Intrasalivary gland injection of botulinum toxin type A is known to treat sialorrhea effectively in children with cerebral palsy. However, oral health may be compromised with escalating dose. In this randomized, double-blind, and placebo-controlled pilot trial, the authors aim to determine the therapeutic effect of low-dose, ultrasonography-controlled botulinum toxin type A injection to bilateral parotid and submandibular glands on oral health in the management of sialorrhea. Twenty children diagnosed with cerebral palsy were randomly assigned to 2 groups. The treatment group received botulinum toxin type A injections, whereas the control received normal saline in the same locations. The authors evaluated subjective drooling scales, salivary flow rate, and oral health (salivary compositions and cariogenic bacterial counts). A significant decrease was found in salivary flow rate at the 1- and 3-month follow-up in the botulinum toxin-treated group. The authors suggest that current protocol can effectively manage sialorrhea while maintaining oral health.

METHOD We examined 56 children with spastic CP (10 diplegia, 12 hemiplegia and 34 quadriplegia) aged 4 to 12 years (35 males, 21 females) and 29 typically developing children. Children with CP were stratified into three groups based on Gross Motor Function Classification System (GMFCS) levels I to II (n=22), III (n=8), and IV to V (n=26). Growth and clinical variables, bone markers, distal femur and lumbar areal bone mineral density (BMDa), and calcaneal broadband ultrasound attenuation (BUA) were assessed. RESULTSThe femur BMDa and calcaneal BUA values were lower in children in low GMFCS levels than in children in high GMFCS levels (p<0.05; femur BMDa: levels I-III, 0.6-0.7g ⁄ cm 2 ; levels IV-V, 0.5g ⁄ cm 2 ; calcaneal BUA: levels I-II, 39db ⁄ MHz; levels III-V, 20-21db ⁄ MHz). Lumbar BMDa and most bone markers did not differ significantly among CP and healthy groups. Regression analysis revealed that growth variables and GMFCS level were mainly associated with lower limb BMDa and BUA, and growth variables were mainly associated with lumbar BMDa (adjusted r 2 =0.48-0.56). None of the bone markers were associated with bone density.INTERPRETATION Bone densities vary and are associated with a number of factors in different skeletal regions in children with CP with a range of motor severities.

These results suggest the muscle strength, especially antigravity muscle strength, were more associated with the bone density of ambulatory children with CP than motor function. The data may allow clinicians for early identifying the ambulatory CP children of potential low bone density.

We investigated anthropometric and fitness variables associated with areal bone mineral densities and broadband ultrasound attenuation in ambulatory children with cerebral palsy. Thirty-four children with cerebral palsy, aged 4-12 years, and 33 normal development children were collected. There were significant differences in femoral bone densities and calcaneus broadband ultrasound attenuation, but not in lumbar bone densities, between cerebral palsy and normal groups. Regression analysis revealed that different anthropometric and fitness variables were linked to bone densities of different skeletal regions in children with cerebral palsy (adjusted r(2) = .41-.67). Growth variables were mainly related to femoral and lumbar bone densities, while muscular endurance was mainly related to femoral and calcaneus bone densities. These findings suggest multiple complex variables can contribute to bone density variations among different skeleton areas in these children. These data can allow clinicians to identifying early these children at risk for low bone density.

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