With the expanding uses of Botox in medicine, including migraines, the number of patients affected by rare complications is also increasing. Doctors may treat their younger cerebral palsy and dystonia patients with this wonder-drug, but once in a while something goes wrong and the child has an unexpected reaction. When these rare side effects occur, the child may have trouble breathing and swallowing, both potentially life-threatening, making an antidote crucial. Although the official Botox antidote may not be readily available, researchers have discovered a new treatment for botulinum toxin side effects in pediatric patients: pyridostigmine.

Treating Children with Botox

When most people think Botox, they think wrinkles, but this neurotoxin treats a variety of medical conditions. Originally a treatment for eye muscle disorders, this versatile drug moved on to other medical disorders including cervical dystonia, upper motor neuron syndromes such as cerebral palsy, urinary incontinence related to a neurologic condition, hyperhidrosis with its excess underarm sweat, and more recently, chronic migraine. Officially, botulinum toxins such as Botox and Dysport are approved in children over twelve to treat the eye muscle spasms of blepharospasm and crossed eyes of strabismus, or leg muscle spasms related to cerebral palsy in children over two, but doctors use these injections off-label to treat a variety of muscle disorders in pediatric patients.

Migraines are one example. Although officially the drug is approved for use in adults, a recent study looked at using Botox injections to help children and adolescents with chronic migraine. Although the study was small, it included patients aged eight to seventeen with migraines from a couple times a week to almost every day of the month. For some children in the study, this chronic headache had a devastating effect: one young lady, for example, spent time in the hospital every month with her debilitating pain and was facing failing a grade in school.

Children have few migraine treatment options, faced with adult-treatment side effects including drowsiness, confusion, and dry mouth. Luckily, the study showed promising results. After a Botox injection in the front and back of their head and neck every three months, the number of migraine days each patient faced dropped to between two and ten. Their migraines seemed to last seven hours at most, and their patient-reported pain dropped considerably. Although the study was small, with only nine children participating, the results were encouraging. Botulinum toxin injections may just be a viable migraine treatment in children.

When Side Effects Happen

With the many on and off-label uses of Botox, even the rare side effects are bound to happen sooner or later. Most patients experience only mild, injection-related side effects, but once in a while, the neurotoxin can travel through nerves to other nearby or distant muscles. This muscle paralysis can become life-threatening if the patient’s throat muscles become paralyzed, causing them to have difficulty breathing or swallowing, but early treatment can help prevent a bad situation from becoming worse. There is an official botulinum toxin antidote but this substance is not usually on hand and can be difficult to get in a hurry, and not only that, it may take several days for the drug to take effect. A quicker, and more accessible, antidote could mean the difference between life and death.

In a recent study, physicians at the Medical University of South Carolina reported cases of rare botulinum toxin complications. In one case, a toddler had difficulty swallowing, with a history of aspiration pneumonia from food and saliva entering the lungs. To alleviate this problem, doctors injected botulinum toxin into her cricopharyngeus muscle to help it relax and allow food to pass into her esophagus. Unfortunately, the muscle-relaxing effects of the injection quickly spread, preventing the pharyngeal constrictor muscles from contracting, rendering them unable to push food toward the esophagus. The young girl was unable to swallow and entered the hospital with choking, vomiting, and difficulty breathing.

In another case, an eight-year-old girl repeated a previously successful botulinum toxin treatment for excess salivation. This time, a week after the salivary gland injection, she entered the hospital unable to eat or drink without choking.

A New Cure for Botox Side Effects

In both cases, doctors felt the need to act quickly to help their young patients. Without the Botox antidote readily available, they turned to pyridostigmine, a common myasthenia gravis medication. Myasthenia gravis causes muscle weakness, and pyridostigmine helps by preventing acetylcholine breakdown. Although the treatment is generally safe for adults, patients with a history of heart problems may experience a slowed heart rate, and there are no previously-reported cases of doctors using this drug to treat botulinum toxin complications in pediatric patients.

Botulinum toxins, such as Botox and Dysport, work by blocking the release of acetylcholine from nerves. When they are unable to release this chemical messenger, the nerves are unable to signal the muscle to contract, and the muscles then relax. Although pyridostigmine is not a Botox antidote, it can counteract its effects. Pyridostigmine helps prevent the acetylcholine from breaking down, so this messenger is still able to tell the muscles to contract. Instead of throat muscles being paralyzed, the doctors thought, the swallowing actions may return to normal after a dose of myasthenia gravis drug.

The treatments seem to have been a success. In the toddler’s case, she was breathing normally two days after her pyridostigmine treatment, and a month later, she was continuing to improve, with no signs of aspiration. Six months after her initial botulinum toxin injection, the girl was free of her gastronomy tube, a definite plus for her quality of life.

As for the eight-year-old, the pyridostigmine also seemed to send her on her way to a quick recovery. With rapid improvement, the young lady was able to eat normally only a week after her botulinum toxin injection. Thanks to her quick-thinking physicians, the girl got back to her usual self quite quickly.

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What This Means for Botox Treatments

There are two main takeaways from this pyridostigmine study. First, although major Botox side effects are rare, they do happen, especially in children and adults who already have trouble swallowing and breathing. The side effects may not occur immediately, and they may occur far from the original injection site, but it is important for physicians to be alert to any potential problems. Second, the study offers a potential new treatment to counteract these side effects. Although the Botox antidote may not be readily available, pyridostigmine may be a viable alternative. This is just a small case study, but it shows promise for children and adults facing botulinum toxin complications.

If you use botulinum toxins to treat migraine, dystonia, or of course wrinkles, you can learn more about Dysport, Botox, and more at Medical Spa RX.