Management

General measures

• Muscle spasm is commonly associated with neurodegenerative disorders, and also with prolonged periods of bed-rest or inactivity
• Early involvement of a physiotherapist is invaluable for advice on moving, handling, positioning and seating, and is essential to prevent the problem worsening
• Massage may be useful and also allows the family to join in care in a practical way, and to have ‘hands on’ time with their child
• Discussion with a paediatric neurologist may be helpful
• Long standing contractures in a child with a relatively long prognosis can inhibit daily caring and may be managed surgically or with botulinum toxin injection. This should be assessed by an orthopedic surgeon
• It is important to distinguish between muscle spasm and spasticity, both of which would require specialist neurological management.

Medication

Baclofen

Form

Tablet: 10mg. Liquid: 5mg in 5mL
(Also available as intrathecal injection for specialist use see below)

Dose (oral)

Initial dose for child under 18 years: 300µg/kg/day in 4 divided doses (maximum single dose 2.5mg) increased gradually at weekly intervals to a usual maintenance dose of 0.75-2mg/kg/day in divided doses with the following maximum daily doses:

Child up to 8 years: maximum total daily dose 40mg/day,
Child 8-18 years: maximum total daily dose 60mg/day.

Review treatment if no benefit within 6 weeks.

Baclofen can also be used intrathecally as a continuous infusion into the lumbar intrathecal space via an indwelling catheter and infusion pump. The rate of infusion can be altered according to the child’s clinical needs at different times of day and is controlled by a computer. This is available at a limited number of centres some of which will provide an outreach service to other areas.

Contraindications and warnings: May cause drowsiness and increased hypotonia. Avoid rapid withdrawal. Use with caution in epilepsy. Risk of toxicity in renal impairment. See other texts for interactions.

Licence: licensed for oral use in children >1year.

Midazolam

Form

Injection: 10mg in 2mL; 10mg in 5mL
Injection may be diluted if required, in sodium chloride 0.9% or glucose 5%. Injection can be used for buccal, intranasal, oral or rectal administration.
Oral syrup and Buccal liquid. Epistatus® is a sweetened, sugar free midazolam formulation containing 10mg/mL; it is packed in 5mL bottles with 4 x 1mL oral syringes and instructions for use.)

Single dose: Intravenous/subcutaneous:
>1month -18yr: 100µg/kg

Buccal

>1month -18yr: 200-500µg/kg (max. 10mg) Epistatus®: The dose for children over 10 years is 10mg, as 10mg/mL liquid (contains midazolam maleate equivalent to midazolam base 10mg per 1mL).

Diazepam

Form

Tablets: 2mg, 5mg, 10mg
Oral solution: 2mg in 5ml and 5mg in 5mL
Injection (solution and emulsion): 5mg in 1mL
Suppositories: 10mg
Rectal tubes: 2mg in 1mL: 2.5mg tube, 5mg tube, 10mg tube

Dose (oral)

1–12 months, initially 250µg/kg twice a day
1–5 years, initially 2.5mg twice a day
5–12 years, initially 5mg twice a day
12–18 years, initially 10mg twice a day, max. 40mg/24hr.

May cause sedation.

Licence: tablets and liquid licensed for use in cerebral spasticity and control of muscle spasm in tetanus.

Ibuprofen

Form

Tablet (immediate release): 200mg, 400mg, 600mg
Tablet (slow release): 800mg
Capsule (modified release): 300mg
Liquid: 100mg/5mL
Granules: 600mg/sachet

Dose (oral)

Neonate: 5mg/kg/dose every 12 hours
Child 1–3 months: 5mg/kg 3–4 times daily preferably after food,
Child 3–6 months: 50mg 3 times daily preferably after food; in severe conditions up to 30mg/kg daily in 3–4 divided doses,
Child 6 months–1 year: 50mg 3–4 times daily preferably after food; in severe conditions up to 30mg/kg daily in 3–4 divided doses,
Child 1-4 years: 100mg 3 times daily preferably after food. In severe conditions up to 30mg/kg daily in 3–4 divided doses,
Child 4–7 years: 150mg 3 times daily, preferably after food. In severe conditions, up to 30mg/kg daily in 3–4 divided doses.
Child 7–10 years: 200mg 3 times daily, preferably after food. In severe conditions, up to 30mg/kg daily in 3–4 divided doses. Maximum daily dose 2.4 g,
Child 10–12 years: 300mg 3 times daily, preferably after food. In severe conditions, up to 30mg/kg daily in 3–4 divided doses. Maximum daily dose 2.4 g,
Child 12-18 years: 300-400mg 3-4 times daily preferably after food. In severe conditions the dose may be increased to a maximum of 2.4g/day.

Cautions: avoid if peptic ulcer or history of; risk of gastrointestinal bleeding (ibuprofen is considered safer than other NSAIDs); avoid if hypersensitivity to other NSAIDS or aspirin. Caution in renal, cardiac or hepatic impairment and asthma. Will cause closure of ductus arteriosus; contraindicated in duct dependent congenital heart disease.

Licence: Granules and 800mg tablet not licensed for children. Not licensed for use in children under 3 months of age or weight less than 5kg.

Dantrolene

Form

Capsules: 25mg, 100mg

Dose (Oral)

The dose of dantrolene should be built up slowly

Child 5–12 years: initial dose of 500µg/kg once daily; after 7 days increase to 500 µg/kg/dose 3 times daily. Every 7 days increase by a further 500 µg/kg/dose until response. Maximum recommended dose is 2mg/kg 3–4 times daily (maximum total daily dose 400mg),
Child 12–18 years: initial dose of 25mg once daily; after 7 days increase to 25mg 3 times daily. Every 7 days increase by a further 500µg/kg/ dose until response. Maximum recommended dose is 2mg/kg 3–4 times daily (maximum total daily dose 400mg).

Contraindications and warnings: Hepatic impairment.

Caution with cardiovascular/respiratory disease. Monitor liver function tests.

Licence: not licensed for this indication in children.

Tizanidine

Form

Tablets: 2mg, 4mg

Dose (oral)

(Usually prescribed and titrated by neurologists)

Child 18 months – 7 years: 1mg/day; increase if necessary according to response,
Child 7 -12 years: 2mg/day; increase if necessary according to response,
Child >12 years: as per adult dose: Initially 2mg increasing in increments of 2mg at intervals of 3–4 days. Give total daily dose in divided doses up to 3–4 times daily. Usual total daily dose 24mg. Maximum total daily dose
36mg.

Licence: not licensed for use in children.

Chloral Hydrate

Is not a specific treatment for spasm but may be helpful in breaking the spasm-pain-anxiety cycle.

Form

Oral Solution: chloral mixture BP; 500mg in 5mL
Chloral elixir paediatric BP 200mg in 5mL, extemporaneously prepared.
Syrup: 500mg in 5mL available as ‘special’
Suppositories; 25mg, 50mg, 100mg, 250mg, 750mg.

Dose (oral/rectal)

Neonate: initial dose of 30mg/kg as a single dose at night. May be increased to 45mg/kg at night or when required,
Child 1 month–12 years: initial dose of 30mg/kg as a single dose at night. May be increased to 50mg/kg at night or when required . Maximum single dose 1g,
Child 12–18 years: initial dose of 500mg as a single dose at night or when required. Dose may be increased if necessary to 1-2g. Maximum single dose 2g.

Contraindications and warnings: Avoid in liver disease and severe renal failure. Caution in cardiac disease, respiratory insufficiency, and gastritis, Avoid prolonged course and abrupt withdrawal.

Licence: unlicensed in children.