IGF1 and Hypsarrhythmia: 1) The small non-hypsarrhythmia subgroup (n = 7) limits the study’s generalizability; 2) The lack of longitudinal IGF-1 profiling prevents accurate correlation between peak IGF-1 levels and spasm control timing; 3) Uncontrolled confounders including variations in birth weight and differences in treatment initiation timing; 4) Parental reports of spasm resolution may contain reporting bias.