National Collaborating Centre for Women's and Children's Health

Spasticity in children and young people with non-progressive brain disorders
use of the term ‘consider’ (rather than ‘offer’) and through specific advice about which drugs should be
used, and how and when they should be introduced, monitored for effectiveness and discontinued.
The GDG noted that oral benzodiazepines (especially diazepam) are frequently used in the
management of spasticity in children and young people. All available trial evidence within this class
was in relation to diazepam. Although the evidence of effectiveness was limited, the comparative
prominence of diazepam over other benzodiazepines in the available literature reflected the group’s
clinical experience in terms of both its common usage and their positive experiences of using the drug
to treat spasticity that was contributing to discomfort or pain, muscle spasms and functional disability.
As such the GDG believed that diazepam should be the recommended benzodiazepine of choice.
Equally, although the evidence of effectiveness of oral baclofen was limited, the GDG considered that
its prominence in the available literature reflected current good practice and positive clinical
experience for the same clinical indications as diazepam. The group therefore considered it was also
appropriate to recommend baclofen.
Although the GDG considered that the clinical indications for considering diazepam and baclofen
overlapped, the group noted that diazepam was likely to have a more rapid onset of action than
baclofen. The group concluded, therefore, that diazepam would be particularly useful in a situation
where rapid onset of action would be beneficial, such as in a severe pain crisis. However, if the goal
was to achieve a sustained long-term effect from oral drug treatment then baclofen would be
preferred. This was because the GDG was concerned about the possibility of adverse consequences
from long-term administration of a benzodiazepine such as diazepam.
The GDG consensus was that a rational approach to the use of oral drugs would be to introduce them
gradually with a stepwise increase in dosage aimed at optimising therapeutic benefit while minimising
the risk of adverse effects such as excessive sedation. The trial evidence relating to baclofen reported
benefits associated with this approach.
The GDG view was that if oral diazepam was offered as treatment, this should begin as a bed-time
dose. If necessary the dose could be increased stepwise and/or a daytime dose added. This was
considered a particularly safe approach as it was the equivalent of giving one of the two divided doses
recommended in the SPCs. This, in turn, reflected the reduced dosages reported in the evidence
considered in the guideline review.
When using oral baclofen, again the group considered it advisable to begin with a low dose and
increase it in steps over 4 weeks. The GDG’s view was that this was the appropriate time period in
which to achieve the intended therapeutic goal with minimal side-effects.
If oral diazepam was chosen at the outset because of its expected rapid onset of action, the GDG’s
view was that consideration should be given to changing to oral baclofen later as this may have a
more satisfactory long-term outcome.
The GDG concluded that if an oral drug was found to have a useful effect in an individual child or
young person (that is, it achieves a desired goal and is well tolerated) it should be continued as
medium-term or long-term maintenance therapy. However, longer term prescription that is
unnecessary and possibly ineffective should be avoided. Therefore, the GDG advised that on each
occasion when a child or young person is reviewed, it should be considered whether a particular drug
treatment is still necessary. Treatment reviews should take place at least once every 6 months.
In the event that an oral drug leads to side effects such as drowsiness, consideration should be given
either to reducing the dose or discontinuing treatment. Similarly, if diazepam or baclofen used alone
have no worthwhile effect within a period of 4–6 weeks then consideration should be given to a trial of
combined treatment with both diazepam and baclofen. Although no evidence was identified to support
the effectiveness of such combined treatment, the GDG considered that this was a rational approach
given the different mechanisms of action of the two drugs.
The GDG considered that there were potential adverse effects associated with withdrawal of
diazepam and baclofen after a long period of treatment. The group therefore recommended that
discontinuation after several weeks' use should be accomplished through staged reductions in dose to
avoid withdrawal symptoms.
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