title: Safety and tolerability of theta burst stimulation vs. single and paired pulse transcranial magnetic stimulation: a comparative study of 165 pediatric subjects.
abstract: BACKGROUND
  Although single- and paired-pulse (sp/pp) transcranial magnetic stimulation (TMS) studies are considered minimal risk in adults and children, the safety profile for theta-burst TMS (TBS) is unknown.
  
  
  OBJECTIVE
  In this comparative analysis, we explored the rate, severity, and specific symptoms of TMS-related adverse effects (AEs) between sp/ppTMS and TBS in subjects between ages 6 and 18 years.
  
  
  METHODS
  Data from 165 participants from 2009 to 2014 were analyzed. Assessment of AEs was performed based on baseline and post-TMS administration of a symptom-based questionnaire that rated AEs on a 5-level ordinal scale (minimal, mild, moderate, marked, severe). AE rates and severity were compared using Chi Square or Fisher's Exact Test depending on data characteristics.
  
  
  RESULTS
  Overall, no seizures or severe-rated AEs were reported by 165 pediatric participants. The rate of AE in all TBS sessions was 10.5% (n = 76, 95% CI: 4.7-19.7%), whereas the rate of AE in all sp/ppTMS sessions was 12.4% (n = 89, 95% CI: 6.3-21.0%). There was no statistical difference in AE rates between TBS and sp/ppTMS (p = 0.71). In all sp/ppTMS and TBS sessions, 20 subjects reported a total of 35 AEs, among these 31 (~88.6%) were rated as "minimal" or "mild". There was no difference in the severity of AE between TBS and sp/ppTMS (p = 1.0). Only one of 76 TBS participants reported an AE rated as more than minimal/mild.
  
  
  CONCLUSIONS
  Our comparative analysis showed that TBS appears to be as safe as sp/ppTMS in terms of AE rate and severity. This report supports further investigation of TBS in children.
authors.affiliation: College of Medicine, University of Cincinnati Cincinnati, OH, USA.
authors.forename: Yaejee H
authors.initials: YH
authors.lastname: Hong
authors.affiliation: Division of Neurology, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA.
authors.forename: Steve W
authors.initials: SW
authors.lastname: Wu
authors.affiliation: Division of Neurology, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA ; Division of Psychiatry, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA.
authors.forename: Ernest V
authors.initials: EV
authors.lastname: Pedapati
authors.affiliation: Division of Neurology, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Horn
authors.affiliation: Division of Neurology, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Huddleston
authors.affiliation: Division of Psychiatry, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA.
authors.forename: Cameron S
authors.initials: CS
authors.lastname: Laue
authors.affiliation: Division of Neurology, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA.
authors.forename: Donald L
authors.initials: DL
authors.lastname: Gilbert
keywords: children; repetitive transcranial magnetic stimulation; safety; theta burst stimulation; transcranial magnetic stimulation; youth