Botulinum toxin and cerebral palsy: time for reflection?

Botulinum toxin A (BTX-A) is increasingly being used in early management of spasticity in ambulant children with cerebral palsy (CP), with the aim of improving function, promoting muscle growth, and delaying the need for surgical intervention. However, there is a lack of evidence about the long-term outcome of BTX-A injections. The focus on spasticity as the predominant problem in younger children with spastic CP may not fully consider the associated muscle weakness. It also raises concern that although BTX-A may improve function in the short term, it has the potential to affect muscle growth and function adversely in the long term. A cautious approach to the early use of BTX-A, with the use of objective outcome measures within a specialized multidisciplinary setting, is recommended, particularly in ambulant children with spastic diplegic CP, until further evidence is available on the long-term outcome of early BTX-A injections in children with CP.