Clinical Short Term Outcome of GuillainBarré Syndrome in ...
* Correspondence author;
Address: Division of Pediatric Neurology, Children’s Medical Center, 62 Gharib St, 14194 Tehran, IR Iran
Clinical Short Term Outcome of GuillainBarré
Syndrome in Children
Mahmoud Reza Ashrafi1, MD, Pediatric Neurologist; Setareh Sagheb 1, MD; Pediatrician;
Mahmood Mohammadi1, MD, Pediatric Neurologist; Anoushiravan Vakili, MD, Geneal Physician;
Abolfazl Nasirian1, MD, Neurologist; Gholam Reza Zamani1, MD, Pediatric Neurologist
1. Department of Pediatrics, Medical Sciences/University of Tehran, Iran
Received: 14/08/07; Revised: 01/11/07; Accepted: 04/12/07
Objective: Several factors are useful in predicting the prognosis of Guillain‐Barre syndrome
(GBS). The objective of this study was to determine the role of clinical presentation scaling to
predict patient's short‐term outcome.
Material & Methods: Forty five patients with the confirmed diagnosis of GBS, according to
international diagnostic criteria, were enrolled in this study. All children who were not able to
walk unaided (i.e., ordinal disability score=ODS ≥3) were treated with intravenous
immunoglobulin (IVIg) alone or with corticosteroid. The primary outcome measures were the
degree of disability at discharge, length of hospital stay, need to intensive care setting and
Findings: Male to female ratio was 1.05: 1 with mean age of 5.9 years. The most common
manifestation was limb weakness (71.1%). Absent or decreased deep tendon reflexes were
seen in 44% and 53.3% patients, respectively. All children experienced some degree of pain,
with moderate to severe intensity (pain faces score ≥3) in 91.2% patients. Cranial nerve
involvement was found in 46.7% children, most commonly as bulbar weakness (40%). Ten
(22.2%) patients were admitted in PICU, and ventilation support was needed for 2 (4.4%) of
them. Clinical response was regain of unaided walking (ODS≤2) which was achieved in 62.2%
patients. After treatment all patients developed significant improvement of functional disability
which was assessed by ODS and arm function scores. A higher ODS at presentation was
associated significantly with a longer hospital stay (P=0.03) and higher arm function score
(P<0.001). Absent tendon reflexes and cranial nerve involvement were associated with higher
functional scores, longer hospital stay and admission in PICU. Also, higher arm function scores
were associated significantly with intensive care unit admission (P=0.01).
Conclusion: These results indicate that the ODS and arm function scores can be applied as
prognostic factor for clinical short‐term outcome among GBS patients.
Key Words: Guillain‐Barré syndrome; Childhood; ODS; Functional disability; Arm Function
score; Pain scale
Iran J Pediatr
Mar 2008; Vol 18 ( No 1), Pp:11-19
12 Outcome of GuillainBarre Syndrome in Children. MR Ashrafi, et al
Guillain‐Barré syndrome (GBS) is an acute
characterized by symmetric ascending
weakness and spontaneous remission[1,2].It is
the most common cause of acute flaccid
paralysis in children which often leads to
respiratory and bulbar compromise[3,4]. The
incidence of the disease has been previously
reported to be between 0.4 to 0.6 / 100,000 in
western countries and 1.5 to 3.4 / 100,000 in
Based on clinical features and electro‐
diagnotic criteria GBS can be sub classified
into heterogeneous groups of syndromes such
as acute inflammatory demyelinating
polyradiculo‐neuropathy (AIDP), acute motor
axonal neuropathy (AMAN), acute motor‐
sensory axonal neuropathy (AMSAN) and
Miller‐Fisher syndrome (MFS). In European
and US studies the AIDP is the most prevalent
form with an incidence between 85% to 90%
of cases with GBS in spite of Asian studies
which report it about 53%[6‐9]. In 70–80 % of
cases an acute infection or vaccination is
reported to have occurred three to six weeks
prior to the neurological symptoms. This is
believed to give rise to an abnormal immune
stimulation that attacks peripheral nerve
tissue. The optimal treatment of GBS in
children based on its availability and similar
results to plasma exchange is intravenous
immunoglobulin (IVIg) in patients who are not
able to walk. Overall, it is believed that
childhood GBS has a more favorable course
and prognosis[11,12]. Different studies have
attempted to identify prognostic factors such
as age, rate of progression and need for
respiratory support with regard to a poor
outcome. However, most of the studies had
retrospective design and only few of them
were performed prospectively[13,14].
Neuropathic pain is commonly found
among GBS patients. Back, buttock and leg
pain have been reported in 32% to 67% of
cases[2,8]. Several studies have shown that
faces pain scales are easily understood by the
children and they are more useful compared
with other assessment tools. Functional
ability of patients at presentation or during
the study and its comparison after treatment
has been investigated frequently to assess the
role of different treatments. These tests
were rarely used as a prognostic factor to
predict the patient’s functional outcome, need
for ICU admission or length of hospital stay.
Moreover, there are limited epidemiological
data reported in Asian populations about
In this study, we prospectively evaluated
the clinical outcome of children with different
subtypes of GBS and their functional outcome
based on Ordinal Disability Scale (ODS), Arm
Function score and Pain Faces Scale (Smiley
Scale) to identify prognostic indicators along
with cerebro‐spinal fluid (CSF) findings and
Material & Methods
After obtaining approval from the Institutional
Ethics Committee and written informed
consent (conforming to the principles in the
Helsinki Declaration), patients, admitted in
Pediatric Neurology ward or Pediatric
Intensive Care Unit (PICU) of Children’s
Medical Center in Tehran, from October 2004
to November 2006 were recruited. Children
from the age of independent walking to 16
years were eligible. Inclusion and exclusion
criteria were based on the published
international research diagnostic criteria of
Asbury and Cornblath.
The GBS was clinically diagnosed by a
consultant neurologist. The clinical and
demographic characteristics, including age,
gender, preceding events, presentation at the
time of admission, cranial nerve palsy,
autonomic dysfunctions, muscle stretch reflex,
duration of hospital stay, and need for PICU
setting were recorded in a standardized chart.
All patients had at least one electro‐
physiological study at the acute period of
disease and CSF analysis. Nerve conduction
studies included motor nerve conduction
velocity (MNCV), sensory nerve conduction
velocity (SNCV), and F‐wave response studies
13Iran J Pediatr. Vol 18 (No1); Mar 2008
performed. Each value of MNCV, SNCV, and F‐
wave latency was compared with age‐matched
normal values. Needle electromyography
(EMG) was performed in all patients. The
clinical classification of the patients was based
on the electrophysiological criteria of Asbury
In addition to the general supportive
managements, specific therapy with IVIg (2
g/kg body weight for 2‐5 days) alone or in
combination with corticosteroid (30 mg/kg/
day intravenous methylprednisolone for 3‐5
days) were administered in case the patients
were not able to walk.
In all children the functional ability of the
patient during the course of the disease was
scored with ODS, arm function and pain score
(Fig 1). These scores were to be recorded
prospectively on a standardized form on a
daily schedule during the hospital stay or until
independent walking was regained and at
each outpatient appointment thereafter. The
scores of admission and discharge time were
recorded to compare functional ability.
Results were reported as the mean (standard
deviation) for quantitative variables and
percentages for categorical variables.
Univariate comparisons of nominal data were
performed with the χ2 and Fisher's exact tests,
and those of ordinal and numerical data were
performed with the Student’s t test, Mann‐
Whitney U test and Wilcoxon and Sign. Also,
analysis of regression was applied to evaluate
consistency of Ordinal Disability and arm
function scores. All statistical analyses were
performed by using program package SPSS,
version 13 (SPSS, Chicago, IL) and SAS version
9.1 for Windows.
During a period of 26 months, 45 children
including 23 (51.1%) males and 22 (48.9%)
females with the confirmed diagnosis of GBS
enrolled in this study. The mean age was 5.9
[3.6] years (range, 1‐15.5 years). The most
common preceding events of the GBS were
respiratory infections (28 cases, 62.2%),
followed by gastrointestinal infections (7
cases, 15.6%) and non‐specific fever (4 cases,
8.9%). In six other patients no triggering
factor was found. The interval between these
events and onset of disabilities ranged from 0
to 30 days [mean 12.6 (7.2) days]. The most
common presenting symptoms were limb
weakness and pain, that was seen in 32 (71.1
%) and 20 (44.4%) of cases respectively. The
average interval from onset to nadir was 4.3
(2.4) days (range, 1‐14 days). Deep tendon
reflexes (DTR) were reduced or could not be
detected in 24 (53.3%) and 20 (44%) patients,
Cranial nerve involvement was found in 21
(46.7%) children, most commonly as bulbar
weakness (gag reflex abnormalities), followed
by facial palsy in 7 (15.6%) patients and
ophthalmoplegia in 3 (6.7%) others. Only one
patient had sphincter dysfunction. Autonomic
dysfunctions were manifested as tachycardia,
orthostatic hypotension, pupil abnormality
and sweating disturbance in 8 (17.8%), 3
(6.7%), 1 (2.2%) and 2 (4.4%) cases,
Eight patients (17.8%) complained of other
sensory symptoms. During admission period
all children evaluated for pain and its intensity
with pain faces scale. All children experienced
0 1 2 3 4 5
Fig 1 The Pain Faces Scale based on Smiley scale;
0= Very happy, no hurt, 1= Hurts just a little bit, 2= Hurts a little more, 3= Hurts even more, 4= Hurts
a whole lot, 5= Hurts as much as you can imagine
14 Outcome of GuillainBarre Syndrome in Children. MR Ashrafi, et al
some degree of pain which was severe (score
4, 5) in 19 (42%), moderate (score 3) in 22
(48.8%) and mild (score: 2) in 4 (8.8%)
patients. With respect to the functional ability,
average of arm function score and ODS was
2.76 (range, 0‐6; median, 3) and 4.13 (range,
3‐6; median, 4), respectively (Table 1).
A lumbar puncture was performed in all
cases within two weeks of the onset of the
illness. The CSF protein concentration was
raised (>45 mg/dl) in 23 (51.1%) patients.
CSF pleocytosis was not found. According to
Table 1‐ Ordinal Disability, Pain Faces and Arm function scores
Scoring System At presentation At discharged
Ordinal Disability Score
1 Able to run
2 Able to walk 5 m unaided
3 Able to walk with aids
4 Not able to walk, able to lift legs
5 Not able to walk, not able to lift legs
6 Intubated, with artificial ventilation
Arm function score
1 Able to raise arms vertically above
head with extended elbows
2 Able to raise arms vertically above
head with flexed elbows
3 Not able to raise hands above head
but able to raise glass of water to mouth
4 Not able to raise glass of water to
mouth but able to raise hands to mouth
5 Not able to raise hands to mouth but
able to grasp small object
6 No functional use of hands
7 Complete paralysis of arms and hands
Pain Faces Scale
0 Very happy, no hurt
1 Hurts just a little bit
2 Hurts a little more
3 Hurts even more
4 Hurts a whole lot
5 Hurts as much as you can imagine
a P<0.0001, Wilcoxon and Sign tests comparing the functional scores of each
patients before and after treatment
b P<0.0001, Regression correlation analysis of functional scores (correlation
coeffiecents were 0.607 and 0.526, respectively)
15Iran J Pediatr. Vol 18 (No1); Mar 2008
Fig 2 Comparison of ordinal disability score before and after treatment
clinical and electrophysiological investigations
38 (84.4%) of cases were classified as AIDP, 4
(2.2%) as MFS and 1(2.2%) unclassified. Ten
(22.2%) patients were admitted in PICU, and
ventilation support was needed for 2 (0.05%)
of them. All patients received IVIG and 8 of
them received intravenous methyl‐
prednisolone, too. The length of hospital stay
ranged from 3 to 12 days [mean 6.81 (2.55)
The primary clinical response was
regaining unaided walking (Ordinal Disability
score ≤2) achieved in 28 (62.2%) patients. The
ODS was ranged from 1 to 4 points (mean
2.34, median 2) at discharge. Arm function
was monitored in 40 patients; its score was ≤2
points in all of them (range, 0‐2; median 1).
This score was impossible for assessment in
young children. After treatment, all patients
developed significant improvement of
functional disability which was assessed by
ODS and arm function scores (Table 1 and Fig
2, 3). One patient died due to respiratory
failure (death rate, 2.2%). At presentation, she
Fig 3 Comparison of arm function score before and after treatment
16 Outcome of GuillainBarre Syndrome in Children. MR Ashrafi, et al
had weakness, severe pain (Smiley score: 4),
tachycardia, cranial nerve palsy (II, VII, IX and
X) and absent DTR.
Data analysis showed that a higher ODS at
presentation is associated significantly with a
longer hospital stay (regression coefficient:
0.339, P=0.03), higher arm function score
(regression coefficient: 0.407, P<0.001). In
addition, patients with more severe pain
(higher Smiley scale) had higher ODS at final
assessment (regression coefficient: 0.315,
P=0.037). Higher functional arm score was
associated significantly with more weakness
(P=0.2), cranial nerve palsy (P=0.01) and DTR
decrement (P=0.004). In addition, these
functional ability scales had consistent results
(Table 1). Absent DTR and cranial nerve palsy
were associated with higher functional scores,
longer hospital stay and admission in PICU
(Table 2). Also, arm function scores at
presentation and discharge was found to be
higher in patients who needed an intensive
care setting (medians 4 and 2 versus 3 and 1
for patients without need to intensive care
setting, P=0.01). Other characteristics such as
age, gender, preceding events, time to
progression of GBS, clinical symptoms, GBS
subtype, and treatment options had no
association with clinical outcome (functional
ability, length of hospital stay and need for
In this study we have investigated the initial
symptoms and the clinical course of GBS
treated with IVIg. Although the incidence of
Guillain‐Barré syndrome has been increased
in Europe and North America during recent
decades in adult group over 40 years of age,
GBS is a disease affecting mainly the younger
age groups of children[18‐20]. However, this
high frequency in children was found only in
AIDP form. In our series of 45 pediatric
populations, 84.4% had clinical and
electrophysiological findings suggesting AIDP
which is concordant with previous studies.
MFS and axonal neuropathy were also
diagnosed in 2.2% and 11.1% of patients,
respectively. Apparently, few cases of
Table 2 Association between patient’s characteristics and clinical outcome
Gag reflex Tendon Reflex
Yes No DecreaseAbsence decrease Normal Yes No
score at presentation
5 4 4 4.5 4 3 4.5a 4
score at discharge
3a 2 2 2 2 1 3a 2
Arm function score
4a 2 3 4 2 1 4a 2
Arm function score
2a 1 1 1a 1 1 2a 1
LOS (median) 5 10 7 6.5a 7 4 7a 5
LOS: Length of hospital stay
a P<0.05, comparing outcome by clinical sings
17Iran J Pediatr. Vol 18 (No1); Mar 2008
pediatric GBS present as MFS form of ataxia,
ophthalmoplegia and arefleixa. Electro‐
physiological classifi‐cation of the GBS
subtypes varied in different studies. A recent
study showed the AIDP, AMAN and
unclassified forms as 35%, 48% and 16%,
respectively; while most other studies
reported the AIDP form as the mainly
diagnosed one. Male to female ratio was
similar to previous reports[13,18]. In this
population, clinical manifestations were
concordant to previous studies.
The majority of patients presented with
limb weakness, which developed in more than
90% of cases during follow‐up. Overall
estimates of pain as an early symptom of GBS
have been reported in 32% to 67% of
cases[2,8]. In this study 42% of our patients
experienced severe pain but some degree of
pain reported in all of them evaluated with
Pain Faces Scale[15,24]. This finding might be
due to use of more sensitive and accurate
method for measurement of pain in children.
During of the disease and follow up period, the
severity of pain associated significantly with
the severity of motor involvement, indicating a
shared involvement of motor and sensory
nerve fibers. As a consequence, not only the
ascending pareses and imminent respiratory
insufficiency must be regarded as important
aspects in the management of a child with
GBS, the problem of pain must also be
anticipated and treated properly.
Apart from clinical symptoms, the finding of
CSF albumin protein dissociation is one of the
most important diagnostic features in GBS.
In our group of patients, when patients
underwent lumbar puncture within two
weeks after initiation of the first symptoms,
half of the patients showed significantly
elevated CSF protein. Other studies reported
that the protein elevation depends on the date
of lumbar puncture from 100 to 60% of the
patients[26,27]. Although GBS is often a self‐
limiting illness, it can be associated with
severe morbidity and even mortality in few
cases. The results of retrospective studies
revealed that IVIG shortened the time to first
improvement and to regain independent
walking[3,4,29,31]. In our study, a standard IVIG
therapy was applied on admission for all
patients being able to walk with aids.
However, frequently the clinical course of
childhood GBS is less severe than that of GBS
among adults and usually recovery is
Outcome of GBS is quite good with an
excellent functional recovery. Many factors
associated with poor outcome are reported in
the clinical studies. These factors are
advanced age, progressive course and severity
of the illness, the presence of other serious
medical disorders and primary axono‐
pathy[28,31]. In this study, abnormal gag reflex
or other cranial nerve palsies and absent DTR
were associated significantly with longer
hospital stay and PICU admission. Also,
patients with cranial nerve palsy, especially
gag reflex abnormality had significantly higher
Ordinal Disability and arm function scores.
There were no significant relationship
between age, gender, preceding illnesses,
clinical symptoms, and duration of
progression,electrophysiological findings and
therapeutic regimes and clinical
outcome(functional ability,length of hospital
stay and need to ventilation support).
In contrast to what has been reported
previously in adults, in this study no
significant relation between any neuro‐
physiologic findings and the severity of
symptoms, or the later course and prognosis
Ventilation support is needed in about 10‐
20% of the patients; but respiratory failure
does not predict a persisting deficit. Mortality
is low in childhood GBS, the death rate varies
among different series, ranging up to
13%[14,33]. In this study it was estimated to be
5% in an intensive care setting. Although not
significant statistically the deaths seem to
occur more often in the older age group. About
25% of deaths occur during the first week and
about 50% during the first month. Cardiac
arrest as a result of autonomic dysfunction is
the commonest cause of death and accounts
for about 20–30% of deaths. Other causes of
death include chest infection, pulmonary
embolism, and respiratory failure[2,33‐35]. In
our study, only 4.4% cases needed ventilation
18 Outcome of GuillainBarre Syndrome in Children. MR Ashrafi, et al
support, one of these children died due to
respiratory failure under ventilator (death
Our study provides further information on the
extent to which abnormal neurological
features impact on the final disability and
hospital care setting in comparison with other
variables. The Ordinal Disability and arm
function scores at the onset of the disease had
significant prognostic value factor for clinical
short‐term outcome in our patients.
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