35 Repeated onabotulinum neurotoxin A injections for drooling in children with neurodisability 1 third injection. Lastly, our definition of clinical success is defined by at least 50% decrease in the drooling quotient or VAS, which may result in limitations because of its dichotomous nature.30 Conclusion Onabotulinum neurotoxin A remained effective throughout the entire treatment course and induced lower baseline levels as well. However, this study reveals a reduced subjective and objective effect of subsequent injections compared to the first onabotulinum neurotoxin A injection and, as such, there is possibly a limit to the effect of repeated onabotulinum neurotoxin A for the treatment of drooling in children with neurodisabilities. This reduction may be (partially) explained by NAb or compensational salivation by alternative glands. Importantly, although there might be a loss of effect after repeated injections, there is continued improvement in a vast degree of the children. Future prospective research should further evaluate the precise clinical role of NAb and compensational salivation after repeated onabotulinum neurotoxin A injections for the treatment of drooling. Acknowledgements Peter Jongerius performed most of the botulinum neurotoxin injections. We want to thank Corrie E Erasmus, Marloes Lagarde, and Sandra de Groot for their contribution in patient care. This study and its analysis were subsidized by Johanna Kinderfonds, Arnhem, the Netherlands, Phelps Stichting voor spastici, Bussum, the Netherlands, and Stichting Rotterdams Kinderrevalidatie Fonds Adriaanstichting, Rotterdam, the Netherlands. All authors report no conflict of interest. None of the authors reported financial disclosures. Data availability statement The protocol, anonymized demographics, and data regarding study outcomes will be shared on request from any qualified investigator.
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