNT injections. BoNT injections can be administered to children with CP with appropriate indications and with necessary precautions during the pandemic.

Highlights

Spasticity affects up to 80% of children with cerebral palsy (CP) [1]
Close follow-up is vital in botulinum toxin (BoNT) injections, one of the first-line treatments in focal spasticity; attention must be paid to the selection of the correct muscle and the need for repeated injections within 3–6 months [4]
The experts agree that BoNT injections can be postponed if there is no deterioration of functional status and other antispasticity strategies may be more appropriate before BoNT injections, especially in children with severe comorbidities

Summary

Introduction

Close follow-up is vital in BoNT injections, one of the first-line treatments in focal spasticity; attention must be paid to the selection of the correct muscle and the need for repeated injections within 3–6 months [4]. The immune system is not mature, and it makes the pediatric patients susceptible to upper respiratory tract infections. COVID-19 is a kind of upper respiratory tract infection at least at the beginning of the disease, the lower prevalence of COVID-19 in children is confusing [6]. They can be asymptomatic or present with most commonly fever and cough (42%). Sore throat, sputum, upper airway infections, pharyngeal erythema, tachycardia, tachypnea, pneumonia, respiratory distress, and hypoxemia are other manifestations [9]

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